Three important books on the history of public health in modern China appeared in 2018, significantly enriching a growing literature in the field. Together they cover a period stretching from the last decades of the Qing dynasty to the 1950s, concentrating on the Republican era, especially from the 1920s to the war period ending in 1945. Although these books address different themes and research questions, all three focus on cities where modern public health policies were first tested and implemented: Shanghai, the financial hub of modern China with a strong colonial presence; Beijing, where the influential Peking Union Medical College (PUMC) financed by the American Rockefeller Foundation, a key player in this history, was established in 1921; and Chongqing, the wartime capital of Republican China.
Chieko Nakajima’s Body, Society, and Nation: The Creation of Public Health and Urban Culture in Shanghai takes a comprehensive approach in covering a wide range of public health topics from the late Qing to the 1950s. Nicole Elizabeth Barnes’s Intimate Communities: Wartime Healthcare and the Birth of Modern China, 1937–1945 focuses on the gender aspect of public health organization, especially nursing and midwifery, in a time of national crisis. Emily Baum’s Invention of Madness: State, Society, and the Insane in Modern China is specifically about Chinese agency in the modern construction of insanity and mental illness as knowledge and practice. All three books are inspired by Ruth Rogaski’s pioneering work on “hygienic modernity” based on treaty-port Tianjin (2004) and Sean Lei’s seminal study on the construction of modern Chinese medicine as a mongrel body of knowledge resembling “neither donkey nor horse” (2014). The books reviewed here contribute new, intriguing layers of complexity to the narrative of China’s modernity framed in terms of the increasingly medicalized body’s pivotal importance in the process of state-building.
Nakajima’s comprehensive book provides a wide range of public health information in modern Shanghai from the late Qing to the first decade of the People’s Republic of China (PRC) concerning institutions and the public health administration (particularly the role of the Shanghai Public Health Bureau), mass hygiene campaigns to combat diseases and sanitize the city, and the popular consumption of hygiene materials and products. In describing the development of institutions, such as hospitals, the author emphasizes not only the impact of foreign influence, as one would imagine for an international city like Shanghai, but also the importance of traditional philanthropy and volunteerism. On public health administration and mass hygiene campaigns, the author emphasizes the state’s role. For example, in evoking the New Life Movement launched in 1934 by Chiang Kai-shek and epidemic control programs managed by the Public Health Bureau run by the Japanese occupants during the war, Nakajima stresses the state’s motivation in disciplining the population, a trend she continues to see in the Communist mass campaigns after 1949. Her attention turns to consumers in the last chapter on commercialized hygiene products. However, because the chapter relies heavily on advertisements and sources on Shanghai light industrialists, the reader learns more about the great variety of hygiene products and their production than about how consumers used them.
Nakajima rightly explores the important question of the relative uniqueness of Shanghai as a city where people were “flexible and pragmatic” in the adoption of modern values and practices (249). Like other major cities in China, modern public health structures in Shanghai evolved from a long tradition of urban philanthropy, led by business and intellectual elites, that later incorporated Western ideas and practices introduced by missionaries and medical experts. To show Shanghai’s uniqueness, it would be useful to trace the origin of native medical charitable institutions managed by elite merchants in the late Qing thoroughly studied by Fuma Susumu in his work on charity halls (1997) and compare these modern medical institutions with British Hong Kong’s Tung Wah Hospital (1872– ) studied by Elizabeth Sinn (1989). The very broad scope of Nakajima’s book inevitably reveals hitherto-neglected areas that beg for more research in modern Chinese public health. The last chapter, for example, clearly suggests the great potential in more closely scrutinizing class, ethnic, and gender for a fuller understanding of the modern public health market.
Barnes’s book on wartime Chongqing precisely takes up the gender aspect of public health, which provides her with a totally fresh look at the city and the war. This original, richly documented, and generously illustrated work focuses on women’s role in solidifying a “national community” through organizing and undertaking public health duties during a time of national crisis. The book builds on both Rogaski’s thesis of “hygienic modernity” and a growing literature on wartime China (Watt 2014). Barnes provides fascinating details on how the war created new professional opportunities and challenges for women as providers of healthcare. The story convincingly proves her claim that the feminization of nursing in China was a direct outcome of the war. Zhou Meiyu, the most prominent of nurses of the time, even became the first female general in Chinese military history. The spread of modern midwifery to rural areas was also made possible with the enthusiastic promotion of Yang Chongrui. However, Barnes is also mindful of the glass ceiling that these women faced in their otherwise brilliant careers. She illustrates this point with the intriguing example of Vera Nieh (Yuchan), director of PUMC’s nursing school. Barnes explains the divergent opinions on Nieh’s performance held by her male and female colleagues in terms of sexism. But because Nieh was severely criticized mainly by her American male superiors, one wonders if there was also a hidden racial factor in this apparent gender divide.
Barnes’s main objective in this work is to demonstrate women’s roles in the creation of a sense of national community at this particular historical conjuncture which, she argues, represented a fundamental shift in the development of public health in modern China and an important stage of state-building. The book provides extensive details on the intimate ties that professional female medical workers such as nurses and midwives established with soldiers, civilians, and refugees. The intertwining effect of gender and class in the process is subtly narrated and convincingly argued, beginning with the New Life Movement actively promoted by Chiang Kai-shek’s U.S.-educated wife, Song Meiling. Whereas Nakajima mentions New Life as one of the many mass movements in modern Shanghai, Barnes highlights the middle-class values and aesthetics promoted in the movement and embodied by Song Meiling. This class element discreetly fortified the new authority acquired by professional female nurses, who were not simply providers of medical care to male soldiers but especially preachers of patriotism urging the wounded to return to the battlefield to fulfill their masculine duty of defending the country. Barnes argues that the Nationalists won the anti-Japanese war by successfully inculcating a strong sense of national community in Chongqing society through public health practices based on new gender relations, but they lost the subsequent civil war to the Communist Party, which created an emotional community that also crossed traditional class lines (118–119).
This book should also be commended for its many excellent photos and illustrations (some very nicely reproduced in color), which Barnes uncovered from various Chinese and American archives. These visual aids often reveal subtleties of the gender element in the construction of “intimate communities”—subtleties that words cannot fully convey, as shown by, for example, a photo showing the awkwardness with which women orderlies assisted wounded soldiers (144) and another showing a female doctor with an attitude of authority examining soldiers for blood donation (137).
Barnes’s inspiring argument opens up new research questions on the trajectories of key female players in the history of public health in modern China, such as Song Meiling, Zhou Meiyu, Vera Nieh, and Yang Chongrui discussed in this book, and many others (see, for example, Leung 2006). Was the model of the “middle-class” feminist portrayed in this book rooted in these women’s American education? or, more precisely, in their close association with PUMC backed by the Rockefeller Foundation? How homogenous was their education and work experience? How was such a model received and integrated into China’s indigenous urban society? Did these women’s wartime experiences determine their postwar trajectories? Some (Song and Zhou) went with the Nationalist government to Taiwan, and others (Nieh and Yang) opted to serve the Communist regime after 1949.
Whereas studying the gender factor in public health history allows Barnes to detect a critical turning point in China’s state-building process, Baum’s construction of “madness” reveals the resilience of Chinese traditional medical practice. By focusing on mental health, an emerging but difficult field of modern Chinese history, Baum’s path-breaking work demonstrates with remarkable clarity and conviction the complexity of China’s quest for “hygienic modernity” from the late Qing to the 1930s. As she says in the conclusion of her book, “Modernity and psychiatric modernity are not just ready-made conditions waiting to be achieved by non-Western populations. Rather, modernity is better conceived as an ongoing process of becoming…” (187; emphasis in original). According to Baum, the history of psychiatry as part of the modern Chinese public health system was clearly a process of neuropsychiatry accommodating itself to the needs of the Chinese people, not one of straightforward West-East “transfer.”
Inspired by the Foucauldian theme of madness and modern Western civilization (and capitalism), Baum does not gauge China’s modernity with Western psychiatry as the “norm.” Methodologically, she analyzes the major shifts in China’s modern social governance by tracing changes in the institutionalization of the insane, or people with severe mental disorders, from the late imperial era to the 1930s. As for the construction of insanity in knowledge and practice, she turns away from the state to doctors, government officials, social workers, and ordinary people who “transformed the very nature of psychiatric modernity itself” (8) through their everyday experiences. As told by Baum, both the institutional setup and knowledge construction on madness were deeply rooted in China’s past.
Baum dates the beginning of China’s psychiatric modernity to 1908, when the first public asylum in Beijing was established. Even though the imperial state’s decision was made under the pressure of having to conform to practices in the West and Japan, the institution was in fact an “attachment” to the existing poorhouse in the inner city, managed by the police and under the jurisdiction of the Bureau of Social Affairs. For the imperial government, poverty and insanity remained inseparable. What the new institution had changed in the governance of social deviance was that the police were now responsible for arresting, detaining, and supervising the insane, and people were no longer obliged to keep their afflicted family members at home. Medical treatment remained insignificant and traditional. The shift from incarceration to Western medicalization did not take place until the 1930s when the Nationalist government collaborated with the American-backed PUMC to develop neuropsychiatric medicine. The replacement of the asylum with the Beijing Psychopathic Hospital in 1934, placed under the Ministry of Health, was a major milestone in the Nationalists’ social engineering project. With the dismissal of Chinese medical practitioners, the recruitment of biomedical experts, new forms of psychiatric treatment, and the recategorization of inmates according to scientific psychology, the new, expanded hospital embodied the “intensely modernist characteristics of hygiene, bureaucratic rationalism, and scientific expertise” that distinguished the Nationalist government from its preceding regimes (129). The American neurologist framing of insanity as a condition “inhibiting the evolutionary progress of the Chinese nation and race” (137) shows the discourse’s tremendous relevance to the Nationalist state-building project.
However, Baum reminds us that, thoughout this history, despite the new scientific discourse, modern neuropsychiatry never completely displaced Chinese conceptions and treatment of mental disorders during this period, nor did it monopolize the language of madness. The resilience of Chinese conceptions of illness and the body was demonstrated by the criticism raised by Chinese social workers at PUMC on the mechanical biomedical view of the body. More generally, Chinese doctors, intellectuals, and patients of this period blended theory, semantics, and practice in Chinese and biomedical medicine to understand and explain psychiatric disorders in their own terms, and to justify variegated treatments including Chinese medicine and folk or religious therapies. Mucous stagnation, for example, remained a cause of disorders, and in Chinese, hysteria was better understood as zangzao, or visceral (uterus) unrest, justifying the treatment with relevant classical Chinese formulas. In this respect, “scientific” psychiatry in modern China was yet another illustration of the “mongrel medicine” analyzed by Lei (2014).
Baum mentions in greater detail another unexpected key actor in this history: the “psychiatric entrepreneur” who invented and capitalized on “modern” elite madness such as “neurasthenia,” a disorder of the refined, civilized, urban professional, introduced through commercial channels in China via Japan. Such disorders were to be treated by private hospitals and doctors publicized by commercial advertisements. The popularity of lucrative commercialized treatments of such disorders, including mongrelized qi intervention and proprietary medicines, show how readily a society commodifies psychiatric disorders constructed through people’s everyday bodily experiences in a creolized language. Is this phenomenon unique to modern China or universal across cultures? Does it persist under different forms today or recede with increased medical standardization?
The three books discussed here demonstrate from different angles the centrality of medicine and public health in China’s modern state-building since the late nineteenth century. They all stress the process of institutional change and the authority of scientific discourse in that process. Although the great transformative power of modern subjects—such as professional women—and new entrepreneurship is deftly demonstrated, the resilience of traditional institutions and knowledge of the natural world proves to be of equal importance. These three excellent books on modern public health invite us to contemplate again this rich, recent past to refresh our understanding of China’s modernity, an ongoing process of “becoming.”
Fuma Susumu. 1997. Chūgoku zenkai zendōshi kenkyū [The study of Chinese charitable associations and charitable halls]. Kyoto: Dōhōsha shuppan.
Lei, Sean Hsiang-li. 2014. Neither Donkey nor Horse: Medicine in the Struggle over China’s Modernity. Chicago, IL: University of Chicago Press.
Leung, Angela Ki Che. 2006. “Dignity of the Nation, Gender Equality, or Charity for All? Options for the First Modern Chinese Women Doctors.” In The Dignity of Nations, Equality, Competition, and Honor in East Asian Nationalism, edited by Sechin Chien and John Fitzgerald, 71–82. Hong Kong: Hong Kong University Press.
Rogaski, Ruth. 2004. Hygienic Modernity: Meanings of Health and Disease in Treaty-Port China. Berkeley: University of California Press.
Sinn, Elizabeth. 1989. Power and Charity: The Early History of the Tung Wah Hospital, Hong Kong. Hong Kong: Oxford University Press.
Watt, John. 2014. Saving Lives in Wartime China: How Medical Reformers Built Modern Healthcare Systems amid War and Epidemics, 1928–1945. Leiden: Brill.
About the Reviewer
Angela Ki Che Leung is Director of the Hong Kong Institute for the Humanities and Social Sciences, Chair Professor of History, and the Joseph Needham-Philip Mao Professor in Chinese History, Science, and Civilization at the University of Hong Kong.