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Histories of Health in Southeast Asia: Perspectives on the Long Twentieth Century

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Health patterns in Southeast Asia have changed profoundly over the past century. In that period, epidemic and chronic diseases, environmental transformations, and international health institutions have created new connections within the region and the increased interdependence of Southeast Asia with China and India. In this volume leading scholars provide a new approach to the history of health in Southeast Asia. Framed by a series of synoptic pieces on the "Landscapes of Health" in Southeast Asia in 1914, 1950, and 2014 the essays interweave local, national, and regional perspectives. They range from studies of long-term processes such as changing epidemics, mortality and aging, and environmental history to detailed accounts of particular episodes: the global cholera epidemic and the hajj, the influenza epidemic of 1918, WWII, and natural disasters. The writers also examine state policy on healthcare and the influence of organizations, from NGOs such as the China Medical Board and the Rockefeller Foundation to grassroots organizations in Thailand, Indonesia, and the Philippines.

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1 Krom Luang Wongsa and the House of Snidvongs: Knowledge Transition and the Transformation of Medicine in Early Modern Siam / Nopphanat Anuphongphat and Komatra Chuengsatiansup

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1   Krom Luang Wongsa and the House of Snidvongs

Knowledge Transition and the Transformation of Medicine in Early Modern Siam

Nopphanat Anuphongphat and Komatra Chuengsatiansup

By the end of the seventeenth century, Ayutthaya, the Siamese capital, along with Melaka and Hoi An, had already become regional centers of trade and commercial exchange.1 Located on an expansive Chao Phraya River with its maze of interconnecting waterways, the entrepôt of Ayutthaya, known to the European as the “Venice of the East,” spawned barges and ships from the high seas as well as sampans from local canals. During its glorious days in the reign of King Narai, the Court of Siam at Ayutthaya was frequented by Portuguese, Dutch, English, and French visitors. They were traders, missionaries, and diplomats who brought along not only new commodities, new religions, and new contracts, but more importantly new knowledge. It was the time for new learning as the new episteme had called into question not only the modus vivendi that the Siamese had long held sway, but also the modus operandi in the technical domains of architecture, engineering, astronomy, and medicine.2

 

2 Pilgrim Ships and the Frontiers of Contagion: Quarantine Regimes from Southeast Asia to the Red Sea / Eric Tagliacozzo

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2   Pilgrim Ships and the Frontiers of Contagion

Quarantine Regimes from Southeast Asia to the Red Sea

Eric Tagliacozzo

Disease was an important yardstick in how Europeans conceptualized the rest of the world during the past several hundred years.1 This was particularly so as the Industrial Age wore on, and definite links started to be established between sanitation and public health in the metropolitan capitals of the West.2 Yet, as Myron Echenberg has shown to such devastating effect in his book Plague Ports, the industrialization of steam-shipping, increased transoceanic travel, and global commerce all went hand in hand, and in fact facilitated the spread of pathogens on a heretofore unparalleled scale.3 Technology enabled the spread of virulent microbes in ways that previously would have taken much longer periods of time. The non-West may have been seen as filthy, diseased, and dangerous by Europeans, therefore, but in the very act of conquering the rest of the world with state-of-the-art technologies, the West also laid some of the preconditions necessary for a number of diseases to spiral out of control.

 

3 The Influenza Pandemic of 1918 in Southeast Asia / Kirsty Walker

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3   The Influenza Pandemic of 1918 in Southeast Asia

Kirsty Walker

The Influenza Pandemic of 1918 has been described as the worst demographic disaster of the twentieth century. It traveled insidiously across the globe in a series of waves, decimating many of the populations it encountered, and claiming an estimated worldwide mortality of up to fifty million.1 It was ruthlessly transnational, traveling surreptitiously through quarantine systems and across state borders. As news of a relatively mild but widespread flu epidemic in parts of Europe and the United States began to be reported, the virus reached Southeast Asia, and from June 1918 it spread across Malaya, the Dutch East Indies, the Philippines, Burma, and Indochina with fearsome speed. By October, the virus had mutated into something more vicious and had penetrated virtually every corner of the region. Official returns of morbidity and mortality were woefully incomplete and imprecise due to non-registration of deaths, missing records, and misdiagnosis, and the death toll has crept steadily higher as demographers have revised their judgments in the years following the pandemic. But even the tentative figures that do exist indicate that the demographic impact was significant. At least 1.5 million died in the Dutch East Indies.2 In Burma, studies have estimated that the flu claimed as many as four hundred thousand lives, equating to between 2 and 3 percent of the population.3 Over eighty-five thousand died from influenza in the Philippines.4 Malaya had at least thirty-five thousand victims.5 Between September and December 1918 alone, over a million people fell ill, and almost thirty thousand died in Siam.6 In Vietnam, Cambodia, and Laos, morbidity in some areas reached 50 percent. There were around thirteen thousand recorded deaths, and in areas outside French administrative control, many more went unrecorded.7

 

4 Disaster Medicine in Southeast Asia / Greg Bankoff

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4   Disaster Medicine in Southeast Asia

Greg Bankoff

Some of the most notorious natural disasters of the past two centuries have taken place in Southeast Asia. Even if death tolls have been greater in other events, the eruption of Krakatoa in 1883 and the Indian Ocean Tsunami of 2004 have come to be widely seen as symbolic of the power of nature and the unpredictability of human existence. Southeast Asia is often depicted as the “Ring of Fire,” the arc of active volcanoes that run through Indonesia and the Philippines; or “Typhoon Alley,” the area between the Philippines and southern Japan where tropical storms usually form before heading westward to wreak their destructive paths across the region. Although danger is no stranger to the lives and lifestyles of the peoples of Southeast Asia and recognition is accorded to their resilience and the varied ways and means by which they have learned to deal with the constancy of threat, little attention has been paid to “disaster medicine,” the system of medical practice primarily associated with emergency medicine and public health during a disaster.

 

5 The Demographic History of Southeast Asia in the Twentieth Century / Peter Boomgaard

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5   The Demographic History of Southeast Asia in the Twentieth Century

Peter Boomgaard

From the middle of the twentieth century, Southeast Asia witnessed a rapid fall in mortality, inaugurating a fundamental demographic transition. By 1945, the very high mortality from infectious diseases in Southeast Asia—detailed in the chapters by Eric Tagliacozzo, Kirsty Walker, and Mary Wilson—had yielded to improved sanitation and the gradual improvement of health facilities and the availability of antibiotic drugs. This chapter considers Southeast Asia’s demographic transition in long historical perspective, providing the demographic background to this volume’s consideration of the politics of health and crisis. It shows, too, that significant underlying drivers of Southeast Asia’s population (and population health) were often invisible to contemporary observers. In the 1950s and 1960s, mortality decline in Southeast Asia provoked alarm as much as relief. Scholars and others were getting worried about high population growth rates. While death caused by starvation had disappeared in most of Europe and North America (“the West”), such was not the case in many Third World countries, then called Underdeveloped Countries (UDCs). In these countries, recurrent famines and high birth rates were not seldom to be found in each other’s company.

 

6 “Rural” Health in Modern Southeast Asia / Atsuko Naono

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6   “Rural” Health in Modern Southeast Asia

Atsuko Naono

Introduction

Over the course of the past century in Southeast Asia, the term “rural” received sometimes sporadic and sometimes considerable attention from colonial governments, postcolonial governments, and international and private organizations concerned with health—such as the League of Nations Health Organization (LNHO), the Rockefeller Foundation, the World Health Organization (WHO), and other non-governmental organizations (NGOs). When and how rural medicine began to be viewed differently from urban medicine, when colonial doctors began to see the medicine differently in rural space and urban space, and when the idea that the village was a place where health was dealt with differently from anywhere else, however, are all questions that have hardly been dealt with directly in the literature on the history of medicine in Southeast Asia. Government records do not make the task any easier. Colonial and postcolonial medical reports are rich in statistics on rural and urban areas, but this terminology is rarely defined. While we might easily define Bangkok, Jakarta, Manila, Saigon, or Singapore as urban areas, in the colonial period, just as today, no single definition of what a rural area constitutes has been agreed upon. During the colonial period, the government authorities identified the village as the major unit of rural society, giving the village an importance and attributing to it administrative functions that it probably never had. These views influenced scholarship on Southeast Asia into the 1980s. It has been only recently that scholars have tried to understand rural Southeast Asia from the inside.1

 

7 Population Aging and the Family: The Southeast Asian Context / Theresa W. Devasahayam

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7   Population Aging and the Family

The Southeast Asian Context

Theresa W. Devasahayam

Population aging is one of the key demographic drivers of the rise in non-communicable chronic disease in Southeast Asia. The phenomenon of aging raises far-reaching questions about the locus of responsibility for elder care in the context of changing family structures and shifting public priorities. It is likely to present a formidable challenge to health policy in Southeast Asia in the foreseeable future, calling into question both the adequacy of public provision and its financial sustainability. This chapter follows from Peter Boomgaard’s overview of Southeast Asia’s demographic transition in the twentieth century, focusing on the past three decades. It shifts the terrain of this volume’s discussion of health to the family, and it adopts a perspective informed by demography and sociology.

The phenomenon of population aging has been a cause of public concern for several reasons. From the perspective of the state, an aging population suggests pressures on government resources that, in turn, have called for swift and relevant policy responses in the areas of fiscal management, income support, the labor market, health care, housing, and social support services.1 In Southeast Asia, the strategy of states has been to provide minimal or residual support to elder care largely with the aim of ensuring that families continue to undertake the role of primary caregiver to the elderly.2 In light of this, we may ask how, then, have families been able to cope with the role of providing care to the elderly and whether population aging has posed unique challenges to these families.

 

8 Epidemic Disease in Modern and Contemporary Southeast Asia / Mary Wilson

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8   Epidemic Disease in Modern and Contemporary Southeast Asia

Mary Wilson

Epidemics can cross borders and encircle the globe. Dynamic and dramatic events, they can seem unpredictable and capricious. They can spread rapidly or slowly and can be caused by old, familiar pathogens, like the bacillus that causes tuberculosis, or by never previously recognized ones, like the SARS coronavirus. They can be introduced from another region or can originate locally and disseminate. They can spread directly from one person to another or can require an intermediary, such as a food or water vehicle, a mosquito or flea vector, or exposure to a contaminated environment. They can kill, sometimes rapidly, or cause only minor symptoms in the majority of cases. Animals are also vulnerable—in some instances to pathogens that are the same as or similar to those that infect humans. Outbreaks of disease in animals, called epizootics, can also have serious indirect consequences for human life and well-being. Epidemics are often highly visible, especially if they cause death, disability, or disfigurement—and especially if the cause is unknown or not well understood. They engender fear and precipitate irrational behavior. Economic consequences often extend well beyond those directly affected. This chapter will discuss epidemics in Southeast Asia and some of the forces that have changed the nature, size, sources, characteristics, and drivers of epidemics over the past 100 to 150 years in this region. Although non-infectious diseases, such as beriberi in the past and obesity today, can also occur in epidemic form, most of the examples in this chapter will be infectious diseases. Because it has been discussed in Kirsty Walker’s chapter, pandemic influenza of 1918–19 will not be included in this chapter.

 

9 The Internationalization of Health in Southeast Asia / Sunil S. Amrith

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9   The Internationalization of Health in Southeast Asia

Sunil S. Amrith

Scholars of Southeast Asia have been more self-conscious than most about the arbitrary boundaries of the region they study. “Southeast Asia” as a term and a concept did not come into widespread use until World War II, when the Allies’ South East Asia Command was established to mirror the geography of Japanese military conquest. In the second half of the twentieth century, the region’s boundaries were defined politically: above all, by the membership of the Association of Southeast Asian Nations (ASEAN), established in 1967. At the same time, the area studies tradition institutionalized the study of Southeast Asia as distinct from South Asia and East Asia.1 In the field of health, too, the emergence of Southeast Asia as a region of knowledge and intervention is closely connected with the development of transnational and international institutions in the twentieth century. However, a recent collection of essays by public health specialists has argued that Southeast Asia’s identity as a region in global health remains ambiguous, its unity obscured by “UN agency groupings of the region that do not take into account historical and geopolitical ties.”2

 

10 Modernizing Yet Marginal: Hospitals and Asylums in Southeast Asia in the Twentieth Century / Loh Kah Seng

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10 Modernizing Yet Marginal

Hospitals and Asylums in Southeast Asia in the Twentieth Century

Loh Kah Seng

In my interview with Kuang Wee Kee, a former leprosy patient, he spoke of the “three brothers” of illnesses that not only drastically affected his life but also caused great anxiety among the public in Singapore since the colonial era. The “little brother,” he said, was mental illness, which was “quite light” in its impact; followed by the “second brother,” tuberculosis; and finally leprosy, the “big brother.” Kuang had suffered from isolation and painful treatment while confined for a long time in a leprosarium under the law of compulsory segregation. Even after his cure and discharge, he and his wife, Ow Ah Mui, also a leprosy sufferer, found that society refused to accept them. Kuang’s comments on the three “big brothers” underline the role of institutional treatment and confinement in Southeast Asia, namely, the tuberculosis clinic, the leprosarium, and the mental asylum.1

 

11 Healing the Nation: Politics, Medicine, and Analogies of Health in Southeast Asia / Rachel Leow

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11 Healing the Nation

Politics, Medicine, and Analogies of Health in Southeast Asia

Rachel Leow

In colonial situations around the world, the relationship among modernity, health, and political power has frequently been invoked by both colonizer and colonized. In India, for example, David Arnold has argued that introduction and spread of Western medical discourses was intended in part to demonstrate the superiority of Western science over “Eastern prejudice” and scientific inertia, to persuade through concrete practices the legitimacy of colonial rule.1 Yet when invoked by nationalist resistance, leaders often did not dispute the scientific superiority of Western health, merely the colonial state’s monopoly over it. In Vietnam, medical self-reliance was one of the most widely available forms of resistance, and in the rallying cry “hygiene is the love of one’s nation” (ve sinh la yeu nuoc) is embedded a view of health inherited from colonial science.2 Ruth Rogaski has traced the shifts in Chinese perceptions of what health (weisheng) has meant over the course of the nineteenth and twentieth centuries in engaging with Western imperial domination, and shown that in this period, notions of Chinese health were dislocated from their deep association with Chinese cosmology, and reoriented towards what she calls “hygienic modernity,” comprising such concerns as bodily cleanliness, racial fitness, and national sovereignty. These new concerns, she argues, were articulated in the idiom of modern Western science, and were in fact precisely qualities that foreign observers criticized China for lacking.3

 

12 Health or Tobacco: Competing Perspectives in Modern Southeast Asia / Loh Wei Leng

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12 Health or Tobacco

Competing Perspectives in Modern Southeast Asia

Loh Wei Leng

In spite of the wide acceptance of tobacco since its introduction from the New World of the Americas to Europe in the mid-sixteenth century, and thereafter disseminated farther afield to other continents by the seventeenth century, there have been those who have been very critical of its use.1

As early as 1604, King James I of England, in his now well-known “Counterblaste to Tobacco,” a diatribe against “this vile custome of Tobacco taking,” which he felt was “a custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lung”; and even as the smoking habit became popular in the twentieth century, dubbed the “cigarette century,” the negative effects of addiction on the consumer have long been recognized.2 What accounts then for the “deadly persistence” of this product when nicotine, the primary addictive agent in cigarettes, chewing tobacco, cigars and pipe tobacco, has been said to be “the leading preventable cause of disease, disability, and death”?3

 

13 The Role of Non-governmental Organizations in the Field of Health in Modern Southeast Asia: The Philippine Experience / Teresa S. Encarnacion Tadem

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13 The Role of Non-governmental Organizations in the Field of Health in Modern Southeast Asia

The Philippine Experience

Teresa S. Encarnacion Tadem

Introduction

The role of non-governmental organizations (NGOs) in the field of health in the Philippine experience could be best understood in the context of the emergence of individuals and NGOs advocating for “health for the poor.” For these NGOs one way of attaining this is through community-based health programs (CBHPs), with emphasis on primary health care (PHC) in the rural areas. These individuals and NGOs also view their health advocacy as part of the struggle to address the massive poverty and socioeconomic inequalities in the country. Although such efforts emerged during the pre–martial law period, it was during the martial law period (1972–86) that this health movement grew. Given their long-term objectives and the nature of their work, rooted as they were at the community level, it was inevitable that during the martial law period, these health advocates and NGOs would ally themselves or even be part of the mainstream left movement in the country—that is, the Communist Party of the Philippines (CPP), its military arm, the New People’s Army (NPA), and its illegal united front, the National Democratic Front (NDF) or the CPP-NPA-NDF. During its incipience, individual community-based health (CBH) advocates and NGOs were given much impetus by church-based movements, whose mission was to serve the poor, particularly in the countryside. The church’s foremost concern of was the health of the church’s constituencies, thus making CBHP advocates natural allies. Aside from being strongly linked with the mainstream left movement and the church movement in the country, CBH individuals and NGOs also drew financial and logistical support externally—either from international church-based movements or funding from foreign governments, mainly through their respective NGOs. With the downfall of the dictatorship in 1986, the post–martial law period ushered in new aspects of CBHP advocacies. One was attaining CBHP goals by joining, or engaging, or confronting government. Another was the emergence of reproductive health rights for women as an important dimension of the CBHP program. Such advocacy would gain support from the mainstream left movement, and following external developments such as the emergence of women’s rights as a priority in United Nations agencies. The split in the CPP-NPA-NDF in 1992, however, would prove fatal to CBHP advocacy. Aggravating this is the opposition of the Catholic Church’s hierarchy to the reproductive health rights of women.

 

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