Disease in the Premodem Period

As noted earlier, from around the beginning of the sixteenth century, a marked economic and social de­velopment occurred in most Southeast Asian states. The development of the region had significant ef­fects in relation to disease.

Changes in the Types of Disease

From the medical historian’s point of view, one im­portant legacy of the European colonization of South­east Asia was the propensity of the colonizers to collect statistics, compile reports, and make detailed observations on illness. These range from simple parish records, as in the Philippines (Owen 1987), to colonial office records such as those that exist for Java and Malaya (see Gardiner and Oey 1987; Manderson 1987). Moreover, European interest in Southeast Asia was not limited to administrative concerns; the region was visited by a good number of scholars, encompassing a diversity of disciplines, and their accounts contain detailed descriptions of the region, its peoples, and history.

Nonetheless, considerable care must be taken in the interpretation of the sources because they gener­ally reflect European preconceptions, regarding both Southeast Asia and disease. Thus whereas figures are generally good for foreign communities, the reli­ability of statistics for the indigenous populations is often questionable (Boomgaard 1987; Gardiner and Oey 1987).

It is true that references to disease in certain types of indigenous sources, such as chronicles, are also often concerned with epidemics. However, these ref­erences, which occur mainly in connection with ac­counts of crises, and the performance of state ceremo­nies, reflect the political or religious function of such sources, rather than an attempt to provide balanced descriptions of disease. In other indigenous sources, such as medical treatises, much space is often de­voted to the description of diseases that do not figure significantly in either European or official indige­nous accounts.

A further difficulty in the interpretation of Euro­pean and indigenous sources alike is that both the systems of classification and the illnesses they sought to classify were changing. In the indigenous languages of the region it was not uncommon, at different times and in different contexts, for a dis­ease to be known under several names. Similarly, early European accounts often differentiated poorly between illnesses, references frequently being con­fined to such general terms as fluxes, or fevers (see Dampier 1927; Cook 1968).

The difficulties thus posed for the identification of illness in modern terms are illustrated by the case of the history of cholera in Siam (Terwiel 1987). It is generally agreed that the first major epidemics of cholera in Southeast Asia occurred in the early nine­teenth century as the result of the spread of the disease from India.

Similar difficulties are encountered in the identifi­cation of other diseases, as seen in the case of lep­rosy, another condition with a long history in South­east Asia. Human figures with features consistent with leprosy are depicted in Khmer bas-reliefs on the Bayon at Angkor, and at Ta Keo (Coedes 1941). The disease was also noted by a Chinese traveler during his stay in Cambodia in 1296 and 1297 (Chou Ta-kuan 1951). Legend also has it that in ancient times, there was a Khmer “leper king” (Coedes 1941; Chou Ta-kuan 1951). But other written accounts do not always permit a fine distinction to be made be­tween leprosy and other skin afflictions. In tradi­tional Thai medical texts, for example, the term that today is used to denote leprosy, ru’an, also includes a range of other skin conditions such as tinea. This is also the case in some early European accounts. Thus the leprosy which William Dampier reported to be widespread in Mindanao and Guam during his 1686 visit was probably the same fungal skin disease, possibly tinea imbricata, later reported by John Crawfurd in Java (Crawfurd 1820; Dampier 1927).

Some of the difficulties mentioned above may be attributed to the complexities of indigenous disease naming, as in the Thai examples, or to the lack of diagnostic expertise of the individual observer, as was perhaps the case with Dampier. More impor­tantly, however, the examples above point to the fact that diseases, their incidence, and the ways in which they were classified, were continually changing. Thus as diseases were changing in virulence, the susceptibility of the population to disease was also changing.

The Development of Cities

The most important factor concerning disease during this period was probably the redistribution of popula­tions, associated in particular with the development of large cities. Whereas in the past the location of cities was primarily determined by strategic consider­ations, which almost certainly would have included the provision of secure food and water supplies, trade and industry now became a major determinant.

In Southeast Asia major cities, such as Batavia, Singapore, Manila, and Bangkok, developed in coastal or estuarine areas as port cities with their associated commercial activities. In these areas, which were usually low-lying or marshy, drainage, the removal of wastes, and the supply of clean house­hold water quickly became a problem. The poor, on whose labor the operation of ports and commerce depended, were faced with the additional problems of crowded housing and a diet that was often barely adequate. In addition to the dangers these condi­tions posed for health, the constant port traffic and the linking of Southeast Asia with the rest of the world meant that the region was increasingly open to the entry of communicable diseases.

Of the Southeast Asian port cities that emerged during this period, Batavia probably had the great­est reputation for unhealthiness. The city was re­ported to be relatively free from disease for some years following its establishment in 1619. But its growth and the development of an adjacent hinter­land placed such demands on the city’s drainage systems and water sources that from the early eigh­teenth century onward disease became a major prob­lem (Blusse 1985). By the time the explorer James Cook called at Batavia in late 1770 to take on sup­plies and prepare his ship for the journey back to England, conditions were extremely bad.

European residents of Batavia were able to insu­late themselves to a large degree from the disease prevalent in the city by moving away from the old areas within the city walls. But the Chinese and Indonesian inhabitants, unable to move, continued to suffer illness at rates that were higher than most other towns in Java (Abeyasekere 1987). Although Batavia provides just one example, this pattern of disease, related to overcrowded and unsanitary liv­ing conditions, existed in most other Southeast Asian coastal cities (Lord 1969; Worth 1985; Manderson 1987).

The growth of cities was, of course, not the only stimulant to disease. Labor, often immigrant, was also required to work plantations and mines, under conditions that also posed considerable risks to health (Cohen and Purcal 1989). Changes in the exploitation of the rural environment also created circumstances that led to the spread of disease, as seen in the association between wet rice cultivation and the spread of malaria in Java (Boomgaard 1987). Similarly, plantation agriculture was instru­mental in the spread of malaria and dengue as well, by providing opportunities for mosquitoes to breed, such as in the water trapped in Latex cups and coconut shells or husks (Wisseman and Sweet 1961).

Economic changes in Southeast Asia also contrib­uted to changes in disease by the creation of a land­less and impoverished class. In part, this class was brought about by the disruption of traditional forms of agriculture, particularly by the development of plantations, the introduction of money economies, and wage labor (Robison 1986). Thus under colonial administrations, the imposition of taxes, to be paid in cash rather than by goods or labor, has been pointed to as a significant factor in the impoverish­ment of many (Worth 1985). On the other hand, as Lysa Hong (1984) has pointed out, taxation systems did not necessarily serve to impoverish populations.

The many economic changes that produced wide­spread poverty meant, of course, that large sections of the population were placed in situations where they were more susceptible to disease, through ei­ther direct exposure or poor resistance. Individuals were also less able to afford the medical care that might have promoted recovery from disease. Thus, in addition to famines, and problems directly related to nutritional deficiencies such as beriberi and rick­ets, the effects of poverty showed up in a range of other diseases. These included chronic respiratory disease, tuberculosis, and eye ailments. Infant chil­dren were one group particularly at risk, and this was reflected in high infant mortality rates, as in Malaya in the early part of the twentieth century (Manderson 1987). The conditions of poverty also meant that the effects of epidemic diseases, as in the - influenza pandemic of 1918, were considerably more pronounced among the non-European population of Southeast Asia (Brown 1987).

Changes in Susceptibility

Balancing the deleterious effects of the development of the region on health were a number of other fac­tors. It was, after all, in the interests of colonists and Southeast Asian rulers alike to ensure a supply of productive labor. By the same token, these economic interests also meant that they often did not do much more than they had to. As Owen (1987) has put it, the colonial system “forced the poorest to the brink,” but it “kept most... from toppling over.” Yet the things that kept the majority of the population from “toppling over the brink” with regard to health were not all attributable to the direct intervention of the state in the treatment and prevention of disease. A number of the changes affecting the susceptibility of individuals to disease occurred at this time, follow­ing from increased contact with the rest of the world. Indeed one consequence of prolonged contact be­tween Southeast Asian populations and the rest of the world was the development of disease resistance. Thus although initial exposure to diseases previ­ously unknown to the region resulted in a high mor­tality, long-term exposure produced resistance to them. Indeed the openness of the region to trade, it has been argued, meant that immunity to most seri­ous epidemic diseases was already developed in much of Southeast Asia prior to contact with Europe (Reid 1988). Moreover, the existence of some dis­eases in the region prior to contact may also have had some effect in minimizing the impact of intro­duced diseases. Thus it has been suggested that the prior existence of yaws in Southeast Asia was a factor in limiting the spread of syphilis introduced by the Europeans (Boomgaard 1987).

Probably of even greater significance in keeping people away from the brink was the introduction of new foods, habits, and customs which followed the European presence in the region. A number of food plants, such as the papaya, potato, tomato, and chilli pepper, which originated in the New World, came to Southeast Asia with the Spanish and Portuguese and rapidly became an important part of the region’s cuisine. Footwear also came to be adopted by sec­tions of the population that would have prevented entry through the skin of parasites such as hook­worm. Traditional unhygienic practices relating to the cutting and treatment of the umbilical cord of the newborn child, which often produced tetanus, also lost favor during this period (Hanks 1963; Manderson 1987).

The Adoption of Western Medicine

Contact with the West also meant contact with West­ern medical practices, although it is doubtful that such medicine had any favorable impact on health prior to the late nineteenth century, when the first major benefits of medical science came to be felt. In fact, even then progress was slow. Colonial doctors and administrators were not, in general, representa­tive of the most advanced thinking of the age (Owen 1987). Furthermore, the medical and health services introduced were based on European models and were mainly directed at the European populations, and at the labor force upon whom they depended.

European efforts directed at improving the health of indigenous populations were often carried out without regard for local beliefs and customs. In its extreme this was seen in measures such as the burn­ing of homes and the desecration of the dead, which took place in Java following the outbreak of plague in the early years of the twentieth century (Hull 1987). Where more sensitive attempts were made to use Western medicine to treat the non-European population, ulterior motives such as religious conver­sion were often at work (Hutchinson 1933; Worth 1985). Besides the suspect attitudes and methods of colonists and missionaries, there were other impor­tant reasons why Western approaches to the diagno­sis, treatment, and prevention of disease were not readily adopted by Southeast Asians. For most, lan­guage and finances also presented practically insur­mountable barriers to the acquisition of Western medical knowledge. Prominent, too, were indige­nous beliefs regarding illness and the working of the body, and negative perceptions of the efficacy of West­ern methods. In the latter case although the value of certain aspects of Western medicine, such as the medicinal use of opium, had long been recognized in Southeast Asia, the efficacy of other features was not apparent. Many of the practices introduced by Europeans in the prevention and treatment of ill­ness were hardly any better than local ones they replaced. These included “cholera drinks,” “cholera belts” (a broad band of flannel worn while sleeping at night to protect the abdominal organs from chill), and dutch wives (cylindrical cushions used to sup­port or protect the body from chills while sleeping at night) (Bangkok Times 1904; Bangkok Times Weekly Mail 1906; Abeyasekere 1987; Owen 1987). Indeed, some European practices, such as bloodletting, ran quite counter to local beliefs (Reid 1988; Bamber 1989).

Nevertheless, there were occasions when features of Western medicine appear to have been well ac­cepted. In some cases, such as in the use of quinine to treat malaria, which became available from the late eighteenth century, acceptance came as a result of the demonstrable pharmacological value of the drug. In other cases it appears that Western medical prac­tices were adopted because of a fortuitous coinci­dence with existing Southeast Asian beliefs. This seems to have been responsible in part for the accep­tance of the treatment of smallpox by vaccination, which fitted well with local beliefs that substances inserted beneath the skin could confer magical power (Reid 1988; Terwiel 1988).

Smallpox Vaccination

Smallpox, at least from the time it was recorded in seventeenth-century accounts, was one of the most feared diseases in Southeast Asia (La Loubere 1691; Lovric 1987; Reid 1988). Traditional methods of treatment, such as herbal medicines and bathing, were largely ineffective against epidemics that oc­curred regularly throughout the region. Little could be done by the local inhabitants except to limit the spread of the disease (Reid 1988). But with increased contact with peoples outside the region, different methods of prevention became available. One of these was inoculation (variolation), involving the deliberate introduction of smallpox matter into the body, usually via the nose, first practiced by the Chinese and Indian populations in the region (Ter- wiel 1988). This technique was also later employed by the Dutch in Java around 1780, and appears to have been practiced by Europeans in Siam from 1833 (Boomgaard 1987; Terwiel 1988). At the re­quest of the Siamese king, inoculation campaigns were begun in Bangkok in 1838 (Terwiel 1988).

Vaccination, a less dangerous and unpleasant form of smallpox prevention, began in Java in 1804, although its spread was limited until the introduc­tion of mass immunization programs (Boomgaard 1987). The Dutch also introduced regulations in 1820 that ensured that outbreaks were reported and contained, which may in fact have contributed more to the control of the disease than did the immuniza­tion program (Boomgaard 1987). In Siam, largely because of problems in obtaining viable vaccine, vac­cination programs against smallpox did not succeed until late in the nineteenth century (Terwiel 1988). In Vietnam, smallpox vaccination appears to have been initiated in order to protect the French military and settlers: Free smallpox vaccination campaigns were introduced among French troops in 1867, and compulsory vaccination of villagers took place in 1871 when a major epidemic occurred. Further mass vaccination campaigns, mainly in the south and cen­ter of the country, were conducted in 1895 and 1896 (Worth 1985; Marr 1987).

It may have been the case that methods adopted by the colonial administrations in the introduction of vaccination were at times heavy-handed. How­ever, the practice does not, in general, seen to have met with resistance from the local inhabitants of the region. This is suggested by the active interest taken by the Siamese, for example, in the pursuit of knowl­edge about vaccination. Where there was reluctance to employ the technique, it appears to have arisen from doubts regarding the viability of the vaccine, rather than from the method itself. This was not always the case in the introduction of other Western practices used in the management of disease, particu­larly in regard to the establishment of hospitals.

Hospitals and Public Health

State involvement in public health care was not new to Southeast Asia. Departments of physicians were a feature of the courts of a number of South­east Asian rulers (Worth 1985; Marr 1987; Bamber 1989). It is likely, however, that the services of such “hospitals” were largely confined to the elite (Marr 1987; Reid 1988). By the same token, it is unclear whether the hospitals that existed in Cambodia dur­ing the twelfth century under the reign of Jayavar- man VII were in fact “open to all” as their inscrip­tions suggested, and whether they can be regarded as “hospitals” in the Western sense. On this point the inscriptions are not clear, and could simply mean dispensaries (Coedes 1941). That this may have been the case is supported by later accounts which comment on a reluctance by Southeast Asian peoples to build or enter hospitals (Hutchinson 1933) because of an association of hospitals with death. For many Southeast Asians, hospitals were seen as places where one went to die, and in all likelihood harbored the spirits of those who had already died there (Chai 1967; Thompson 1967; Abeyasekere 1987). The fact that a number of hospi­tals were originally founded by missionaries as hos­pices for the care of the victims of epidemics, or those suffering incurable illnesses, would have done little to change this view (Yuwadee 1979; Worth 1985).

Hospitals created by colonial governments were generally not intended for the use of most non­European Southeast Asians but, rather, for the mili­tary and civilian personnel serving the colonial ad­ministrations. Thus, the health care service provided by the Dutch East India Company was for company servants, as was the hospital system introduced by the British in the Malay states from 1878 (Chai 1967). In Vietnam hospital facilities were introduced in the late nineteenth century, largely for the care of the colonial army and administration (Worth 1985).

Where hospitals were established specifically for the benefit of workers, the funding appears to have come mainly from the groups concerned. For exam­ple, the Chinese Hospital established by the Dutch in Java was financed by taxes on Chinese residents (Abeyasekere 1987). The “paupers” hospitals associ­ated with mining centers, which were established by the British in Malaya, were also funded by taxing the Chinese workers (Chai 1967).

The impetus to establish hospitals in Southeast Asia did not come solely from colonialists. In the case of Siam, for example, the monarch played an important role in introducing the hospital system. On a temporary basis, hospitals had been estab­lished in Siam, from the early nineteenth century, in order to care for the victims of epidemics (Yuwadee 1979; Muecke and Wichit 1989). In 1855 an offer of land and materials for the building of a hospital was made by the King to an American missionary doctor, but was not taken up (Terwiel 1983). The first state- financed hospital, Siriraj (Wang Lang), was estab­lished at the order of the King following the cholera epidemic of 1881, and officially opened in 1888 (Sanguan 1973). Although it is probable that he was counseled by the European and American doctors in Siam at the time, the Siamese monarch was well acquainted with Western medicine, having previ­ously traveled to Singapore and Batavia, and there is no reason to doubt that the initiative came from the Court (Yuwadee 1979).

Medical services were initially staffed, in both colo­nial and noncolonial Southeast Asia, by European or American doctors. Some attempts were made to train local people in medical procedures, for exam­ple, the dokter-djawa of Java, who carried out some basic treatments (Boomgaard 1987; Gardiner and Oey 1987). In general, however, access to a full West­ern medical education was beyond the reach of most Southeast Asians, and even where entry to medical schools was possible, problems remained. For exam­ple, for some years after its opening in 1890, the Western medical school established in Bangkok suf­fered a shortage of Siamese students, probably be­cause of the long, difficult nature of the course, its expense, and the uncertain prospects facing gradu­ates (Yuwadee 1979). In Malaya, positions in the Civil Service were closed to non-Europeans and non­Malays, thus denying Chinese doctors employment, regardless of their qualifications (Chai 1967).

Southeast Asian Disease and the Development of Western Medical Science

Closely linked to the development of colonial medi­cal services was the establishment of research insti­tutes for the study of “tropical diseases.” From the standpoint of scientific inquiry, Southeast Asia had long played an important role in Western medicine. The region was an important source of Western ma­teria medica such as cloves, menthol, camphor, benzoin, and, after 1850, quinine. Southeast Asia also figured prominently in the development of bo­tanical and pathological taxonomy, and a number of influential figures in the development of Western natural science traveled to the East Indies as doctors in the employ of the Dutch.

The first research institute concerned with tropi­cal medicine, later to become known as the Pasteur Institute, was set up by the French in Saigon in 1890, and a further three branches were established in other parts of the colony (Morin 1938; Worth 1985). Their purpose was initially military, being intended to carry out research on the diseases — in particular, dysentery and malaria - which severely affected French troops stationed in Vietnam.

The British also founded research institutes. The London School of Tropical Medicine was opened in 1899 in order to undertake scientific inquiry into tropical diseases, and to prepare medical officers for service in the Crown Colonies (Chai 1967). In 1901, in response to a request from the Resident-General of the Federated Malay States, a Pathological Insti­tute, which later became the Institute for Medical Research, was opened in Malaya (Chai 1967).

In the context of the development of the specialty of tropical medicine, the establishment of these in­stitutes has been viewed by some writers as “impe­rial arrogance” (Owen 1987). Certainly, by their focus on scientific research into diseases, rather than public health measures, they served imperial­ist ends in several ways (Worboys 1976; Owen 1987). In the short term, it might therefore be ar­gued that Southeast Asia did far more for Western medicine than Western medicine did for Southeast Asia. Nevertheless, in the long term, Southeast Asians came to benefit substantially from the knowledge of disease that was generated by these research institutes. The French laboratories in Viet­nam were, for example, the site for important re­search on plague, smallpox, rabies vaccine. The Malayan Institute was largely responsible for un­dertaking the research that established the nutri­tional basis of beriberi, a discovery that was given wide publicity at the first biennial meeting of the Far Eastern Association of Tropical Medicine. This conference, held in Manila in 1910, was attended by medical officers from most of the countries of the region (Bangkok Times Weekly Mail 1904; Chai 1967). The findings were subsequently dissemi­nated into areas of Southeast Asia that were out­side direct colonial control, and otherwise unlikely to benefit from the work of the research institutes.

The Impact of Western Medicine on Traditional Perceptions OfDisease

Indigenous views of disease were largely disre­garded in the introduction of Western medical sys­tems (Owen 1987). Even in Siam, where there was a degree of freedom in the adoption of Western-style medical education, traditional medicine was offi­cially neglected. In fact, it was originally omitted from the curriculum of the medical school when that curriculum was set up under the direction of West­ern doctors in 1889. Later, however, at the request of the king, traditional medicine was included, but only as an optional subject; because of differences between the Siamese and Western doctors engaged to teach in the school, it was only in 1907 that courses in Siamese medicine became a compulsory part of the curriculum (Yuwadee 1979). Tellingly, one reason for the pressure to introduce traditional medicine into the medical curriculum in Siam came from doctors who had completed the course and gone to work in provincial areas. They complained that they were unable to make use of indigenous medi­cines to treat patients when the scarce supplies of Western medicines and equipment were exhausted. The doctors argued that if only they had had some basic training in traditional medicine, they could be of greater value to the provincial population (Yuwadee 1979).

Although Western medicine may have been beyond the reach of most Southeast Asians, it nevertheless produced changes in the ways in which those without direct access perceived disease (Owen 1987). The germ theory of disease, for example, was integrated into indigenous beliefs regarding illness causation. For example, among the Agusan Manobo of Minda­nao there is a belief that disease may result from germs carried by supernatural agents (Montillo- Burton 1982). However, in applying germ theory, a distinction may be made by Southeast Asians be­tween diseases endemic to the region and those that are “foreign.” In this case, it is only the foreign dis­eases that are caused by germs (Montillo-Burton 1982).

In other cases, there appear to have been semantic changes in traditional terms for illness in order to accommodate Western disease categories. An exam­ple is the Thai term mareng, which (as discussed earlier) in the past signified a “deep-seated ulcer” and came to refer to cancer. Similarly, wannarok, the currently employed Thai term for tuberculosis, for­merly referred to “illnesses involving infections or abscesses” (Bamber 1989). In both these cases, the effect has been to emphasize one part of a wide semantic range, so that the resultant meaning con­forms more closely to that of disease categories in Western medicine.