[Special Feature: Infectious Diseases in History] Nagayo Sensai and Cholera Epidemic Prevention

In the series of events from the restoration of imperial rule by the 15th Shogun Tokugawa Yoshinobu (1837–1913) to the establishment of the new Meiji government, the Western model became established as the foundation for Japan's nation-building. Activities in the medical and hygiene sectors were no exception, and Westernization was pursued. Consequently, the mission of Nagayo Sensai (1838–1902), who was appointed to accompany the Iwakura Mission in 1871, was to investigate Western medical education systems.

Departing from Yokohama, Sensai landed in the United States in December of that year. Everything he saw and heard there was fresh, and he was astonished by the vast differences between Japan and the West. He later wrote that experiencing an elevator in a hotel made him feel as if his "liver had been plucked out" (a Japanese expression for being startled).

After completing his inspections of educational institutions and hospitals in the United States, Sensai traveled through London and Paris to Berlin. This had been his destination since leaving Japan, and it was a place of great interest as he sought to deepen his understanding of medical education systems. In Berlin, Sensai was moved to see the scenes he had once learned from Dutch doctors like Pompe in Nagasaki during his studies in the late Edo period unfolding before his eyes. Furthermore, in Berlin, he not only deepened his understanding of medical education systems but also found the opportunity to become interested in the "health protection" promoted by the government.

Sensai focused on efforts for "health protection" indicated by terms such as Gesundheitspflege, Gesundheitswesen, and öffentliche Hygiene. He had also heard terms like "Health" and "Sanitary" during his previous investigations but did not initially understand them; however, after his stay in Berlin, he understood them to bring about similar effects. Sensai understood these administrative activities materialized in the West as efforts to encompass a "special administrative organization in charge of general public health protection" and to apply medical sciences and other academic disciplines "politically" in cooperation with local and police administrations. In the West, there was a mechanism for the government to be directly involved in the "health protection" of residents.

Regarding this as a "completely innovative project for which even the name does not yet exist in the East," he brought it back as a "souvenir" to Japan. Sensai argued that since the government's involvement in the health of residents was recognized in the West, which Japan used as a model, it was only natural for Japan to have such initiatives as well.

Upon returning from the Iwakura Mission's investigation, Sensai was appointed as the Director of the Medical Affairs Bureau of the Ministry of Education and began working on the enactment of a basic law for "health protection" modeled after the West. The result was the enactment of the "Medical System" (Isei) in 1874.

In enacting the "Medical System," Sensai pondered a word to express Western efforts like "Gesundheitspflege" and chose "Eisei" (Hygiene). In the process of reaching this, words like "Kenko" (Health) and "Hoken" (Health Preservation) initially came to mind, but he remembered the word "Eisei" appearing in a dialogue with Gengsang Chu in the Chinese classic "Zhuangzi." He examined the implications of this word himself and, although it was not identical to the original meaning, he liked it because the "characters looked elegant" and the "sound was not bad," so he selected it. Sensai designated the "health protection" he focused on in the West as "Eisei."

Following the enactment of the "Medical System," a policy was shown to promote "health protection" with the intent of the central government alongside local officials. Sensai confirmed the government's authority for this project within the "Medical System" and aimed to materialize his vision by exercising this authority.

The year after the "Medical System" was enacted, the administrative tasks regarding medical education within the system remained with the Ministry of Education, while tasks for "health protection," including infectious disease prevention, were transferred to the Ministry of Home Affairs, and Sensai continued to be involved.

Immediately after the transfer, "health protection" was handled by the "Seventh Bureau," but its name was soon changed to the "Sanitary Bureau" (Eisei-kyoku). Sensai, who had previously expressed "health protection" as "Eisei" when enacting the "Medical System," named the department the "Sanitary Bureau" because it was the department in charge of "health protection" affairs. Sensai then became the first Director of the Sanitary Bureau of the Ministry of Home Affairs to lead this new department. It was not until 1891 that Sensai was released from this responsibility, having led Japan's "health protection" for over 16 years. Sensai's efforts later came to be described as "The history of the Sanitary Bureau is the history of Nagayo Sensai."

Meanwhile, as Sensai was busy creating the mechanism for "health protection," a cholera epidemic struck the Sanitary Bureau of the Ministry of Home Affairs.

Cholera epidemics in the Meiji period began in 1877 and occurred intermittently thereafter in 1879, 1882, and 1886. In 1879 and 1886, more than 100,000 lives were lost. Thanks to the contributions of Robert Koch (1843–1910) and others who led German "laboratory medicine," it later became known that cholera was an infectious disease caused by cholera bacteria, but in the early 1880s, it had not yet been clarified why people contracted cholera. Consequently, people were in a panic, and rumors that doctors were the ones taking the lives of cholera patients led to some becoming victims of bamboo spears.

Following the cholera epidemic of 1877, Sensai and other officials of the Sanitary Bureau responded in a state of frantic confusion, but during the 1879 epidemic, they established an advisory body consisting of medical experts called the "Central Sanitary Board." In terms of administrative organization, the advisory body was organized as a staff organization. Sensai believed that the "health protection" he focused on in Berlin was the "political" application of medical sciences and other academic knowledge. To achieve this, policy formulation based on academic findings was required. Therefore, the "Central Sanitary Board" was expected to mediate between academia and policy as a staff organization.

The "Central Sanitary Board" was established in the summer of 1879, and by the end of that year, "Sanitary Sections" were established in prefectures and "Sanitary Committees" in towns and villages. This led to the formation of a line organization as a chain of command with the Sanitary Bureau of the Ministry of Home Affairs at the top.

With the preparations complete for this line organization and the staff organization seen in the "Central Sanitary Board" to interact, it became possible to turn medical sciences and other academic knowledge into policy and for the government to implement it, as Sensai had sought.

To increase the effectiveness of infectious disease prevention, Sensai hoped for the activities of the "Sanitary Committees," which could directly communicate the intentions of the Sanitary Bureau to residents regarding disinfection and hygiene. However, he did not stop there and also focused on the residents who were on the receiving end of the prevention measures promoted by the government. Thus, Sensai began activities to help residents accept "health protection" themselves. As a result, the Great Japan Private Sanitary Association was established in 1883.

Although the Great Japan Private Sanitary Association was labeled as "private," those who worked hard for its establishment and guided it toward realization were figures on the government side involved in the planning and implementation of infectious disease prevention measures, such as Sensai and other Ministry of Home Affairs bureaucrats, army and navy surgeons, and professors from the University of Tokyo School of Medicine. Local doctors and residents participated as members, aiming to increase the effectiveness of "health protection" by sharing hygiene information revealed at lectures and other events. The Great Japan Private Sanitary Association was a semi-governmental, semi-private organization.

Sensai stated that there are two approaches to promoting the health of residents: "Individual Hygiene" and "Public Health." The former refers to efforts seen in what was known as "Yojo" (health preservation) since before the Meiji period, while the latter refers to "health protection" such as infectious disease prevention implemented as "government laws," which Sensai focused on in the West.

When residents realize that their freedom is restricted by law, they try to avoid violating it. However, in infectious disease prevention, simply not violating the law was not enough; above all, it was necessary for the residents themselves to desire a long life without illness. For these reasons, expectations for the Great Japan Private Sanitary Association grew. This was because individuals who once understood the importance of "health protection" through discussions at the association were expected to contribute as "pioneers of society" by "educating those who are self-destructive."

Through the association, Sensai hoped to train local leaders and promote residents' understanding and cooperation in "health protection" by sharing hygiene information in the region. For Sensai, the establishment of the Great Japan Private Sanitary Association was an effort to stand on the "side of the people" and "kindly explain the logic and principles to awaken them from their delusions." In addition to the existing "official" efforts, Sensai aimed for "health protection" backed by the cooperation of both the government and the people by gaining the understanding and cooperation of the "private" sector.

In cholera countermeasures after 1877, the police were utilized in addition to officials from the Sanitary Bureau and local officials. The police also participated in the "Central Sanitary Board" established during the process of advancing cholera countermeasures. In response to this situation, Sensai stated that in promoting infectious disease prevention, involvement with police administration was necessary in addition to cooperation with local administration.

Sensai emphasized "academic movement" in "health protection." He hoped this movement would be understood by residents through doctors and municipal officials, but if that was not possible, he envisioned intervention based on the authority of the police rather than "leaving it entirely to autonomy."

On the other hand, the police had recognized their involvement in the health of residents as part of administrative policing since the first decade of the Meiji period. Therefore, when implementing infectious disease prevention, it was possible for the police to play a role in the line organization alongside the "Sanitary Sections" and "Sanitary Committees."

Thus, the police were a necessary element for the realization of "health protection" and were actually involved in the response. However, Sensai severely criticized situations where the police took the lead.

Once residents were confirmed to be patients, they were admitted to isolation wards called "hibyoin." The mortality rate for cholera was high, and many did not return alive. Consequently, residents feared the government's measures and chose to hide patients. If the police were to lead this isolation policy, it would be prompt from Sensai's perspective, but it led to an evaluation of being "stereotypical." While police-led infectious disease prevention emphasized the coercive and uniform aspects, it tended to neglect considering the circumstances of the patients, which Sensai saw as a factor that alienated the cooperation of residents.

Sensai's position of questioning this coercive and uniform response can also be confirmed in the issue of attaching disease name labels to patients' homes.

The 1880 Infectious Disease Prevention Regulations required attaching disease name labels to patients' homes, but because residents disliked it, the Dajokan (Grand Council of State) decided to stop attaching the labels in 1882. However, when cholera began to spread again from 1885 to 1886, the police, unable to manage the large number of patients, asked the Central Sanitary Board to allow the reinstatement of the labels. At that time, it was Sensai who opposed this police request. The reason was that if labels were attached, residents would dislike the government's measures and cooperation would not be obtained. Sensai allowed the attachment of labels from a realistic standpoint in large cities like Tokyo because of the high population and number of patients, but he argued it was unnecessary in rural areas where residential areas were more dispersed compared to cities. However, Sensai's position was not accepted, and the attachment of disease name labels was reinstated.

Furthermore, in 1885 and 1886, the "Prefectural Union Sanitary Board," which Sensai had created in consultation with local sanitary section chiefs, and the "Sanitary Committees," which were expected to deliver the government's intentions directly to residents, were abolished. On the other hand, a "Memorandum" for infectious disease prevention was created in 1886 that encouraged police intervention, and the involvement of the police in infectious disease prevention tasks was explicitly stated in the local government official system. Particularly in the 1886 "Memorandum," the "extermination" and "isolation" of infectious diseases through the authority of the police were strongly demanded.

In this way, following the cholera epidemics after 1877, the involvement of the police in infectious disease prevention was strengthened on one hand, while the involvement of the Sanitary Bureau of the Ministry of Home Affairs was reduced on the other.

Sensai did not intend to immediately exclude the police from infectious disease prevention. However, if the measures after 1886 were seen as being "handled solely by the police," emphasizing coercive and uniform aspects, it would become difficult to obtain the cooperation of residents who could not agree with this, and the promotion of cooperation between the "official" and "private" sectors that Sensai had hoped for through the establishment of the Great Japan Private Sanitary Association would become difficult. Looking back on this movement in later years, Sensai lamented it as the "Setback of '86."

With the issuance of the 1886 "Memorandum," police intervention was largely permitted at the site of cholera countermeasures. However, the following year, revisions were already being forced, and a policy of questioning the "awareness" of residents was adopted. This line of the revised 1886 "Memorandum" was confirmed and refined with the issuance of a new "Memorandum" in 1890.

The 1890 "Memorandum" called for the "sharing of roles" among doctors, residents, neighbors, sanitary officials, and police officers in infectious disease prevention. Through this revision, signs of liberation from the measures "left entirely to the hands of the police," which Sensai had worried about since 1886, began to appear.

As already seen, Sensai preached the necessity of "Public Health" in addition to "Individual Hygiene." In "Public Health," the role of the administration is required, but no matter how enthusiastically the "government offices" establish measures, residents will perceive infectious disease prevention as "government work," making it difficult to obtain their cooperation. Therefore, he expected the "awareness" of the residents themselves and called for "uniting and cooperating" while being conscious of their respective "boundaries" from the perspectives of the "official" and "private" sectors, also taking police intervention into account. The 1890 "Memorandum" was indeed in line with Sensai's vision.

Sensai's perspective on cooperation between the "official" and "private" sectors was also incorporated into water supply projects.

While Sensai worked energetically on the enactment of basic laws for "health protection," including infectious disease prevention, and the formation of central-local relations, he did not often touch upon the specific details. However, he was enthusiastic about "sanitary engineering," namely the spread of water supply and sewage systems. The results can be seen in the laying of the Kanda Sewers in 1883 and the enactment of the Waterworks Ordinance in 1890. The former is remembered as the first culvert built by Japanese people. The latter was realized as Sensai's efforts to spread waterworks in Tokyo as part of the Tokyo City Improvement Project after 1887 were evaluated alongside efforts in Osaka and elsewhere. Since the fact that residents became patients through water contaminated with cholera bacteria was seen as a problem, Sensai positioned "sanitary engineering" as the "fundamental basis" of infectious disease prevention.

In the Waterworks Ordinance, a new basic law for waterworks enacted as one of the results of Sensai's efforts, not only the responsibilities of the "official" sector in laying waterworks but also the roles played by the "private" sector were clearly stated. While residents could demand management of water quality and quantity from the "official" sector, the water supply equipment inside houses and the small pipes for connecting to the mains were the responsibility of the "private" sector. It was planned here that the water supply project would also bring about effects through the government and the people each fulfilling their roles.

In Japan's "health protection," including infectious disease prevention since the modern era, one can see Sensai's efforts and results everywhere, as he sought cooperation between the "official" and "private" sectors to advance the "political application" of medical sciences and other academic knowledge.