[Special Feature: Infectious Diseases in History] Takagi Tomoe, the Father of Medical Hygiene in Taiwan, and His Countermeasures Against Infectious Diseases

On April 17, 1895 (Meiji 28), the Treaty of Shimonoseki was signed by Japanese plenipotentiaries Ito Hirobumi and Mutsu Munemitsu and Qing plenipotentiary Li Hongzhang, resulting in Japan's possession of Taiwan. For Japan, Taiwan was its first colony. However, the early management of the colony was by no means smooth sailing. This was because Japan not only encountered fierce armed resistance from the Taiwanese residents but also had to respond to severe sanitary conditions and the resulting damage from infectious and endemic diseases.

In fact, the Japanese army that landed in Taiwan in 1895 suffered disastrously from malaria everywhere. From the time Japan took possession of Taiwan until the early Taisho era, the disease that caused the most deaths in Taiwan was malaria, with approximately 10,000 deaths every year. For the Government-General of Taiwan, how to improve the sanitary conditions in Taiwan and eradicate infectious and endemic diseases became an urgent issue. In this context, an important role was played by Takagi Tomoe, who was later called the father of medical hygiene in Taiwan.

In this article, I would like to examine the role of Takagi Tomoe in Taiwan's medical hygiene from three perspectives: the philosophy of medical hygiene, the development of medical and health institutions, and the prevention and eradication of infectious and endemic diseases.

Takagi Tomoe was born in 1858 (Ansei 5) in Matsugoya Village (now Iwaki City, Fukushima Prefecture) in the domain of Honda Etchu-no-kami in Oshu, as the second son of nine siblings. To study medical sciences, he went to Tokyo and studied at Ogata Koreyoshi's Tekijuku (Tokyo Tekijuku, which existed in Kanda Surugadai from 1872 to 1878) and the Police Medical School before transferring to Daigaku Toko (the East School of the University). There, he received instruction in German from hired German medical teachers such as Baelz and Scriba. After graduating from the University of Tokyo School of Medicine in 1885, he became the director of Fukui Prefectural Hospital and later the director of Kagoshima Hospital. In 1892, Kitasato Shibasaburo opened the Institute for Study of Infectious Diseases (hereinafter "ISID") with the support of Fukuzawa Yukichi. The following year, Takagi, who looked up to Kitasato as his mentor, resigned from his position as hospital director and began working as an assistant at the ISID. When the plague broke out in Hong Kong in 1894, at Takagi's suggestion, the Japanese government dispatched Kitasato and Aoyama Tanemichi, an assistant at the University of Tokyo School of Medicine, to Hong Kong. Kitasato discovered the plague bacillus there, but Aoyama contracted the plague. Because Fukuzawa Yukichi was concerned that Kitasato might also become infected, Takagi went to Hong Kong to replace Kitasato and nurse Aoyama.

After returning to Japan, Takagi became the head of the treatment department at the ISID, and in 1896, he concurrently served as a technical official of the Ministry of Home Affairs (his superior was Goto Shinpei) and the director of the Serum Institute. After the end of the Sino-Japanese War, as Goto Shinpei's right-hand man, Takagi was in charge of the isolation, accommodation, and treatment of soldiers suffering from cholera at the Ninoshima Temporary Army Quarantine Station in Hiroshima. Due to the results of that quarantine, Goto Shinpei was highly evaluated by Kodama Gentaro, who was then the Vice Minister of War, and was scouted as the Director of the Health Bureau of the Ministry of Home Affairs. Meanwhile, Takagi studied abroad in Berlin, Germany, for two years starting in 1897, investigating and researching the health systems of various European countries. After returning to Japan, he returned to the ISID, but in 1900, he was appointed as the head of the Infectious Disease Prevention Section of the Health Bureau of the Ministry of Home Affairs, where he demonstrated his true ability in eradicating the plague in the Hanshin area.

The reason Takagi was able to be active in Taiwan later was that he had knowledge of bacteriology learned at the ISID and in Germany. The various tasks he performed after becoming the head of the Health Section of the Government-General show that bacteriological theory was the main axis of the development of medical sciences in Taiwan.

When Kodama Gentaro became the 4th Governor-General of Taiwan in 1898, he appointed Goto Shinpei as the Director of the Civil Administration Bureau of the Government-General of Taiwan (later renamed Civil Governor). Then, in 1902, Goto called Takagi to Taiwan.

Takagi Tomoe took up his post in Taiwan in April 1902 and stayed in Taiwan for over 27 years until returning to Japan in August 1929 (Showa 4). During that time, from 1902 to 1919, Takagi successively held positions such as Engineer of the Government-General of Taiwan, Director of the Government-General Hospital, Principal of the Government-General Medical School, Head of the Taiwan Branch of the Japanese Red Cross, Temporary Head of the Quarantine Section of the Government-General, Head of the Health Section, and Director of the Government-General Research Centers and Institutes, playing a major role in the development of medical sciences and hygiene in Taiwan. Takagi himself summarized these 18 years as "belonging to the most active period."

As is well known, after the Meiji Restoration, Japan used German medicine as a model, introduced Western standards, and built a medical system according to its own needs. At that time, Japan introduced not only the German medical system but also concepts such as social hygiene, racial hygiene, and state medicine. These concepts constituted the ideological elements of Japan's colonial medicine. After Japan took possession of Taiwan, it tried to transplant the concept of public health to Taiwan as well.

Before taking up his post in Taiwan, Takagi Tomoe already had an interest in Taiwan's health issues. In 1896, he published a paper titled "The Opium Problem in the New Territory" in the "Journal of the Private Sanitary Association of Japan," advocating that "a health bureau with the same authority as the civil administration and the army and navy bureaus should be established, with a doctor of both talent and learning as its head, to greatly expand the health administration."

In April 1910, Takagi stated the following in the preface to the book "Sanitary Conditions in Taiwan":

"When the various nations manage their colonies, they first propagate religion to strive to lead the people into the realm of civilization. When the Empire governs its colonies, it replaces religion with medical arts to let the people witness and experience the blessings of civilization firsthand."

Unlike the Western powers, Japan focused on the spread of medical arts instead of religion in Taiwan.

(1) The Role of the Government-General Medical School

Civil administration was established in Taiwan in April 1896 (Meiji 29), and Goto Shinpei, who was then the Director of the Health Bureau of the Ministry of Home Affairs, was commissioned as a health advisor to the Government-General of Taiwan. At Goto's suggestion, a doctor training center was established within the Taihoku Hospital in March 1897, gathering dozens of Taiwanese youths who understood Japanese to teach them general studies and the basics of medical sciences.

On March 31, 1899, the official regulations for the Government-General Medical School were promulgated, and on April 1, Yamaguchi Hidetaka, the Director of Taihoku Hospital, concurrently became the principal.

In March 1902, Takagi was appointed as the second principal of the medical school and served for 13 years until his retirement in March 1915. At that time in Taiwan, there was no concept of modern medical hygiene, the treatment of doctors was not good, and because it took five years to graduate, recruiting students was quite difficult. Therefore, Takagi personally went to Taichu, Tainan, Taito, and other places to conduct entrance examinations. As a result, after 1905, the number of young people wishing to enter the medical school gradually increased, and competition became fierce.

In operating the medical school, Takagi mainly focused his efforts on the following three aspects. First, because there was a tendency for graduates of Tokyo Imperial University to be reluctant to take up posts in the colonies at that time, he invited excellent graduates from the Kyoto Imperial University School of Medicine and other institutions as teachers. Second, he established a system for medical school teachers to study in Germany for three years to obtain a Ph.D. in Medicine, aiming to cultivate excellent human resources. Third, Takagi himself took charge of lectures on physiological hygiene and also lectured on ethics and moral training. At every year's graduation ceremony, Takagi always gave the students the instruction, "Become a human being before becoming a doctor," striving to improve their morals as physicians.

Takagi tried to spread knowledge about infectious diseases through the students of the medical school. He occasionally held lecture meetings with an interpreter to lecture on the dangers of infectious diseases. Takagi recognized that because of the medical school, even if the students did not become doctors after graduation, they could inform the general public about the dangers of epidemic diseases, the relationship between malaria and mosquitoes, and the relationship between the plague and rats.

At that time, medical school students were supposed to do their practical training at Taihoku Hospital. However, Taihoku Hospital was far from the medical school, and Japanese patients did not have very good feelings about practical training by Taiwanese students. Therefore, Takagi built a new Japan Red Cross Taiwan Branch Hospital on the medical school grounds, and from February 1905, it began to be used as the practical training hospital for the medical school.

At that time, the use of the Taiwanese language was prohibited at the National Language (Japanese) School. However, the use of Taiwanese was permitted at the medical school. Furthermore, when Takagi gave instructions to the students, he always spoke to them as a father would to his son, so he was highly respected by both teachers and students.

In April 1919 (Taisho 8), the medical school was renamed the "Government-General Medical College," and medical education in Taiwan entered a new stage. By 1919, the medical school had trained 544 Taiwanese doctors. Many Taiwanese doctors opened independent practices and became the main force of modern medicine in Taiwan. Not only that, many Taiwanese doctors were elected as heads of credit unions, members of state and city street councils, and members of the Government-General Council, becoming leaders in Taiwanese society.

(2) Establishment of the Government-General Research Centers and Institutes

In March 1896, the Government-General established a pharmaceutical factory. As part of the work of the inspection department of the factory, water quality tests and various chemical experiments for hygiene were conducted. Later, scientific tests for industry related to plants, agriculture, and industry, as well as experiments on medical drugs, also came to be performed. In May 1901, the Government-General Monopoly Bureau was newly established, and the work of the pharmaceutical factory was taken over by the Monopoly Bureau. However, the equipment at that time was extremely crude and was by no means capable of conducting experimental research. The situation was similar for the ore analysis of the Mining Section of the Bureau of Productive Industries and the laboratories of the hospitals and medical schools. Because there was no gas equipment, alcohol lamps were used, and because there was no running water, pressurized water could not be used.

In view of such a situation, Takagi proposed the establishment of a research institute to Goto Shinpei and steadily made preparations. In 1906, Takagi concurrently became the head of the Certification Section of the Government-General Monopoly Bureau. With the support of the Director of the Monopoly Bureau, Nakamura Yoshikoto, surplus funds from the factory construction costs were allocated to the construction costs of the research institute. Also, at the Imperial Diet in the spring of 1906, he was able to obtain a subsidy of 550,000 yen as a continuous project for five years starting from fiscal 1907.

In April 1909, the Government-General Research Centers and Institutes were established, and Takagi concurrently became the first Director. The Government-General Research Centers and Institutes consisted of three departments: the Director's office, the Chemistry Department, and the Health Department. According to Takagi, at first, even high-ranking officials of the Government-General viewed the research institute as a nuisance. It was only after Civil Governor Uchida Kakichi took office in August 1910 that it was finally recognized that "this very institution is the most necessary for the development of civilization on this island."

In March 1915, Takagi stepped down as the principal of the medical school and began to focus on being the Director of the Government-General Research Centers and Institutes. In December 1916, the research institute was reorganized, and in addition to the Chemistry and Health Departments, the Brewing Department, Animal Department, and General Affairs Department were established. The research institute was mainly in charge of (1) matters concerning research, investigation, and testing for production and hygiene, (2) the manufacture and distribution of yeast and other bacterial materials for production, and (3) the manufacture and distribution of serum and other bacteriological preventive and therapeutic products.

The Government-General Research Centers and Institutes researched almost everything related to production and hygiene in Taiwan without omission and strove to provide materials that were clear at a glance to the public. As a result, it made great contributions to society in the fields of applied chemistry, brewing, and tropical hygiene. At that time, the Government-General Research Centers and Institutes were manufacturing vaccines for cholera and influenza, and if they had been sold at market prices, they would have been enough to cover more than a year's expenses for the research institute.

Takagi not only put effort into the operation of the medical school and the research institute but also into the operation of academic societies. In August 1902, the Formosan Medical Association was established, and Takagi was elected as its president. In September of the same year, the first issue of the "Journal of the Formosan Medical Association" was published, providing a platform for medical research in Taiwan. That "Journal of the Formosan Medical Association" continues to be published today.

In October 1896, the Government-General of Taiwan issued the "Infectious Disease Prevention Regulations," designating cholera, plague, dysentery, smallpox, typhus, typhoid fever, diphtheria, and scarlet fever as infectious diseases. In addition, endemic diseases such as malaria and beriberi were also frequent. Among them, the ones that raged most fiercely were the plague and malaria.

(1) Eradication of the Plague

The Government-General of Taiwan established the Taiwan Endemic and Infectious Disease Investigation Committee in October 1899 to proceed with research and investigation into the prevention and eradication of infectious and endemic diseases, as well as the treatment of opium smokers. Among these, the prevention of the plague is said to be the first step in the health business in Taiwan. Takagi was appointed as a member of the committee in August 1902 and as its secretary in July 1904.

According to Takagi, when he first took up his post, more than 100 dead plague rats were left every morning in the vacant lot of the new office building, which was truly a "miserable sight." In the vicinity of the official residence where Takagi lived, plague patients appeared every year. In 1904 in particular, the number of plague patients rose to 4,500, of which the number of deaths reached 3,374.

Takagi cited the following six points as the causes of the plague epidemic in Taiwan. (1) The plague broke out in Taiwan in 1896, but because bandits were rampant in various places at that time, the police had no room to think about hygiene. (2) Taiwanese houses and streets were extremely filthy, narrow, and dark, making them suitable for the spread of the plague. (3) The Taiwanese people did not know that the plague was an infectious disease and thought it was a curse from gods or Buddhas. (4) Not only the Taiwanese but also many of the Japanese in Taiwan lacked knowledge about the plague. (5) Because the authorities or police officers could not communicate with the Taiwanese people, misunderstandings often arose between the two sides, hindering epidemic prevention measures. (6) Many of the authorities and police officers had no experience in plague prevention.

In October 1903, it was decided to establish a Temporary Epidemic Prevention Section in the Police Headquarters of the Civil Affairs Department of the Government-General, and Takagi was appointed as its head. The countermeasures Takagi hammered out were the demolition of old-style houses where the plague was likely to occur and the extermination of rats. By 1912, a total of 4,876 houses had been demolished, and by August 1919, 41,923,644 rats had been captured. As a result, the plague virus was finally eradicated. For this reason, on June 12, 1920, Takagi was awarded the Grand Cordon of the Order of the Rising Sun by Emperor Taisho.

The eradication of the plague improved the sanitary environment in Taiwan and promoted the modernization of Taiwanese society. It is said that this established the credibility of Japan's colonial rule in Taiwan.

(2) Malaria Prevention

Originally, the Taiwanese called malaria "cold-heat disease," and the indigenous people called it "susori-san," regarding it as something that could not be eradicated.

According to Takagi, at that time, construction of the Miaoli-Taichu longitudinal railway was underway, but due to the influence of malaria, all employees from engineers down contracted the disease on three occasions, making work impossible. In one barracks, there was a situation where only eight men in a battalion were standing with rifles.

When Koike Masanao, the Director of the Medical Affairs Bureau of the Ministry of War, inspected Taiwan in September 1901, he proposed mosquito prevention methods, which were immediately implemented and were quite effective within the army. However, similar methods were tried at factories and other places but did not work well. This was because the Japanese army was orderly and strictly disciplined, but the Taiwanese residents at that time could not be forced to live like the army.

In view of such a situation, in 1910, Takagi advocated the implementation of systematic malaria prevention measures and submitted a report. From that year, experimental prevention methods were implemented in Hokuto, Taihoku Prefecture, and from the following year in several places such as Ako Prefecture and Hozan Prefecture. Based on those results, the "Malaria Prevention Regulations" and the "Enforcement Regulations" for the same were enacted in April 1913. The main points of the regulations were, first, the extermination of Anopheles mosquitoes, which act as the medium of transmission, and second, the treatment of malaria patients or parasite carriers until they were completely cured. As a method for this, major malaria epidemic areas were designated as malaria prevention areas, and residents within those areas were subjected to medical examinations and blood tests, and parasite carriers were forced to take medication free of charge. At the same time, the filling in of ponds and reservoirs, the installation of drainage ditches, and the clearing of bushes were carried out.

Malaria prevention stations were established in malaria prevention areas. The Government-General dispatched medical officers and held training sessions to impart knowledge related to prevention. As a result, the malaria mortality rate is said to have peaked in 1915 and decreased thereafter. However, malaria could not be eradicated during the period of Japanese colonial rule, and it was finally eradicated only in 1965. This tells the story of how difficult the eradication of malaria was.

Today, in Taiwan, the achievements in medical hygiene are evaluated as the most excellent in Japan's colonial administration. In fact, after 1920, "health" and "hygiene" became common terms in Taiwanese society. As of 1921, the birth rate in Taiwan reached 43.2 per 1,000 people. Meanwhile, as of 1923, the mortality rate was 21.6, reaching its lowest level since 1906. This is, needless to say, closely related to the improvement of the medical and health environment in Taiwan and is the result of the tireless efforts of Takagi Tomoe and others. Therefore, Tu Tsung-ming, Takagi's student and Taiwan's first Ph.D. in Medicine, highly evaluates Takagi Tomoe as Taiwan's "Governor-General of Hygiene" and the "father of medical hygiene."