Introduction
Historians have made great contributions to the study of state and public health in Chinese cities in the early 1900s. Ruth Rogaski has studied Tianjin and described how residents who had previously used the convenience of open fields were forced at gunpoint to defecate in public toilets constructed by the authorities.Footnote 1 Kristin Stapleton has showed how the Chengdu authorities moved slaughterhouses outside the city walls, banned the cleaning of rice and clothing right next to wells and ordered people to stop feeding pigs in the streets.Footnote 2 Others who have studied public health have focused on Shanghai, Beijing, Nanjing and Guangzhou.Footnote 3 These scholars have documented and demonstrated how state intervention in health issues – central to reform movements of the Euro-American urban landscape in the nineteenth century – made its way to China in the late Qing dynasty through European imperial expansion.
While most related studies have focused on foreign concessions or big cities, many in the Qing dynasty and the early Republican period, this article examines the case of the urban areas in a south Chinese county under Nationalist rule (1929–49). When the Nationalist government came to power and made Nanjing the capital in 1928, their nation-building policies involved a comprehensive, nationwide health care system. The Nationalist theory was that the country needed a physically strong populace to carry out national protection and reconstruction. By then, hospitals, toilet and garbage matters, drainage and sewage systems and so on were no longer solely a concern for big cities, but also for smaller towns. Alongside large-scale and costly infrastructure works, Nanjing required that county governments take on the role of moulding the people into a health-conscious public by providing intensive education and surveillance. However, unlike cities under colonial rule or other big cities that were heavily supported and educated by foreign and local public health experts, county governments had to implement these programmes in their own ways. They had to reformulate or sometimes even reinvent public health implementation methods. They also found themselves dealing with subtle and unexpected administrative and practicability problems.
This article focuses on the most controversial issues in urban public health in Shiqi, the county capital of Zhongshan: the imposition of sanitary regulations and campaigns and the state provision of western medicine. Zhongshan is located in the west of the Pearl River Delta, south of Guangzhou and north of Macau. Xiangshan was the county's original name, translated as ‘fragrant mountain’, before it was renamed Zhongshan in 1925 in honour of Sun Yat-sen, who often went by the name Sun Zhongshan. At the time, the county contained over 1.1 million people of which 20,000 resided in its six towns including Shiqi, the county capital, 10,000 were overseas while the rest lived in 391 villages.Footnote 4 Most overseas workers supported Zhongshan through remittances, and some even brought to their hometowns medical technology and other knowledge.
In 1929, the Nationalist government celebrated Zhongshan as a model county and put it directly under Nanjing's jurisdiction.Footnote 5 The promulgation of the county provoked conscious efforts on the part of local authorities to reform the county. However, the two aforementioned issues related to public health reveal how Zhongshan hastily entered into the race for modernity without proper long-term urban planning, not to mention planning for rural areas. Ultimately, as this article will demonstrate, the local authorities found themselves caught between Nanjing's pressure to reform and state–society tension resulting from hastily planned reform programmes.
The propaganda activities: ‘let's raise the international status of our country’
With the proclamation of model county status, Zhongshan authorities formulated a list of public health-related project plans: to establish public hospitals and a hospital for lepers, to build waterworks in order that the entire county should eventually be supplied with tap water, to construct markets so as to avoid hawkers occupying the streets and to build public parks and sports stadiums where residents could exercise and compete.Footnote 6 Thus far, plans were in place. However, the government, while striving to modernize the county, had a list of infrastructural projects to finance. Not surprisingly, a sound economy was their priority. Only a small portion of the government's fiscal budget was allocated to public health funding. This was spent on street cleaning. No other money was available for public health infrastructure development.Footnote 7 Most of these essential public health-related facilities were not to be found even 17 years later. There were no projects to ensure clean drinking water or any waterworks system, and there were no public toilets of a sufficient standard. Although the local government had begun the registration of pharmacies, doctors and other medical staff, there were no campaigns to clamp down on those who were unregistered.Footnote 8
To the local government, the failure to provide adequate public health facilities and medical care comparable to private institutions (to be examined in the final section) could discredit the model county and even threaten governmental authority. The ‘thorough cleaning campaign’, which served as mass education on personal and public sanitation, also proved an inexpensive means of consolidating power. In December 1928, Nanjing established the Ministry of Health and, together with the national constitution, formulated the ‘public health strategy’, ideally to ‘ensure better health of the people and provide health care and state medicine’.Footnote 9 Nanjing announced a nationwide ‘movement for hygiene’ (weisheng yundong) that consisted of two thorough cleaning campaigns: the summer campaign to take place in mid-May each year, and the winter campaign in mid-December.Footnote 10 Zhongshan followed suit. The county magistrate, backed with the authority of Nanjing and the local government, organized thorough cleaning campaigns in Shiqi.
Shiqi lies at the centre of Zhongshan county, on the west side of a bend in the Shiqi River, which drains creeks that run from Guangzhou in the north, connecting to the West River running down to Macao in the south. With the introduction of steamboats, Shiqi grew rapidly into a market town and by the 1940s, this town of 244 km2 in size had a population of 85,200 people.Footnote 11 Shiqi only had a handful of factories and ricemills but maintained a bustling commercial presence, rice-trading being the most important factor. A web of 13 market streets spread from the wharves of Shiqi River towards the government district in the east and then out to residential areas in all directions. In the 13 streets, the only streets in Shiqi paved with concrete in the 1930s, people lived and worked in the same place and these shophouses – home and business in one structure – filled the two sides of the streets. There were hotels, restaurants and a large number of native banks.Footnote 12
Despite having a long history in local and foreign trade and much experience in western medication, the thorough cleaning campaign was new to Shiqi. It may be difficult for readers to understand how the Chinese of the period regarded sanitation practices as an ‘invented problem’, as Xu Yamin states: ‘The perpetrators of all the condemned “wicked” forms of conduct, such as litterbugs and street-corner urinators, were all new offenders that could not be found, say, in the Qing legal code.’Footnote 13 In Zhongshan, as almost anywhere in China, such conduct had existed, but was never a problem until the local government repeatedly issued regulations, and until newspapers and periodicals joined in the criticism of unhygienic practices. The rest of this section looks at how residents, who were suddenly ordered to regard such ancient and ordinary behaviour as offences, reacted to the state's demand for the mandatory thorough cleaning campaign. Furthermore, under the name of the ‘movement for hygiene’, the new public health regimen entered into the lives of residents, as officers policed people in relation to cleaning their houses, imposing punishments on those who kept dirty premises. From the authorities’ point of view, searching each and every house was the best way to break down barriers that hid unsanitary habits, a belief that existed in nineteenth-century Great Britain and now was brought to China.Footnote 14 How did the residents in Shiqi take such surveillance? Did they open their doors to the police? What implications do the answers to these questions have regarding the state–society relationship?
When the British first introduced to China the idea that the state should take care of public health issues, and even penetrate into the private life of the populace, the Qing authorities were displeased. Viceroy Li Hongzhang, for instance, was most shocked to learn that the Chinese were ‘suffocated’ with sulphur gas, which was a method used by the British government in Hong Kong to fight the plague epidemic there in 1894.Footnote 15 By the 1930s, the government's concept of interference in people's lives had completely changed. The government began to centralize standards of character development. Schools were one of the areas targeted to implement rules of individual behaviour that were based on hygiene, cleanliness, timeliness and propriety.Footnote 16 Outside schools, the appearance of new regulations suggests that the government believed effective surveillance was necessary to keep places clean and people healthy. The official searching and inspection of private facilities by public officers became a legally approved policy. Parallel to the ‘movement for hygiene’, in 1928, the state announced the ‘Regulation on Cleaning up of Filth’ (Wuwu saochu tiaoli). Article Six of the Regulation stated that health inspectors were permitted to enter private land and houses to inspect sanitary conditions.Footnote 17
In Zhongshan, the earliest lengthy description of the thorough cleaning campaign was connected to the New Life Movement, when public health issues became prominent. Inspired by the Movement, Magistrate Yang Ziyi (1878–1953) initiated a five-day thorough cleaning campaign in Shiqi in the summer of 1935.Footnote 18 Magistrate Yang, educated in Germany in the early Republican period, issued precise orders to shop owners and residents in Shiqi: all interior floors, walls and furniture had to be cleaned, and garbage had to be put outside the entrance, to be collected by street cleaners. Yang went even further than the requirements issued by Nanjing. He ordered residents to take their pillows, mattresses, clothes and books to be aired in the sunlight. Residents whose items were found not to be clean and tidy were fined.Footnote 19 No information was found regarding the results of the 1935 campaign but one could imagine that mobilizing the entire town, that is, 85,200 people, to air their belongings in open spaces required much state–society co-ordination.
Although the campaigns were not as frequently held as had been prescribed, they persisted even during the Second Sino-Japanese War. There was one campaign in June 1938 and another in December 1939.Footnote 20 After Shiqi and most of Zhongshan fell to the Japanese in March 1940, thorough cleaning campaigns took place in Xiaolan, a town under Nationalist rule.Footnote 21 The persistence of the campaign during the war suggests some degree of enthusiasm on the part of the local government to keep public spaces clean. Soon after the war ended, these campaigns fully resumed, first in Xiaolan and, by June 1946, in Shiqi again.Footnote 22
More efforts were put into propaganda activities.Footnote 23 During the summer campaign in 1947, Magistrate Sun Qian and other officials wrote newspaper articles which claimed: ‘unclean habits are uncivilized. . .and sound public health can revive nationhood and let's raise the international status of our country’.Footnote 24 There were other reminders too: ‘Zhongshan is a model county which used to be well known for its clean streets, but these few years street cleaning efforts were curbed by the government's budget. Now, everyone should cooperate with the Health Department which is putting great effort into the county's public health improvements.’Footnote 25 No information, archival or contemporary, supports the magistrate's claim that Zhongshan had been well known for clean streets. In any case, Magistrate Sun, the same aggressive person who had attempted to confiscate Qiaoli Hospital (see final section) once again assured Nanjing that he was in line with the state's practice of associating hygiene with civilization and with the modernization of the country. By expressing these beliefs, the magistrate was carrying out civic education and at the same time reminding the public of state legitimacy to impose controls on people's behaviour.
Indeed, inspectors made their way into private premises without difficulties. All residents opened their doors. Officers found the results of the 1947 campaign to be generally satisfactory.Footnote 26 We do not know the number of shops and houses that were inspected, but we know 162 of them did not fulfil the sanitation standard. The owners of these shops and houses accepted punishment; 35 of them were sentenced to one day of hard labour and the rest paid a fine. From this particular inspection, the Health Department collected 885,000 yuan, which was used to pay for street-cleaning expenses, including wages paid to street cleaners, and for purchasing garbage carts.Footnote 27 The winter campaign of 1947 identified improvements: only 100 shops and houses were not up to the required standard of cleanliness.Footnote 28 Not only were residents participating in the campaign, but the large number of prosecutions tells us that inspectors and volunteers were also doing their job.
During the 1930s and the 1940s, the imposition of these campaigns was probably the least costly gesture necessary for the state to maintain its authority in public health management. The campaigns cleverly enabled the police forces to mobilize school students and volunteers to make residents responsible for their own household hygiene. By sending officials into houses to inspect their sanitary conditions, the authorities were regulating the private lives of the people. These campaigns did not encounter resistance; the authorities successfully went into houses and made prosecutions.
However, this lack of resistance does not suggest that all Shiqi residents were enthusiastic about complying with the authorities. The success of the campaigns was more likely a result of their intermittent occurrence and the limited alteration to everyday life as a result of government regulations. The truth is that residents were making last-minute preparations for the campaigns: during the summer campaign of 1948, a newspaper article claimed that most people edged in to clean up only before the summer heat arrived and infectious diseases became widespread. The newspaper article also suggested that the campaigns should take place more often, such as, during every season.Footnote 29 After all, the thorough cleaning campaign was a component of civic education and its success required much more long-term effort from the government's side.
Finally, it should be remembered that the effectiveness of the campaign, if any, was limited to Shiqi. The same newspaper article suggested to the authorities that campaigns should be organized in all towns and villages and not only in the county capital.Footnote 30 However, county-wide cleaning campaigns were constrained by great variation in population density. Unlike big cities such as Guangzhou and Shanghai, where residents were clustered together, Zhongshan's 391 villages were scattered over an area of 22,457 km2 and that made co-ordination difficult. The county government structure also limited the size of the campaign. In Shanghai, the Health Bureau and the Municipal Office organized cleaning campaigns, and the ‘movement for hygiene’ advanced easily.Footnote 31 Unlike Shanghai, Zhongshan had only the Public Health Department (under the Police Bureau and without extra staff) to rely on. It was the responsibility of the policemen to arrange campaigns but Zhongshan had a little over 1,000 policemen in the 1920s and 1930s.Footnote 32 This size of the police force was very small when compared to Guangzhou's 4,000 policemen for a similar population size.Footnote 33 With inadequate numbers of policemen and a scattered population, it would have been impossible for Zhongshan to mobilize all the villages, some with thousands of residents, to participate in the campaigns.
Limits to government intervention: the mismatched state provision and residents’ sanitary needs
Municipal surveillance during the thorough cleaning campaign encouraged residents in Shiqi and some other towns to clean their houses, but the campaign proved ineffective in maintaining everyday cleanliness in public space. Residents in Shiqi co-operated well in the thorough cleaning campaigns which were organized but infrequent periodic events. However, the Zhongshanese resented forced changes in their everyday household routine. As in the case of colonial Singapore, discussed by Brenda Yeoh, many Zhongshanese too were ‘capable of knowledgeable and at times skilled strategies to prevent control over their daily practices and management of the environment from being totally wrested from them’.Footnote 34 In Shiqi, residents did not actively challenge the imposition of sanitary regulations, but by quiet non-compliance and non-cooperation many of them were able to escape the daily interference associated with the sanitary regulations, an attitude which was different from that found during the cleaning campaigns.
As early as 1925, the authorities already produced wooden garbage bins to be placed in the streets of Shiqi. However, many of these bins were either maliciously damaged or were stolen.Footnote 35 No information can be found about whether broken and lost garbage bins were replaced until 1947, when they were once again produced and placed in the streets in Shiqi. Since standard surcharges for street cleaning were minimal, the authorities had to find other ways to finance these garbage bins. In August 1947, the Police Bureau organized four Cantonese opera performances to raise funds. They raised 39 million yuan. With nationwide hyperinflation taking place, this sum of money was only enough to produce 60 wooden garbage bins that were four cubic feet in size.Footnote 36
Needless to say, 60 garbage bins had a limited effect in keeping Shiqi clean. In May 1946, some Shiqi policemen reported to the police chief that the road along the Shiqi Creek, where many retail shops were located, was filled with garbage. The policemen issued warnings to these retailers, and ordered them to throw garbage in their own garbage bins and to empty them in garbage carts each day when they were driven past.Footnote 37 Needless to say, these policemen's interventions did not work. The authorities received many more complaints about littering. In March 1947, some shop owners wrote a letter to the Health Department complaining that the problem of accumulated debris was becoming critical: garbage was forming little hills at the corners of many streets. The shop owners urged the authorities to take the matter seriously.Footnote 38 In May 1948, the head of Zhongshan County Library complained to the police chief that residents in the neighbourhood were disposing of garbage in the streets. The Library urged the police department to request that these residents clean the streets and also put ‘no littering’ signs in the streets near the library.Footnote 39 Towards the end of the Republican era, similar complaints continued to be made. In April 1949, the ‘Zhongshan School for Teachers’ (Zhongshan shifan xuexiao) in Shiqi complained to the Police Bureau about retail shops near the school ignoring sanitation orders and throwing garbage as they liked.Footnote 40
Sanitary-related complaints did not mention that people were using the streets as public conveniences, but with the limited number of public toilets, it would not have been surprising to find urine and human excrement in alleys. There were six public toilets in Shiqi, constructed in 1936 during Tang Xiaoyi's reign. These toilets were thoughtfully located near temples, markets and the piers along Shiqi Creek, where they would be most needed.Footnote 41 However, they were not properly maintained and never renovated. By the late 1940s, they were too dirty and malodorous to be used, and they eventually had to be demolished. Magistrate Sun Qian planned to tear down these old toilets and build new ones, but the budget was not sufficient to remove even a single toilet.Footnote 42 The unusable toilets, together with Sun's reminder to policemen to keep an eye on people who littered, spat or relieved themselves in the streets, suggest that urine and human excrement contributed to street dirtiness.Footnote 43
The aforementioned complaints made by the library, the school and so on show that some Zhongshanese were conscious of public health issues. They believed that government surveillance was necessary to keep places clean. Xu Yamin tells us that ‘when Beijing's residents refused to obey public sanitation regulations and continually ignored “public morals” by dumping garbage on the streets and urinating at neighbourhood corners, they were concerned the government was creating a social base for the rise of an “authoritarian” state power, which increasingly relied upon the police force to rule the streets and neighbourhood’.Footnote 44 In Zhongshan, with its littering problem, there was a social base for ‘authoritarian’ state power: more importantly, some Zhongshanese had actually invited such state power. However, looked at from another point of view, these Zhongshanese who were utilizing their right to request services from their civil servants were practising their rights as citizens. These Zhongshanese were more concerned with whether the government was able to keep their neighbourhood clean than with the state's authoritarianism.
During this period, Shiqi residents were also polluting the river. Without easy access to proper garbage disposal, dumping refuse into the river was the most convenient way, if not the only way, to get rid of their garbage. In 1932, the authorities noticed the seriousness of the problem and passed a regulation to forbid residents from polluting the river.Footnote 45 However, the regulation did not bring about improvements. In 1947, the river and dyke maintenance committee complained to the police chief that retailers along the creek and people on boats were throwing a lot of garbage into the water. In response to the complaints, policemen were sent to warn the litterers.Footnote 46 It should be remembered that the shop-lined riverbank was two kilometres long with over 200 shop-houses, and in addition there were numerous boats stationed at, and passing along, the river.Footnote 47 Thus, potential litterers were numerous. Regulating the cleanliness of the river through surveillance was almost impossible. Only through residents’ self-discipline and their awareness of environmental health could they keep the river clean. Littering problems on the highways were the same: the authorities found that Shiqi residents were also disposing of broken tiles and other garbage along the highways, to the extent of blocking the traffic.Footnote 48 All these examples show that the Shiqi authorities did not have waste management under control.
One would also expect that the sanitary conditions in Huangpu, the town that carried out a thorough cleaning campaign during the Second Sino-Japanese War, remained poor. Residents were disposing of garbage freely in the streets.Footnote 49 One morning in February 1946, a mother and her daughter caught littering were taken to the police station. As a punishment, they were asked to sweep the streets for one day.Footnote 50 Some shopkeepers threw garbage including leftover food into the streets and a labourer disposed of pigs’ excrement in a neighbour's pond. These shopkeepers were also punished by the Huangpu Police Station, being forced to work as hard labourers for a day. Only one worker, a new immigrant into the county, was excused and was released on bail.Footnote 51
According to Gao Meifang, who actively participated in Nanjing's public health reform during the 1930s and the 1940s, leftover food and bones, wastewater from the kitchen and dead pests or even farm animals were the items most commonly found among household garbage in Chinese cities.Footnote 52 Indeed, Shiqi retailers were throwing dead rats into the streets. In 1930, the situation was getting critical and the Health Department had to enforce a ban on such activities. They also produced iron boxes for dead rats, and each day street cleaners emptied these boxes. According to government reports, the iron boxes effectively lessened the number of dead rats thrown out onto the streets.Footnote 53
Dead rats were disposed of properly but the general mission of ‘civilizing’ Zhongshan, as Xu Yamin put it, had not been accomplished to the extent that the streets of Zhongshan could generally be kept clean. The new ‘civic’ and ‘hygienic’ culture had yet to flourish.Footnote 54 The problem was how to inculcate a culture of hygiene. The effectiveness of rat boxes in minimizing the number of dead rats thrown onto the streets suggests one possible reason for the unclean streets and rivers. Rat boxes were hung on the lampposts in every street and lane in Shiqi. They were handy to use. But the authorities’ requirement that residents keep public places clean was not accompanied with the proper and convenient disposal of garbage. It is probable that, for many residents, the 60 litter boxes were not within reach. Sanitation required the authorities to put in place sufficient garbage bins and street cleaners; unfortunately, these were not available in Zhongshan.
The Zhongshan authorities were well aware that the efficiency of sanitary reforms depended not only on the thorough cleaning campaigns that took place at most twice a year, but also on the maintenance of hygiene on a daily basis. They employed street cleaners and also contracted private firms to collect and deliver garbage to the designated dumping ground on the outskirts of the town.Footnote 55 They were well aware of their limited budget, but the solutions were complicated. They collected extra surcharges to hire street cleaners, but fee collection was extremely difficult.
During the Second Sino-Japanese War, street cleaning must have been extremely limited, if not non-existent: as one newspaper article suggested, the smell was so bad that passers-by had to cover their noses when they walked along the streets.Footnote 56 After the war, street cleaners were hired. However, shop owners felt it was not right that fees were collected from them: they were forced to bear most of the financial burden and other residents only paid a small amount. In December 1945, 1,400 shops in Shiqi were divided into four ranks, depending on the revenue they earned. The ones that earned most had to pay a 500 yuan monthly street-cleaning fee (jiejing fei) and those that earned the least paid 100 yuan each month. Households also bore part of the expenses: each of the 8,500 households paid 20 yuan each month, an amount that was far less than shop owners were paying.Footnote 57 Residents in Shiqi were so reluctant to pay for street cleaning that in March 1946 the Health Department had to dismiss 20 street cleaners (leaving only 28). In reporting this situation to the county magistrate, the Health Department claimed that Shiqi actually needed 60 street cleaners, many more brooms and four more carts, so that all streets, including the alleys, could be cleaned.Footnote 58 Even the magistrate could present no solutions to the problem: he could only respond by reminding the Health Department that, according to the instructions (xunling) of the Guangdong Provincial Government, the Health Department was responsible for funding street cleaning.Footnote 59
As a last resort, and out of desperation, the Health Department made an upward adjustment in street-cleaning fees in 1946. It was not a good decision. In order to maintain a troop of 35 street cleaners in Shiqi, each earning a daily wage of 1.2 catties of rice, the authorities had to double the fee collected from shop owners and raise the fee collected from households fivefold.Footnote 60 Fees had to be raised because in 1946 the widespread inflation became obvious. A year later, it became uncontrollable. In December 1946, each dan of rice cost 320,000 yuan,Footnote 61 the next year, 500,000 yuan and by May 1948, 5,000,000 yuan.Footnote 62 As fees were raised, street cleaning, which must have improved the sanitation in Shiqi, became much more burdensome.
The authorities understood that the city needed street cleaners, but they did not understand that not everyone wanted street cleaning given the high cost the people had to bear. Suzhou had a similar experience in the early 1900s. The establishment of a public health organization definitely added to the taxation pressure on peasants. These added costs did not produce extra benefits in their lives. Requirements for night soil treatment, such as specific buckets, covers and tags for night soil collectors, brought extra costs that were eventually transferred to peasants: that is, the buyers of night soil.Footnote 63 In Shiqi, the problem was not so much one for the peasants but for the shop owners. The drastic increase in fees aroused resentment. This became obvious in November 1946, when the Shiqi Merchants Association wrote a letter to the authorities voicing their discontent. The Association proposed that street-cleaning fees should either be collected equally from every resident or covered by police surcharges.Footnote 64 A meeting was held in the Police Bureau regarding the proposed ideas. The former option was not workable because residents could not bear any higher fees. The latter was also rejected because the police department was already facing problems in financing police salaries.Footnote 65
Without a better solution to these financial problems, we could expect that fee collection would remain as difficult, if not become more difficult. In February 1948, the Police Bureau had to seek help from the Shiqi Town Office: asking the Town Office to take on responsibility for fee collection for street cleaning. However, the situation had by no means improved.Footnote 66 Arrearage was serious and another five street cleaners had to be dismissed.Footnote 67 Half a year later, the Shiqi Town Office wanted to give up its responsibility for managing street cleaning.Footnote 68 After several negotiations, the Police Bureau and the Shiqi Town Office came to a compromise and together they collected street-cleaning fees.Footnote 69 The latest information available about street cleaning before ‘liberation’ was that they could only afford 21 street cleaners to sweep 13 main streets.Footnote 70
From a political standpoint, reluctance in paying street-cleaning fees was a sign of the Nationalist government's failure in ‘tempering bodies and moulding moral characters’, as Robert Culp termed Nanjing's projects that created and instilled modern forms of civility.Footnote 71 In theory, elites, students and even the government ‘stressed active and direct involvement by all citizens in community affairs. . .[and] asserted that moral regulation and active self-discipline, rather than individual freedom and the expression of self-interest, were fundamental to republican politics’.Footnote 72 However, from the standpoint of household economy, it is understandable that residents were unwilling to pay their fees. Since the majority of fee-payers did not live in these main streets, they did not directly benefit from street cleaning. It follows that the making of self-disciplined citizens involved more than moulding them through education. Comprehensive urban planning and effective bureaucratic management were equally essential. The street-cleaning issue, the provision of 60 garbage bins for the entire county capital, litter regulation that was almost impossible to execute and the six unusable public toilets were largely problems of urban planning and bureaucratic management. More importantly, these were everyday dissatisfactions Shiqi residents had to face. Consequently, there is no reason why Shiqi residents should have been happy to pay their street-cleaning fees. Given the aforementioned problems, the large-scale thorough cleaning campaigns had only occasionally reminded the Shiqi residents of the presence of the state's authority in public health without delivering obvious long-term benefits.
The model county and the incomplete model hospital
The sophisticated Zhongshanese did not need the state's introduction of western medicine: a modern medical system existed. The imposition of an inexperienced model government did not improve the system, rather it caused significant difficulty for the government, a private hospital and Zhongshanese residents. The medical situation generated an even higher degree of tension than the tax for garbage collection.
Although the public commonly disregarded sanitation, they were concerned with personal health. In the county, thousands of local residents were seeking western medication every month. For instance, Tongyin Hospital located in Xiaolan town provided medication to over 1,800 people every month.Footnote 73 Similarly, each month between 1930 and 1934, the Duxi village clinic provided free medication to over 200 patients and approximately half of the number of babies born in the village were delivered there.Footnote 74 Among the 94 private hospitals and clinics, Qiaoli Hospital (Overseas Chinese Hospital), founded by a Californian Zhongshanese named Xiao Huichen (1900–57) and sponsored by a large number of Zhongshanese, was the largest. Completed in 1932, it had over 80 beds and served over 2,000 patients each month in 1946.Footnote 75 Qiaoli was known to be the best hospital in the delta area.Footnote 76
These private medical entities were predominantly sponsored by local residents and overseas Zhongshanese. Liping Bu has said that the public health campaigns in China in 1915 and 1916 were ‘started by advocates of modern medicine and embraced by the Chinese people. . .as a response to social and political needs of transforming the country from a weak traditional society to a strong modern state’.Footnote 77 By the 1930s, the health goals of local and overseas Zhongshanese and their families were in line with Nanjing's policies to improve medical treatment, and so the massive donations to hospitals and clinics were not surprising. The county's local and overseas philanthropists backed this social change with money. Back in Duxi village clinic, financing free medication was never a problem. In November 1932, that is two years after it was established, the clinic fund amounted to 730 yuan and one year later in October 1933, the fund had increased to 2,700 yuan.Footnote 78 By contrast, the local community eventually came to rely on private entities for medical provisions, whether free or charged.
At the same time, we already saw how Zhongshan failed to provide the complete range of Nanjing-mandated health facilities. However, as a model county, Zhongshan was held in unusual esteem by the higher authorities, and it could not afford to neglect public health reforms entirely. The Nanjing government required all counties to have at least one public hospital where budget allowed. Being eager to meet Nanjing's requirements, Zhongshan magistrates attempted to build public hospitals. In 1929, when Tang Xiaoyi was the county magistrate, he launched a plan to construct a harbour at Tangjia Wan, located on the east coast of the county. His plan was to make Tangjia Wan a city that could meet international standards and a proper public hospital was indispensable. Indeed, a public hospital was completed in Tangjia Wan in 1932, mainly through donations. However, two years later, the hospital ceased operation and the harbour project was abandoned at the same time as Tang declared his resignation.
The new magistrate, Liang Hongguang, came to office in 1934, bringing a new set of plans. He wanted a public hospital that provided free medication and hospitalization for the poor. Liang proposed the establishment of the Pingmin Hospital (the Commoners’ Hospital). Volunteers were recruited to organize donation campaigns for the building of the hospital. Many local philanthropists made generous contributions. One of them donated a piece of his farmland to the hospital.Footnote 79 When Liang died two months after being appointed magistrate, he was succeeded by Yang Ziyi. Yang carried on with Liang's plans, and was even more aggressive. He released a lump sum of 1,000 yuan from the county treasury, in addition to 500 yuan every month for the hospital to provide free medication to the poor.Footnote 80 The hospital began to operate in 1935 but in 1939, when the Japanese occupied Zhongshan, it was moved to the countryside and was soon closed.Footnote 81
Thus, in the first Nanjing decade (1928–37), the model county faced a dilemma. Given limited resources and the problems of budget allocation, the new government had to make choices, and so did the administration of the designated model county. These different choices reflected the discrepancies between the local governments' capacity and priorities, and the people's idea of their medical needs. To the authorities, the provision of western medication was not first on their list. Economically and administratively, roads and bridges, a modern court system and a proper police department were more important. The improvement in public health was naturally devolved to the residents and overseas Zhongshanese who gave it a higher priority than the authorities.
However, almost two decades after the promulgation of the model county status, and after the Second Sino-Japanese War (1937–45), Zhongshan anxiously understood the political need for a public hospital, something that Nanjing desperately wanted.Footnote 82 Zhongshan needed one ‘real’ public hospital – not a hospital inside a Police Bureau (which served as a clinic). But again, facing financial problems Zhongshan found that impossible to achieve. The authorities then decided to make use of aggressive means to establish a public hospital: they attempted to confiscate Qiaoli Hospital.
In December 1947, Magistrate Sun Qian (1908–99) attempted to borrow a few wards from Qiaoli Hospital to be used by the public hospital. Despite the need, and despite threats, Qiaoli rejected the magistrate's request.Footnote 83 From a letter written by the members of Qiaoli's board of directors to Xiao Huichen, who was then in the USA, we learn that the authorities had sent military troops to threaten them to hand over the hospital to the Zhongshan government.Footnote 84
Interestingly, during the same period, a scandal was exposed in a local periodical Jianzhong banyuekan: it had to do with the poor conditions and poor services provided by Qiaoli Hospital: ‘Qiaoli Hospital has over 20 wards but they are mostly empty. On the second floor of the Hospital, there are two large wards for “poor patients”. One ward contains only one empty bed. The other ward has only one unattended patient. The floor is dirty and the ward stinks.’ The article goes on to describe the non-standardized charges of the hospital: ‘No one except the person-in-charge of the hospital knows how fees are charged. They are sometimes more expensive than those charged by private doctors.’Footnote 85 In the same volume of the same periodical, another article states:
One day in mid-1948 a sick and jobless man named Yang Zu from Shunde jumped down from a building in Shiqi to commit suicide. Yang did not die but was severely injured and was sent to Qiaoli Hospital. However, the Hospital was unwilling to accept him unless he could pay in advance for his medication. Yang did not have the money but fortunately enough a retired overseas Zhongshanese agreed to pay for all medical expenses the Hospital charged him. This incident aroused public resentment against the Hospital. Many residents requested the directors to turn the Hospital over to the authorities.Footnote 86
Official statistics noted earlier, which suggest a different story from that described by Jianzhong banyuekan, lead us to suspect that the articles were being deliberately provocative. Official figures for out-patients and those hospitalized in Qiaoli Hospital tell us that the wards were not empty. Furthermore, almost half the number of patients were treated free of charge. If Qiaoli's conditions were poor, the Jianzhong articles had nevertheless exaggerated the conditions. Regardless of the accuracy of the articles, we can be certain that parties were utilizing the magazine as a platform to voice their dissatisfaction. The fact that an article requesting that the local authorities take over Qiaoli was published during the time when the state desperately wanted the hospital undoubtedly arouses suspicions.
The Qiaoli board of directors responded to the articles in Jianzhong by claiming that they were false accusations levelled by the local government. The board of directors claimed that spreading rumours about Qiaoli was a tactic that was being applied by the local government as an excuse for confiscating the hospital. They urged Xiao Huichen and other overseas Zhongshanese not to believe the rumours. The board of directors admitted that they had to charge expensive fees because they were in an extremely difficult state after the war, when much equipment was lost.Footnote 87 They emphasized that all other rumours were untrue.Footnote 88 However, as a result of public pressure, Qiaoli finally wrote a newspaper article in order to apologize to the public. They admitted that on some occasions, they were ‘not able to help the ones in need’ because the hospital was too poor. Qiaoli also promised the public that they would provide free medication and hospitalization to the poor.Footnote 89
After several rounds of negotiations between Qiaoli and the local government, in September 1949 Qiaoli agreed to lend out a few wards to the public hospital.Footnote 90 Qiaoli Hospital managed to avoid government takeover and continued to operate independently until 1951, when it was finally taken over by the Communist government.Footnote 91
Social tensions caused by public health issues were not new to China. In Tianjin in 1911, ‘one of the most telling conflicts between the forces of hygienic modernity and elements of Chinese society took the form of a clash between Japanese Concession authorities and the night soil carrier guilds of the city. . .in the end, neither side could claim victory’.Footnote 92 There were also uneasy moments when the government was incapable of tackling urgent public health issues. For instance, when Guangzhou had a cholera outbreak in 1932, the municipal government did not take up voluntarily the responsibility for water supply. ‘It was not until after the populace strongly voiced its demand that the government agreed to provide free clean water to the urban poor.’Footnote 93 Nevertheless, Guangzhou's Public Health Bureau managed to set up a hospital and a medical school and many other facilities.Footnote 94
It should be noted that in the case of Tianjin, in the conflict between night soil carriers and the authorities, the sewer system ‘represented a compromise between indigenous techniques and new technologies’.Footnote 95 In Zhongshan, however, the conflict between the government and Qiaoli could serve as an example of what Ruth Rogaski termed the ‘hegemony of hygienic modernity’.Footnote 96 A look at Guangzhou reveals the reason why Zhongshan turned to aggressive acts such as the malicious defamation of Qiaoli Hospital. Although Guangzhou was inefficient in dealing with the 1932 cholera outbreak, it was the city that Zhongshan always looked up to, and it already had public hospitals and even a medical school. Since Zhongshan had been granted the title of ‘model county’, the authorities could not leave the work to private organizations and philanthropists, who would undoubtedly have done a better job. Nevertheless, the limited ability of the local authorities and the deficient fiscal budget did not match with the state's expectations of the model county. A public hospital was too expensive. Rather than allowing privately owned Qiaoli to operate peacefully to save people's lives, the attempt to confiscate Qiaoli was a sign of the model government's desperate desire to save face. In other words, for Zhongshan, the political purpose of establishing a public hospital, and of assuring the state that they were in step with the country's plans for modernization, was as important as, if not more important than, the humane purpose of a hospital.
While Qiaoli openly apologized for not being able to provide free medication to all those in need and promised the public they would do a better job, the Zhongshan government's achievements in the county's public health were minimal and promised nothing. At the same time, they were imposing regulations and penalties in the thorough cleaning campaign and constantly demanding additional taxes. It would not be surprising to find tensions between the local government and the society exacerbated, expressed by people's non-compliance with rules and regulations and tax avoidance.
Conclusion
The Nationalist government introduced experimental public health programmes in remote villages but both the state and public health experts found that health improvements were curbed by extreme poverty. In many parts of northern China, fundamental problems existed, including the lack of water. Even factory-made toothbrushes were unaffordable. In these places, public health programmes were unrealistic.Footnote 97 In Zhongshan, which did not suffer from extreme poverty, the implementation of public health programmes involved other more complex problems: political concerns, resource allocation and planning were some of them.
Constrained by political concerns, the strategic use of resources was a dilemma for all levels of the government. For instance, during the Second Sino-Japanese War when the Nationalist government moved the capital from Nanjing to Chongqing, ‘political and ideological exigencies drove them [Chongqing] to concentrate their efforts in addressing issues that Guomindang state officials endorsed’.Footnote 98 Thus, for the wartime government, maternal health services were prioritized for women and military medicine for men. At the county level, governments also had their strategic concerns. Zhongshan's development works related to a long list of political and economic reforms which were implemented to show the rest of China they were the model. Accordingly, the urban planning budget largely went on infrastructure and government administration. Consequently, public health reforms and civic education had to be put to the bottom of the to-do list.
Since most public health initiatives could not be carried out, strenuous efforts were made to implement those that the local government believed were attainable. However, these projects were not properly planned and eventually produced significant tension among various social groups. First, the bi-annual thorough cleaning campaign was not followed by continuous mass education and by the promotion of sanitation. Public health, especially regarding sanitation, generally remained poor in Zhongshan, and the authorities received many complaints from the public. Second, the hiring of street cleaners was not accompanied by a well-planned fee-collection system. Instead, the collection of fees caused much resentment among Shiqi residents. Third, hospitals were built and abandoned and apparently wasted donors’ funds. The attempted confiscation of Qiaoli Hospital shows how Zhongshan was reformulating public health implementation methods based on political reasons rather than on the basis of practicality and effectiveness. Such urban administration problems caused public resentment which was exacerbated by the fact that urban residents in 1930s and 1940s Zhongshan had already fully accepted the idea of the state's responsibility for reforming the health care system. Many had no doubts regarding their entitlement to receive proper medication, and their right to a clean and healthy living environment.
Modern-minded authors in Zhongshan who wrote newspaper and periodical articles often placed the blame on residents for their lack of moral conduct and social responsibility. Historian Xu Yamin follows this line and claims that mobile residents were the ones producing sanitary problems in big cities. This fact is undeniable because a large percentage of the city population was made up of mobile residents. However, placing the blame on certain groups of the population is less meaningful than seeking to understand the cause of the problem. The success of public health reform largely depended on whether the state was able to retrain the population into self-disciplined modern citizens. For political purposes, Zhongshan government abandoned systematic planning of public health reform while running the race for modernity with big cities.
All in all, the promulgation of the model county was not entirely helpful to Zhongshan's social development: the county failed to instil in the people a unified conception of and a sense of responsibility for public health. Perhaps more than other tensions caused by the government efforts to modernize, the failure of public health initiatives damaged relations between society and the state.
