[Special Feature: Infectious Diseases in History] Nagayo Sensai and the Prevention of Cholera Outbreaks

Amidst the series of events from the restoration of imperial rule by the 15th Shogun Tokugawa Yoshinobu (1837–1913) to the establishment of the Meiji government, the use of Western models for nation-building in Japan became established. Activities in the fields of medical care and hygiene were no exception, and Westernization was pursued. Thus, 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" (meaning he was utterly astounded).

After completing his inspections of educational institutions and hospitals in the United States, Sensai traveled through London and Paris to Berlin. Berlin had been his destination since leaving Japan, as it was a place of great interest for deepening his understanding of medical education systems. In Berlin, Sensai was moved to see scenes unfolding before him that reminded him of what he had learned from Dutch doctors like Pompe van Meerdervoort in Nagasaki, where he had studied since the end of the Edo period. Furthermore, in Berlin, he not only deepened his understanding of medical education systems but also found an opportunity to take an interest in the "health protection" promoted by the government.

Sensai focused on efforts for "health protection" denoted by terms such as Gesundheitspflege, Gesundheitswesen, and öffentliche Hygiene. He had also heard terms like "Health" and "Sanitary" during his previous investigations, which he initially did not understand, but after his stay in Berlin, he came to understand them as bringing about similar effects. Sensai understood these administrative activities, which were being given concrete form in the West, as efforts to incorporate a "special administrative organization in charge of the general health protection of the citizens" and to apply medical sciences and other academic disciplines in a "governmental" manner in cooperation with local and police administration. In the West, there was a mechanism for the government to be directly involved in the "health protection" of its residents.

Describing it as a "completely innovative undertaking for which even the name does not yet exist in the East," he brought this 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 was using 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 Medical Affairs Bureau Director 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 over a word to express Western efforts such as "Gesundheitspflege" and decided on "Eisei" (Hygiene). In the process of reaching this decision, words like "Kenko" (Health) and "Hoken" (Health Preservation) initially came to mind. However, he recalled the word "Eisei" appearing in a dialogue with Gengsang Chu in the Zhuangzi, one of the Chinese classics. He examined the implications of the 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," and so he chose it. Sensai thus designated the "health protection" he had noted in the West as "Eisei."

Following the enactment of the "Medical System," a policy was set forth to promote "health protection" through the intentions of the central government along with local officials. Sensai confirmed the government's authority for this undertaking within the "Medical System" and aimed to give concrete form to his vision by exercising this authority.

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

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 the "Medical System" was enacted, 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, meaning he spearheaded 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."

While Sensai was busy creating the framework for "health protection," a cholera outbreak struck the Sanitary Bureau of the Ministry of Home Affairs.

Cholera outbreaks 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. However, in the early 1880s, it had not yet been elucidated why people became cholera patients. Consequently, people were in a panic, and rumors that doctors were the ones taking the lives of cholera patients even led to some becoming victims of bamboo spear attacks.

During the cholera outbreaks from 1877 onwards, Sensai and other officials of the Sanitary Bureau responded in a state of frantic confusion. However, during the 1879 outbreak, 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 had noted in Berlin was the "governmental" application of medical sciences and other academic disciplines. To achieve this, policy formulation based on academic knowledge 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 with each other, it became possible for the government to turn medical sciences and other academic disciplines into policy and implement them, as Sensai had sought.

To increase the effectiveness of infectious disease prevention, Sensai had high expectations for the activities of the "Sanitary Committees," which could directly communicate the intentions of the Sanitary Bureau—such as the need for disinfection and hygiene—to residents. However, he did not stop there; he also focused on the residents who were on the receiving end of the government's preventive measures. Thus, Sensai began activities to help residents accept "health protection" themselves. This resulted in the establishment of the Great Japan Private Sanitary Association in 1883.

Although the Great Japan Private Sanitary Association was called "private," those who worked hard to establish it and guided it toward realization were individuals 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 sanitary information disclosed 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 had noted 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 trying not to violate the law was not enough; above all, it was necessary for the residents themselves to desire a long life free of disease. For this reason, expectations for the Great Japan Private Sanitary Association grew. This was because individuals who 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 toward "health protection" by sharing sanitary information in the community. For Sensai, the establishment of the Great Japan Private Sanitary Association was an effort to stand on the "side of the people" and "awaken them from their delusions by kindly explaining the logic and righteousness." 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 from 1877 onwards, 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 implementation of 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 placed great importance on "academic movements" in "health protection." He hoped these movements would be understood by residents through doctors and municipal officials, but if that was not possible, he envisioned intervention based on police authority rather than "leaving it entirely to autonomy."

On the other hand, since the first decade of the Meiji period, the police had recognized their involvement in the health of residents as part of administrative policing. 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 in 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 would lead to an evaluation of being "stereotypical" or "formulaic." While police-led infectious disease prevention emphasized the authoritative and uniform aspects, it tended to neglect taking the patients' circumstances into consideration, which Sensai saw as a factor that discouraged cooperation from residents.

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

The 1880 Infectious Disease Prevention Regulations required disease name labels to be attached to patients' homes, but because residents disliked this, the Dajokan (Grand Council of State) decided to stop the practice in 1882. However, when cholera began to spread again from 1885 to 1886, the police could no longer manage the large number of patients and asked the Central Sanitary Board to allow the reinstatement of the labels. At this time, it was Sensai who opposed the police's request. His reason was that if labels were attached, residents would dislike the government's measures and cooperation would not be obtained. Sensai allowed the labels in large cities like Tokyo because of the high population and number of patients, but he argued they were unnecessary in rural areas where residential areas were more dispersed. 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 Boards," 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 "Manual" for infectious disease prevention was created in 1886 that encouraged police intervention, and the involvement of the police in infectious disease prevention duties was explicitly stated in the local government organization system. In particular, the 1886 "Manual" strongly called for the "eradication" and "isolation" of infectious diseases through police authority.

In this way, following the cholera outbreaks from 1877 onwards, the involvement of the police in infectious disease prevention was strengthened, while the involvement of the Sanitary Bureau of the Ministry of Home Affairs was reduced.

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

With the issuance of the 1886 "Manual," 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 "Manual" was confirmed and refined with the issuance of a new "Manual" in 1890.

The 1890 "Manual" 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 in the hands of the police," which Sensai had worried about since 1886, began to appear.

As we have 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 "official business," making it difficult to obtain their cooperation. Therefore, he placed expectations on the "awareness" of the residents themselves and sought "cooperation" from the perspectives of both the "official" and "private" sectors, being conscious of their respective "boundaries" while also taking police intervention into account. The 1890 "Manual" was indeed in line with Sensai's vision.

Sensai's perspective on cooperation between the "official" and "private" sectors was also incorporated into waterworks 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 of each. 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 after Sensai's efforts to spread waterworks in Tokyo as part of the Tokyo City Improvement Project from 1887 onwards were evaluated alongside efforts in Osaka and elsewhere. Because the issue of residents becoming patients through water contaminated with cholera bacteria was viewed as a problem, Sensai positioned "sanitary engineering" as the "fundamental basis" of infectious disease prevention.

In the Waterworks Ordinance, the 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 to be played by the "private" sector were clearly stated. While residents could demand management of water quality and quantity from the "official" sector, the cost of water supply equipment inside houses and the small pipes for connecting to the mains was the burden of the "private" side. It was intended that waterworks projects would also bring about effects through both the "official" and "private" sectors fulfilling their respective roles.

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