The Health Officer's year: smallpox, plague, cholera and the milk cart, 1871–1932

The short answer. The Settlement’s health service began in 1861 as one man inspecting nuisances, and by 1932 was a department with branch offices, a laboratory that made its own vaccine by the hundred litres, two isolation hospitals, a sanatorium and a slaughterhouse. Its reports count what it did, year by year: 380 free vaccinations in 1904, 6,108 in 1912, 47,058 in 1928, 262,475 in the war year of 1932. The same reports count plague rats by the ten thousand, cholera summers, adulterated milk, and the Chinese residents who, for decades, had reason to distrust a foreign doctor’s needle and said so in the streets.

One inspector, then a doctor

The Council appointed a sanitary inspector, James Carlyle, in September 1861, in the middle of the Taiping refugee years. A doctor came ten years later: Edward Henderson, a physician in practice, was made part-time health officer in 1871. His report for 1881 is a small census of a small town. He registered 111 foreign deaths in a foreign population he put at 8,000, resident and passing. Thirteen deaths that year were certified as cholera, but only two were residents; the rest were seamen. He thought cholera did not pass from the sick to their attendants, and he told the Settlement to boil milk from the Chinese dairies, which he had inspected every fortnight.

A full-time health officer, Arthur Stanley, arrived on 11 February 1898, and the Public Health Department dates from then. He brought the Pasteur treatment for rabies to Shanghai in 1899, built the department’s laboratory and hospitals, and served until 15 April 1922, when the pension list records his retirement, at £500 a year, under the single word “Age”; he had been on furlough in England since the end of 1921. His successor as Commissioner of Public Health was C. Noel Davis, who had joined the department in 1908, with J. H. Jordan acting in the post by 1928. The thirty-odd annual reports Stanley and Davis signed are the source for most of what follows.

Vaccination, with a reward

Smallpox was the disease the Council could do something about. From 1871 it vaccinated Chinese children free and paid for the privilege: a reward of 300 copper cash to a child whose vaccination took. In 1873, 488 children came, and the rewards cost 15.58 taels. Chinese charities worked the same way. A proclamation of 1881, which the Council printed in translation, announced free vaccination at an establishment near Sinza, with 100 cash to poor parents for each child and 200 more if the pustules developed well. The inoculation Chinese families knew was the older variolation; the Settlement’s reports note, as late as 1912, that people still wanted it done in spring, as custom required.

The numbers grew slowly, then fast. In 1904 the Health Office vaccinated 380 people, while the municipal laboratory sent out 34,000 tubes of calf lymph, enough for 170,000 vaccinations by other hands. In 1912 the Council had sixteen sub-district health offices, each serving about 30,000 people, with a Chinese lecturer speaking weekly and a bellman to gather the crowd; they vaccinated 6,108. By 1925 the branch offices did 44,700 free vaccinations a year, and the health officer reckoned that 85 per cent of infants were vaccinated. In 1928 the fourteen branch offices vaccinated a record 47,058 people, 45,871 of them Chinese. Then came 1932. During the fighting in Hongkou that winter the department ran what it called “a semi-compulsory campaign against smallpox”, six weeks long, in which “130,000 persons were subjected to vaccinations in streets and refugee camps”, with 60,000 more at the branch offices, and the year’s total reached 262,475, five times the record of four years earlier. The gazetteer’s totals run to half a million free vaccinations in the first quarter of the century and more than a million between 1911 and 1930.

1910: plague, rats and rumour

The disease the department feared most it caught early. Plague-infected rats were found in the Settlement in December 1908, and a “complete plague survey” was kept up from then, with every dead rat brought to the laboratory and opened. In October 1910 the acting health officer began his monthly report with a sentence that needs no gloss: “The long expected appearance of Human Bubonic Plague in the Settlement has dwarfed all other matters of interest as regards Public Health.” The infection was traced to rats from a large godown at the corner of Kansuh Road in Hongkou, fumigated at the start of the month after two plague rats were found there, where the staff had been picking up dead rats for weeks. The response was the full Edwardian repertoire: a plague station, isolation wards, steam disinfection, “a daily house to house inspection”, whole blocks evacuated, ringed with rat-proof barricades and fumigated with sulphur, and the interiors of houses torn out and rat-proofed.

The Chinese residents of Hongkou did not take it quietly, and the November report is the Council’s own account of why. “Extravagant tales of kidnapping of hundreds of children, of wanton disrespect shown to the dead, of alleged rudeness and misconduct on the part of the Plague Prevention Staff and various other slanders” had “formed the pretext for popular disturbances”, and the house-to-house visitation was suspended on 9 November. The Mixed Court magistrate had written to the Council the day before urging tact: “a riot must be avoided.” The Council replied on 16 November that “the disturbances of the following day in Hongkew though in themselves not serious, might have grown into riot” but for prompt repression. The health officer’s defence was arithmetic. “The total number of Chinese removed to Hospital during the outbreak only amounted to nine persons, of whom three succumbed to Plague”; one died of blood poisoning, five went home within days, and all but one were adults. The Chinese way of coffining the dead, he added, “satisfies all ordinary sanitary requirements”, and the solicitude “expressed even by foreigners in regard to imaginary desecration of the dead betrays unworthy suspicion of Health Office methods”. The search resumed “tentatively” on 22 November, but “in deference to native prejudice, trained Lady Inspectors accompanied by foreign-trained Chinese practitioners were engaged for the work instead of the Assistant Sanitary Inspectors previously employed.” They found no new cases. Pott adds the other concession: when the Council tried to forbid families from holding the usual funeral rites for plague deaths “it came into conflict with the strongest religious sentiment of the Chinese people, and was obliged to modify its ruling.” A daotai’s proclamation, sealed by the senior consul, explained the inspections to the Chinese public in December.

The rat war went on for years and the figures are in the report for 1911. In 1910, 19,559 rats found dead were examined and 249 were infected; in 1911, 14,929 and 138. “Nearly 177,040 rats were trapped and burnt” in 1911, and “close on six million phosphorus baits were laid, about a ton of poison being used”, in cubes coloured bright blue so that no one would mistake them for bread. 11,653 houses in plague foci were “temporarily rat-proofed”, their furniture carried out so that every hole could be plastered, bricked or wired. The infection, the department found, had come in from the north: from Chapei, “the beggar settlement” beyond the Northern District boundary, “outside Municipal control and very insanitary”, where the Chinese authorities had taken no measures against rats at all. Between 22 July and 23 August 1911 “upwards of 80 cases of Bubonic Plague were reported” there, in an area of some 10,000 people bounded by Haining Road, North Chekiang Road, the railway and North Thibet Road, 26 of them seen by the inspectors of the Chinese Public Hospital under a working arrangement the Council had published in January. Against it the Council built a barrier of a kind no other city tried: “a barrier of rat-proofed houses about 250 feet wide” along the boundary, 2,483 houses permanently rat-proofed by the year’s end “at a cost of a little under $15 a house”. In June 1911 the Chinese gentry opened their own isolation hospital in Chapei. The Eastern District, where the first rats had been found in 1908, had none after May 1910. The report for 1917 was “the first report for nine years without a plague map”; the Settlement had been free of plague in man and rat since June 1916.

Cholera summers

Cholera came most summers and some years stayed. The reports are careful about the word. In 1912 an unusual number of people, foreign and Chinese, had acute diarrhoea of the choleraic kind, and Japanese ports declared Shanghai infected; but the laboratory found the organism in none of the cases it examined, bar one brought in from Songjiang, and the disease was “not officially recognised as cholera”. The advice was the same either way: eat and drink nothing that has not recently been boiled or cooked, and avoid the sliced melons of the hawkers.

In 1925 it was the real thing. The outbreak began at the end of July and ran until November. Among the Settlement’s Chinese residents 467 cases were notified, 146 confirmed in the laboratory, and 72 people died; among foreigners there were 25 cases and 7 deaths. The laboratory isolated cholera vibrios from Suzhou Creek. Other ports quarantined ships from Shanghai from August to mid-November. The Council held 100 beds in reserve at its isolation hospital and needed eleven of them; the Red Cross summer hospital and the Chinese infectious diseases hospital took most of the patients. Three epidemic years followed, and then a quiet one: in 1928 the Settlement notified 24 Chinese cases, confirmed four, and buried six. The laboratory had made 8,512 doses of cholera vaccine for a summer that did not need them.

The epidemic of 1932 was the one the department fought with everything it had, and its report is unusually honest about the result. Cholera “appeared in epidemic form on April 30 and disappeared on September 23”. Among resident foreigners 44 cases were notified and 13 died, “a somewhat high death rate”; among resident Chinese 1,544 and 149. Across the Settlement, the French Concession and the Chinese districts around them the count was 5,439 Chinese cases notified, 2,966 confirmed and 426 dead. The commissioner put it in proportion: “if the population factor is considered there have been far heavier epidemics in the past, 1919 being one of the worst years”, and his list of severe years ran 1907, 1912, 1919, 1926, 1929, 1932. The campaign was the first run on wheels. “From May till the end of September a total of 200,210 inoculations was done,” 59,232 of them in June, “the greatest number done in one month”, and “by far the greater work was carried out by the motor vans, by means of which street inoculations, and visits to schools, factories, godowns, etc., were made”; the laboratory “made nearly four hundred litres of vaccine” for it. Then the verdict. “Early in the epidemic chlorination of wells was organized as it was considered worthy of trial, free water was supplied in selected areas, and cholera inoculations were carried out, though it appears improbable that any of these measures had much influence on the outbreak.” The hospital report was blunter still: of the cholera patients admitted, “23% of the cases had been inoculated”, figures which “seem to cast some doubt on the efficacy of cholera inoculation”. In the municipal isolation hospitals 28 per cent of foreign cholera patients and 18 per cent of Chinese died; the Chinese isolation hospital admitted over 1,900 patients that year, a fifth more than in 1931.

1917: scarlet fever and the death rate

Scarlet fever was, in the Council’s view, a disease foreigners had brought. “After a period of comparative absence Scarlet fever became prevalent during the spring of the year, reaching almost epidemic proportions among certain sections of the population,” the report for 1917 says, and it was deadlier in Shanghai than at home: “In Shanghai about 18 cases in every hundred die and there is no indication yet of any diminution in fatality, which at home is well below 5%.” The first recorded foreign death in the Settlement was in 1873; the first real epidemic was 1902, and the 1917 outbreak was about half its incidence, “since when the Foreign population has trebled and the Chinese doubled itself”. Pott counted 70 cases among foreigners and 423 among Chinese in five months.

Pott also records that “just before the outbreak” Stanley had pointed to “an enviable record”: a death rate of “15.4 per thousand among foreigners, and 13.2 per thousand approximately among the Chinese population.” Those are the Council’s figures for 1915, as its own twenty-year table shows, and 1917 undid them. The foreign rate that year, “calculated from 410 deaths occurring among the resident Foreign population of 19,755, is 20.7 as against 14 in 1916”; the Chinese rate was 14.9. The department’s definition was precise and limiting: six months’ continuous residence made a resident, and non-residents’ deaths were left out of the rate altogether.

The buildings

Stanley’s department got its buildings in 1904, at the east end of Range Road in Hongkou: a hospital for infectious disease, opened in December that year, a disinfecting station, a public mortuary and quarters for the inspectors. The hospital charged foreigners six taels a day for a private room and two for a ward; for Chinese patients the wards were free. The laboratory, by then, did more than vaccine: in 1904 it examined 601 specimens, gave 22 people the Pasteur treatment for rabies, and had begun producing diphtheria antitoxin. In 1912 it examined 23,322 specimens and found plague in 238 rats.

By 1925 the Council ran four hospitals. The foreign isolation hospital admitted 408 patients that year against 310 in 1924, “mainly in the Smallpox, Cholera and Tuberculosis Wards”, on a nursing staff of “9 Foreign and 12 Chinese nurses”. The Chinese isolation hospital admitted 502 against 391, “mainly from Smallpox and Cholera”, with its smallpox wards open ten months of the year and “a large number of cases received in a moribund condition”, many from Chinese territory. The Victoria Nursing Home, the Settlement’s general hospital for foreigners, admitted 974 patients against 870, 173 of them maternity cases. And the Council paid a grant to the oldest hospital in the city, the Shantung Road Hospital, “founded on the 5th December 1846 at a meeting of British Residents with Sir R. Alcock in the chair” and on its present site since 11 July 1873; it had treated 3,183 in-patients and 117,397 out-patients in 1924, and at the ratepayers’ meeting of April 1925 a motion from the floor raised the Council’s grant from 7,500 to 20,000 taels. Henry Lester, whose bequest after his death on 14 May 1926 gave it its later name, had been the architect of the 1873 building.

In 1928 the Council’s hospitals had 396 beds: 130 in the foreign isolation hospital, 142 in the Chinese, 98 in the police hospitals, and the rest maternity and mental. The Victoria Nursing Home “closed on May 15” that year, after twenty-five years, its maternity and mental blocks carrying on, the mental ward “much too small for the number of patients who seek admission”; a tuberculosis sanatorium was going up on Hungjao Road to replace the wards at Range Road. By 1932 the beds numbered 510.

The death rate, year by year

The department’s own measure of itself was the death rate, and its reports let the series be read.

Year	Foreign deaths per 1,000 residents	Chinese deaths per 1,000
1915	15.4	13.2
1917	20.7	14.9
1925	16.4	11.2
1928	16.05	13.23
1932	12.82	17.65

The foreign figure for 1925 was “the lowest within the last five years”, after 17.1 in 1924 and 17.2 in 1923. The Chinese figure for 1928 rests on a mean population of 821,400 and 10,868 resident deaths, of which “36% of the total deaths were infants and children up to the age of 5 years”; in 1925 infants under one had been 12.9 per cent of Chinese deaths, against 15.4 the year before. The Chinese figure for 1932 is the one the department disowned. “9,993 deaths included under the heading of ‘Exposed Corpses’ in the return refer to unwanted bodies, composed of beggars, indigents, still-born children and female infants, etc., dumped on vacant plots of land for collection and burial by Benevolent Societies,” 55 per cent of all the Chinese deaths recorded, and “it is impossible to analyse in any way the figures obtained.” Birth registration, without which no infant mortality rate could be calculated, began only in 1932, with 715 foreign and 1,332 Chinese births recorded, “by no means complete”.

Milk and meat

The other half of the department’s work was food. The Council built its first slaughterhouse in 1876; by 1904 no meat could be sold in the Settlement without a municipal stamp, and 290 animals were rejected that year as unfit. In 1928 the slaughterhouse killed 101,726 animals, 1,961 more than the year before, took $55,680.95 in fees from 52 registered butchers, and kept “over five hundred head” in sheds built for 340.

Dairy inspection began in 1882 and licensing in 1898; in 1904 the licensed dairies kept 951 cattle. The laboratory’s milk work tells its own story: of 456 samples examined in 1912, 67 were adulterated, 58 of them simply with water, and the health officer noted that imprisonment and the cangue, the wooden collar of the Chinese court, had “a marked deterrent effect” on the dairymen. A Dairy Branch was set up on 1 April 1924 on the advice of a Pure Milk Commission, and the trade was sorted into grades. There were 42 licensed dairies then and 33 at the end of 1928, 8 Grade A and 25 Grade B, 22 of them Chinese-owned, with 1,948 cattle between them; of 1,858 formal samples taken from licensed dairies in 1928 only 23 were not genuine, against seven of eleven from the unlicensed ones. What the department did not do until 1932 was make anyone pasteurise. It had set a bacteriological standard, “but pasteurisation was not made compulsory for either grade”, until “the beginning of 1932, when all Grade ‘A’ dairies were instructed to pasteurise all their dairy produce” after raw samples were found to contain live tubercle bacilli. In 1932 about 1,730 cows in 26 dairies gave the Settlement some 20,350 lb of milk a day, and a pint of pasteurised milk cost 35 to 42 Mexican cents against 20 to 30 for raw.

What the sources disagree on

Pott’s “1917” death rates are the Council’s 1915 figures; the report for 1917 gives higher ones, and both are given here. The Council’s report for 1910 is not on the Internet Archive, so the plague story is told from the monthly reports in the 1910 Gazette and the comparison figures printed in 1911. Human plague cases are counted as nine “removed to hospital” in November 1910 and not totalled for the year. The Chinese death rates rest on a population estimate the department itself called uncertain, and the 1932 figure on a return it said it could not analyse. And the department’s confession that inoculation, chlorination and free water had little effect on the 1932 epidemic sits in the same report as the boast of 200,210 inoculations; the two were written by the same office in the same year.

What to look for

The health buildings on Range Road, now Wujin Road, are gone, as are the branch offices and the rat-proof barrier along the Chapei boundary. The Shantung Road Hospital is the Renji Hospital, still on Shandong Road, the oldest hospital in the city. Gansu Road in Hongkou, where the plague rats of 1910 were found, is a short street of warehouses and flats north of Suzhou Creek. What survives of the department is the habit: the free vaccination, the stamped meat and the inspected milk were the Settlement’s most ordinary exports to the rest of the city.