Against all odds: vanquishing smallpox in far-flung Japan

In the case of Japan on the other hand, one barely needs to scratch the surface of its history and literature to find the scourge of smallpox. It is general knowledge that the Great Buddha at Tōdaiji temple in Nara was erected to propitiate the gods after a smallpox epidemic in 737 which killed four grandsons of Fujiwara no Kamatari. Descriptions of one of Japan's greatest writers of the Edo period, Ueda Akinari, inevitably refer to his childhood case of smallpox which left him partially paralysed in his hands, eventually blinded, and with a major chip on his shoulder accounting for the misanthropic nature of his writing. One of bunraku's favourite plays Tsubosaka Kannon Reigenki features the protagonist Sawaichi, blinded with smallpox and disfigured with the scars of his disease. Vaccinations against smallpox were still mandatory in 1979 for visitors to Japan, as I discovered through my own experience.

Thus it is not surprising to find considerable scholarship on this topic and The Vaccinators: Smallpox, Medical Knowledge, and the ‘Opening' of Japan, by Ann Jannetta comprises a major contribution. It is also an inspiring celebration of ‘human ingenuity and international cooperation' (p. xvi), and not without considerable contemporary relevance in this post 9/11 era where threats of bio-terrorism (including the re-introduction of smallpox) abound, and we are constantly reminded of the imminence of pandemics such as avian flu or influenza.

The Vaccinators provides a meticulously documented and compelling account of the invention and spread of the technique of smallpox vaccination and in particular the vicissitudes of its introduction into Japan in the first decades of the nineteenth century. The main theme teased out in the work is the crucial role played by networks and human connections in this process, but other strands of inquiry include the extent to which Japan had in effect already ‘opened' at least in the area of medicine well before 1868, and the reasons why so many of the new Meiji bureaucracy were recruited from the ranpō (Dutch medicine) community. The role of special expertise (in this case proficiency in the Dutch language and Western medical techniques) in social advancement is another important theme.

The first chapters of the work are devoted to a contextualisation of her study: Jannetta sketches the history of smallpox in the world and in Japan (where it had become endemic and largely a killer of children from at least the twelfth century), and then describes, in fascinating detail (though perhaps not recommended for the squeamish), early attempts to combat smallpox by utilising and fine-tuning the technique of ‘variolation' (creating immunity in a patient by deliberately infecting them with a mild case of smallpox). Variolation was the main defence against smallpox before the invention of vaccination and was practised with considerable success and popularity in countries such as China, Turkey and Britain but never really caught on in Japan. This anomaly allows Jannetta to engage with one of her major arguments, the extent to which the propagation and life-saving effects of new therapies are dependent on the existence of an infrastructure in terms of a medical establishment, journals, and active lateral associations which allow their discussion and dissemination. Although such networks existed in western Europe and both sides of the Atlantic, they did not exist at the time in Japan when variolation techniques were first introduced, and thwarted their uptake. The same negative situation applied when first news of the vaccination technique reached Japan, but was no longer the case when at last the vaccine safely reached Japan approximately fifty years later.

Jannetta then proceeds carefully to document the process by which Edward Jenner invented his method of vaccination against smallpox through inoculation with cowpox virus in Britain in 1798, and provides a minute but absorbing account of how vaccination techniques and the highly fragile, heat- and humidity-susceptible cowpox vaccine reached far flung corners of the globe, including the Philippines, Macao and Canton. The pre-requisite for such transmission was the existence of human networks, be they political, religious, commercial or personal; the importance of the human-to-human contact is emphasised, as arm-to-arm inoculation with the cowpox vaccine was the only reliable method of transmission. Jannetta reaches the inevitable obverse conclusion of this discussion: ‘Places and people that were disconnected...were unable to claim the benefits of this diffusion of knowledge about Jenner's cowpox vaccine. The Japanese Islands were just such a place.' (p.52)

And so the focus moves to Japan, and its points of contact, tenuous as they were, with the rest of the world. The pivotal setting is the Dutch Factory in Nagasaki, where strictly controlled official foreign trade was permitted with the Dutch. It was here that news of the Jennerian vaccination technique first entered Japan, conveyed from a warehouse master at the Dutch Factory to a young Japanese interpreter Baba Sajurō in 1803. However, written details of this technique took almost twenty years to start to circulate, even though Baba had heard about vaccination techniques three separate times (even having refused a gift of cowpox scabs from a British commercial ship captain in 1818, which as a gift from a foreigner would have violated Japanese law ). He finally completed his translation of a Russian vaccination tract in 1820.

By this time, about 1817, a very solid state vaccination programme existed in the Dutch East Indies, and initiated by the Dutch for apparently humanitarian reasons, numerous, persistent but unsuccessful attempts commenced to transport viable cowpox virus from Batavia (today's Jakarta) to Japan. They were eagerly assisted by Japanese physicians, by now well-acquainted through various circulating translated texts with the method of cowpox inoculation. The role from 1823 of the Dutch Factory physician Philipp von Siebold (in fact German but court physician to William I of Holland, the ‘Merchant King,' intent on improving trade with Japan) in establishing horizontal networks among his former students who made ‘Jennerian vaccination their cause célebrè [sic]' (p. 101) is especially singled out. Eventually in 1849 viable cowpox virus was at last successfully imported to Nagasaki and three Japanese children (from the interpreter and medical community) were vaccinated. The narrative becomes a real nail-biter here, as only one vaccination ‘took', leaving ‘the entire supply of cowpox vaccine in Japan ... contained in the pocks on the arm of Narabayashi Kensaburō.' (p. 133)

Miraculously and despite the odds, from this point vaccination in Japan spread rapidly and widely. Particular attention is paid to the vital role played by the local daimyo, who encouraged by example and allowed their own children to be vaccinated, and by ranpō physicians who had laid the groundwork in educating the daimyo into the benefits of vaccination and created networks throughout Japan across social and domainal divisions along which inoculation could rapidly spread.

Consciousness of the need to convince more physicians and the general public was also clearly a major indicator of the rapid successful dispersal of smallpox vaccination: within months of the first successful vaccination at Nagasaki, numerous publications about vaccination were in print for the medical audience, as well as fliers and woodblock prints to convince the general public of the merits of this procedure.

Until this point, the propagation of vaccination had largely been a private endeavour, endorsed actively by domainal lords, but not the bakufu. Jannetta suggests possible reasons behind this detachment of the centre (ignorance? failure to be informed? the weight of the shogunal edict in 1849 prohibiting the practice of Western medicine in Tokugawa territories?), and proposes her own convincing theory that the bakufu position was in fact not opposition but ‘tacit approval' (p. 158): a shrewd ‘turn a blind eye' but ‘wait and see' strategy. Once it became clear that the risks of vaccination were low, the bakufu was willing to engage in vaccination initiatives. Interestingly, and indicative of the bakufu's cautious approach, was the fact that the first target population were ‘non-Japanese' Ainu, in the Ezo territories to the distant north in 1857.

By 1858, the bakufu had been persuaded to authorise the construction of a vaccination clinic in Kanda, Edo. A direct descendant to this clinic, the Otamagaike Vaccination Clinic, was the Tokyo Imperial University Medical School. The sponsors of the Clinic, including four of von Siebold's students but also including wide representation from a younger generation of physicians, are regarded as the ‘founding fathers of modern medicine in Japan.' (p.164)

In 1858 the bakufu opened the Western-style Nagasaki Medical School. Three years later a Western-style hospital opened as its teaching hospital. In these institutions Japanese physicians could train and work openly with Dutch physicians for the first time. Several were descendants of the early vaccinators in Japan and became major figures in the new Meiji bureaucracy. Their policies ensured that from 1872 all infants were required by law to be vaccinated, and vaccinations were free, an unbelievably progressive public policy just four years after the fall of feudalism.

This thread of the story therefore provides one of the intriguing secondary fairytale-like narratives of the work: how the marginalised and at times persecuted ranpō doctors came to end up in key positions at the very centre of the new Meiji government, formulating its public health and medical education policy. Expressed a different way, Jannetta shows how expertise in medicine, especially ranpō, brought social opportunity and power, as many of these individuals came from peasant or low-ranking samurai backgrounds.

This is indeed an impressive and formidable piece of scholarship. One of its great strengths is the extensive use Jannetta has made of primary and contemporary sources written in several languages: Japanese, French, Dutch, German, Russian (she acknowledges assistance in translation of Dutch and German sources). It is meticulously footnoted and documented. It is also liberally supported with various charts, tables, maps, appendices (for example of Philipp von Siebold's students) and a glossary. Chinese characters in these appendices are provided for all Japanese personal names, and generally for terms in the glossary, but not, inexplicably, for such key terms as tennentō (smallpox) or o-tsūji (a senior Nagasaki interpreter). These fine features of the work ensure that The Vaccinators is certain to become a vital reference for researchers in this field.

It is by no means an easy read: although exceedingly well written, the enormous detail

and proliferation of names in particular at times is overwhelming. However, as if aware of this possible criticism, Jannetta has ensured that the webs of intricate detail and minutiae hang from an exceptionally strong structure. The work moves ineluctably from periphery to centre in its chapter framework, deftly steering and propelling the reader with effective use of sub-titling within chapters. Moreover, the central plot itself is of utter simplicity: the discovery of vaccination and its introduction to Japan. In addition, Jannetta is careful to relate repeatedly the relevance of detail to theme. For example in Chapter Five the interconnecting biographies of seven ranpō physicians who played a key role in introducing Jennerian vaccination to Japan serve as cogent case studies of the strengthening and expanding ranpō personal and professional network in early 19th century Japan, so crucial to the eventual success of vaccination in Japan.

And some of the detail is riveting, for example relating to the bakufu purges of von Siebold's students in 1829, resulting in several executions, and again ten years later, ending in deaths or suicides. It becomes clear that involvement in ranpō had high risk implications. No wonder Baba refused his gift of smallpox scabs. Or details about the vital role which instruments of the Catholic Church would play in the vaccination of populations in the Spanish American colonies, even to the extent of offering papal indulgences to reward parents who returned to have their child vaccinated within six months after baptism. As noted above, detail is never gratuitous as it always supports Jannetta's central theme of the crucial role which institutions, systems and in this case authority play in effective public health operations.

This work also makes a significant contribution to knowledge about the operation of the Dutch Factory at Dejima in Nagasaki, even providing insight into the extent to which the Dutch often succeeded in ‘fooling' the shogunate to ensure their own commercial interests were served: they concealed from the bakufu vital news of the Dutch East India Company's transference to government ownership in 1796, the fact that from the 1790s ships of nationalities as diverse as American, Russian or British (disguised as Dutch ships) were carrying the Dutch trade from Batavia, and even Napoleon's defeat of Holland. On the other hand, this view is balanced by another perspective in which even the Dutch are vassals of the shogun, their ‘tribute' being in the form of knowledge.

This is a work of immense value and appeal to scholars and students of late Edo and early Meiji history, society and culture, the history of rangaku (Dutch studies) and ranpō (Dutch medicine) in Japan, the history of science and medicine, public health and epidemiology. Ann Jannetta is to be congratulated on her prodigious achievement.

 

Penelope Shino (Dr)
Lecturer
East Asian Studies Programme
School of Language Studies
Massey University
Palmerston North
New Zealand

Email: p.a.shino@massey.ac.nz