Episode 91 – Dr. Susan Burns (Chicago)

Originally published on February 5, 2019

[This transcript has been edited for clarity.]

Tristan Grunow: This is the Meiji at 150 Podcast. I’m Tristan Grunow. Today, my guest is Dr. Susan Burns, Professor of History, and East Asian Languages and Civilizations at the University of Chicago. Dr. Burns is the author, recently, of “The Japanese Patent Medicine Trade in East Asia: Women’s Medicines and the Tensions of Empire,” in Gender, Health, and History in East Asia, edited by Izumi Nakayama and Angela Leung, and published by Hong Kong University Press in 2017. Dr. Burns, thank you so much for talking with me today.

Susan Burns: Oh thank you for giving me an opportunity to join the podcast.

TG: You have this forthcoming book Kingdom of the Sick: Leprosy, Citizenship, and Japan, looking at leprosy in particular, but also the history of disease in Japan. And so, much of your work has looked at Japan’s long 19th century. So I’m curious: could you tell us about this work on leprosy that you’re doing? And what position does the Meiji Restoration play in this history of disease in Japan?

SB: That’s a great question. So, leprosy since about the year 2000 has become a really big human rights issue in Japan, primarily because of the very long history of requiring people with leprosy to be quarantined. And much of the literature being written in Japan on this issue starts with the first national law, which was promulgated in 1907, and so, the sort of master narrative that has emerged over the last two decades focuses on the role of the modern state in creating stigma of leprosy and enforcing this requirement that people with leprosy be confined in leprosy sanitarium or leprosaria, as they’re often termed.

And in my book, I became aware quite early on that in fact, there was a long history of stigma, and that leprosy came to national consciousness in the 1870s, in the aftermath of the Meiji Restoration, long before the state itself was interested in leprosy as a public health issue. So in the early years after the Restoration, the Meiji government was primarily concerned with acute infectious diseases like cholera, typhoid, typhus, and leprosy as a chronic disease (generally understood to be a hereditary disease in this period) wasn’t a big public health concern. So by taking up this transition from the early modern period over the 1868 divide, I was able to see, I think, something quite new about leprosy, and who were the actors or agents in transforming it into a public health issue.

If I could back up a little bit, it’s quite clear that leprosy became an issue in the medieval period. People with leprosy were classified as hinin or one category of outcaste people, and they were often marginalized within medieval society. And then after the formation of the Tokugawa shogunate, we see that people with leprosy come to be incorporated into the early modern system of status. So they are, again, defined as a group of outcaste people, which, in this context, comes to mean people who have officially recognized begging rights, and so, there’s also an early modern process of spatial marginalization. So, people with leprosy are confined in what are called “leprosy huts” or “leper huts,” or in leprosy villages. There’s some kind of variation based upon the domain, and whether it’s a urban vs. rural setting, so we find a pattern of stigmatization of people with the disease, and spatial segregation in the early modern period. So, that’s the first part of my book.

And then second part comes to look at the post-Meiji Restoration period, and one of the first things that happens is that when the new Meiji government in 1871 issues the Emancipation Proclamation, which brings an end to hinin or outcaste status, eta status. The official begging rights that had sustained people with leprosy who were confined in either a leper hut or a leper village, these people (many of whom were disabled) were left without any means of support, and because this system of segregation then dissolved quite quickly, people with leprosy became newly visible because now, they’re begging in places where they didn’t appear previously. So, I think that’s one moment when they come into public visibility as they’d never been before, and then what happens is that you see new individuals becoming interested in the plight of people who suffered from leprosy.

So, in the early newspapers in Tokyo certainly, but also in Osaka, in places like Sendai or Akita, new provincial or prefectural capitals I should say, you see journalists talking about the need to do something, that the plight of these people have to be addressed and calling upon the Meiji government to do something to aid them. Then another one of the developments in this period is that foreign missionaries from Great Britain, from France and then from the United States also take note of the difficulties of people who suffered from leprosy, many of whom are either on their own to safeguard the reputation of their families or because their families come to feel that they are a burden, force them out. So, you see missionaries, then, involved in creating hospitals and other kinds of institutions to house people with leprosy.

And then the third element is that the new, emerging modern medical marketplace also becomes interested in people who suffer from leprosy. And so, we see new kinds of medical entrepreneurs, many of whom are actually people who are trained in kanpō, or Sino-Japanese medicine, getting involved in selling what we would call patent drugs that they claim are effective for leprosy, or creating new hospitals that offer inpatient treatment. So, there’s a variety of things that are happening in the 1870s and 1880s in civil society that bring leprosy into the public sphere as it had never been before.

TG: You were talking about leprosy in the medieval period. I kept thinking about these scrolls of affliction that depict the different stages of karmic retribution, and you were talking about leprosy as a disease of karmic retribution. And then as you were saying, by the 1870s and 1880s, we get to more germ theory understandings of disease. Does that impact the government’s reaction to these diseased bodies?

SB: Well, I think in terms of medical discourses, actually three moments. And one is indeed, the medieval understanding of leprosy (or rai or raibyō, as it was termed in Japanese) as a karmic retribution disease or also a heavenly retribution disease. You know, it reflects the rise of Neo-Confucian discourse. But then, in the early modern period, you see its redefinition as a bad blood disease, as a disease that originates in blood or blood ki as it was understood in Sino-Japanese medicine, so that it arises when blood becomes hot and stagnant, when it ceases to flow through the various vessels of the body. The key thing about this new medicalized understanding of leprosy is that once it’s thought of as a bad blood disease, it is understood as something that then can be transmitted from parent to child. And so, this is the moment when the idea of leprosy as a hereditary disease really takes hold in Japanese society.

In the medieval period, under the idea of karmic retribution, individuals were stigmatized, but then, under this idea of leprosy as a bad blood disease, it comes to be defined as a disease of the lineage and so, even people who were not infected, if they had somebody within their lineage who was infected, the stigma became much wider. And so, it’s in relation to this that you have new taboos against marrying people who come from a family where someone has the disease. So, it becomes newly stigmatized in relation to this new medicalized understanding of the disease.

Now, because it’s understood as hereditary…and in fact, the pattern of infection that everybody who’s talking about leprosy takes note of, that it often appeared within familial groups not by casual contact. And this does indeed reflect what we know about the modern epidemiology of leprosy – that you don’t easily catch it. So, in the period after the Meiji Restoration, the idea that it is hereditary is not easily overcome. Hansen, the Norwegian scientist who discovers the mycobacterium that causes leprosy and lepra… it’s a sensation, and yet there’s a great deal of resistance to the idea that leprosy is infectious not only in Japan but really, globally. And that is because of the peculiar way in which the disease works in that you can have long-term, sustained and intimate contact with the sufferer and not be infected. So, there’s a great deal of debate in Japan in the 1870s and really, well into the 20th century about whether there’s something else going on, whether it is an infectious disease in the way that tuberculosis, for example, is.

TG: At the risk of eliciting a collective groan from the listeners, when you’re talking about institutionalization and the state gaze of disease brings to mind Foucault’s Birth of the Clinic. So, did you find similarities? Is this an example of institutionalized power or were you resisting that comparison to Foucault?

SB: You know, I think I am resisting it. I think there’s a number of distinct moments. So, one of these first moments in the modern period is a new confidence on the part of many Japanese doctors that leprosy can be cured. And so, we see in the 1880s and 1890s a real confidence on the part of a group of doctors in Japan, based in Tokyo . The most famous figure is a guy named Gotō Masafumi, and his son whose name is Gotō Masanao. Masafumi is a kanpō doctor, and he develops a whole array of proprietary medicines, and they are really quite effective in relieving the symptoms of leprosy. And he gains an international reputation for being able to treat leprosy effectively, and based upon this, his son is hired by the Bureau of Health in Hawaii. He attracts patients from Hawaii and the West Coast of the United States and from China, who come to Tokyo to seek treatment. And so, there’s a real confidence and a celebration of Gotō Masafumi and his imitators, the whole slew of them who are establishing private leprosy clinics in Tokyo.

So, there’s that moment, and then there is a growing awareness around the turn of the century that while these proprietary medicines can relieve the symptoms of leprosy, it is not a cure. And that’s when, I think, Japan, like other countries around the world, becomes infected with what has been called “leporiphobia.” And there’s a new call on certain figures within the Japanese Parliament (the Diet) to confine sufferers of leprosy. Now, what’s interesting here is that while you have certain figures within the Diet calling for the confinement of all sufferers of leprosy, people within the Bureau of Health in the Home Ministry don’t buy into this kind of hysteria. And instead, they are concerned with what were often called “wandering leperers,” and I want to put this in scare quotes. I don’t believe we should ever reduce people to their disease, so I’m using “leper” in the historical sense, in which it was used in this period.

So, the figures within the Bureau of Health think that this should be treated not as a public health issue, but as an issue of poverty and poverty relief. The first law (the one that was promulgated in 1907) called for the creation of leprosy institutions to aid impoverished people with leprosy. And so, there’s actually quite a strenuous process to determine whether people had any other means of support, and if they did, they were not subject to confinement. It was only those who were truly in desperate straits that became the objects of this 1907 law, which created these regional institutions to house impoverished leprosy sufferers, and there are five of these. They were public institutions paid for by groups of prefectures that were joined together, so there were five so-called “zones,” and each one of these “zones” had their own institution.

And that’s really the state of things until 1931 when there’s a new law or I should say, a revision of the 1907 law, which opens up these institutions to all sufferers of leprosy. Although the law said that people who were a threat to public health could be confined coercively, it’s clear that people who were involved in developing the law felt that people would step forward for voluntary institutionalization based upon the possibility of treatment and support. So, I don’t think it neatly fits the Foucauldian model.

TG: You were talking about these institutions and these hospitals that are erected around Tokyo and around Japan, and I understand that this led you into geomapping, and this is something you even brought into your classroom now. So, could you tell us about this geomapping project that you’re doing, and how you’re using it in your class?

SB: Sure. So, when I discovered the large number of private leprosy hospitals that were being created (the first one is in the late 1870s and then into the 1880s and ‘90s), I was quite interested in the question of where in Tokyo these institutions were located. And as you and many of your listeners probably know, Tokyo was destroyed in 1923 with the Great Kantō Earthquake and then with the bombing in 1945. So just by looking at the addresses of these institutions, it’s very hard to figure out where they actually were.

And so, that got me interested in the question of mapping them. I took a couple of courses on ArcGIS, and I was able to map these 15 or so leprosy hospitals, and I was quite intrigued by the fact that they were in some of the most densely populated parts of Tokyo. They were often near streetcar stops. One was actually quite close to the Imperial Palace, so it’s not what I expected, you know. I thought they’d be in outlying parts of the city, so that got me thinking about where other medical institutions in this early post-Restoration period were located, and we see a whole slew of hospitals being established, one of these new modern institutions that is created in relation to the government program of medical modernization and what we call the new medical marketplace.

So then, I charted syphilis hospitals and clinics, new psychiatric hospitals (or asylum as they were called in those years), then I mapped TB hospitals and clinics, and now I’m working on quarantine hospitals that were established during periods of cholera epidemic. So, I became quite enthusiastic about how ArcGIS could become a mode of analysis as well as a way of providing visualization of the results of my analysis. And I have taught a course on the history of Tokyo several times. I have actually called it the History of Edo/Tokyo because we start in the early modern period.

The last time I taught the course, I devoted four sessions to instructing students on basic ArcGIS skills in our computer lab, and then I encouraged them or I should say required them to develop their own projects that had to incorporate maps that they had created on ArcGIS. And the students did a fantastic job producing these really rich projects that showed me aspects of the city of Tokyo that I hadn’t been aware of. So, I found that it was a great way of getting students to engage with the cityscape in its materiality rather than as the idea of Tokyo.

TG: Now I’m really curious where all of these institutions were located. You said they were interspersed with the city, and certainly not on the outskirts, where in [the] North American context, we’d expect asylums off out in the middle of nowhere.

SB: I should say that the asylums were actually the outlier in my study because whether TB, syphilis, and of course, the leprosy hospitals, all of those tended to be located within the business districts of the city. But the outlier were actually the early psychiatric hospitals, and these indeed tended to be in suburban areas, what were village areas that would later come to be incorporated within the city. And I think (I thought about this for quite a while) it is because the crime that was associated most closely with the mentally ill was actually arson, and as you probably know and I think many of your listeners know, Tokyo as a city (well, Edo as a city) that was largely constructed of wood had historically been subject to a number of extremely damaging fires. And so, I think this idea that the mentally ill were prone to arson meant that the directors of these institutions were not keen to establish them in densely populated areas of the city. So, those institutions were outliers in that they did indeed tend to be outside the city proper.

TG: And you mentioned arson in Edo, and I was reminded of the punishment for arson, [which] was burning at the stake. And that would happen at these execution grounds like Suzugamori or Kozukappara in Edo, but those areas are marginalized in the city maybe because of, maybe, ideas of karmic retribution and pollution of death. That doesn’t happen in the case of these other hospitals then.

SB: Yes. I mean, I was really quite intrigued. You know, my first case study was leprosy, and I was really surprised, but I guess I would say that because by probably the late 18th-early 19th century, you know, this idea of leprosy as a hereditary disease had really taken hold. That stigma of karmic retribution wasn’t as potent as it had been in the medieval period, and so, I think the way in which the stigma of leprosy operated is that people were not necessarily concerned about casual contact. It was marriage, for example, that was a problem, marrying into a lineage.

So, we see even there’s a famous conference in 1919 that brings together the directors of the early public sanataria, people within the Bureau of Health and the foreigners who headed up the missionary endeavours for housing people with leprosy. And interestingly, all of the foreign missionaries (Christian and Catholic missionaries) called for laws forbidding marriage between healthy people and people with leprosy, so they are still very much within this idea that leprosy is a hereditary disease. On the other hand, the Japanese involved with public health policy toward leprosy regard it as an infectious disease, and they are not interested in putting these kinds of laws into place. So, I was quite interested to read against the grain of the Japanese language historiography on leprosy, which I think has missed some of the interesting complications of this particular story.

TG: Another project I understand you’ve been working on is Gender and Law in the Japanese Imperium. And is there a gendered aspect to leprosy treatment?

SB: Yes. You know, I think of myself as a social historian of medicine and public health with a deep interest in gender and sexuality. One of the themes that’s running through my book on leprosy is the policy of sterilization that was widely used within Japan’s leprosy sanitaria, and the early public sanitaria, at the point of origin, had a policy of sexual segregation. And this, I think, reflected to some degree this concern about the well-recognized pattern of parent to child infection. So really, from the point at which they were established, the public sanitaria had in place this ideal of sexual segregation. The institutions, I argue, were actually organized around this, so we often, in fact, every case, we see the male dormitories and the female dormitories situated apart and generally, with some kind of barrier.

In one case, it was an actual guardhouse, but in other cases it’s the shared facilities, the place where people cooked and ate, the recreation area, that those would be situated between as a kind of barrier. But very soon, the directors of these early institutions discover that patients would have none of it. So, an early focus of patient resistance was on this policy of sexual segregation. Eventually, because of patient resistance, they begin to allow men and women to form relationships and form sexual relationships, and inevitably, the population of these institutions were mainly people between the ages of 18 and 40, so prime reproductive age. People began to have babies, and there was a great deal of concern about the health of these children.

Initially, the director of the Tokyo sanitarium tries to place children that were born to patients within the sanitaria into the poorhouse of Tokyo, which was actually charged with caring for abandoned children. But he found that they were neglected by the staff, and then he became interested in fostering them with people who were living in the agricultural villages nearby the sanitarium, but he was unable to come up with funds that were traditionally a part of a fostering relationship.

So eventually, he hits upon the idea that male sterilization by the use of vasectomy, which was then a very new medical procedure, could be the key to allowing people to have sexual lives within the sanitarium, but not have children. So, this doctor engages in a period of experimentation on animals to perfect the procedure, and then he asks for patient volunteers. And in his account, people step forward and agree to undergo vasectomy as a test case, and over the course of…this happens in the 1910s through 1945, male sterilization is widely used in all of Japan’s leprosy sanitaria. There’s several published studies, and everything that I’ve been able to discover in terms of documentary evidence is that it was based upon voluntary participation. There is, I think, evidence both ways about whether people were coerced or not. There are a number of people who undergo vasectomy who are not within an institution, so then it could only have been voluntary because there was no way to coercively require people to undergo sterilization who were not in an institution. On the other hand, certainly within institutions, I think, it comes to be taken that this is the ethical thing to do, and so certainly, given that, people may have felt a degree of psychological coercion.

TG: The Meiji at 150 Podcast is hosted by Tristan Grunow at the University of British Columbia in Vancouver, Canada. This podcast would not be possible without the cooperation of the UBC Centre for Japanese Research and the technical assistance of the UBC Faculty of Arts ISIT. Find out more about the Meiji at 150 Project, including the Meiji at 150 Lecture Series, Digital Teaching Resource and Workshop Series by visiting our website: meijiat150.arts.ubc.ca. Thank you for listening.


*Citation for this episode:

Susan Burns, interview with Tristan Grunow, The Meiji at 150 Podcast, podcast audio, February 5, 2019. https://meijiat150.podbean.com/e/episode-91-dr-susan-burns-chicago/.

The Meiji at 150 Podcast is hosted, produced, and edited by Tristan Grunow, with editorial assistance from Joshua Linkous. Transcripts by Kelly Chan.