Epidemic Prevention in Chinese History

The Chinese nation has had to constantly contend with disease throughout its thousands of years of history. From ancient times to today, our country has accumulated a wealth of experience from efforts to prevent and control the harm caused by disease, particularly severe infectious diseases. It is worth looking back on this experience to see what lessons can be drawn from it.

I. The historical damage wreaked by epidemics

The number of epidemics recorded in Chinese history is enormous. The Chronological Table of Epidemic Diseases in Ancient China contains 826 records before the year 1840, with many of these epidemics having seriously impacted the country's political, economic, and social development.

It is well known that the Battle of Red Cliffs during the Three Kingdoms Period in 208 witnessed the defeat of the army under the warlord Cao Cao by the joint forces of Liu Bei and Sun Quan. However, there was another important factor influencing the outcome of the battle that was not included in the classic novel Romance of the Three Kingdoms. In the historical text Records of the Three Kingdoms, it is written, "Cao Cao arrived at the Red Cliffs and engaged Liu Bei, but was unsuccessful. At the time there was an epidemic, and many officials and officers died, so he withdrew and retreated." 

In the year 754 during the Tang Dynasty, general Li Mi attacked the kingdom of Nanzhao in present-day Yunnan Province with 70,000 troops. In preparation for the battle, Nanzhao strengthened its defenses and cleared the fields. The Tang army ran out of provisions, and was eventually defeated after most of the soldiers died from hunger and disease. Wails of agony echoed in villages around the country as parents lost their sons and wives lost their husbands, and it was said that no matter how many thousands of men were sent to conquer Nanzhao, none would return. This became the fuse that sparked the rebellion against the Tang emperor by An Lushan and Shi Siming in 755, dragging the once flourishing dynasty into decline.

During the war to resist the Mongol armies in the late Southern Song Dynasty, the Diaoyu Fortress in present-day Sichuan Province withstood siege for an astounding 36 years. At the time, an epidemic spread among the Mongol forces. In The History of the Yuan Dynasty, it is written that while the Great Khan Mongke was personally leading his army in the year 1259, a severe epidemic broke out among troops stationed at Diaoyu Mountain in Hezhou, which forced the withdraw of the Mongol armies. However, this granted the soldiers and civilians of the Southern Song a reprieve, allowing them to ultimately hold out until the year 1279.

The outbreak of disease also had a profound historical impact during the fall of the Ming Dynasty and the rise of the Qing Dynasty. It is recorded that Beijing suffered from a major epidemic that lasted from 1641 to 1643. The Veritable Records of the Reign of Emperor Chongzhen states, "a great pestilence descended on the capital, with tens of thousands dying each day." The epidemic was so severe that it deprived Beijing of the troops it needed to defend itself, and the city was thus easily taken when the peasant army of Li Zicheng later attacked.

The above are just a few examples that took place at key historical junctures. In reality, it could be said that not one year has gone by without one disease or another spreading to a certain degree somewhere across the vast land of China and harming the health of the people.

II. The expansion of knowledge on epidemic prevention

Every epidemic is inevitably met with efforts to counter it. Even the ancient oracle-bone inscriptions, the earliest written records in Chinese history, show measures that were taken to fight disease thousands of years ago. For example, one section advises people to stay away from those who are ill, because they may have a contagious disease. At the ruins of Yin, ancient capital of the Shang Dynasty (17th-11th Centuries BC) in present-day Anyang, Henan Province, where many of these relics were unearthed, well-built sewers were also discovered. This suggests that the ancient city already had public health facilities that helped reduce the incidence of epidemics.

In The Rites of the Zhou Dynasty, it is written that during the Zhou dynasty (1046-256 BC) the king's court conducted regular checks of people's homes to drive away disease, and that there were officials responsible for burning various kinds of wood corresponding to different seasons in a ritual intended to stop epidemics. The Rites of the Zhou Dynasty is also the first piece of writing in which the now commonly used combination of Chinese characters for the word "prevention" is used. The use of medicine to intervene in the spread of disease also emerged in this period, with the Classic of Mountains and Seas describing seven types of medicinal herbs.

The Qin Dynasty (221-206 BC) bamboo strip texts unearthed in Yunmeng County, Hubei Province describe mechanisms for relocating convicts afflicted with leprosy. Furthermore, the Han Dynasty (206 BC-AD 220) had organizations for sheltering and treating the common people at times when epidemics were raging. In The History of the Han Dynasty, it is written that people with contagious diseases were brought together and isolated in designated dwellings where they were given treatment. This represents the first relatively standardized record in China's history of epidemic prevention.

During the Qin and Han dynasties, the discipline of Chinese medicine gradually matured under the guidance of traditional philosophical thought, and theories and techniques to prevent and control disease were developed on the basis of practical experience. The Yellow Emperor's Classic of Internal Medicine, which is regarded as a classic of Chinese medicine, contains fully fleshed out ideas on epidemic prevention and control. It states that whether or not external causes lead to illness is determined by one's internal vital energy, namely the physical constitution and the strength of one's immune system, and therefore boosting one's vital energy can prevent illness. The book advises people to take preventative measures before they get sick, seek treatment early on if they have symptoms of illness, and take steps to avoid recurrence of their illness after treatment. Other Chinese medical classics such as Treatise on Cold Damage Disorders and The Herbal Classic of Shennong provide differential diagnosis methods and medicinal knowledge related to disease prevention and control. These classical theories have had far-reaching impacts on later generations.

Under effective theoretical guidance, Chinese society's understanding of epidemic prevention and control has constantly evolved.

Firstly, our understanding of contagiousness has deepened. For example, in further differentiating diseases according to their contagiousness, the Sui Dynasty physician Chao Yuanfang (a. 550-630) stated that infectious diseases were spread through pestilential factors, with each having their own particular causes. On this basis, Wu Youke (1582-1652), a famous Ming Dynasty scholar and author of the Treatise on Pestilence, formed a theory of these factors. He wrote that pestilential factors were simultaneously material and immaterial, making the insightful inference that epidemics might be caused by some kind of invisible substance. This comes very close to a hypothesis of microbial etiology.

Secondly, our epidemic prevention and treatment methods have advanced. On the level of prevention, the Eastern Han physician Hua Tuo (a. 145-208) introduced the use of medicated liquor and the Eastern Jin Dynasty scholar Ge Hong (284-364) introduced the use of powdered medicine made of monkshood, Chinese bellflower, and other herbs, while later on others introduced the use of powder made from wrinkled gianthyssop as an everyday supplement to boost vital energies. During the Tang and Song dynasties, aromatics were widely used to prevent disease, while in the Ming Dynasty (1368-1644) it was popular to burn the dried rhizomes of atractylodes to purify the air. A folk technique for preventing smallpox through inoculation emerged around the middle of the Ming Dynasty, and after constant development, by the Qing Dynasty (1616-1911) it had spread to many places, including the imperial palace where members of the court were vaccinated. A number of foreign envoys also came to learn about this technique and took it back to Europe. On this basis, the English physician Edward Jenner (1749-1823) invented the cowpox vaccination technique, laying the foundation for the eventual extermination of smallpox globally. On the level of treatment, earlier theory on exogenous febrile disease led to the formation of systems devoted to the study of epidemic febrile illnesses and infectious diseases, thus providing clinical practice with more comprehensive theoretical guidance.

Thirdly, our prevention and control measures have constantly improved. Institutional measures for preventing epidemics were already in place by the Jin Dynasty. The Book of Jin states that courtiers who had three or more family members infected with disease were forbidden from entering the palace for 100 days, even if they were not sick themselves. During the Song Dynasty (960-1279), people were careful to cremate and dispose of the remains of those who had died from disease as quickly as possible. In the Qing Dynasty, an area was set up in the imperial palace to quarantine those infected with smallpox, and it was stipulated that visits by relatives were only allowed after the infected had been isolated for nine days.

The above shows that ancient China had a wealth of experience and theories regarding epidemic prevention, but there were also some obvious bottlenecks.

During the Song Dynasty, multiple epidemics occurred, and the government frequently dispatched medical officials to distribute medicine and provide relief in local communities. This painting by Song Dynasty artist Li Tang is a vivid depiction of how doctors would treat patients at the time. FILE PHOTO 

The first bottleneck was the lack of organized epidemic prevention. This problem was inevitable due to the limitations of feudal rule. Every time an epidemic spread among the people, local governments and prominent community figures could often only make temporary efforts to take people in and distribute medicine, while sustained measures were lacking. The Ming Dynasty scholar Lu Kun once cried out that all prefectures should devote special funds for training doctors and purchasing materials to make medicine in order to prepare for potentially disastrous epidemics. In the backward and chaotic age of feudalism, however, it was basically impossible for such calls to have a real impact.

Another bottleneck was the lack of protective skills. Although it was recognized that diseases could be contagious, it was impossible to stop them at the fundamental level. This limitation was a serious theoretical challenge to ancient epidemic prevention efforts, and was discussed by scholars during the Song Dynasty. Constrained by scientific and technological factors, ancient scholars had no way of knowing that there were pathogens of different sizes floating in the air, and were therefore unable to invent protective tools or effectively eliminate these pathogens.

III. Great doctors that have emerged during epidemics

Doctors are essential in efforts to prevent and control disease. In ancient China, wave after wave of great doctors stepped up during severe epidemics, leaving behind valuable experience and inspiration for later generations.

Between 1910 and 1911, a major outbreak of plague erupted in northeast China. The Qing government assigned Wu Lien-teh, a doctor of Western medicine, to take charge of epidemic prevention efforts in the three northeastern provinces of Heilongjiang, Jilin, and Liaoning. By preventing the spread through a series of isolation methods, Dr. Wu was able to effectively bring the epidemic under control. This photo was taken while quarantine measures were in place. In 1911, Shenyang hosted the International Plague Conference, the first international medical symposium ever hosted in China.

FILE PHOTO

During the final years of the Eastern Han Dynasty, the renowned doctor Zhang Zhongjing (a. 150-215) wrote his famous Treatise on Cold Damage Disorders in the midst of an epidemic. The book identifies the different stages of these illnesses based on meticulous analysis of changing symptoms, and recommends corresponding therapies. It thus became a classic work on the concept of differential diagnosis in Chinese medicine. Zhang emphasized the importance of a spirit of responsibility among doctors for using their skills to treat the illnesses of their superiors in society while also using them to save the people of lower social strata from suffering. In his medical research, he adopted a rigorous approach through which he diligently studied ancient teachings while also learning extensively from folk remedies. As a result, he became known by later generations as the "Sage of Chinese Medicine."

In his work On the Absolute Sincerity of Great Physicians, the famous Tang Dynasty doctor Sun Simiao (a. 541-643) established the standards of ethics for Chinese medicine. For example, the text states that doctors must have a compassionate heart, and pledge themselves to saving living beings from suffering. It also states that when treating the sick, doctors must not hesitate out of concern for their reputation. Sun practiced what he preached, taking in and treating more than 600 lepers who had become social outcasts as a result of their affliction. He was thus revered for his medical ethics and skills by later generations, earning him the title "King of Chinese Medicine."

In the year 1232, the Mongol armies began a siege of Bianjing at the present-day city of Kaifeng. The soldiers of the State of Kin fought for months to defend the city, but then a major epidemic occurred. The History of Kin states that this great pestilence lingered for more than 50 days and claimed the lives of more than 900,000 people. To this day, scholars still have differing opinions about what kind of disease caused the disaster. At the time, however, the famous doctor Li Gao (1180-1251) employed the approach of Chinese medicine to establish the Spleen-Stomach Theory, which postulated that managing internal disorders of the spleen and stomach would allow the body to conserve vital energy and resist pathogens. This applied particularly to people who were malnourished as a result of the chaotic wartime environment. For acute diseases, Li Gao created a toxin-purging beverage that saved many lives, and the formula for this medicine was passed down in the form of stone tablet carvings.

During the Ming and Qing dynasties, many methods for combatting disease emerged that are still used today. All of these breakthroughs were pieced together by well-known doctors on the basis of their practical experience. Sometime between 1893 and 1894, a serious outbreak of plague occurred in southern China, spreading from Gaozhou, Guangdong Province to Guangzhou and Hong Kong and subsequently lasting for years. During the outbreak's initial spread, a doctor of traditional Chinese medicine in Gaozhou named Luo Rulan conducted thorough research, bravely entering affected areas to repeatedly observe patients' conditions and gradually developing an effective treatment. However, when the epidemic flared up again the following year, it was discovered that the original treatment was now ineffective. Luo again began conducting practical research, finding that the pathogen had become more aggressive. The dosage of medicines used to treat the disease was therefore doubled, and over 90% of the infected were ultimately saved. He wrote about his discoveries in the Compilation on Plague, which was later widely disseminated and put to use by doctors across the country.

Confronted with all kinds of epidemics, generation after generation of great doctors have stood firm in the face of danger, developing treatments and accumulating valuable experience through practical efforts. At the same time, however, we must also recognize the difference between prevention and control. For example, although Luo Rulan discovered effective treatments for the plague, he could not find a way to stop it from spreading. The Shen Bao newspaper reported that tens of thousands of people died in Guangdong Province in 1894 alone, with an additional 200,000 death as a result of the epidemic over the decade that followed. Meanwhile, Hong Kong adopted quarantine measures to curb the spread of the plague in 1894. Rigorous checks were enforced on transportation, and infected persons were put in isolation at centralized facilities. In the end, there were 2,552 related deaths in Hong Kong that year. At the time, there were still no effective treatments since the medical community had just discovered the pathogen that caused the plague, so Hong Kong's success in fighting the epidemic was mainly the result of preventative measures. This illustrates the fact that when combatting infectious diseases, even the best treatments are hindered by limits on how quickly or broadly they can be deployed, and therefore we must rely on forceful preventative measures to restrict transmission. With the world becoming increasingly interconnected since the beginning of modern times, epidemic prevention is no longer a matter for individual countries, but rather an issue that is regional or even global in scale.

IV. The Chinese experience of laying equal emphasis on Chinese and Western medicine

The arrival of modern Western medical science in China in the late Qing Dynasty lead to much rivalry and debate between proponents of Chinese medicine and Western medicine. Meanwhile, the Qing government was dragging its feet and failed to institute systematic public health reform. Sometime between 1910 and 1911, a major outbreak of plague erupted in northeast China, threatening Beijing and Tianjin. The Qing government also faced immense diplomatic pressure since the northeast fell into the sphere of influence of Japan and Russia. It was under these circumstances that Wu Lien-teh, a Malayan-born Chinese doctor trained in Western medicine, was called upon to take charge of epidemic prevention efforts in the three northeastern provinces of Heilongjiang, Jilin, and Liaoning. Through a series of quarantine and prevention measures, Dr. Wu was able to bring the epidemic under control. In 1911, the International Plague Conference was held in Shenyang. This was the first international medical symposium ever hosted in China.

After the founding of the Republic of China on January 1, 1912, national organizations for public health and epidemic prevention were gradually established, including the Central Epidemic Prevention Bureau, the North Manchurian Plague Prevention Service, the Northwest Epidemic Prevention Bureau, the Inner Mongolia-Suiyuan Epidemic Prevention Bureau, and the Seaport Quarantine Bureau. Meanwhile, provinces successively established public health administration organizations that included epidemic prevention in their functions. In 1916, 1930, and 1944, national legislation regarding the prevention and control of infectious diseases was released.

Since public health-related work advanced quite slowly, many urban and rural areas still relied solely on traditional Chinese medicine to prevent and treat infectious diseases. At the time, some began to question the scientific basis of Chinese medicine, with many even suggesting that it should be abandoned altogether. 

Dr. Tu Youyou, chief researcher at the China Academy of Chinese Medical Sciences, discovered the antimalarial effects of sweet wormwood after sifting through countless ancient Chinese medical texts. She extracted the active compound artemisinin from the plant, which has saved millions of lives around the world. In 2015, she was awarded the Nobel Prize in Physiology or Medicine. Pictured left to right: Dr. Tu, a sweet wormwood plant, and antimalarial tablets. FILE PHOTO

However, practitioners of Chinese medicine had in fact long been absorbing new knowledge and playing an important role in the prevention and treatment of infectious diseases. For example, during the 1917-1918 plague outbreak that affected Shanxi Province, doctors of Chinese medicine including Cao Yuansen and Yang Haoru went to Datong to coordinate with doctors of Western medicine on epidemic prevention efforts. During the 1919 cholera outbreak in the Langfang area, Yang Haoru, Kong Bohua, and other doctors of Chinese medicine went into the villages to treat the sick and were warmly welcomed. The experiences of these doctors in fighting the two epidemics were later recorded in the book Treatment and Analysis of Eight Infectious Diseases.

In 1924, Shanxi Province once again suffered an outbreak of plague. The Shanxi Society for the Improvement of Chinese Medicine assigned three doctors of Chinese medicine that were also knowledgeable of Western therapeutic techniques to take charge of the fight against the epidemic. Combining elements of Chinese and Western medicine, these doctors were able to quickly bring the outbreak under control. Afterward, they compiled detailed reports describing the effects of Chinese and Western treatments. Their work is testament to the clear value of coordination between Chinese and Western medicine.

The government of the Republic of China later adopted the Regulations on Traditional Chinese Medicine, giving Chinese medicine legal status. During the War of Resistance Against Japanese Aggression from 1931-1945, Chinese medicine was incorporated into the wartime epidemic prevention system. First-aid hospitals employing Chinese medical techniques were established under the Central Bureau of National Medicine, and these played an active role in providing relief to soldiers and civilians in areas such as Nanjing and Chongqing. In addition, a national drug research laboratory was established due to the fact that supplies of the anti-malarial medication quinine were cut off. Studies performed through this organization proved that the evergreen hydrangea, a plant used in Chinese medicine, showed positive results in treating malaria. Researchers then extracted dichroine, the effective component of the herb, and determined its chemical structure, capturing the attention of the global pharmacology community in the process.

The border regions controlled by the CPC all instituted public health and epidemic prevention policies that combined elements of Chinese and Western medicine. Speaking at Yan'an University's opening ceremony in 1944, Mao Zedong said, "Chinese and Western medicine share the common goal of curing disease.... We therefore make the following call: doctors of both disciplines must cooperate with each other." The border regions also made extensive use of Chinese herbal medicines to prevent and treat epidemic diseases.

The establishment of the socialist system after the founding of the People's Republic of China opened up a whole new path for our country's public health and epidemic prevention efforts. In August of 1950, the PRC held its first national public health conference, which set the guiding principles of focusing on prevention and seeking integration between Chinese and Western medicine. In 1951, the CPC Central Committee issued directives on enhancing epidemic prevention and medical care, which laid out a comprehensive plan for national epidemic prevention efforts. Over the last several decades, China has vigorously carried out vaccinations, continuously conducted public health campaigns, built nationwide public health and epidemic prevention systems, developed laws and regulations to counter infectious diseases, and launched dedicated prevention and treatment efforts against plague, schistosomiasis, malaria, leprosy, tuberculosis, and AIDS. Smallpox was essentially eradicated in 1961, as was polio in 2000, and the numbers of people falling ill from numerous types of infectious diseases fell to historic lows. At the beginning of the 21st century, China rebuilt its national disease prevention and control systems and further augmented work related to public health and the prevention of contagious diseases. We successfully combatted novel infectious diseases including SARS, avian influenza, and the SFTS virus. Thanks to constant improvements in public health and preventative medicine, the health of the people has been well protected, with average life expectancy rising from 35 years at the founding of the PRC to 77 years today. As a result, people now have stronger feelings of fulfillment, happiness, and security. Seven decades of experience in fighting to prevent epidemics since the founding of the PRC has taught us that in a country with a population as large as ours, it would have been impossible to secure the success we have achieved in the public health domain without the firm leadership of the CPC, the unified and highly efficient socialist system, the guiding policy of putting the people first, and the vigorous progress we have made in medical care.

Throughout this process, traditional Chinese medicine has played a positive role, and demonstrated its wide range of special qualities. When an outbreak of Japanese encephalitis, now called encephalitis B, occurred in Shijiazhuang, Hebei Province between 1954 and 1955, a doctor of Chinese medicine named Guo Keming was able to save numerous patients. After the Chinese medical treatments that he used were proven effective by on-the-spot investigations conducted by experts from the Ministry of Health, they were shared throughout the country. When another outbreak of Japanese encephalitis occurred in Beijing in 1956, Pu Fuzhou, a renowned doctor of Chinese medicine, applied the same techniques used in Shijiazhuang. Finding that the effects were not ideal, he decided to add medicines used for dispelling dampness from the body after considering Beijing's particular circumstances and achieved good results.

In 1967, China launched Project 523 to research and develop new antimalarial medications. Through this project, a scientist named Tu Youyou discovered the compound artemisinin and extracted it from sweet wormwood, a plant used in Chinese medicine. After a long period of testing involving nationwide cooperation, it was proven that the compound has positive antimalarial effects. In 2015, Tu was awarded the Nobel Prize in Physiology or Medicine for her work. This shows that there are many treasures worth looking into in the vast catalogues of Chinese medicine.

During the 2003 SARS outbreak, when China was trying to implement effective measures to prevent and control this new and completely unknown disease, Chinese medicine played an active role in treatment, earning approval of experts from the World Health Organization for its positive results in bringing down fever and reducing the incidence of residual symptoms. This reflects yet another strength of Chinese medicine in the treatment of epidemic diseases. In cases where it is unclear what kind of pathogen is causing a particular disease, Chinese medicine can be used as a diagnostic tool on the basis of its traditional theories regarding the relationship between nefarious and vital energies and offer patients relief quickly.

Evidently, by taking full advantage of traditional medicine and boosting coordination between Chinese and Western methods as our nation continues to vigorously enhance our scientific and technological sophistication in the medical field and improve mechanisms for preventing and controlling infectious diseases, we will be able to drive epidemic prevention work forward in the new era.

At present, the Chinese people are locked in a serious battle against the COVID-19 pandemic. But with the firm leadership of the CPC Central Committee with Xi Jinping at its core, with the solid material foundations laid down since the founding of the PRC and particularly since the launch of reform and opening up, with the support of the Chinese spirit bred through patriotism, reform, and innovation, and with the bravery of our medical personnel fighting on the front lines, the heroic Chinese people will undoubtedly overcome the specter of disease and win the battle against this epidemic. 

Zheng Hong is Professor of Zhejiang Chinese Medical University.

(Originally appeared in Qiushi Journal, Chinese edition, No. 4, 2020)