Mission impossible: the American schistosomiasis delegation's visit to China in 1975.

Introduction

In 1949, the establishment of the People’s Republic of China (PRC) resulted in the cessation of mainland China’s diplomatic ties with Western countries. Only after U.S. President Richard Nixon’s visit to China and the signing of the Shanghai Communiqué in 1972 were Sino-American diplomatic relations formally established. Academic exchanges between the PRC and the United States then began. Formed in 1966, the Committee on Scholarly Communication with the PRC (CSCPRC) had, since 1973, facilitated many U.S. scholars’ visits to China by acting as liaison with its Chinese counterpart (mainly Chinese Academy of Science) and providing economic support. Between 1973 and 1978, several American delegations traveled to China on scientific and academic exchanges concerning matters such as acupuncture anesthesia, herbal pharmacology, paleanthropology, insect control, and plant studies. The American Schistosomiasis Delegation (ASD) was among the exchange groups [1]. The CSCPRC began discussing a study tour on schistosomiasis with the PRC Scientific and Technical Association in May 1973; a trip took place from April 8 to May 2, 1975.

Unlike members of other scholarly delegations, the ASD members were dissatisfied with the tour because they were not granted access to the places and people they had wanted to visit and meet, so no significant achievements resulted from their trip. Their hosts, members of the Chinese Medical Association, however, were less concerned with engaging in meaningful scientific exchanges. Instead of providing the necessary assistance to the ASD, they frequently controlled the delegation’s itinerary and withheld information from them. The ASD issued a report in The American Journal of Tropical Medicine and Hygiene [2], in which it commented on the manner in which the Chinese medical scientists had hosted the visit.

This paper attempts to place the problems encountered by the ASD in China in a historical context and explore why in 1975 the Chinese Medical Association, as the official host, was reluctant to show the delegation the actual extent of schistosomiasis infection in the PRC.

Background of the ASD's visit to China

The ASD consisted of 12 members, with Ernest Bueding of Johns Hopkins University and Paul F. Basch of Stanford University, respectively, acting as chairman and deputy chairman of the delegation. Among the other members were six parasitologists and medical experts, one anthropologist, one historian, one chemist, and one representative from the U.S. Department of State. According to the members’ research output prior to 1975, none had conducted studies of schistosomiasis in China. It would, therefore, be interesting to know why they joined the delegation and came to China to understand the control of this epidemic.

Schistosomiasis japonica is a parasitic and fatal disease in tropical and subtropical areas where water snails, the intermediate hosts of the parasite, live. The southern provinces of China such as Anhui, Fujian, Jiangsu, Jiangxi, and Zhejiang had been seriously threatened by this disease. The spread of schistosomiasis, which adversely affected agricultural production, prompted Chairman Mao Zedong to initiate a mass anti-schistosomiasis campaign in 1955 under the slogan of “Schistosomiasis has to be eliminated.” The campaign, which integrated mass mobilization, science, agricultural production, local construction projects, and preventive works, aimed at ultimately removing one of the obstacles to the development of agriculture.

On June 30, 1958, Mao read reports in the newspaper People’s Daily that were related to eliminating schistosomiasis from Yujiang county in Jiangxi Province. Mao was very happy and could not sleep, instead writing a poem entitled “Farewell to the Plague Spirit” to commemorate the campaign in Yujiang county. Since 1958, the Chinese central government continuously promoted the idea that schistosomiasis had been controlled and the disease completely eradicated in 167 prefectures and cities, accounting for more than half of the total endemic areas. It is hardly believable that the PRC could have eliminated the illness in all the provinces between the 1950s and the 1970s. However, by the 1970s, it seemed the epidemic had been brought under control in some counties and provinces, ostensibly through Mao’s political will. The achievement made by the PRC in controlling schistosomiasis startled the world, which since then has remembered Mao as a fighter of schistosomiasis [3].

Many scholars considered that the anti-schistosomiasis campaign, which began in the 1950s, had in many ways effectively eradicated the disease. Brian Maegraith, professor of Tropical Medicine at the University of Liverpool, visited China in 1958 to study schistosomiasis and subsequently recorded his observations in his article “Schistosomiasis in China,” published in The Lancet. The article stated that “The Chinese have set as their target the practical control of schistosomiasis within twelve years from now. Their cooperative enthusiasm, skill and dedication to the task should enable them to achieve this objective.” [4] Tien-Hsi Cheng from the Department of Biology at Pennsylvania State University wrote in his essay “Schistosomiasis in Mainland China: a review of research and control programs since 1949,” published in 1971, that although there was considerable success in the prevention of schistosomiasis in the 1950s, the outbreak of the Cultural Revolution delayed the complete eradication of the disease [5].

In 1972, Hua-ling Nieh Engle and Paul Engle translated Mao’s poem “Farewell to the Plague Spirit” into English and gave an account of the schistosomiasis prevention campaign carried out in the 1950s [6]. Following their field study in 1972, Dr H.F. Hsu and Dr S.Y. Li Hsu co-authored and published in 1974 an article titled “Schistosomiasis in the Shanghai Area,” in which they mentioned that “this disease is now under control, as exemplified by the disease-free Hua Tsao commune, previously an important endemic area of schistosomiasis.” Members of the ASD could have learned about the efforts made by the PRC central government and local communes in combating schistosomiasis through reading these English language publications. It is not surprising that China’s ability to accomplish widespread control of schistosomiasis as early as the 1950s, as suggested in the articles, had attracted the attention of the ASD members, although they were not themselves schistosomiasis researchers or epidemiologists with a specialization in China.

Frustration to the ASD

The ASD arrived in Beijing in April 1975, with the Chinese Medical Association its host for the duration of the trip. Instead of immediately visiting the infected regions, which were concentrated in southern China, the members stayed in Beijing after their arrival. George H.W. Bush, then the U.S. ambassador in China, recorded in his memoir that the Chinese officials took the delegation members to the Great Wall and the Forbidden City for sightseeing and to famous restaurants to taste Chinese food. In the end, the members of the ASD could not achieve the objectives of their trip. Bush wrote, “Only after numerous requests — and finally complaints — did the Chinese bureaucracy break down and permit the Americans to examine their native snails.” [7] It was obvious that the Chinese ministers never intended to allow the ASD members to observe the infected areas. The ASD report stated that out of the 25 days of the trip, fewer than eight days were spent studying the prevention and treatment of schistosomiasis, and the remaining time was spent touring historical sites, factories, and facilities for youngsters and workers. After repeated demands, the ASD eventually was permitted to visit some limited locations along the Yangtze River, namely Shanghai and its nearby areas. Considering that members of the Han Dynasty Studies Delegation, who arrived at China in 1981, were able to go to places as far as Dunhuang in Gansu Province, the province furthest to the west [8], it appears difficult to explain why the mobility of the ASD was so severely restricted.

According to the ASD report, the information about schistosomiasis that the delegation had wanted to obtain was the following:

the extent of schistosomiasis infection in China after the Cultural Revolution, especially the prevalence rates for different endemic areas;

data, obtained through direct interviews with staff at institutions that had led the prevention campaign for the past 20 years;

the expenditure by the central government on disease control and the localities of disease control; and

the lessons learned by China from the prevention campaign that would be useful for other developing countries affected by the same disease.

The Chinese interference in the delegation’s trip, which can be categorized into the following three main aspects, caused the ASD’s failure to obtain any of the above information:

the delegation’s itinerary was under strict scrutiny and control;

the information about schistosomiasis supplied by the Chinese Medical Association was sketchy and vague, most of it dating back to the 1950s; and

the interviewees had been carefully selected and each gave standardized answers.

The scope of the interference suggests that the unwillingness of the Chinese to disclose information was not limited to a few officials. Instead, it was part of a central plan to restrict the activities of the delegation and provide only information censored by the Chinese Medical Association. Needless to say, such official information did not really assist the ASD in understanding the transmission, prevention, and treatment of the disease in 1970s China. For example, David Lampton pointed out that the number of beds the ASD members noted on their visit to a county hospital was not representative of the situation prevailing in other regions of China [9].

The discontent of the ASD with the overly official and rigidly structured itinerary probably came as a surprise to the host, the Chinese Medical Association, which had the experience of organizing a similar visit in 1972 for Dr H.F. Hsu and Dr S.Y. Li Hsu. When these experts went to Hua Tsao county (an endemic area in the western suburb of Shanghai) to study schistosomiasis, they made no complaint about their itinerary in their report. It was obvious that the places and people the two scholars visited and met were carefully planned and controlled by the Chinese Medical Association to ensure that all information they received and the observations they made suggested that the anti-schistosomiasis campaign had been a success. Moreover, other delegations sponsored by the CSCPRC to a certain extent also faced similar restrictions and they did not seem to have objected to their host’s behavior. Members of the Herbal Pharmacology Study Group, for whom sightseeing tours also had been arranged and who had been similarly prohibited from talking to the Chinese scientists in private during their visit in 1974, did not express any dissatisfaction with the limitations they faced in conducting their observations in their report [10]. This was because, unlike the ASD members, they were able to see what they had come to see.

Although representatives of the Chinese Medical Association repeatedly informed the delegation that schistosomiasis was completely eliminated in many endemic areas and the ASD concluded in its report that the Chinese interventions prevented it from objectively assessing the preventive measures adopted in China and their effectiveness, the ASD succeeded in making several important observations on the basis of the first-hand information collected during its short trip, which contributed to the construction of the history of schistosomiasis prevention in China. The ASD revealed that the schistosomiasis prevention units formed at the local level were unconnected to each other, and there was no channel for these units to share their research findings. Further, regarding medical research, they found the Chinese had emphasized their diagnoses and the screening of traditional Chinese drugs for anti-schistosomal activity, but no basic work on the immunology of schistosomiasis was being performed. A similar emphasis also was noted in their treatment of the host snails, as the Chinese were only concerned with wiping the snails out completely and their disinterest in studying the hosts of the disease was evident in the absence of the requisite equipment in their laboratories. The ASD report also found a lack of understanding of the quantitative work that had been done and of retrospective epidemiological investigations. Notwithstanding the limited extent of observations allowed, the ASD was sufficiently astute to note that “it is clear that even in some sites seen by our delegation, schistosomiasis is not yet a thing of the past.” Had the delegation traveled to the regions where the disease was most prevalent, such as Jiangxi Province or Hunan Province, its likely findings would undoubtedly have been alarming and unwelcome by the Chinese central government and the Chinese Medical Association. Why were the Chinese so desperate to ensure that the ASD would not discover that the official claim that schistosomiasis had been completely eradicated in most of China was false? The answer to this question may be found in the tightly woven relationship between schistosomiasis and communist politics at the time of the Cultural Revolution.

Schistosomiasis and the Cultural Revolution

The concluding comments of the ASD report state that “in some recent publications and broadcasts, Lin Piao [Lin Biao] is vigorously attacked because of his ‘counterrevolutionary’ statements that ‘schistosomiasis cannot be eradicated.’ These exhortations would hardly be needed if eradication had already been achieved.” In its report, the ASD interpreted the publications and broadcasts to mean that Lin Biao exposed the truth that schistosomiasis had, in fact, not yet been eliminated, and for this, he was being persecuted. Had the ASD considered such reports in the political context and deciphered their true meaning, it would have been able to deduce the reason for its failure to successfully carry out its mission.

Lin Biao, a political rival of Mao Zedong, died with his family in a plane crash when they attempted to escape from China on September 13, 1971. In 1974, during the Cultural Revolution, Mao’s wife Jiang Qing started the “Criticize Lin Biao, Criticize Confucius” movement, which reached its climax by 1975, the year the ASD arrived in China. Although Lin Biao was not actually closely associated with the anti-schistosomiasis campaign, he was the target of the popular slogan “Destroy Lin Biao and Confucius, Eradicate snails completely with conviction,” since schistosomiasis prevention and politics had long been inseparable issues in China.

Contrary to the ASD report, the person who had said that schistosomiasis could not be eliminated was Wei Wenbo, deputy leader of the nine-man Anti-Schistosomiasis Committee set up in 1955 under the auspices of the Central Committee of the Communist Party. During the Cultural Revolution, Wei Wenbo was labeled a counter-revolutionary. In 1968, Liu Shaoqi, the then president of the PRC, was accused by his political enemies of being a “capitalist roader” and traitor to the Communist Party and was subjected to vigorous attacks for more than a year. Beginning in 1970, the movement against Liu Shaoqi, who had died by then, was revived. Two newspaper editorials were published in Wenhui Bao and Jiefang Ribao on March 10, 1970, criticizing Liu Shaoqi for having turned the control of schistosomiasis, which was a matter of public health, into a power struggle. At the same time, Wei Wenbo was denounced as pro-Liu Shaoqi, and the statements made by Liu and Wei concerning eradication of schistosomiasis became the subject of severe criticism.

Mao launched the anti-schistosomiasis campaign in 1955. However, Liu Shaoqi thought the campaign squandered national wealth and labor without generating actual benefits. Wei Wenbo commented that it was impossible to eradicate all the host snails, since there was no way to completely remove the soil in which the snails lived and eradication of the disease could not be achieved within a generation. More importantly, the public health movements that commenced in the 1950s often stressed the importance of mass participation, and this characteristic was also dominant in the anti-schistosomiasis campaign. It was vital to the success of the campaign that the masses were mobilized to destroy the innumerable host snails. Wei Wenbo’s alternative opinion that experts should be relied on in controlling the epidemic was interpreted as being against the Cultural Revolution’s motto of negating the supremacy of professionals and technology. Because their views were contrary to Mao Zedong’s ideology, both Liu Shaoqi and Wei Wenbo were labeled counter-revolutionaries during the anti-Liu Shaoqi and Wei Wenbo movement started in 1970, and eliminating schistosomiasis was promoted as a symbol of the overthrow of Liu and Wei. Many articles published at the time in the daily newspaper Renmin Ribao opined that Liu Shaoqi disrupted the schistosomiasis prevention work. The same allegation was leveled in 1975 at Lin Biao, even though he was unconnected with the anti-schistosomiasis campaign. Clearly, the anti-schistosomiasis movement was manipulated as a weapon to achieve political ends.

At the time of the ASD visit to China in 1975, the control of schistosomiasis continued to be a sensitive political subject. Since Chinese officials in the 1960s already declared schistosomiasis eliminated in most of the affected regions despite the fact that it was still prevalent in many areas, staff of the Chinese Ministry of Health provided the ASD with standardized answers and 20-year-old data to prove that the disease had been eradicated and reinforce that impression to avoid being labeled counter-revolutionary and associated with members of the Liu-Lin camp.

The second visit to China

In 1984, Professor Paul F. Basch, the deputy chairman of the ASD, was sponsored by the CSCPRC to revisit China and study the prevalence of schistosomiasis there. In 1986, Basch published an article, “Schistosomiasis in China: An Update,” in The American Journal of Chinese Medicine, discussing his observations from the trip [11].

According to Basch’s report, the itinerary of this second visit was completely different. Basch was permitted to visit five cities, namely, Shanghai, Wuhan (Hubei Province), Hangzhou (Zhejiang Province), Xiamen (Fujian Province), and Hailar (Inner Mongolia Autonomous Region). In addition, he made a trip to a relatively remote rural area in Hubei Province. Basch was provided relevant information about schistosomiasis by many people on numerous occasions. Materially, Basch’s report also differed considerably from the ASD report. Besides pointing out the achievements made in controlling schistosomiasis, Basch also reported on its epidemiology in the provinces with the most infections and the operation of the disease control station in Yangxin county in Hubei Province, one of the disease epidemic centers, where he stayed for 24 hours to conduct observations. These were tasks that had been impossible to accomplish on his first visit as a member of the ASD delegation.

The absence of the sorts of restrictions imposed on the ASD mainly can be attributed to the fact that in 1984 Mao Zedong was already dead and the Gang of Four responsible for the atrocities committed during the Cultural Revolution had been arrested and punished, resulting in schistosomiasis and the question of its complete eradication no longer perceived as politically taboo subjects with a counter-revolutionary connotation.

Conclusion

Commencing in the 1950s, when Mao gave the order that “schistosomiasis has to be eliminated,” the anti-schistosomiasis campaign had mobilized a huge number of people (especially for the killing of snails) and triggered complementary agricultural production and water conservation projects. A task that in the beginning was about public hygiene and disease prevention became a political tool during the Cultural Revolution to destroy Liu Shaoqi, Lin Biao, and Wei Wenbo. The Chinese Ministry of Health and the Chinese Medical Association were extremely sensitive to the ASD’s visit, made at a time of a large-scale internal power struggle. Although the information about the disease (official or otherwise) that the ASD had hoped to obtain was available, nobody in China was willing to take the political risk of disclosing it.