The Modern Epidemic: A History of Tuberculosis in Japan (review)

In contrast to the abundant scholarship now available on the social history of disease in Europe and North America, disease in East Asian history remains a relatively unexamined topic. William Johnston’s study of tuberculosis in modern Japan is a very welcome addition to the field.

Johnston approaches the history of tuberculosis on three levels. In the first section, he presents a classic epidemiological history, beginning with a lucid discussion of the disease and its symptoms, followed by an analysis of the reasons behind the emergence of Japan’s “modern epidemic” in the late nineteenth century and its intensification in the early twentieth century. He argues that while the disease was endemic to Japan from earliest times, it became epidemic only after the country began to industrialize in the late nineteenth century. Mortality from tuberculosis began to rise in about 1880, but the disease really took off between 1900 and 1919, when Japan’s textile industries matured. Japan’s experience with tuberculosis thus mirrored Europe’s during the Industrial Revolution. In this sense, Japan suffered the disadvantages of followership rather than its “advantages.” ¹

In the second section, Johnston probes the tension between modern biomedical conceptions of tuberculosis, on the one hand, and popular conceptions of the disease, on the other. In what is perhaps the most fascinating of his nine chapters, the author examines a mass murder case involving Toi Mutsuo, a young man with an advanced case of tuberculosis. Toi gruesomely killed thirty-one people in his mountain hamlet before killing himself. His suicide note stated that he had been driven to murder because of his neighbors’ abhorrence of his disease and their cruelty toward him. Rather than simply using this story to illuminate the problem of stigmatization, Johnston skillfully demonstrates that the psychological pressures on Toi arose less from his status as village outcast than from his perception, based on his having absorbed the latest in biomedical literature, that his fellow villagers were unreasonable in ostracizing him. Murder was thus his revenge for their inability or unwillingness to “become modern.”

In a subsequent chapter, Johnston analyzes images of tuberculosis as revealed in modern Japanese literature. He identifies three distinct groups, each with its own reading of the disease: an urban, highly educated stratum that latched onto bacteriological explanations of TB etiology; the rural population, which viewed the disease through a prism of moral significance; and the cultural middle class, which reflected characteristics of both extremes. At times this division seems artificial and overly dichotomous: rural Japan comes to be associated with tradition, stigma, and superstition; urban Japan, with modernity, urbanity, and science. Moreover, it is at odds with the evidence presented: Toi Mutsuo, for example, lived in an isolated rural hamlet and yet kept up on the latest developments in TB research. To be fair, Johnston acknowledges that this tripartite division is useful only for heuristic purposes (p. 156). Nonetheless, he sometimes seems to overemphasize the modernity of urban Japan and the traditionalism of rural Japan—discussing, for example, the social schism that existed between “progressive intellectuals” and the “conservative traditionalists, [that divided] the urban and urbane from the rural and provincial” (p. 147).

Johnston then takes up the issue of the development of state-directed tuberculosis control in Japan. He argues that the state did not truly endeavor to bring the disease under control until its vital interests were challenged. Only in the 1930s, when the illness of soldiers and factory workers threatened to undermine the Japanese war effort, were effective measures implemented against the disease. This section provides an excellent narrative of the evolution of Japanese public health institutions, beyond those dealing directly with tuberculosis.

In his conclusion, the author draws explicit comparisons between the historical experience of tuberculosis and our contemporary experience with AIDS, noting that, in many ways, AIDS and our responses to it echo the past. Given Johnston’s comprehensive and intelligent treatment of his subject matter...