Conocimientos, Actitudes y Prácticas de la Población

The Geography of MIH and Pre-revolutionary Yunnan

As outlined in the previous chapter, maternal and infant health (MIH) provided a field for adapting international health programs to Chinese conditions, tethering international health organizations and the “imperialism of free nations” to Chinese social dynamics and newly founded organs of the Chinese Nationalist government. But beyond the discursive and ideological dimensions linking state-building to global health and new imperialisms, MIH produced material effects that aided the Nationalist Republic’s legibility to an emerging international order. The productive dynamics of biopower’s operation in both foreign

philanthropy and state-building, evident in the expansion ever deeper into the interior and into rural areas, aided Nanjing’s accumulation of a territoriality, which, as many scholars have noted, remained a prerequisite criterion for modern nation-states.210 Amid the emerging order of the interwar world, MIH linked the particular needs and customs of Chinese society to the broad projects of new imperialism, while also linking metrics of mortality that sorted populations to the management of women’s reproduction. These developments further helped provide a path

210 _{See Thongchai Winichakul, Siam Mapped: A History of the Geo-Body of a Nation (Honolulu:}

University of Hawaii Press, 1994), 16-17; Antony Anghie, “Colonialism and the Birth of International Institutions: Sovereignty, Economy, and the Mandate System of the League of Nations,” NYU Journal of International Law and

through which the Nationalist state might obtain the population and territory necessary to gain equal footing with great powers on the world stage.211

The last chapter demonstrated how both foreign and Chinese actors framed maternal and infant mortality rates as the product of unhygienic childbirth and as quantifiable evidence of China’s relative backwardness. This chapter and the next demonstrate that MIH proved critical not only for the aims of Rockefeller philanthropies in China, but also for Nationalist colonization of the interior during the 1930s and 1940s. The biomedical “facts” of women’s varied capacity to reproduce and nurture effectively separated China from great powers, but also rural and Western regions of China from more cosmopolitan and urban areas of the coastal East. MIH thus

provided an idiom of difference that underwrote Nationalist interventions in distant provinces, often carried out in partnership with foreign actors, as benevolent civilizing missions to rescue suffering women and children in contested regions and thereby affirm both the population and territory subject to Nationalist governance.

However, the move to rapidly expand MIH institutions and personnel produced

unexpected effects. In addition to the implications for Chinese feminisms discussed in Chapters Five and Six, international and national investments in a rapidly expanding MIH network had a decentralizing impact on the Nationalist health system. Reporting on a tour of China during 1942, John Grant of the Rockefeller International Health Division (IHD) noted, “The quantitative expansion in the provinces of ‘health units’ is almost incredible, particularly under war

circumstances. The concept of State Medicine may almost be said to be over-sold to the

211 _{I draw here from the insights of world systems theorists, who have pointed to a fusion of capitalist and}

territorial logics as integral to the rise of the modern world system. See Giovanni Arrighi, The Long Twentieth Century: Money, Power, and the Origins of Our Times, 31-34; see also Prasenjit Duara, “Introduction,” in Duara, The Global and Regional in China’s Nation Formation (New York: Routledge, 2009), 4-5.

public.”212 As one of the original architects of midwifery reform outlined for the Rockefeller Foundation, China’s primary problem no longer lay in a dearth of medical institutions by 1942. Rather, the vast network of institutions had now exceeded what the Nationalist health

administration could adequately oversee.213

Thus, from local cases, we see both the vast reach of Nationalist-era MIH programs and the unevenness of central-government oversight. In some cases, the extension of state and philanthropic projects relied on ever-growing numbers of local practitioners and health officials, many of whom remained flexible when not indifferent to national policies. With a primary focus on the province of Yunnan, this chapter argues that an expanding network of reproductive health practitioners and institutions connected the aims and resources of international and national health organizations to individual households in rural and remote regions of China prior to the PRC. Rather than emphasizing this development as a straightforward triumph of the Nationalist state, I show how this network of institutions proceeded unevenly, often dependent on local pragmatists who took advantage of state and foreign investments while operating at the margins of state authority.

The Geographic Expansion of MIH Programs

From its original imagining by Yang Chongrui and John Grant, Beiping’s First National Midwifery School (FNMS) had been intended as an initial step toward a much broader program to promote hygienic childbirth and mothercraft throughout China. As these large-scale reforms to

212 _{John Black Grant, “Report on Trip to China: July 16 – August 6, 1942” (RAC, Rockefeller Foundation}

Archives, Sleepy Hollow, NY, RG 2, Series 601, Box 240, Folder 1662).

213 _{Ibid. I also draw here from the insights of two recent dissertations. See Mary Augusta Brazelton,}

childbirth and mothering came to fruition through the policies and offices of the Nationalist government, they proceeded in accord with the Nationalist-state’s territorial expansion. In

tandem with military campaigns to vanquish rival militarists, public health, often spearheaded by midwifery reform, extended Nationalist influence well beyond the eastern nucleus of Nanjing’s power to reach such distant locales as Yunnan and Gansu by the mid-1930s.

Three years after the founding of FNMS and the National Midwifery Board, national authorities began to realize the goal of expanding the nascent MIH program that operated under the auspices of the NHA. Due to the flagship status of the Rockefeller-affiliated FNMS and Yang Chongrui’s simultaneously held post as Director of the NHA’s Maternal and Child Health

Division, FNMS became central to midwifery reform throughout the Nationalist realm. Staff at FNMS helped to determine licensing standards for midwives while supplying staff for newly organized hospitals and midwifery schools throughout the country. Although, in some cases, midwifery training schools and maternal health centers became departments within larger institutions of public health, the issue of childbirth often served as the “entering wedge” for the National Health Administration (NHA) in a given locale, much as it had for the IHD in the years prior to the Nanjing Decade. In many provinces, the founding of a midwifery training school preceded the later establishment of provincial hospitals and health bureaus, intentionally built around the pioneering efforts of midwives and obstetricians.214

Yang Chongrui’s annual reports to the Rockefeller Foundation attest to the central role of FNMS in the dramatic and rapid expansion of state-sanctioned MIH institutions during the 1930s, and the compatibility between Rockefeller and Nationalist Party aims. In 1932, FNMS staff founded officially recognized midwifery schools in the provinces of Shaanxi in the West

214 _{Marion Yang (Yang Chongrui), FNMS Fourth Annual Report, 1932-3 (RAC, Sleepy Hollow, NY,}

and Jiangxi in the South. In the same year, FNMS graduates and staff founded additional “rural midwifery homes” in remote areas of these provinces in a move to combat the geographic obstacles that separated many in rural regions from hospitals of provincial capitals.215

Soon thereafter in fall 1933, the effort to expand the reach of the NHA’s MIH program brought about a second national midwifery school, the Central Midwifery School, in the capital city of Nanjing. This school operated in close association with the Central Field Health Station of Nanjing, founded in 1931, which many pointed to as evidence of the legitimacy and

effectiveness of the NHA. Though planned through cooperative efforts of the League of Nations Health Organization (LNHO), the Rockefeller IHD, and the NHA, the Nanjing Central Field Health Station maintained financial independence from its outset in accordance with the demands of LNHO advisor Ludwik Rajchman and Rockefeller IHD Far East Director Victor Heiser. Midwives trained at the affiliated Central Midwifery School featured prominently in reports sent to New York and Geneva that asserted the Nationalist state’s rightful position among the modern member states of international organizations. These widely circulated reports came replete with photographic evidence of vaccinations and medical training classes, demonstrating Nationalist China’s active participation in the international project to advance public health within and beyond Chinese borders.216

The rapidly expanding network of MIH institutions placed a considerable strain on the staff and resources of FNMS. When the Central Midwifery School of Nanjing opened in 1933, Yang Chongrui took a three-month leave of absence from FNMS to serve as the new school’s interim director, while a steady stream of recent graduates left Beiping to work for new training

centers and hospitals throughout the Nationalist Republic. In fact, most midwifery schools and maternity hospitals founded by the NHA and its provincial subsidiaries in the 1930s were staffed by graduates, teachers, midwives, and doctors from FNMS in Beiping. By mid-1934, just five years after the founding of FNMS, there were ten provincial schools, three municipal schools, and fifty-four registered private schools overseen by the NHA, in addition to the two national schools in Beiping and Nanjing. Together, these schools constituted a multidirectional network through which rural women who had received basic training in local or provincial schools went on to pursue advanced study at national-level schools in Beiping and Nanjing. These educational pilgrimages between core and periphery aided the integration of provinces into the Nationalist republic, as reports circulated both within and outside China asserted the links between the national program and its localized iterations.217

Sources: “Quanguo zhuchanshi dengji tongji zhaiyao 全國助產士登記統計摘要,” Neizheng diaocha tongji biao 《內政調查統計表》4， no. 15 (1933): 14; Marion Yang (Yang Chongrui), FNMS Fifth Annual Report, 1933-34

217 _{Marion Yang (Yang Chongrui), FNMS Fifth Annual Report, 1933-34 (RAC, Rockefeller Foundation}

Archives, RG 5 Series 3, Box 222, Folder 2774); This report provides only the English names used by these Chinese graduates of FNMS. Where possible, I have provided Chinese names by matching transliterations with the names provided in Chinese-language sources.

0 500 1000 1500 2000 2500 3000 3500 4000 1938 1934 1933

Figure 3.1 - Number of Professional Midwives

Registered with the NHA

(RAC, Rockefeller Foundation Archives, RG 5 Series 3, Box 222, Folder 2774); Weisheng tongji 《衛生統計》 (Chongqing: Neizhengbu 內政部, 1938), 34-35.

As shown in Figure 3.1, the founding of new training programs significantly increased the total number of biomedically trained midwives registered with the NHA during the Nanjing Decade. A total of 1,234 midwives had received licenses from the NHA and its subsidiaries by 1933, a figure which grew to 1,883 one year later. Four years later in 1938, the NHA reported that the total number of licensed midwives had nearly doubled to 3,694.218 Though this total number remained proportionately modest given China’s vast territory and population, the figure remains significant given the then short life of the NHA and the geographic limits of Nationalist power, which had only begun to reach to distant Western provinces when these statistics were collected. The growth reported in 1938 preceded the wartime expansion of MIH and public health in western provinces outlined in the following case studies of Yunnan and Gansu. Further, the data in Figure 3.1 only reflect practitioners who had formally registered with the NHA. The dispersed, multifaceted nature of MIH programs with varied ties to the Nationalist state produced a more diverse and capacious landscape of practitioners than can be seen from these data alone.

Provinces are listed in descending order of percentage of midwives (left to right) starting with Zhejiang. One midwife is listed here from Taiwan, though Taiwan was a Japanese colony in 1933. Source: “Quanguo zhuchanshi dengji tongji zhaiyao 全國助產士登記統計摘要,” Neizheng diaocha tongji biao 《內政調查統計表》4， no. 15 (1933): 14

The significant increase in the number of licensed, biomedical midwives coincided with a widened geographic distribution of official, biomedical midwifery practice. As shown in Figure 3.2, roughly half of all licensed midwives registered in the provinces of Zhejiang and Jiangsu in 1933. These bordering provinces along the Yangzi Delta constituted the locus of Nationalist power and one of the most economically developed regions of the country. Nonetheless, Figure 3.2 also shows that official registration and licensing procedures had stretched, to a limited extent, across a wide geographic area as early as 1933, merely four years after the founding of FNMS, thereby aiding the integration of distant and contested regions into the Nationalist polity. Figure 3.3 (below) provides more detail on the geographic distribution of registered midwives by highlighting the reach of FNMS graduates specifically. By 1935, FNMS graduates had reached

Figure 3.2 - Provincial Distribution of LIcensed Midwives, 1933

(percentage of national total)

Zhejiang Jiangsu Guangdong Hubei Fujian Shanghai Anhui Jiangxi Hebei Hunan Liaoning Shandong Sichuan Nanjing Henan Jilin Guangxi Shanxi Yunnan Beiping Guizhou Suiyuan Taiwan

as far west as Sichuan (Szechuan) and Gansu (Kansu), though most remained concentrated in eastern provinces.

The following case of Yunnan and the next chapter’s discussion of Gansu show an accelerating trend toward expansion in numbers and distribution of MIH personnel and

institutions from the mid-1930s to the later 1940s. As seen in these cases, the intertwined efforts of foreign philanthropists and national authorities to reform Chinese childbirth reached to rural areas of distant provinces by the later 1940s. This expansion aided and depended on Nationalist accumulation of territory, even as it produced decentralizing effects that allowed for adaptations of national policies to local conditions.

Souce: Marion Yang, Sixth Annual Report, First National Midwifery School, July 1, 1934 – June 30, 1935 (RAC, Rockefeller Foundation Archives, RG 5, Series 3, Folder 2775).

Yunnan in Late Qing and Early Republican China

Yunnan remained on the periphery of Chinese states before the mid-1930s. The Yuan and Ming dynasties maintained little control over the region, and most aspects of governance fell to local chieftains. In the eighteenth and nineteenth centuries, Han immigration to Yunnan

expanded along with the Qing empire, fueling conflicts between local powers, Han immigrants, and the Qing state. In addition to cultural diversity, a tropical climate, and untamed terrain, disease thwarted Yunnan’s penetration by outside powers. Malaria in particular posed a significant challenge to the administration of Yunnan by the Qing state and Han governors. Susceptibility to malaria helped to materialize the ill-defined borders between ethnic categories that became integral to the hierarchical relations of Qing administration in the region. But, malaria also restrained Qing expansion into Yunnan, particularly in the southwestern frontier. In much of the region, the Qing state was forced to rely on allegiances with local chieftains, with the prevalence of infectious disease shoring up Yunnan’s position as an untamed land at the periphery of the empire.219

This mode of governance became difficult to maintain amid an influx of migrants fleeing famine and economic crisis in southern and central China during the mid-nineteenth century. Increasingly, tensions between locals, immigrants, and the Qing state erupted into violence, including a three-day massacre of ethnic Hui by Qing forces in 1845. After a later massacre of an additional 3,000 Hui in 1856, Du Wenxiu, a Muslim convert of Han ancestry, founded an

219 _{David Bello, “To Go Where No Han Could Go for Long: Malaria and the Construction of Ethnic}

independent sultanate in Yunnan, in a movement later referred to as the Panthay Rebellion of 1856-73. The Qing state responded with brutal force, and as many as five million people died during the prolonged conflict. Many of varied ethnic groups supported the Dali Sultanate, and Du himself called for multiethnic unity against Qing forces. Some Hui in the region were spared when they joined with the Qing to suppress the rebellion. Many others fled across ill-defined borders into British Burma, Laos, and Thailand. In the wake of the rebellion, the Qing state asserted firmer control over Yunnan, but many continued to contest Qing authority until the empire’s collapse in the early twentieth century.220

Following the Xinhai Revolution of 1911, Yunnan remained largely autonomous throughout the early Republican period. After a brief alliance with the Beiyang Republic, the provincial Yunnan Army split from the Beiyang Army in resistance to Yuan Shikai’s attempt to reinstate the monarchy in 1916. For the next two decades, local military leaders ruled Yunnan with little outside intervention. Yunnanese militarists entered into a fragile union with Sun Yat- sen’s Nationalist Party from its base in Guangdong in the 1920s. However, the Yunnan army fragmented shortly thereafter as a result of internal factionalism and the power struggles within the Nationalist party after Sun’s death in 1925. In 1927, Long Yun, an ethnic Yi general, became the dominant military and political leader in Yunnan. Long served as provincial governor

nominally loyal to the Nanjing-based Nationalist government from the late 1920s until 1945, though the central Nationalist government had limited authority in the province before the mid- 1930s.221

220 _{It should be noted that ethnic divisions were very much in flux during this period. Joseph Francis Ford,}

The Local Histories of Yün-nan (London: China Society Occasional Papers, no. 19, 1974), 20-25; see also David G. Atwill, The Chinese Sultanate: Islam, Ethnicity, and the Panthay Rebellion in Southwest China, 1856-73 (Stanford, CA: Stanford University Press, 2005), 185-94, passim.

As in most matters, Nanjing exercised little influence over public health in Yunnan during this period. According to several reports, a small office in the Kunming police station oversaw all matters pertaining to public health in the province in the early decades of the

twentieth century. The response of political leaders in Yunnan to the early dictates of the central Ministry of Health (before its reorganization as the NHA) affirms what scholars have written regarding Nationalist governance during the Nanjing Decade. Local leaders expressed deference to the Nationalists, who had little if any control over the province. In 1928, political leaders in Yunnan acknowledged the national law that ordered the founding of provincial health bureaus. In accordance with these laws, provincial leaders announced the founding of a new provincial health administration in August 1930. This early bureau took up the task of improving water quality and treating infectious diseases. The provincial administration also founded the Kunhua provincial hospital in Kunming, which remained one of its few lasting achievements. Like other largely autonomous provincial authorities throughout China during this period, Yunnanese leaders also announced a plan to comply with the 1929 national law requiring government oversight of doctors and midwives. However, archives bear little evidence that local authorities took actual steps to implement these plans, aside from a brief expression of intent to comply with national regulations. According to several different reports, these efforts lacked funding and the militarist government maintained other priorities.222

Yunnan, Nationalist Sovereignty, and Global Health

222 _{Yunnan sheng minzhengting wunian weisheng gongzuo baogao 《雲南省民政廳五年衛生工作報告》}

(Historical Documents, Yunnan Provincial Library); see also “Yunnan zhibian duban gong shu zhixing zhangcheng 雲南殖邊督辦公署暫行章程”; Yunnan sheng zuzhi fa ling’an, no. 2《雲南省組織法令案 （二）》(Nanjing,