In 1911, another epidemic swept through China. That time, the world came together
Updated 0430 GMT (1230 HKT) April 19, 2020
A railway cutting through the hills of Manchuria, circa 1906.
(CNN)In 1911, a deadly epidemic spread through China and threatened to become a pandemic. Its origins appeared to be related to the trade in wild animals, but at the time no one was sure.
Lockdowns, quarantine measures, the wearing of masks, travel restrictions, the mass cremation of victims, and border controls were deployed to try to lower the infection rate. Yet more than 60,000 people died in modern-day northeast China, making it one of the world's largest epidemics at the time.
When the disease was eventually brought under control, the Chinese government convened the International Plague Conference in the northern city of Shenyang -- close to the epicenter of the outbreak.
In attendance were virologists, bacteriologists, epidemiologists and disease experts from many of the world's major powers -- the United States, Japan, Russia, the United Kingdom and France.
Illustration of the Reaper (allegory of Death) above Manchuria, which was published in Le Petit Journal, in France, in 1911.
The purpose of the conference was to find the cause of the outbreak, learn which suppression techniques were most effective, discover why the disease had spread so far so fast, and assess what could be done to prevent a second wave. While the conference was not without some finger pointing, it was mostly a genuine attempt to learn.
As the world now faces a pandemic characterized by a lack of a globally co-ordinated response and multilateral effort on the part of political leaders, the collaborative aspects of the 1911 conference in north-eastern China are worth reconsidering.
Today, the World Health Organization (WHO) appears compromised, the virus has been racialized, major nations are angry with each other and competing for resources and control of the narrative, while poorer countries are left to fend largely for themselves.
Compared to 1911, we appear a polarized and divided world.
Marmots and plague
The Great Manchurian Plague that broke out across northeastern China in 1910 was devastating.
From the autumn of 1910, until the outbreak was finally suppressed the following year, an estimated 63,000 people died. The epidemic hit international headlines when it reached the northeastern city of Harbin, in today's Heilongjiang province. Harbin was then part of what was known as Manchuria, a vast, agriculturally important but sparsely populated region situated on the juncture of the Chinese, Japanese and Russian spheres of influence. The majority of the territory was Chinese-governed, with Japan controlling the port area around Dalian and Russia running Manchuria's railways.
Harbin was an international city, home to many Russians who worked for the China Eastern Railway (CER), which connected the Trans-Siberian Railway to the Japanese-controled port city of Dalian. The city was also home to large communities of Japanese, Americans and Europeans engaged in trades connected to the railway.
That included the fur trade, and it was from this industry that the disease most likely came.
Tarbagan marmot (Marmota sibirica), a species of rodent in the family Sciuridae, in steppes around Khukh Lake, Mongolia.
The Tarbagan marmot was a species of rodent that lived mostly on the grasslands and steppe of Mongolia and neighboring Manchuria. European, American and Japanese furriers had long purchased sable, mink and otter furs from local hunters, but had never been interested in the coarse fur of the Tarbagan marmot. But new dying techniques at the start of the century allowed marmot fur to pass as an affordable alternative for better-quality furs.
Thousands of nomadic local hunters were tasked by foreign buyers with bringing marmot hides, which soared in value in the years before the virus. Rural hunters had long avoided using diseased marmots for food, but did not think to cast aside the hides of sick animals -- especially not when they were worth so much.
Pinpointing the initial outbreak of the plague is hard, but it was first officially noted by Russian doctors in Manzhouli, an Inner Mongolian town on the Chinese-Russian border, which had grown up around the CER. The symptoms were alarming -- fever followed by haemoptysis (the coughing up of blood). In Manzhouli, the dead were left in the street and railway freight cars were turned into quarantine wards.
A picture of victims of the Great Manchurian Plague.
Just as viruses spread fast along airline routes today, back then the railways facilitated the spread. Fear in Manzhouli meant many people followed the routes the marmot hides had taken along the CER to the Heilongjiang city of Qiqihar, and then on to Harbin.
Cases of the pneumonic plague appeared in major rail termini -- Tianjin, Beijing and along the Beijing to Wuhan railway. Even Shanghai, almost 2,000 miles from Manzhouli, reported a case and considered a lockdown of the city to prevent wider infection. In the crowded slums of Harbin, the disease took hold swiftly. By November 8, 1910, Harbin had a death toll of 5,272.
Initial response and debates
The response to the outbreak was rapid, given the logistical constraints at the start of the 20th century.
Quarantine centers were established, mostly in converted rail freight cars, for people the authorities thought had have come into contact with the disease -- relatives of the dead plus those in the fur trapping and trading business.
If the quarantined didn't show symptoms within five-to-10 days they were released with a wire wristband fastened with a lead seal stating they were plague free. But if symptoms did show, the entire freight car was essentially doomed, given the disease's staggering near 100% mortality rate. Burials were forbidden; mass cremations were enforced.
In Harbin, the Chinese authorities' lead doctor Wu Lien-teh, a Malaysia-born ethnic-Chinese medic educated at Cambridge University, was managing to contain the outbreak.
This photo taken sometime between 1910 and 1915 shows Dr. Wu Lien-teh, a Cambridge-educated Chinese physician who pioneered the use of masks during the Manchurian Plague of 1910-11.
Wu began post-mortem exams of victims and crucially established that the disease was pneumonic plague and not bubonic (the difference between the forms of plague is the location of infection; in pneumonic plague the infection is in the lungs, in bubonic plague, the lymph nodes). He also heavily recommended the wearing of face masks.
By early 1911, China had mobilized doctors and epidemiologists from across China to converge on Harbin. Wu knew there was a big deadline looming. Chinese New Year was officially January 30 and Wu knew that limiting travel would be almost impossible during the annual migration home for so many Chinese people.
If the infection rate wasn't brought down, then it risked becoming a nationwide epidemic.
The response was sometimes harsh -- any lodging house where an infection appeared was burnt to the ground. But overall Wu's anti-plague measures worked. So-called "sanitary zones," quarantines, lockdowns, isolation, travel restrictions and face masks were all implemented and appear to have brought the infection rate in Harbin down by the end of January.
Infections had spread, however, along the rail line. By the start of January 1911, Shenyang had over 2,571 deaths. Eventually, quarantining and travel restrictions in Shenyang began to take effect and the infection rate fell. But the rail line extended onwards and several towns close to the major port city of Dalian reported cases.
In Dalian itself, mass inspections of train and ship passengers were instituted, the line was then shut, and ferries from Dalian ordered to remain in port. This meant the plague never reached Dalian.
Though cases continued to pop up across Manchuria and occasionally beyond, in Harbin, Wu declared the plague suppressed at the end of January 1911, with a final mass cremation of victims.
It was time to convene an international conference to try to find out why the outbreak had been so severe and widespread -- and which anti-plague measures had worked best.
A conference in Shenyang
Yale professor William C Summers notes in his 2012 study of the Great Manchurian Plague that: "By the end of January 1911, the momentum for some sort of international consortium of 'experts' to come together in China was building rapidly."
The conference was not without risk for the Chinese.
China had a Russian-controlled rail line running through a vast swathe of its territory, Japan was ensconced in Dalian and controlling China's major northern seaport, and the European powers and US had treaty ports up and down the country.
Kitajskaya street in Harbin circa 1932.
Still, they pushed ahead with hosting, which helped China avoid the charge of doing nothing in the aftermath of the epidemic. All attendees pledged that the conference was primarily concerned with scientific investigation, and not with imposing any further controls on China from outside.
By April 3, 1911, Shenyang's Shao Ho Yien palace had been turned into a conference center that included meeting rooms, laboratories for experiments and living quarters for the delegates. As well as the principal countries mentioned, Italy, Mexico, the Netherlands, Germany and Austria-Hungary all sent experts. Many were from prestigious institutes.
The main body of the conference sought to deal with eliminating the bad science and gossip, and getting to the scientific root of the bacteria. It was high-level science for the day -- bacterial toxins, surface agglutinins, variant strains. There was also discussion of modes of contagion such as coughing and false theories such as the passing of the bacillus on food. There even was talk of what we would now call asymptomatic patients and super-spreaders.
Containment was a major theme. What had worked best? Emergency quarantine and travel measures, certainly. Also, the early use of face masks which predated Wu's discovery of the bacillus as pneumonic. Additionally, the rapid construction of plague hospitals to isolate the infected and potentially infected from ordinary hospital patients.
Harbin Railway Station, taken in about 1900.
The conference wrapped on April 28, 1911, with closing remarks by Wu. Ultimately, China's fears that Russia, Japan or the European powers would use the conference to advance their political aims against China didn't materialize.
The conference's conclusions and resolutions dealt with the science of the plague, the need for sanitary improvements, quarantine regulations and the unwitting cause of the epidemic, the Tarbagan marmot.
Closing the conference Dr Wu urged that: "Every effort should be made to secure effective medical education in China."
Global responses
In 1911 there was no WHO.
The response to the epidemic, the job of trying to limit its spread and suppress it, was left to individual nations, often nations with political antagonisms.
There were no politicians in Shenyang, only scientists who saw the need for a global intergovernmental response -- and a global health organization. That did begin to emerge after the First World War with the League of Nations formed in the wake of the 1919 Paris Peace Conference. The League took on matters relating to health through its Health Bureau, formed by an executive section of medical experts.
The bureau targeted the eradication of leprosy, malaria and yellow fever and successfully helped to contain epidemics of typhus in Russia and various outbreaks of cholera and typhoid in China between the wars. After World War II, the League's successor, the United Nations, created the WHO.
The Great Manchurian Plague did not ultimately spread in any serious way to the rest of China, Mongolia or Russia. The shutdown of Dalian port stopped the spread out from Manchuria to major destinations in Japan, Korea, Hong Kong and elsewhere in Asia.
From there it could have moved by ocean liner to Europe, America and throughout the world. But it didn't.
Summers, the historian, said that containment was down to a joined up response.
"Such a conjunction of the right knowledge, the right resources, and the right people has not always been the case in other global challenges of epidemic disease," he said.
Measures taken today around the world -- specially constructed quarantine hospitals, mask wearing ordinances, enhanced sanitary practices, travel restrictions, grounded planes and dedicated teams of healthcare workers -- in many ways replicate those taken 110 years ago in northeastern China.
However, the major players today -- the US, China, the nations of the European Union, and Japan -- seemingly have little interest in a coordinated response to the health crisis and prospects of any apolitical conference seem remote.
In 1911, the world's leading disease experts were eager to get to China.
Perhaps that is what needs to happen at some point after the coronavirus pandemic: the world's scientists could circumvent the politicians to find a way to meet, share and discuss Covid-19 in an open forum.
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How Malaysian plague fighter Wu Lien-teh laid down lessons for Wuhan virus
- A century ago, Wu stopped a pneumonic plague that killed 60,000 in northeast China using preventive measures considered ahead of their time
- Wu’s lessons still hold relevance in modern medicine today, a Singapore professor says
Wu Lien-teh helped to contain a plague in Harbin in 1910. Photo: Handout
As the number of
continues to rise in China and elsewhere, the efforts of a Malaysian doctor who ended a pneumonic plague that killed 60,000 in northeast China a century ago bears lessons for the current pandemic, according to a professor in Singapore.
Wu Lien-teh, a doctor from Penang, was called to Harbin in 1910 to combat a plague, which he found was being transmitted from diseased animals to humans amid a bustling fur trade. More than 95 per cent of infected patients died.
Wu implemented preventive measures to contain the outbreak at a time when antibiotics were not available, including setting up quarantine units, imposing travel bans, and convincing Russian and Japanese authorities to shut railway services to Harbin. Patients who had succumbed to the plague were also cremated in large numbers in hygienic locations.
Wu’s records of his containment efforts – found today at the library of the National University of Singapore (NUS) – formed the basis for accurate clinical decisions in terms of treatment and infection prevention, said Paul Tambyah, President of the Asia Pacific Society of Clinical Microbiology and Infection.
“They also provided valuable information for policymakers who had to make decisions about quarantine, shutting down sections of cities and the allocation of resources,” said Tambyah, a professor of medicine.
The trans-Siberian railway, which carried both passengers and goods for trade to Europe – including fur from Siberian marmots, a species of rodent, harvested in northeast
– had facilitated the transmission of the plague. Someone with the disease could board a train in Harbin and in a matter of days be in Paris or Berlin, Tambyah said.
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“This dramatic escalation of global travel highlighted the perils of emerging infectious diseases,” he said.
“It is important not to draw too many parallels from a very different time and situation, but in my opinion, the scientific approach is always critical,” Tambyah said.
“The key is international cooperation, transparent sharing of data and not being afraid of rejecting measures that do not work,” he said. “That is the best way to limit the damage from these emerging infectious diseases, and it has been for the last 100 years or more.”
By March 1911, the pandemic was contained, earning 32-year-old Wu a reputation as a plague fighter. A month later, he chaired the International Plague Conference in Shenyang, which was attended by scientists from Britain, China, France, Germany, the United States and other nations.
Wu’s efforts to battle the Harbin plague earned him a nomination for the Nobel Prize for medicine in 1935 – making him the first person from what is now Malaysia to be nominated – although he did not win the prestigious award.
Nevertheless, he remained well regarded as an infectious diseases expert by Chinese Malaysians and within China.
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Born in 1879 to a Guangdong father and Penang-born Chinese mother, Wu was the first ethnic Chinese person to read medicine at the University of Cambridge. He worked in the government health service after leaving Britain for Kuala Lumpur in 1903, then ran a private practice the following year.
In 1910, he moved to Harbin to investigate the plague at the invitation of the Chinese imperial government of the Qing dynasty.
Wu fled China in 1937 during the Japanese occupation and moved to Ipoh in northwestern Malaysia, where he opened a general practice.
Charles Toh*, 89, a Singapore doctor, was among the patients who went to Wu’s clinic.
“Whenever I had a fever or sore throat or any other sickness, my parents would take me to see him,” Toh said, adding that the clinic was always busy due to Wu’s fame.
“In those days, when knowledge of infectious diseases was so backwards ... and there were no antibiotics available, it was amazing he could save so many lives [in Harbin],” Toh said.
“He was a good communicator. He had no airs. His clinic was packed with patients because he was so famous and he had extensive expertise in infectious diseases,” he said.
Wu died in Penang in 1960. A museum in Harbin is dedicated to him. He was awarded honorary degrees from many universities including the University of Hong Kong, Tokyo University and Johns Hopkins University in the US.
*Charles Toh is the author’s father, who was born and raised in Ipoh, Malaysia where Wu was based. Toh Han Shih is a Singaporean writer in Hong Kong.
