Shortly after World War I, the League of Nations began to implement numerous international programs to deal with the global problems of the day. These programs investigated, shared information, and standardized responses and policy across an extensive background of social and medical issues. Despite the current narrative of the League of Nations as a failure due to its inability to prevent the outbreak of a series of wars, it was a success in preventing the outbreak of another kind: Pandemics, that should be remembered. As the League of Nations was still forming, the world was finally experiencing a decline in the deadliest pandemic in modern history, the H1N1 Influenza outbreak of 1918-1919. This so-called “Spanish Flu” potentially killed more humans than WWI and WWII combined. Estimates range from 50 to 100 million deaths and between 250 and 500 million infected (1). The global scale of the outbreak meant that it was a critical focus for the new League of Nations in the 1920s and 1930s. The League quickly began to organize structures for detecting, sharing information, analyzing, and protecting against infectious diseases such as Influenza, Plague, Cholera, and others.
Policemen in Seattle wearing masks made by the Red Cross, during the influenza epidemic. December 1918. (National Archives at College Park, Md. Record number 165-WW-269B-25)
The League didn’t have to wait long for an opportunity to implement it’s infectious disease prevention programs. In 1921 after the first Soviet invasion of Poland resulted in the Soviets routed back to Russia, Poland experienced an outbreak of typhus and dysentery.
With the condition of Europe still in shambles from the war and the Influenza pandemic, the outbreak in Poland threatened tens of thousands of lives all over again. The League sprang into one of it’s earliest actions. It focused its first initiatives in Poland, which became a foundation for their later global programs. (2) Even two non-European League members, Siam and Japan, contributed funds to support the medical mission to Poland, transcending and reversing the centuries of European dominance in international medical support missions. This groundbreaking act becomes ironic, given that the League had rejected Japan’s call for racial and religious equality that Siam silently supported, yet it was these two independent Asian nations the League had relegated by race to second tier nations, that stood up to provide the first global funds to save European lives.
The initiative in Poland was a success, and on April 15, 1921, the League of Nations organized a Warsaw Health Conference in the Polish capital to implement a similar program across Europe. (3) Programs were soon enacted to establish mechanisms to control similar outbreaks in Europe. Again Japan and Siam stepped forward to advocate for a regional program in Asia. The Japanese focusing on expanding the Australian focus to include non European colonies in the Pacific islands, and Siam to promote a separate body to develop regional cooperation in Southeast Asia.
Next to the Sinitic mainland (Northeast Asia or “China”) (4), Southeast Asia had regular outbreaks of infectious diseases that jumped national borders. These frequent outbreaks represented both a challenge and an opportunity for medical professionals of the time. The European governments of occupied Southeast Asia did not coordinate responses to the periodic outbreaks with independent Siam or, indeed, each other before the League of Nations initiatives in the 1920s and 1930s.
Infectious disease study in the Southeast Asian region primarily held promise for not only increasing the overall global knowledge of contagious diseases but advanced the humanitarian efforts in the area through the mechanisms of communication of information on the outbreaks and coordination of responses such as quarantines. The League of Nations developed a remarkable program over the next two decades that contains the foundations of today's global health organizations and programs.
Historical records of Siamese outbreaks of infectious diseases began in 1357.
However, little data is recorded other than the abandonment of capitals and generalizations. Modern data begins to take shape in the 1820s when the first of six Cholera outbreaks claimed a reported 30,000 lives (5). Siam, and the surrounding kingdoms, and then occupied colonies, experienced regular outbreaks into the 1920s when the League of Nations programs began. The reduction of the Cholera outbreaks is a combination of a renewed emphasis on Public Health and Sanitation, combined with the regional information sharing, coordination of resources and responses, and a strict protocol on quarantines.
The focus on information sharing and quarantine protocols were especially important in preventing the large scale outbreaks from migrating across borders and limiting the impact on civilians. In 1919, before the international measures were implemented, there were a reported 13,000 deaths in Siam. The next outbreak was caused by quarantined foreign sailors who jumped ship and illegally swam to shore. That outbreak in 1925 produced only 8,000 victims. Finally, the 1929 eruption, with full League of Nations protocols and recommendations in place, saw the deaths reduced significantly to only 1,600 in Bangkok. (6)
Siam enacted mandatory vaccinations, with a hefty fine for those who didn’t obtain them. “Provincial health authorities ran awareness campaigns in schools, gave medical advice, handed out brochures, put up posters, screened educational films, and worked to improve wells and latrines.”(7) Indeed some areas in Siam rivaled remote parts of America and England for health services.
Information sharing and coordination of quarantine of ports to inbound passengers became critical during this period of increased international travel. Everything from merchant to passenger ships were tracked, and radio and telegraph communications were used to update cities thousands of miles distant from Tokyo to Jakarta and everywhere in between. Prince Charoonsakdi Kritakara (1875-1928), the Siamese delegate to the League, solicited to the League, along with Japan to increase the focus on health initiatives, including establishing an “epidemiological intelligence service” in Asia.
Prince Charoonsakdi Kritakara (center) with the Siamese delegation to the League of Nations. Prince Charoon was responsible for the Siamese efforts to successfully expand the League Health programs to Southeast Asia.
On 11 March 1924, Prince Charoon’s lobbying effort paid off. The League Health Section established the Far Eastern Bureau. It replicated the programs designed for Europe in Asia.
“The mandate of the bureau was to collect and transmit information on infectious diseases from all countries in the Far East, to collect statistical information as well as relevant laws and administrative measures in Far Eastern countries, to publish the gathered information and to make it available to the League and all Far Eastern countries and finally to respond to requests for assistance in health questions from individual governments in the region.” (8)
On June 7th, the nations in the region selected Singapore as the headquarters. (9) The League quickly took stock of the current infectious disease situation for Siam, European occupied territories, and non-members of the League such as the US-occupied Philippines. The 1924 report demonstrates the scale of the investment in time, energy, and resources the League took to identify the issues that the Far Eastern Bureau would have to take over the next two decades. (10) Upon the passing of Prince Charoon, Sakol Varavarn Minister of Health assumed the duties of the representative to the Far East Bureau, and promoted Siamese participation and leadership, along with unified statistical reporting. Non-member nations such as the United States via the Rockefeller Foundation, and Japan (after it left the league in 1932) provided support. They participated in the Far Eastern Bureau, demonstrating the level of importance to the international community regardless of political differences. The intelligence sharing began in 1925 and offered standard weekly radio broadcasts of the regional status. Eventually, One hundred eighty ports were participants in the program. Siam, as the other nations did, provided a roll-up of information to the Bureau in Singapore to be included in the weekly reports Special alerts went out when outbreaks were detected. Limited coordination of responses was conducted via Singapore. The measures directly assisted local authorities in implementing rapid and effective quarantines to limit the spread and impact of disease outbreaks.
Siam built new quarantine facilities to prevent a repeat of the foreign sailors jumping ship and starting a Cholera outbreak in 1925. In the 1930s, a new quarantine area was built on land outside of Bangkok. The 466 passengers were detained for five days while they underwent screening, which detected 14 suspected cases. These suspected cases were removed immediately to the new Infectious Disease Hospital facility in Samut Prakan. After two weeks, there were no new Cholera outbreaks. The system integrated Siam at multiple levels in the process of information, containment, and treatment. The full support and participation by Siam potentially prevented thousands of deaths. Siam’s commitment to public health and containment of infectious diseases crossed all social boundaries. The King of Siam, Rama VIII, was quarantined with the rest of the passengers when the MV Selandia found one passenger sick with smallpox in 1939. No one from the Kings court nor the King was allowed to bypass the quarantine. When the region began to develop air travel, the aviation industry integrated into the system. Disinfecting aircraft and requiring travelers to have proof of vaccines became the norm in Siam. The League of Nations epidemiological intelligence service and Far Eastern Bureau, was responsible for saving tens, if not hundreds of thousands of lives over the course of 20 years in Southeast Asia. The ability of the program to successfully reduce political and historical barriers between the nations in the region in order to rapidly implement measures to contain pandemics is noteworthy in its success. Nations that before were adversaries were now working as allies on a united campaign against the outbreak of deadly diseases.
Notes:
1. Further research is needed to tabulate more accurate numbers of infected vs. deaths. The global nature of the epidemic and the variance of documentation, in many areas being non-existent, makes tabulating difficult, if not impossible. Nevertheless, the numbers are still within a very inaccurate range due to the lack of reliable data. Some nations, such as the US, have more accurate numbers due to organized record keeping, archiving, and collection methods. For example, see https://www.archives.gov/exhibits/influenza-epidemic/records/south-beach-patients-book.pdf 2. https://biblio-archive.unog.ch/Dateien/CouncilMSD/C-268-M-215-1921-IV_BI.pdf
3. https://biblio-archive.unog.ch/Dateien/CouncilMSD/C-91-M-50-1921-IV_BI.pdfand for the World Health Organization History of the impact of the Warsaw Health Conference on global health development see https://www.who.int/archives/fonds_collections/bytitle/fonds_3/en/. The World Health Organization’s summary of the history infers that the Warsaw Health Conference directly led to global initiatives. This is not accurate. It was later lobbying by Siam and Japan that brought these programs to Asia.
4. “Sinitic Mainland” is a more precise geographical and historical based term than the colloquial term “China.” It is used in The Historical Detective Agency’s articles via the principle of evidence-based descriptions. A future article on when and how “China” entered into the lexicon of both the West and modern 20thCentury Asia and the historical inaccuracies it brings with it is forthcoming.
5. The accurate number may never be known due to the lack of specific observations and assessments. The 30,000 figure was from B.J. Terweil’s chapter in Norman Owen (ed) Death and Disease in Southeast Asia: Explorations in Social, Medical, and Demographic History. Singapore: Oxford University Press, 1987, pp 142-160. Also, see Prince Sakol Vavaran. Public Health and Medical Service in Siam. Bangkok: Bangkok Press, 1930.
6. The final outbreak of this period was from 1935-1937 and documented at 10,000 deaths. However, there are factors that make a comparison to previous years difficult without further data. The 1930s saw a more efficient system of government enacted in Siam, with medical services extended into rural and remote parts of the country. These additional medical facilities meant that more reports of exposure and deaths were incorporated into the total numbers that were not collected prior to that time. Large immigration of rural farmers into Bangkok, and an extended urban area, meant that in some regions, overcrowding had begun, with the resulting increase in the potential for transmission of disease. Numbers from Stephen Hell. Siam and the League of Nations Modernisation, Sovereignty and Multilateral Diplomacy, 1920-1940. (Bangkok: River Books, 2010.), p 144.
7. from Stephen Hell. Siam and the League of Nations Modernisation, Sovereignty and Multilateral Diplomacy, 1920-1940. (Bangkok: River Books, 2010.), p 145.
8. Ibid., p. 146. 9. https://biblio-archive.unog.ch/Dateien/CouncilMSD/C-223(a)-M-79(a)1924-III_EN.pdf 10. https://biblio-archive.unog.ch/Dateien/CouncilMSD/C-167-M-43-1924-III_EN.pdf
For more research:
US National Archives:
Limited online collections, however, you can contact the archivists directly or visit the various locations to obtain more than is online. League of Nations Archives:
Drag down the collection selection to “LON” before the search bar to search for League of Nations material. World Health Organization League of Nations Collection:
Rockefeller Foundation History
The Rockefeller Foundation is an example of a private philanthropic organization that maintained an American support mechanism in Siam before and during the League of Nations period. It demonstrates how the American people were able to contribute and share information and support while not being official members of the League. It is essential to consider non-official contributions to the historical development of nations as well as the conventional ones.