Kingdom of the Sick: A History of Leprosy and Japan, by Susan Burns

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Leprosy occupies a prominent place in Japanese history, with over 700 books on the topic published since the year 2000. Susan Burns deftly lays out the reasons for this centrality in the introduction to her monograph, the first in English on the history of leprosy in Japan.

In the 1990s, victims of historical injustice ranging from comfort women to prisoners of war repeatedly sued Japan’s government. Though grounded in fact, these lawsuits were generally unsuccessful as matters of law, with the striking exceptions of suits launched by Hansen’s disease patients confined in state sanitaria. In the early 2000s, first Japanese patients, then those in former colonial sanitaria in Taiwan and Korea won their suits and cash damages from Japan. Burns argues that these lawsuits have warped the historical record, privileging “denunciatory” stories of confinement, abuse, and forced sterilization while suppressing other narratives. She sets out to set the record straight in her account of the longue durée of leprosy and attitudes and policies toward it from the 700s CE to the present day.

As Chapter 1 explains, rai 癩, the Japanese term for leprosy, derives from the Chinese lai, which was imported into the Japanese archipelago with continental texts and technologies in the mid-first millennium CE. The early Japanese imperial state regulated the lives of lepers (raisha 癩者) in a variety of ways, defining raisha as “polluted” and facilitating their expulsion from families into the outcast group known as "non-human" (hinin 非人). As Buddhism and especially the Lotus Sutra gained influence from the late 1100s, karmic interpretations of the disease were layered atop the stigma of “pollution.” Like many Indian sutras, the Lotus Sutra defined rai as karmic, corporeal evidence of wrongdoing.¹

Chapter 2 explores rai in the early modern era (1600-1868) when some medical practitioners treated the disease as somatic rather than spiritual. Early-modern Japanese doctors debated whether the disease was caused by miasma (akki 悪気) or “self produced” (jihatsu 自発) by bad behavior and bad blood. Burns traces the influence of Chinese medicine and Confucian texts on Japanese accounts of rai, and explores treatments ranging from acupuncture to “southern barbarian” [European] medicines, which despite their name, used ingredients from Chinese rather than European pharmacology. Burns also discusses Luke Demaitre’s analysis of leprosy in thirteenth to seventeenth-century Europe, where Biblical theories of causation declined in favor of humoral theories.² Whereas Demaitre argued that secularization could entail destigmatization, Burns argues that in Japan, the shift from “bad karma” to “bad blood” stigmatized entire lineages and justified their social exclusion. As “blood” talk diluted the connection between rai and actual cases of leprosy, raisha emerged as a hereditary status group subject to exclusion even in the absence of disease.

Chapters 3 and 4 explore leprosy in the Meiji era (1868-1912), when hereditary status groups were dissolved, “liberating” raisha from segregated villages while depriving them of early-modern entitlements to alms. Fascinating in these and subsequent chapters is evidence that Japanese routinely positioned themselves at the cutting edge of global anti-leprosy campaigns rather than as needing to “catch up” to the West. Entrepreneurs, scientists, and officials in the United States and Europe repeatedly turned to Meiji Japan for guidance on how to treat leprosy. However, as it became clear that Japanese treatments could not cure Hansen’s disease, an international consensus emerged in favor of quarantine.

Nonetheless, Burns argues in Chapter 5 that Japan’s 1907 Leprosy Prevention Law was a form of poor relief aimed at cleaning leprous beggars off the streets rather than segregating all infected persons. Japan’s public sanitaria, developed after 1907, were “porous by design” because their designers “did not anticipate that patients would want to flee.”³ That indigent patients proved less than grateful for shoddy, sex-segregated group dwellings forced adjustments in sanitarium design, such as construction of moats and barbed-wire barricades. Patients also secured certain privileges, such as improved food and opportunities for recreation. Sanitarium residents also won the right to marry, defeating sex segregation, an innovation that provoked the institutional turn to sterilization and abortion. Throughout Chapters 5-8, Burns details the development of sanitaria as contingent on negotiations between agentic raisha and state and medical authorities.

Chapter 6 explores the expansion and re-envisioning of sanitaria in the 1930s as institutions designed to encompass patients of means and education as well as the poor. Ever more confident of its world leadership in fighting leprosy, Japan now positioned sanitarium patients as patriotic and progressive participants in that mission. Chapter 7 details the extension of sanitaria to colonial Korea and Taiwan and the increasingly coercive nature of confinement in sanitaria amid Japan’s descent into authoritarianism and total war. Chapter 8 discusses leprosy amidst the post-World War II revival of democracy and patient activism in Japan. Under Allied occupation (1945-52), Japan began manufacturing Promin, the drug discovered by Dr. Guy Henry Faget of the U.S. National Leprosarium to be effective in treating or even curing leprosy. Patient activists in Japan pushed for the rapid distribution of Promin, and for the right of recovered residents either to leave sanitaria or to stay. The right to stay was preserved even after leprosy was effectively eradicated and the Leprosy Prevention Law repealed in 1996.

The scope and depth of Burns’s research into the medical, religious, political, legal, social, and international aspects of leprosy in Japan is impressive. Yet her book is marred by a few flaws, such as repeated misspellings of political scientist Tiana Norgren’s name.⁴

A more substantial problem is that in her postwar history, Burns never discusses the grounds on which some leprosy patients won lawsuits against the Japanese government. Perhaps Burns assumes readers will already be familiar with the “denunciatory” history advanced by her chief intellectual foil, Fujino Yutaka.⁵ But given that little of Fujino’s work is available in English, many readers will likely know only what Burns tells them. She accuses Fujino of cherry-picking evidence, citing only residents critical of sanitaria. Burns makes an important point that some residents appreciated access to free medical care and housing, and to procedures like sterilization and abortion, which were less accessible outside sanitaria before 1948. Yet in making this argument, Burns too cherry-picks her evidence, citing not a single resident who complained of coercive sterilization or other gross abuses of human rights. An otherwise unknowing reader might come away from this book believing that Japanese courts in the 2000s were wrong to rule in favor of plaintiffs, or even that plaintiffs were money-grubbing hysterics with no grounds for complaint against Japanese sanitaria and government. In this sense, the necessary corrective Burns provides may be an overcorrection.

Despite this shortcoming, Burns’s tome will be indispensable to scholars and graduate students of the transnational history of medicine, public hygiene, disability, and discrimination, as well as to historians of Japan.

Endnotes

¹  Susan L. Burns, Kingdom of the Sick A History of Leprosy and Japan (Honolulu: University of Hawai’i Press, 2019), 31.

²  Luke Demaitre, Leprosy in Premodern Medicine: A Malady of the Whole Body (Baltimore: Johns Hopkins University Press, 2007).

³  Burns, Kingdom of the Sick, 141-42.

⁴  Burns, Kingdom of the Sick, 230, 297 n.16, 314.

⁵  See e.g. Fujino Yutaka, Nihon fashizumu to iryō: Hansenbyō o meguru jisshōteki kenkyū [Japanese fascism and medicine: Empirical research on Hansen’s disease] (Tokyo: Iwanami shoten, 1993).