Anti-Tuberculosis Campaign

The Anti-Tuberculosis Campaign in Republican China

Introduction

Tuberculosis was the single greatest cause of death in the Republic of China. However, it was not then listed among the notifiable infectious diseases. This lack of of official recognition for the threat of tuberculosis undoubtedly would influence how it was weighed in relation to other infectious diseases, both in the view of the public and in the minds of healthcare

professionals. Such professionals generally held and popularized the belief that China was suffering from a tuberculosis crisis arising from unhygienic eating and sleeping habits, with particular attention given to the common habit of spitting. With attention placed on these habits cultivated within the traditional Chinese family, tuberculosis was commonly labelled a “family disease.” In the 1930s, healthcare professionals and advocates introduced measures aimed to improve individual hygiene, placing a new emphasis on individual responsibility for public health unique to Chinese society.

The resulting reforms were scientifically informed but also responsive to the shifting perception of tuberculosis in the eyes of the public. Indeed many endorsed measures were not proven to be effective: more hygienic forms of communal eating, for instance, would not be effective against an airborne pathogen. This meant that, while the portrayal of tuberculosis was largely scientific, the specific measures promoted by public health advocates were actually negotiated between traditional Chinese and Western values.

A central focus of the anti-tuberculosis campaign in the Republic of China was individual responsibility. This involved educating the public on how personal habits could have far-reaching consequences, in the process targeting specific behaviors that contributed to the spread of contagion. Advocates launched campaigns against spitting, encouraged people to sleep with their windows open, and addressed the increasing consumption of milk. In many ways, measures drawn from the West came up against traditional Chinese values. This conflict inspired innovative compromises, in which China found a unique way to educate the public and address the threat of tuberculosis.

The Shifting Perception of Tuberculosis

In the late nineteenth century, the medical missionary Benjamin Hobson produced the first translations of Western medical textbooks into Chinese. Hobson identified several terms in Chinese that could be used to refer to pulmonary tuberculosis.1 Among these lao was the most prevalent, because it referred to a number of different symptoms that could indicate the disease. Some considered lao to be an internal injury caused by exhaustion, while others insisted that it was an infectious disease transmitted from dead bodies by invisible worms. In the late Qing dynasty, possibly due to increasing research, lao was more frequently regarded as a disease of “imbalances in the body’s economy and flow of blood and qi caused by irregular lifestyles, overwork, or unfavorable environmental conditions.”2

In the same era, Robert Koch succeeded in isolating Mycobacterium tuberculosis, the pathogen that causes the disease. After successfully producing cultures of the bacteria, Koch produced tuberculin, which debuted as a new therapy for tuberculosis but later proved useful only as a diagnostic test. In 1890, following Koch’s discoveries, the Chinese ambassador Xue Fucheng (薛福成) sent a mission member to study in Koch’s laboratory. Chinese elite had already begun to rely on Western sciences in the wake of the Opium War, and the related embrace of Western medicine only strengthened in the twentieth century, when Chinese medical students increasingly studied abroad. Indeed in 1933, when the National Anti-Tuberculosis Association of China (NATAC) was founded in Shanghai, most executive directors had received Western medical training.3

From the left: New Way-Sung 牛惠生 (Niu Huisheng) chairman of the NATAC, received his MD from Harvard University; Wu Lien-teh 伍連德 (Wu Liande), council member, graduated from the University of Cambridge; Yen Fu Ching 顏福慶 (Yan Fuqing) council member, graduated from Yale Medical School.

At the end of the nineteenth century, however, consensus on disease causation marked an essential difference between Western and Chinese medicine. In the West, diagnosis relied on X-ray photography, which could be used to identify tuberculosis before the appearance of symptoms. In China, diagnosis mainly relied on descriptions in medical texts and clinical experience. There were exceptions: Ding Fubao (丁福保), for example, had studied under the physician sent to work in Koch’s laboratory. Fubao strictly followed Western procedures for diagnosing and treating his patients, but Fubao, who mostly treated the wealthy, was something of an outlier. 4

Despite the different practices adopted by Western and Chinese physicians, their patients received the same advice: to recuperate with sufficient nutrition. Indeed, treatment was highly limited before the development of the antibiotic streptomycin in 1943. Nevertheless, Chinese doctors who received an education in Western medicine would perceive the disease differently. This in turn impacted the public perception of disease and shaped public health measures.

As more and more Chinese doctors trained in the West, broader understandings of tuberculosis in China also began to shift. Our records of media coverage from the period show that information on tuberculosis was becoming more accessible to the public in the 1930s. Before the 1920s, only 145 articles published in Chinese newspapers mentioned tuberculosis. That number increased to 465 in the 1920s, peaking at 2101 during the 1930s before suddenly declining to 722 in the 1940s.5
Most of the articles from the 1930s and 1940s identified that tuberculosis was a disease caused by bacteria or some kind of germ, and some even traced the history of how tuberculosis bacteria was discovered:

In 1865, the Frenchman Villemin [Jean Antoine Villemin] injected a tubercule from a dying man into animals, which later died due to ‘laobing.’ From this experiment, tuberculosis was named “feilao” (pulmonary tuberculosis). In 1882, Robert Koch, a German doctor, found bacteria to be the real cause under the microscope. As its look was bacillary, it was named “tubercle bacillus.” 6

Some newspapers invited medical professionals to write columns on tuberculosis to provide advice for preventing and coping with infection. In 1946, an article published in Yishi Bao not only discussed the general diagnosis and treatment of tuberculosis, but also speculated whether streptomycin, a cutting-edge treatment at the time, was speci c to the tuberculosis bacteria.7 There was also a broad debate over the safety of BCG-vaccination – another signal that Chinese medical professionals kept abreast of their Western counterparts. Naturally, these efforts to popularize knowledge of tuberculosis drove the public to accept scientific explanations of the disease, especially within literate, urban populations.

Beyond this scientific turn, tuberculosis was named among other diseases as an obstacle to national rejuvenation. In the New Life Movement (NLM), Chiang Kai-shek urged his fellow Chinese citizens to follow a strict hygienic code in order to contribute to a revitalized and disciplined population.8 Meanwhile Zhang Junjun, the chief-editor of NATAC’s of official magazine Fanglao, offered a more specific illustration. In the first issue of Fanglao, he directly tied the control of tuberculosis to national rejuvenation, arguing that tuberculosis had trapped China in a state of sickness. Eradication of tuberculosis then became national rejuvenation itself.9 Zhang’s nationalism echoed widespread sentiment in the 1930s, especially after the Japanese invasion of Manchuria.

The increasingly scientific understanding of tuberculosis was thus tied to a shift in the national consciousness. Healing tuberculosis was the same as healing China. These perception shifts are two sides of the same coin – tuberculosis became a "national disease" representing a lack of progress to which science seemed to be the only solution.

Purple Zodiac Sign Animated Presentation.png

Case 1 : Phlegm

Phlegm connected the tuberculosis crisis with Chinese tradition in surprising ways, even though its role in spreading tuberculosis was obvious. When a person inhales foreign matter from the air, the respiratory system may react with inflammation, which causes mucus production. This mucus is moved by cilia from the bronchi in the lungs to the throat, where the body is stimulated to cough. The phlegm expelled contains all kinds of bacteria, including, in the case of tuberculosis patients, the deadly M. tuberculosis.

A Chinese Way of Spitting

In fact, expelling phlegm, or simply spitting, was a deep-rooted tradition in China. Early in Chinese history, spitting became a mark of wealth when only the wealthy could eat as much as they wanted and spit where they pleased. It also became a habit when visiting others’ homes. Rather than rudely knock on the door, visitors would notify their host with conspicuous coughing, which gradually developed into spitting. Indeed the habit of spitting in China became so deeply rooted that it altered international perceptions. It is said that when the ambassador Li Hongzhang visited Western countries, he once spit in someone’s garden.10 His affronted hosts then asked the ambassador to buy the garden as recompense. Li’s gaff shows us that at the time, people in Western countries considered China to be barbaric due to uncivilized behavior such as spitting. Sun Yat-sen, a pioneer and director of the modernization of China, would later write in his that
breaking the habit of spitting would show foreigners that Chinese people were civilized and in control of their bodies, which would help to curtail foreign intervention.11 12

Spittoon

However, concerns about spitting were of course much larger than worries about presentation. In the early twentieth century, spitting became more offensive as it was more widely known to be a primary culprit in the spread of tuberculosis. The argument that people should stop spitting in order to fight the spread of tuberculosis reflected an increasingly scientific understanding of the disease. Medical professionals and public health advocates faced the challenge of finding accessible ways to communicate this scientific understanding to the public and persuade people to change their habits.

Purple and Black Simple Technology Keynote Presentation (1).png

The Western View in China: Phlegm as a Carrier of Mycobacterium Tuberculosis

When M. tuberculosis is diffused in a person’s lungs, the danger is not only the risk of infection but also the air breathed out, which will contain scores of the bacteria. When people with tuberculosis bacteria in their lungs cough or spit in public areas, the pathogen will spread whether or not they have developed diagnosable symptoms. Quite a lot of writers and doctors wrote articles informing readers that phlegm was dangerous because of the potential to spread M. tuberculosis from the lungs. For this reason, people were instructed not to spit on the ground. Various illustrations were used to educate readers, pointing out, for instance, that if the phlegm is spit on the ground, the tuberculosis bacteria will also be on the ground. Then as the phlegm dries out, the bacteria could release from the dried phlegm and spread through the air. Writers also emphasized the danger to children, who often play on the ground and have a tendency to put their fingers in their mouths. Children therefore have a higher risk of touching contagious phlegm directly, making them some of the most vulnerable to tuberculosis infection. Communicating a scientific understanding of tuberculosis in these highly relatable ways helped to convince the public that spitting could be a health hazard.

In many ways, Sun’s concerns with modernization were also echoed in these campaigns. Writers often suggested that spitting was impolite and uncivilized, tying the health benefits to seemingly distant concerns about good manners. At the same time, billboards appeared around the country warning people not to spit, not only in the name of health but also as a way of developing manners and becoming more civilized. When newspapers offered advice on how to deal with phlegm, they always claimed that spitting was both harmful to others’ health and a marker of bad personal qualities. Anti-spitting campaigns framed themselves as promoting more civilized behavior through the control of one’s body, rather than solely promoting the bene t to public health.

Public Spittoons: A Compromise 13

In Republican China, anti-spitting campaigns realistically aimed to build up new habits of spitting in
specific places, rather than abolishing the habit of spitting altogether. In fact, some doctors expressed concern that swallowing infectious phlegm into the digestive system could be more harmful to patients than spitting it out, potentially resulting in intestinal tuberculosis. A compromise would have to be made.

In early 1907, the very first Chinese anti-spitting campaign was launched in Hong Kong, fighting against the compulsory fines set by the local government.14 Initially, this anti-spitting campaign was not aimed at controlling tuberculosis or any other disease. Instead, it was used to show that Chinese citizens had the ability to control their own bodies – that is, to self-govern. By 1935, large cities in China such as Shanghai were hosting several anti-spitting campaigns that called upon people to spit into spittoons. Their posters recognized spitting as a necessary action, making spittoons as necessary and normal as public toilets.

When this traditional understanding of spitting came together with the fight against tuberculosis and the goals of modernization, a strange compromise emerged with the public spittoon. These spittoons reflected a mixture of traditional attitudes towards phlegm and increasing recognition that such norms needed to change. It is possible to argue that adopting Western approaches to controlling contagion was more acceptable in China when promoted as a form of modernization. Nevertheless, when asking whether to spit or not to spit, the country chose a middle way. During this early encounter with modern epidemiology, spitting in a fixed place was much more acceptable than placing a sudden ban on spitting altogether.

Case 2 :
Opening Windows

pitting was not the only habit targeted by anti-tuberculosis campaigns, nor was it the only instance in which a compromise was reached between Western and traditional Chinese values. Other simple habits, such as opening windows and doors, proved to be an effective way to slow the spread of tuberculosis. Because the disease spreads through respiratory droplets in the air, keeping rooms well-ventilated can largely stem the spread of infection. According to a research study conducted in Lima, natural ventilation in tuberculosis wards from open windows and doors can actually work just as effectively as modern mechanical ventilation. 15 Anti-tuberculosis campaigns in China recognized the benefit of natural ventilation, and they walked a line between Western and Chinese values to convince the public to open their windows and let in the wind.

A Long-Standing Fear of Wind in Chinese Tradition

Opening windows may have been effective in stemming the spread of tuberculosis, but it was not a common habit at the time for Chinese people to sleep with their windows open. In fact there was a deep-seated fear of wind in Chinese tradition. According to traditional Chinese medicine, wind is harmful to health because it brings cold air (寒氣) into the body, which obtained many negative associations through history. From antiquity well into the twentieth century, numerous Chinese medical texts linked various acute and severe diseases to cold air. 16 Indeed, Zhangzhongjing’s “Shang Han Lun,” or “Treatise on Cold Damage Diseases,” is one of the most famous texts in traditional Chinese medicine. 17 This book in fact covers a range of diseases, but its title demonstrates that diseases related to the cold are given a special status.

Treatise on Cold Damage Diseases

Zhang Zhongjing, one of the most famous doctors in the history of traditional Chinese medicine

Traditional Chinese medicine compares winter water to human blood, arguing that cold air causes the blood to stagnate just as it causes water to freeze in winter. Cold wind was thus considered very likely to cause blockage in the body's system of meridians and collaterals. In light of these medical theories, it is not difficult to understand why Chinese people developed the habit of closing doors and windows before sleeping.

Opening Windows to Combat TB in America

Sleeping with the windows closed is not an uncommon phenomenon, nor is the habit limited to China. Before the 1910s, almost every individual in America slept with their windows tightly closed as well. Americans at the time strongly believed that night air and drafts were detrimental to human health. According to Katherine Ott, a research study conducted in 1908 and 1909 found that in America, tuberculosis was widely associated with catching a chill.18 People believed that the night air was charged with unhealthy moisture and that the air in a closed room was actually less dangerous than the moist air outside.

In the 1910s, however, the habit of keeping windows and doors shut quickly changed in response to anti-tuberculosis campaigns. Ott points out in her study that opening windows is one of the most important measures for patients to take when recovering at home, because this allows them to get as much fresh air as possible. Cultivating this habit in America was made possible by first convincing the public that having outside air owing into the home was beneficial to one’s health. The increasing popularity of outdoor activities also played an important role in changing people’s attitudes towards outside air. These shifting beliefs helped to convince Americans that sleeping with their windows open promoted good health.

Mont Alto Sanatorium for tuberculosis, Pennsylvania: male patients are shown sitting in deckchairs in the "open air".

Propaganda: A Mixture of Traditional Chinese and Western Values

In the Republic of China, when the spread of tuberculosis caused massive deaths all over the state, public health advocates realized the necessity of learning from the West in order to control the disease. The need to open windows was one of these Western notions. Traditional theories about cold wind in Chinese medicine were satirized by public health advocates and supporters of modern medicine. During the anti-tuberculosis campaign, these reformers actively promoted bringing fresh air into the home by opening windows and doors.

The basic treatment for TB is ... fresh air.

Fresh air was described as the enemy of M. tuberculosis. In response to traditional beliefs, public health advocates promoted the idea that breathing in fresh air can turn “dirty blood” into clean Qi (清氣), and food into nutrients.22 In order to explain and justify this measure to the public, public health advocates took up a popular Chinese proverb from Master Lü's Spring and Autumn Annals: "running water would not become putrid (流水不腐)."

Reformers used this proverb to suggest that moving air is unlikely to be harmful.23 By relating wind to water, it was much easier for public health advocates to persuade Chinese people to believe that flowing air is not only harmless, but in fact of great bene t to human health. In response, Chinese people started to believe that opening the windows and letting in the wind could strengthen vitality.

At the same time, public health advocates promoted the idea that proper outdoor recreation can be beneficial to tuberculosis patients. For this they borrowed another famous proverb from Master Lü's Spring and Autumn Annals: “A door-hinge is never worm-eaten (户枢不蠹.)”

Reformers explained that a door-hinge is never worm-eaten because of its constant motion, which by extension would mean that regular exercise can help a person stay healthy. 24

At Red Cross Monthly, a newly designed poster showed a picture of three ladies picnicking outdoors. 25 The poster was intended to encourage people to spend more time outside, breathing in fresh air. Encouraging outdoor activities helped to lessen fear of cold wind, eventually encouraging people to sleep with their windows opened wide.

Medico-athletics introduced from the Soviet Union is effective to treat TB

Opening windows was a crucial part of fighting the spread of tuberculosis. While it seems like a simple habit, public health advocates in China overcame many difficulties before they were able to convince people that opening their windows and letting in the wind was beneficial to human health. Their successful campaigns required combining measures introduced from the West with traditional Chinese values. This made “opening the window” a more persuasive idea to people living in the Republic of China.

Case 3:
Food for Recovery

Diet is an important consideration for patients undergoing treatment for tuberculosis. Many symptoms of tuberculosis, such as fatigue, low spirits and loss of appetite, are all seen in modern Chinese medicine as signs related to physical exhaustion. As a result, people commonly think that tuberculosis patients need to take in more nutrition than the average person in order to regain their physical strength and overcome the disease. By this logic, the diet of a tuberculosis patient should be supplemented with beef, chicken, sterilized milk, eggs and other foods high in calories and rich in protein.

However, a heavy diet rich in protein can actually burden the digestive system of a tuberculosis patient. It is now believed that patients should pay attention not only to how much food they eat and how nutritious it is, but also to how easy it is to digest. For tuberculosis patients, a balanced diet is especially important. Foods high in protein should be supplemented with fruit and vegetables, and it is recommended that patients chew and swallow slowly in order to ensure the absorption of nutrients. Of course, needs vary patient to patient, so the appropriate diet will vary according to the constitution of the person. In Chinese, this is called “因地制宜, 因人而異,” meaning, things vary from person to person, and one must adjust measures to local conditions.

Accepting Milk with a Western Perceptive

In China, milk is not traditionally considered to be a tonic food or drink, 26 but it does have a long history here. One of the earliest appearances of milk in Chinese medical literature is in Ben Cao Jing Ji Zhu (本草經集註), a medical text written by the Taoist priest Tao Hongjing, who lived during the Northern and Southern dynasties. 27 Hongjing writes that milk tastes sweet and that its essence is neutral, making it a suitable drink for both cold (寒) and hot (熱) natured people. In ancient Chinese medicine, milk was considered to be good for the lungs and stomach, and more importantly, capable of supplementing one’s strength. Historically, however, milk was not a staple for the Han people; rather, it was seen as a characteristic drink of the nomadic people living in the frontier. This did not change even during the Yuan and Qing dynasties, which were established by nomadic people. Instead, the Mongol and Manchu emperors and nobles actively integrated with the Han people and imitated their eating habits. As a result, the custom of drinking milk was not widely promoted to the public. In addition, dairy cattle were not introduced to China until the late Qing dynasty, when milk from water buffalo and other traditional sources was in limited supply. 28 In contrast, Westerners had a long-established habit of drinking milk. In the midst of a national crisis, Chinese of officials at the turn of the twentieth century considered that Westerners might be stronger because they drank milk. As a result, Chinese dairy advocates successfully lobbied the Qing government to send representatives to the 1908 World Milk Fair and promoted related government projects, such as establishing demonstration dairy farms, expanding the range of farming and educating the public in dairy farming skills.

With the increased scale of fresh milk production and the growth of market demand, the nutritional value of milk received increasing attention. Scientific articles analyzing the chemical composition of milk began to appear in a number of newspapers and magazines. Milk was soon widely seen as a kind of tonic containing high levels of protein, calcium and other vitamins, rather than just a simple food or drink. It was generally accepted as beneficial to one’s health, both by the general public and the of officials involved in the anti-tuberculosis campaign. Chinese physicians believed that milk was useful for treating anemia and malnutrition. Meanwhile, Western medicine encouraged recovering patients to eat more semi-liquid food, recommending Western foods such as milk and biscuits instead of traditional Chinese porridge or rice paste. 29

Moreover, in the tense political environment at the time, the individual health of Chinese citizens became closely linked with the health of the nation. If drinking milk could make the body strong, that could translate into the strengthening of China.

An advertisement for milk in Republican China: Drinking kedi milk every morning is better than taking any supplements

Pasteurization

Milk was recommended to recovering patients, but it was also, of course, a major route of transmission for tuberculosis bacteria. This was partly due to the circumstances surrounding cattle farming. Cows were not systematically bred in the late Qing dynasty and the Republic of China, which led to widespread mixing of cattle breeds in various areas. Coupled with poor management, cows became susceptible to infection, including bovine tuberculosis and brucellosis. As a result, milking sick cows became a serious problem in the dairy industry. In 1900, officials in Shanghai used tuberculin as a diagnostic test to determine the infection rate of tuberculosis in local cow herds. They determined that about 20% of the cattle were infected. 30

This situation was not effectively addressed until 1925, when the government introduced the standard pasteurization method from the United States. Pasteurization involves heating milk to a temperature of 62.8°C for thirty minutes in order to kill the bacteria. This method of disinfection uses sterilizing machines with a simple and convenient operation, which allowed pasteurization to be quickly applied across the dairy industry. The introduction of pasteurization prevented the transmission of bovine tuberculosis to humans. It should not surprise, therefore, that almost all the reports and newspapers about rehabilitation insisted that milk must be pasteurized.

Pasteurization Process

A New Understanding of Milk in Chinese Medicine

Some proponents of traditional Chinese medicine raised objections to the supposed benefits of drinking milk. They argued that milk is cows’ blood, which is yin (陰) and thus cold in nature. Long-term drinking of milk would then make the human body slowly become more prone to cancer, diabetes, cardiovascular disease and other illnesses. Milk in Chinese medicine was also assigned the attributes of a paste (膏粱之味),31 meaning that it was hard to digest and contributed to the production of phlegm. This would mean that a tuberculosis patient could actually exacerbate their illness by drinking milk. Additionally, an estimated 90 percent of the Chinese population has the lactose intolerance gene, implying that most people with tuberculosis during the late Qing dynasty and the Republic of China would suffer from frequent diarrhea after drinking milk, which would make the patients even weaker.

Conclusion

Although tuberculosis was not listed in the notifiable infectious diseases in the Republic of China, it would be careless to assume that it was neglected by public health advocates. During the 1930s, increasingly scientific information about tuberculosis was regularly communicated to the public in newspapers. These efforts to educate the public were matched by a number of public health measures undertaken as part of a national anti-tuberculosis campaign.

In order to encourage the general public to accept scientifically supported prevention measures, public health advocates chose a compromise between Western and traditional Chinese values to engage in a more accessible discourse with the public. Public spittoons were the product of finding a balance between scientific measures and Chinese habits. Encouraging people to open their windows involved answering deep-rooted fears with a reframing of traditional proverbs. Pasteurized milk was promoted by public health advocates to ensure that the health benefits of milk were not undermined by the presence of dangerous bacteria. The anti-tuberculosis campaign was not a simple embrace of Western science; rather, it was embraced as part of national rejuvenation and tailored to Chinese sensibilities. A balanced approach to public health, informed by both Western and Chinese values, proved successful in stemming the spread of tuberculosis in the Republic of China.

Bibliography

Andrews, Bridie J. “Tuberculosis and the Assimilation of Germ Theory in China, 1895– 1937.” Journal of the History of Medicine and Allied Sciences 52, no. 1 (1997): 114–157.

Bing qing dao le shi dang jie duan, zai yi shi zhi dao xia ying yong Su Lian xian jing de yi liao ti yu, you hen hao de xiao guo

(Medico-athletics introduced from the Soviet Union is also effective). Shanghai Anti-Tuberculosis Association.

Image taken from U.S. National Library of Medicine Digital Collections

(https://collections.nlm.nih.gov/catalog/nlm:nlmuid-101557477-img) Reproduced under a Creative Commons

license CC0 Public Domain (https://creativecommons.org/publicdomain/zero/1.0/)

Blue ocean waves taken during daytime .Image taken from Pixabay (https://pixabay.com/photos/water- owing-spatter- owing-water-2130047/) . Reproduced under a Creative Commons license CC0 1.0
(https://creativecommons.org/publicdomain/zero/1.0/)

Bu ke rao shu de cuo wu. A poster published by Shanghai: Zhongguo fang lao xie hui. Retrieved from the U.S. National Library of Medicine Digital Collections. Reproduced under a Creative Commons license CC0 Public Domain.

Cheng Shiquan 程石泉. “Tutan 吐痰 [Spitting].” Jilian huikan 11 (1930): 31.

Chinese woodcut, Famous medical figures: Zhang Zhongjing. Gan Bozong. Tang period, 618-907. Image taken from Wellcome Collection. Reproduced under a Creative Commons license CC BY 4.0.

Door Hinge. Image taken from Public Domain Pictures. Reproduced under a Creative Commons license CC0 Public Domain.

Dr. Way-Sung New. Image taken from common.wikipidea.org. Reproduced under Public Domain.

Escombe, A. Roderick, Clarissa C. Oeser, Robert H. Gilman, Marcos Navincopa, Eduardo Ticona, William Pan, Carlos Martinez et al. “Natural Ventilation for the Prevention of Airborne Contagion.” PLoS Medicine 4, no. 2 (2007): 311-316. Cited in Tonks, Alison, ed. "Opening Windows Could Slow the Spread of Tuberculosis." BMJ 334, no. 7592 (March 2007): 500-501.

Fei jie he bing de ji ben zhi liao, shi yao you shi dang de xiu xi, ying yang, yang guang, he xin xian kong qi (Basic treatment of TB is good rest, nutrition, sunshine, and fresh air). Image taken from U.S. National Library of Medicine Digital Collections. Reproduced under a Creative Commons license CC0 Public Domain

"Feilao de fangzhi [Prevention and Control of Consumption].” Yishi Bao. September 22, 1965.

Huang Sanjin. “Zhongxiyi kan niunai [Chinese and Western Medicine Look at Milk].” Huang Shaojie Handbook of Chinese Medical Knowledge. 20 October 2015.

Huang Qingquan 黃清全. “Laobing he jiehe 癆病與結核 [Laobing and Tuberculosis].” Xinwen Bao. November 7, 1937.

Kowner, Rotem, Guy Bar-Oz, Michal Biran, Meir Shahar, Gideon Shelach-Lavi, eds. Animals and Human Society in Asia: Historical, Cultural and Ethical Perspectives. Cham, Switzerland: Palgrave Macmillan, 2019.

“Laobing fangzhi 癆病防治 [Prevention and Treatment of Tuberculosis].” Yishi Bao. September 22, 1946.

Lei, Sean Hsiang-lin. “Habituating individuality: The Framing of Tuberculosis and Its Material Solutions in Republican China.” Bulletin of the History of Medicine 84, no. 2 (2010): 248–279.

------“Habituating the Four Virtues: Ethics, Family, and the Body in the Anti-Tuberculosis Campaigns and the New Life Movement.” Bulletin of the Institute of Modern History, Academia Sinica 74 (2012): 133–177.

------“The Birth of Public Spittoons: Hong Kong's Anti-Spitting Controversy and the Chinese Community's Response.” Bulletin of the Institute of Modern History, Academia Sinica 96 (2017): 61-95.

------“The Pride of Public Spittoons? Anti-Spitting Movements in Hong Kong, New York, and Shanghai.” Bulletin of the Institute of Modern History, Academia Sinica 98 (2017): 1–47.

Li Hengjun. “Jibing zhishi, yiliao wenhua yu weisheng xiandai xing: Jindai Zhongguo feijiehebing de shehui yu wenhua shi (1850-1940 niandai): (1850-1940) 疾病知識、文化與衛生現代性:近代中國肺結核病的社會與文化史 (1850-1940年代) [Tuberculosis in Modern China: A Social and Cultural History (1850-1940s)].” PhD diss., National University of Singapore, 2014.

Mont Alto Sanatorium for tuberculosis, Pennsylvania: male patients are shown sitting in deckchairs in the open air, during 'rest hour'. Wellcome Library no. 582391i. Image taken from Wellcome Collection. Reproduced under a Creative Commons license CC BY 4.0.

Mountain Window View. Image taken from Public Domain Pictures. Reproduced under a Creative Commons license CC0 Public Domain.

Mycobacterium tuberculosis Bacteria, the Cause of TB. Image taken from flickr. Reproduced under a Creative Commons license CC0 Public Domain.

Mycobacterium tuberculosis Bacteria. Image taken from flickr. Reproduced under a Creative Commons license Attribution 2.0 Generic.

Ott, Katherine. Fevered Lives: Tuberculosis in American Culture since 1870. Cambridge, MA: Harvard University Press, 1996.

Protein foods: meat, eggs, cheese, milk with measuring tape on white wooden background. The concept of diet. Image taken from flickr. Reproduced under a Creative Commons license Attribution 2.0 Generic

Pi Xian 丕显. “Jia ting wei sheng chang shi: ru he pu mie fei jie he 家庭卫生常识:如何扑灭肺结核 [Family health common sense: how to exterminate tuberculosis].” Jia ting zhou kan 96 (1935): 42.

Ru Linfang. “Zhongyi fandui niunai [Chinese Medicine against Milk].” Pikebang. October 10, 2013.

Spittoon. Image taken from Public Domain Pictures. Reproduced under the license of Walters Art Museum to Wikimedia Commons.

Spring Garden Window Frame View. Image taken from Public Domain Pictures. Reproduced under a Creative Commons license CC0 Public Domain.

Sun Zhongliang 孫忠亮. “Jie he zheng de jia ting liao yang fa 結核症的家庭療養法 [Family Therapy for Tuberculosis].” Red Cross Monthly 16 (1947): 17.

Tan Shixing 譚世鑫. “Feijiehe zhiliaofa yu bingzhe xinyu hou zhi shenghuo fangfa 肺結核治療法與病者新愈後之生活方法 [Tuberculosis Treatment and Lifestyle after Recovery].” Fanglao Yuekan 1, no. 3 (1935): 133–141.

Yan Fuqing. Image taken from common.wikipidea.org. Reproduced under Public Domain.

World TB Day. Images taken from Joint Base Andrews. Reproduced under a Creative Commons license CC0 Public Domain

Wu Lieh-Teh. Image taken from George Grantham Bain Collection. Reproduced under Public Domain.

Zhang Junjun 張俊君. “Cong minzu fuxing yundong shuodao fanglao yundong 從民族復興運動說到防癆運動 [Discussion from National Rejuvenation to Anti-TB Campaigns].” Fanglao Yuekan 1 (1934): 3–6.

Zhi ren zhi mian bu zhi fei. A poster published by Shanghai: Zhongguo fang lao xie hui. Retrieved from U.S. National Library of Medicine Digital Collections.

Zhuang Weizhong 莊畏仲. “Laobing de yufang fa 癆病的預防法 [The Prevention of Consumption].” Xinwen Bao. February 13, 1939.