The 1969 Ramon Magsaysay Award for Government Service

BIOGRAPHY of Hsu Shih Chu

HSU SHIH CHU was destined to grow up knowing hardship and war. He was born on May 5, 1906 in Tachiao, Fenghua Hsien (County), Chekiang Province in imperial Manchu China. His parents were poor, hardworking silk workers. During his early school years the established order fell before the revolution against the Ch'ing Dynasty and the attempts to establish a modern republic. He attended medical college to the accompaniment of continuing civil war and the invasion of China by the Japanese. Joining the public health service during the latter part of this period, he worked on health problems as World War II raged around him. Finally he retreated with the Nationalist Government to the island province of Taiwan where as Chief of the Rural Health Division of the Sino-American Joint Commission on Rural Reconstruction he was to make his international reputation. Through all these years of turmoil and bloodletting HSU maintained his optimism, his sense of service and a dedication to ameliorating the health problems of the Chinese people.

HSU attended the American mission Ningpo Baptist Middle School. In 1926 he was sure enough of his own principles to stand aside from his classmates during a city-wide student strike. "I refused to go with them," he wrote. "I think I saw further than they did. I knew politics could not solve my country's problems—only science could really help." But he was an astute enough politician to persuade the Communist student leaders not to destroy the school. As a result Baptist Middle was the only missionary or government school in the area to remain intact.

Graduating that year, HSU enrolled at the Medical College of Cheeloo Christian University in Tsinan. He went on a scholarship—which he later repaid in full—from the American mission hospital, Ningpo Hwa Mei. While there HSU was inspired by a young American medical missionary, Dr. Susan S. Waddell, who later became his wife. It was she who encouraged him to specialize in public health in order to improve the well-being of large numbers of people instead of just a few private patients.

During his second and third years at the college HSU helped establish two community-supported primary schools in nearby villages. Giving of his free time daily, he persuaded the villagers to provide buildings and furniture for the schools; he also taught. This undertaking had a permanent effect on HSU's thinking. He learned through this work that "success is the fruit of unceasing, continuous, toilsome and often monotonous routine."

Graduating from Cheeloo in 1932 HSU, at the age of 27, went on to post-graduate training at Peking Union Medical College. He interned in the college hospital during the academic year 1932-33, and was a fellow in the Public Health Department in 1933-34. As such he was sent to the famous Mass Education Movement Center organized by Dr. James Y.C. Yen (1960 Ramon Magsaysay Awardee for International Understanding "for sharing the wealth of his experience and creative leadership in rural reconstruction in Asia") in Ting Hsien of Hopeh Province. Yen had discovered that the average Chinese paid the equivalent of 40 U.S. cents annually for health Services, including payments to herb doctors and offerings to gods. He and his colleagues realized that for only 10 U.S. cents per person annually they could provide a modern health service to rural areas, including a 45-bed hospital in each hsien and a health center in each township. (In retrospect HSU feels that the error this program made was that the money to support the work came from the outside, rather than from the local communities.)

After training at Ting Hsien Dr. HSU was sent to practice what he had learned at Lichingkou, a backward district of some 70,000 persons which lacked the simplest of health facilities. To demonstrate the value of medical attention he successfully treated the all-prevalent trachoma, in one month's time convincing local leaders of the need to establish a health station. The town supplied a fairly large building for the project. Financial support for personnel came from the 30 nearby villages and the Mass Education Movement.

In late 1934 HSU accepted a position in the Hunan Provincial Health Administration as a public health expert. His first field assignment was in the Longlishih District of Changsha County where, again, no medical or health facilities existed. He was invited to establish a health station by the district magistrate, who said he would use money designated for a police station if HSU could prove its practicality. Warned that the people preferred police protection from bandit raids to health protection, HSU and his assistant nevertheless accepted the challenge. They set themselves up in the only available building—a temple on the outskirts of town. Ignoring their own danger from bandits, they set about establishing a school health program. They also gave free medical consultations to people who came from miles around—by foot and sedan chair. Seeing the response to HSU's efforts, the town chief agreed with the district magistrate, and the police station was replaced by a health center. The center was opened just two months after HSU and his assistant arrived, with ceremonies attended by provincial as well as district officers, including the governor and the health commissioner. The success of this venture spurred the creation of other health stations by provincial and local governments. One problem they failed to solve, however, was how to find individuals to run them with the sense of mission and dedication shown by HSU.

In 1935 HSU went to Nanking—at that time the capital of Nationalist China—as Director of the Rural Health Training Center at the National Public Health Personnel Training Institute. He was concurrently named Chief Health Officer of Kiangning, a very poor county of 450,000 people which was made a demonstration area by the national government. HSU was recommended for these posts by Dr. J. B. Grant of the Rockefeller Foundation who had watched HSU's work in Longlishih; the Foundation was working with the Ministry of Health in training rural health personnel.

As Director of the Rural Health Training Center HSU was responsible for training about 360 persons annually—at the rate of 30 or more in 10 one-month classes a year. The trainees were doctors, nurses, midwives and sanitation specialists.

As Chief Health Officer of Kiangning HSU was charged with developing a health program for the area. He first got the magistrate of Kiangning to introduce tax reforms whereby rich landlords and poor peasants alike were publicly registered and equitably taxed; the middleman role of tax collector was abolished. Tax collections increased that year from Chinese National Currency (CNC) $350,000 to over CNC$1,000,000, even though the peasants' taxes were often reduced by five-sixths. "Now we had money, almost more than we could spend," commented HSU. He and his colleagues, however, needed statistics as well as money before beginning their pilot program. They mobilized school teachers and students to take a census which was completed in five days. (A salutary side effect of this census was that as people were required to keep cards on their doors listing any change in vital statistics due to birth, marriage or death, the government was able to identify and expel bandits and political undesirables who did not belong there.) The end result was that HSU was able to finance and build a health center in the county seat staffed by four doctors plus nurses and assistants; six health stations in outlying towns staffed with one doctor, a public health nurse, a sanitary inspector and two attendants; and a number of sub-stations staffed with a public health nurse, a midwife and an attendant, many of whom were trained at his Center.

These interlocking programs administered by HSU between the years 1935 and 1937 were so successful that governors of other provinces requested the Center to train their medical/health personnel, and they set aside funds to establish health organizations similar to that developed by HSU in Kiangning. HSU's first year and a half in these jobs, however, was made particularly difficult by the murder of his wife in October 1935 and the resulting police investigation lasting 15 months. A rickshawman was eventually found guilty. "In memory of his beloved wife" HSU recommitted himself during these years to the promotion of rural health care for "his poor and underprivileged countrymen."

In 1937 HSU received a Rockefeller grant to study at Johns Hopkins University School of Hygiene and Public Health. When he returned from his year in the United States he assumed the position of Dean of the Medical Officers Training Class of the National Public Health Personnel Training Institute at Kweiyang, Kweichow, deep in the interior.

Soon after he arrived to take up his post, word was received that an epidemic of malignant malaria was devastating eastern Kweichow. The population was so afflicted that the autumn harvest could not be gathered. The mountainous region was infested with bandits notorious for killing before they robbed. As none were willing to go to the relief of this stricken area, HSU volunteered to go himself. With 20,000 quinine tablets, some equipment and a small amount of money, he, a laboratory technician and two medical attendants set off. They found villages where all the inhabitants were too ill even to cook. After 10 days of treatment most recovered. For three months HSU and his dedicated team visited village after village, prescribing and healing, walking more than 300 kilometers over difficult terrain. HSU had to supplement the meager government allowance to the team by using US$50 of his own savings, a large sum at that time.

Recognizing that malaria was a major health problem in China, increasing in frequency and morbidity as the Chinese were forced to move south and west under pressure from the Japanese armies, HSU accepted an assignment with the National Health Administration to direct the newly established Malaria Research Institute. This Institute was funded by the Rockefeller Foundation in 1940 at Chefang, in the Shan State of Yunnan Province near the Yunnan-Burma border. Malaria was hyperendemic among the Shans who nevertheless had a low mortality rate from it; the disease, however, was often fatal to Chinese who moved into the area. With him on this assignment HSU brought his new wife, Yao Shiaoying, a nurse whom he had known for some time.

In 1941 the Japanese invasion of Burma forced HSU to move the Institute laboratory, under conditions of great hardship, to the outskirts of Chunking, now the capital of beleaguered China. Barely escaping a surprise Japanese air raid, the team evacuated equipment in three vehicles over the militarily-famed Burma Road; lack of space forced HSU and his wife to leave some of their own possessions behind. Arriving in Chungking after a month of travel, the staff set up the laboratory and resumed their study, although financing became increasingly difficult to obtain. In January 1944 HSU was sent on a Rockefeller grant to India and Ceylon to examine malarial research in those countries. He returned in May the same year.

After Allied victory over the Japanese in August 1945 and the end of 14 years of Japanese occupation of parts of China, the laboratory was moved to Nanking, once again the capital of the Nationalist regime. It was integrated into the National Institute of Health and continued to enjoy Rockefeller funding.

HSU remained as Senior Technical Expert at the Malaria Laboratory until 1948. That year he turned down a Rockefeller travel grant to study health programs in the Americas, India and Europe. Instead, at the urging of the Vice-Minister of Health he joined the SinoAmerican Joint Commission for Rural Reconstruction (JCRR) which had been established in Nanking as a result of the China Aid Act passed by the United States Congress in the spring of 1948.

The JCRR, perhaps the most successful aid program in the world, is operated jointly, and semi-autonomously, by three Chinese and two American Commissioners appointed by their respective presidents, assisted by specialists from both countries working as equals. It is a combination "university and a community center aiming to study and improve the living conditions and welfare of the people in rural communities. Its staff has the opportunity to develop his or her philosophy and ideas and work out ways [to achieve them] . . . through government organizations, private agencies or directly with end users. In such a unique institution, Dr. HSU has his opportunity to manifest and develop his usefulness."

HSU has described the JCRR as a catalyst for local level change. As he has said, in the middle years of the 20th century cities were changing rapidly, with the exception of the slums, but the villages and the local and county governments remained static. They had resources—both manpower and financial—but needed an enzyme, a motivating force, to get them to move. The provincial and national governments were too remote. The JCRR, and in the field of health specifically the Rural Health Division (RHD), became that force. The motivating force behind the RHD has been Dr. HSU.

HSU joined the Health Committee of the JCRR as a member and Executive Secretary. As a result of the chaos resulting from the rapid advances made by the Communists the committee form was dropped and a Rural Health Division was soon established with HSU as its Chief.

HSU had learned by experience that only where local government and local people were involved were health centers effective. This lesson was reinforced by his discoveries after the war when he returned to provinces where he had worked. There he found the public health programs in total neglect. Not a brick remained of the house and hospital he had constructed in Kiangning demonstration county. Everything that had been built with outside—i.e., foreign, national or provincial—money and help had been destroyed, either by the Japanese, the Communists or by public apathy.

What did survive, however, were "all my health stations, sub-stations at village level, at township level." Those stations, built in temples or the like because he couldn't afford proper buildings, remained. HSU insisted, therefore, that local governments pledge to match RHD monies by setting aside a certain percentage of their budgets for rural health. He told the officials: "Now you do only two things—you tax and you conscript, and the people hate you. Health work is on the other side and is positive."

Health problems on the mainland of China in 1949 were monumental. The government was called upon to provide sanitation and public health services to 450 million people, 85 percent of whom lived in rural areas. The medical schools were training only 200 to 400 doctors a year, and the Nationalist government was under constant attack by the Communist armies. The JCRR nonetheless set to work in Kwangtung Province to set up health centers in each market town (hsien capital) and to set up health stations in each of the six to eight districts. "A hospital is not necessary," HSU wrote at this time. "We must concentrate on preventive work. . . use nurses or midwives. The job is organizational and educational." This made good sense not only because of limited funds and staff, but also because the main diseases of rural China were trachoma, skin diseases, parasitic diseases and epidemic diseases, all of which could be prevented or cured by cleanliness, sanitation and simple disinfectants. Malnutrition was considered an economic problem and outside the scope of the health service at that time.

The first step required of a local government by the RHD was to set up a health board of local people—teachers, merchants, religious—excluding the gentry who ran the government. The board was to be independent of government which was often rife with nepotism and corruption; the board alone would have the power to remove personnel. When a hsien government acquiesced to these conditions, the RHD agreed to provide US$200 for each health center and US$100 for each health station for equipment, medical supplies and a small operating budget. To ensure that the staff worked hard and that they moved out into the villages, the RHD paid them bonuses on the basis of the number of patients they saw.

The JCRR, which was limited by law to the area under Nationalist control, was moved to Taiwan in 1949 when the Communists took Canton (programs in Kwangsi and Szechuan continued to receive support until those provinces were taken later that year). HSU, technically a member of the Kuomintang Party, was basically apolitical and he seriously considered staying on the Chinese mainland. He felt that whatever the government, the need of the people would remain. However, when the JCRR moved to Taiwan he followed suit, continuing as Chief of the Rural Health Division.

On Taiwan, which had been returned to China in 1945 after 50 years of Japanese rule, rural health facilities were mainly inoperative. Before World War II Japan had done much to decrease malaria and cholera and reduce infant mortality there. It had also begun a biannual house-to-house cleanliness inspection program. When HSU arrived his first priority was development of a province-wide network of local health stations. Proposing revitalization of the existing health stations and the establishment of others on the same basis as on the mainland, he continued to insist on local support, with a local board to raise funds, provide space and employ the minimum staff of doctor, nurse and midwife. Rejecting U.S. aid funds for hospitals or other major projects, he requested instead that the U.S. aid mission pack units of medical equipment according to his specifications and ship them directly to the health centers, which it did. The RHD in turn, to encourage health workers to visit schools and homes, provided per diem cash, bicycles and "delivery" and "visiting" bags. During Fiscal Year 1950 (July 1,1950-June 30, 1951) 104 existing health stations were revitalized and 148 new ones were established. Each received from the RHD US$100 to US$600 according to its needs; on the average the RHD contributed US$1 to every US$33 locally raised.

In two years there were 356 health stations on the island. To test their viability, beginning in 1952, free allocation of medical supplies and per diem cash grants were withheld. HSU got permission from the JCRR to spend the US$200,000 saved as a result of this move on new buildings of a standard to meet RHD specifications, replacing unsuitable older buildings. A 1,080 square foot building was designed with structure and furnishings to cost US$8,000, half of which would be provided by the RHD. The local committee was required to purchase 3,600 square feet of land and to raise the matching US$4,000 for construction. Fifty townships were screened and recommended for the plan. The success of the program was so great that in 1953 there was demand from other townships to participate. To meet this recognized need and interest with the limited funds available to the RHD, local bodies were now required to come up with two-thirds of the building costs as well as supply the land, furniture and a fence. Building plans of greater flexibility were developed to be constructed according to the financial status and the needs of the populations of the new townships. Construction of dormitories for medical personnel followed. These community health stations became, according to Professor Neil A. Jacoby, "genuine community enterprises, which progressively evolved to a self-support basis."

The health programs themselves started in a simple and personal way with insistence first on personal hygiene—washing hands before eating and after elimination, having personal eating and drinking utensils and towels —because in 1949 over 95 percent of the people had intestinal parasites and 60 percent of the school children had trachoma, both problems of personal care. The next step was to preach home sanitation, cleanliness, orderliness, beautification and fly control. In the usual farmbouse cleanliness was practiced only at the time of the Chinese New Year when the trash of the previous year was removed. Through the schools and visiting nurses, women were taught to clean their kitchens, hang up their pots and pans, keep the pigs and fowl out of the house, build and cover latrines and keep food and water covered. When they had clean and orderly homes, HSU urged them to paint the doors and windows and plant flowers. He believed that beauty gave one an added sense of dignity and pride.

Fly control required village cooperation. The RHD discovered that concentrated organic phosphorus mixed with oil, coloring matter and sugar and placed on a plate would attract flies who died 10 seconds after eating it. The product was distributed to the villagers in 38 to 50 gram packages which would last one household one month. This method was so successful that whole villages experienced a sharp reduction in flies in a matter of weeks. The fly elimination program, HSU says, "made us very popular," and it increased villager willingness to cooperate with other programs.

Along with fly control HSU pushed public sanitation projects, especially a three year latrine-building program. More than 800 schools constructed eight-seat latrines and towns and villages were encouraged to build or upgrade public facilities of this nature. As a result of this work HSU was asked by the government to be the co-convener of the Provincial Taiwan Environmental Sanitation Guidance Committee.

Supply of medicines at reasonable cost for the health projects was solved after HSU was asked to handle the sale of US$400,000 worth of drugs donated by the U.S. aid mission for the purpose of creating counterpart funds, stabilizing drug prices and eliminating hoarding and black marketeering. In agreeing to do so he took on both powerful foreign drug exporters and Taiwan merchants who were engaged in driving up prices. He was warned not to get involved and later to get out of the operation, but he was no more concerned by threats from these sources than he had been by those of bandits in his years on the mainland.

HSU began by getting the government and merchants to agree upon a price. He then sold his stock of drugs to health centers and non-profit medical institutions at 70 to 80 percent of the fixed price. The market soon slipped to the RHD price whereupon HSU lowered his price another 20 to 30 percent. After three months there was no more hoarding or black market; after six months merchants were selling at a loss. Since the idea was not to destroy the drug market but to bring order into it, HSU then persuaded the government to set a 25 percent ceiling on profits and advised his health stations to buy on the open market. He stabilized future prices by getting the government to earmark each year eight percent of the total national requirement of foreign currency for RHD purchases of basic drugs such as sulfa and a few common antibiotics. The success of the program was "due to careful planning and a clean operation." The surest way, HSU says, to keep an operation clean is by leading an upright life because people "dare not lure the righteous man with common material means of liquor, women, a gift or attractive job."

For training and education of health personnel the RHD assisted in establishing the Tainan Nursing School and has given financial aid to the Taipei and Taichung nursing schools to improve their teaching facilities. It helped establish the Institute of Public Health which trains medical officers in public health measures, and the Taoyuan and Hsinchu public health refresher training centers where nurses, midwives, medical attendants, sanitarians and nursing students receive four- to six-week courses. It also facilitated the work of foreign missionaries in constructing the Hualien Mennonite Hospital for Aborigines and in rebuilding the Changhua Christian Hospital.

At the same time he was using the RHD as a catalyst to develop health stations, HSU was working on a primary school health program. He convinced the Provincial Commissioner of Education to prevail upon each of the 1,240 primary schools on the island to send one teacher each for a two-week special health training program in Taipei, to be conducted by public health doctors and nurses under the auspices of the RHD. The teachers were required to teach other teachers what they had learned; health was to be emphasized in primary schools as much as Chinese and mathematics.

The teachers who attended the courses were given honorary titles of School Health Teachers and were given a unit pack of DDT for head lice, simple medication for eyes and skin and a set of record forms to keep on all students. Scales were sent to the schools free of charge. The cost of the program was shared equally by the JCRR and the Department of Education. Follow-up was by Department of Education teams and through annual school demonstrations whereby individual schools were required to put on a demonstration with other schools required to attend. Progress has been rapid. Infestations of head lice have disappeared. The World Health Organization (WHO) and United Nations Children's Emergency Fund (UNICEF) have joined in tackling trachoma.

When UNICEF, and later WHO, offered to take over these and other JCRR health projects, HSU welcomed them and worked to make their involvement possible. A problem existed: the international organizations had no funds for local expenditures; the provincial government had no unallocated funds. HSU therefore arranged with the JCRR to channel some of its monies through the government to cover local travel, per diem and accommodation expenses for international health personnel. For the first year or so the JCRR did not get credit from the international organizations for its aid and HSU remained as a backstage worker, seeking no recognition for making the operations possible. However, as Lao Tze wrote centuries ago, "He achieves without claiming credit for himself. Because he does not claim credit for himself, he is always given credit." In due time HSU's actions were noted.

Five international teams were eventually sent to Taiwan to work on maternal and child health care, tuberculosis, malaria, venereal diseases and hospital nursing. All were supported with JCRR funds, as arranged by HSU, until the provincial government was able to take over this extra financing two years later. The results of the actions of these teams were that malaria dropped from 1.2 million cases in 1950 to only 433 cases in 1957 (it was eradicated in 1965); the rate of trachoma and conjunctivitis dropped from 80 percent to 10 percent; the rate of VD fell to 5.8 percent and tuberculosis mortality dropped from 285 per 100,000 to 55.

When UNICEF attempted a diphtheria inoculation program, however, it failed. The serum had to be injected intramuscularly and there were not enough doctors in rural areas to give the injections. U.S. aid mission medical officers suggested to HSU that diphtheria could be controlled by developing a subcutaneous injection which could be given by nurses and midwives. HSU discussed it with serum specialists who worked it out. The U.S. provided the needed materials, the provincial government paid for the cost of the injections and the RHD provided "pocket money" as HSU calls it, money for transportation and accommodations, for the nurses and midwives who devoted all their time to the program for a short, intensive period. The result was an immediate drop in diphtheria cases from the thousands to between 300 and 400. Cholera was also eliminated as a scourge. Of the 12 million people on Taiwan in 1957, 10 million were inoculated, and, when cholera struck, nurses were immediately sent in to teach sanitation as well as quarantine the area.

Dr. HSU was instrumental in establishing the Taiwan Sera and Vaccines Laboratory which developed the diphtheria and other sera. When he arrived on Taiwan in 1949 the production of biologicals for human usage was in the hands of the Hygienic Laboratory of the Provincial Health Administration and the Institute of Tropical Medicine of National Taiwan University. He saw that both were poorly equipped and poorly managed and needed badly to be integrated, but both organizations refused to consider such a move. HSU therefore discussed the problem at length with the president of the university who was finally won over, but died before he could make any change. HSU had therefore to wait until a new president was selected and could be convinced of the wisdom of his plan, and a new U.S. aid specialist arrived, before he could finally get the two organizations to amalgamate.

On September 25, 1951 the new Taiwan Sera and Vaccines Laboratory was officially established. The JCRR immediately expedited an order for equipment for the laboratories. In the meantime six specialists were sent to the United States for advanced training. As a colleague commented, from the long, drawn out negotiations in connection with this project "HSU has learned that to successfully bring people of different interests towards a common objective one needs wisdom, patience, enthusiasm, a desire to contribute and not possess, and humbleness.

Other major health projects undertaken by the RHD under HSU's leadership during the past 20 years include rehabilitation of 77 waterworks with the result that today there are 263 waterworks which supply potable water to 38.9 percent of the population. A rat poisoning program was undertaken on Quemoy Island to eliminate the plague, and the mass vaccination of dogs on Taiwan has resulted in the elimination of rabies. Filariasis was eradicated in the offshore Pescadores Islands, and a province-wide smallpox vaccination campaign in 1955 finally eradicated that disease.

In 1957 HSU broadened RHD's program to include food processing and nutrition, a logical result of his interest in increasing the physical well-being of the farmer by increasing his economic basis. Food processing permits better nutrition by preserving food for future use and it is a bridge between agriculture and industry, on the one hand absorbing surplus raw materials and adding to the economic betterment of the agriculturist, on the other creating industrial jobs and earning foreign exchange. It also forces a modern outlook on the participants, requiring of them a scientific approach to techniques and modern standards of sanitation and personal hygiene.

Nutrition had been a RHD concern since the early 1950s when the Division did a soybean feeding study, adding soybeans to the rations of some 10,000 soldiers. Their rapid improvement in health and physique resulted in a corresponding improvement in morale. The RHD later introduced soybean milk into school lunches.

In food processing HSU persuaded the JCRR to offer technical and financial assistance to pineapple canning processors and found ways to reduce the amount of mold in canned pineapple from a wholly unacceptable 80 percent to 4 to 7 percent, and to reduce the bursting rate of the cans from 3 percent to .08 percent, .02 percent lower than the standard in western countries.

In 1959 HSU undertook to assist the button (French) mushroom industry. The mushrooms grew well in Taiwan but local demand for them was limited. HSU was interested in promoting them as an extra cash crop for farmers as they could be grown in the slack season and required no extra land. The RHD persuaded four canneries to experiment in processing the mushrooms according to a method worked out by RHD specialists. The canneries on their part had to agree to help the farmers by paying a previously agreed upon price, and they had to find their own export markets. The target, HSU states, "was to can 45,000 cases between November 1959 and April 1960." The goal was dramatically exceeded: 135,000 cases were canned and exported during that period. By 1964 the number of cases exported had risen to 1,650,000 per year. The industry has continued to expand, earning US$31 million in foreign currency in 1967 alone.

Asparagus was another vegetable that came to the attention of HSU and the RHD. A Chinese from the mainland had experimented with growing asparagus on Taiwan but had found little local interest in the fresh produce. He was planning to dig up his fields when by chance he came into contact with the RHD which convinced a cannery to process the crop. The venture was successful and both demand and supply grew rapidly. RHD specialists helped further by recommending keeping asparagus in cold storage before processing to improve flavor, and peeling it to reduce the fiber content. They also suggested a way of reducing grit on the spear. As a result canned asparagus is a thriving export produce with a foreign currency earning in 1967 of US$24 million.

In 1964 the RHD helped usher the now rapidly increasing frozen food processing industry into Taiwan when it gave technical advice to a farmer experimenting with freezing pea pods for export. The RHD sent nurses to instruct him and others in what HSU refers to as "operating room aseptic techniques." Some 115,000 pounds of quick frozen pea pods were produced and exported that year; production and sale the following year increased five-fold. HSU later was instrumental in solving "the processing problem of color change" in freezing mushrooms for the foreign market. These successes led to experimentation with other fruits and vegetables.

Industries processing food primarily for domestic consumption which have been aided by scientific advice from the RHD have been as disparate as the soybean milk industry which was advised on sterilization of its bottles, and the dehydrated mushroom industry which was introduced to a new system of hoe air drying.

The food processing industry, like other labor intensive industries, has been able to capitalize on the surplus of labor in Taiwan, particularly of young people. Although surplus labor is an advantage at one stage in industrial development, HSU early saw the long term disadvantages of excess population: a stable economy can not train and absorb an unlimited number of new workers, to say nothing of feeding them without spending precious foreign exchange to import grain. HSU realized that much of the failure of prewar efforts to improve health and living standards on the .mainland was due to lack of population control, but at that time no means had existed for introducing birth control measures into rural communities. By 1950, however, the picture had changed. On the basis of new knowledge and techniques the JCRR that year prepared and issued half a million booklets for distribution entitled The Happy Family, recommending family size limitation by the rhythm method. Although rudimentary techniques were available, the time was not right. The public reacted unfavorably and the government—particularly the military—saw birth control as a Communist plot to reduce manpower and therefore their ability to retake the mainland, and to undermine the teachings of the leader of the Nationalist revolution, Dr. Sun Yat-sen.

Sun had noted early in the 20th century that although other nations had greatly increased in numbers during the past 100 years—the United States by 1,000 percent and Japan and England by 300 percent—China had remained stable. Sun feared that China would eventually be assimilated and lose its identity, therefore he preached large families. What he did not allow for was the conquest by western medicine of the great killer-epidemics of earlier centuries and of improved food distribution in times of famine, with the resultant decrease in deaths and upsurge in population. In Taiwan the natural increase jumped between 1947 and 1951 from 20.16 to 38.40 per thousand, a frightening figure when projected into the future.

Luckily HSU and the RHD could point to their accomplishments of the preceding year—establishment, for example, of 252 rural health stations —hardly the work of enemy agents. The JCRR, however, pulled back and awaited a more favorable time to broach the subject again.

By 1952 the furor had died down and the time seemed appropriate to gather hard data that would support future family planning efforts. The Rockefeller Foundation and Princeton University offered technical and limited financial assistance. The RHD therefore undertook a demographic study of 2,404 women of childbearing age in Yunlin County. Among other findings the random sampling noted that the death rate of children in families of one to three children was 10 percent, accelerating as the number of children increased. In families of 10 or more children the death rate was 26 to 32 percent. HSU referred to these as "wasteful deaths." Moreover, the number of female children "adopted out" and usually exploited in one way or another, often being forced into early prostitution, increased from half of one percent for families of one to three children to 10 percent in families of 10 or more. This seemed to confirm that families did not want large numbers of children and if they had them, either did not, or could not, care for them.

In 1954 the Minister of Education foresaw the problems arising from the rapidly increasing number of children—e.g., the need for increased numbers of schools—and suggested to HSU that he undertake some sort of family planning program. HSU responded that the Minister would have to line up leaders in all fields and of both sexes and start a family planning association before the RHD would become involved again. In August 1954 the China Family Planning Association was established as a voluntary organization.

Family planning was introduced by the RHD as a supplement to first aid training and introduced first into military villages built by the government for soldiers and their dependents who had come over from the mainland. The excuse used was to teach first aid to two households in every lane in order to care for the civilian population in case of Communist air raids. Nurses and midwives sent out from the health stations to offer this training were paid by the RHD and given family planning training by the Association. Family planning was treated as a health problem and an offer of assistance in this field of health was made at the end of every first aid session. The response was immediate. Military families were unable to raise large numbers of children on an officer's pay of US$20 or less a month, let alone on an enlisted man's allotment, even allowing for subsidized housing, rice and oil. The aid/family planning program was next offered to villages of civilians.

RHD involvement in family planning was endangered in 1957 when the JCRR program officer of the U.S. aid mission, a Catholic, requested that financial assistance for such purposes be withdrawn. HSU took the case to the Chief of Mission, asking him to clarify the American position. The Chief, when assured by HSU that the Premier "had urged the JCRR to go ahead with family planning work provided no publicity be made and that Chinese religions did not oppose," told him to proceed with RHD family planning sponsorship. To appease the program officer, HSU relates, family planning information henceforth was offered as a "pre-pregnancy health" measure instead of "for the reduction of wasteful deaths."

A second crisis arose in 1959 when the former chairman of the JCRR wrote a newspaper article strongly urging the need for island-wide birth control. Adverse public reaction to this frontal assault, plus President Eisenhower's statement that U.S. aid funds could not be used for family planning, caused the government to hesitate in its support of the China Family Planning Association. However, HSU, meeting with the Governor of Taiwan and other provincial officials, convinced them that excessive births were an economic and military liability. He pointed out that if you have to feed and educate 400,000 more people each year, money will have to be drawn away from industrial investment, educational costs will rise astronomically, and in 15 to 20 years you will have to provide 400,000 new jobs per year. If there are no jobs the people will be dissatisfied and no outside Communist arms will be needed to overthrow the government —it will be overthrown from within. HSU, however, seeking to defuse rather than anger the opposition, urged that family planning continue to be treated as a health problem, not as an economic issue. The Governor saw the wisdom of HSU's arguments and instead of curtailing support, arranged for the first time to set up "pre-pregnancy" health services in government hospitals and health units. The RHD promised to provide any necessary additional funding. The first year the Governor set aside US$50,000 for the program, doubling and redoubling the amount in the next two years. The fourth year the government agreed to assume 50 percent of the program's expenses. The RHD continued to make up the balance.

Between 1959 and 1961, of the 361 health stations on the island, 120 of them added a "pre-pregnancy health worker" to their staffs. The program had now moved, with HSU's assistance and pushing, from a voluntary plan to one sponsored by the government, although still not so

acknowledged. The Population Council of New York and the University of Michigan had also lent their support to the development of the Taichung Population Studies Center which was established "within the general framework of the Provincial Health Department."

The way was not without future stumbling blocks. The next governor had to be convinced all over again of the need for the program. Originally opposed, he finally gave it his moral support, adding that on no account should he to asked for an official endorsement—in such case he would have to come out against it.

In July 1962 HSU temporarily suspended training nurses in family planning to free them to help with a cholera epidemic of foreign origin which had struck Taiwan, and family planning Braining funds were used to carry out anti-cholera training. The Provincial Health Commissioner was properly appreciative of this aid. As a result he agreed to assist the RHD in a pilot project near Taichung which had as its goal 5,000 loop (an intrauterine device) acceptors in the next six months. The RHD had agreed to provide half the doctor's fee for loop insertion, the patient was to pay the other half. In actuality 10,000 women were accommodated.

A study done in connection with this program found that 90 percent of the women questioned favored family planning and that 85 percent did not wane more than four children.

Besides this evidence of high public acceptance, the RHD had another argument in favor of increased government support. The nurses who had worked with the cholera stricken villages reported that sanitary measures alone were inadequate to prevent another epidemic—improved living conditions and birth reduction were necessary. The Chairman of the JCRR took these positions to the Vice President and concurrent Premier, "soliciting his help, to advise the Governor to authorize the Health Commissioner" to start a limited family planning program for the poor in fishing villages, salt fields, coal mines and slum districts in the cities—in all 10 percent of the island population. In early 1964 the Premier accepted the proposal.

The JCRR that submitted an increased budget request of US$750,000-worth of local currency for family planning activities. Its plan was to bring the rate of population down from 3 percent to 1.S percent in five years. The idea was to concentrate on married women aged 20 to 39 who account for 90.6 percent of births. The medical cost to the RHD of the loop insertion program would, over a period of five years, be US$450,000; salaries for an additional 120 workers would be US$300,000. The government doubled the amount requested and gave it for use over a five year period so that the JCRR would not have to ask for matching U.S. funds—funds which might not to granted. The budget category was shown as "family health" to avoid possible political opposition, U.S. or Chinese. The China Maternal and Child Health Association was organized to handle training and distribution of contraceptives instead of the China Family Planning Association.

The same year HSU enlisted Madame Chiang Kai-shek, who was Chairman of the Chinese Women's Anti-Aggression Association, on his side. At his suggestion she visited some of the military dependents' villages under the Association's care and was impressed with what she saw being done. At the same time she recognized the need for expansion of the program. As a result of her intercession, the General Headquarters of the Combined Services Force asked the RHD to help in villages not yet covered by the Association. To maximize the use of their limited personnel the RHD suggested that nurses sent out do only family planning counseling, not general health, and that they concentrate on women in the 20 to 44 age bracket. Women who requested help could be sent to a military hospital for loop insertion. In this way, utilizing personnel carefully, more than 500 villages were visited by the end of 1966.

The military was now lending its strong support to family planning as a necessary morale booster. In 1966 the Surgeon General's Headquarters of the Army signed an agreement with the JCRR to conduct family planning training programs for all recruits; each year 100,000 recruits go through basic training. HSU undertook this program after nine months of careful planning. Four half-hour segments were devised which discuss the importance of family planning, reproductive psychology, contraceptive methods, and the recruit's personal life and where he could obtain contraceptives.

1967 was a year of continued progress. With the participation of HSU, the Ministry of the Interior's Population Policy Study Committee, reactivated that year, drew up two documents for submission to the Executive Yuan (cabinet): "Outline of Population Policy of the Republic of China," and "Regulations Governing the Implementation of Family Planning in Taiwan." In September the National Economic Planning Board, of which the Premier is chairman, asked HSU to report on the family planning program and its impact on the economic development of Taiwan. HSU took advantage of this opportunity to urge the Premier to spur the Executive Yuan to approve the foregoing documents.

Acceptance of the proposals, however, did not come until May 1968 and only then because Taipei had been chosen to host the Conference on Population Program in East Asia. The Conference was jointly sponsored by the Population Council of New York and the China Maternal and Child Health Association in cooperation with the national government of the Republic of China. It was the first such conference to be held in this part of the world; everyone invited came, even from countries without diplomatic relations with the Nationalist regime. HSU was appointed Executive Secretary. It was his position as chief organizer of the conference, and his close relationship to the newly appointed Secretary-General of the Cabinet that enabled him to persuade the government to announce its official support of a national population policy on the opening day. This not only put the government firmly behind birth control as an accepted policy, it also got the conference off to a good start, inspired it to meet annually in other member countries, and led to the establishment of the Chinese Center for International Training in Family Planning.

Funded in part by the Population Council, the Center will, as HSU writes, "promote the exchange of experiences . . . and stimulate the progress of family planning in other countries." It will also remove some of the burden from the RHD which, in the past few years, has had over 400 visitors from 23 nations interested in learning about its work in this field.

The "Regulations Governing the Implementation of Family Planning" accepted by the cabinet specify that each health station will have one medical doctor or midwife and a home visitor added to its staff. HSU hopes the provincial government will release the funds necessary for implementation to the townships so that selection and accounting may be at a local level.

Under HSU's prodding, arrangements have been made with the Ministry of Education to develop a family planning curriculum for medical schools, establish refresher courses for teachers, and train journalists as family planning "specialists" so that they can prepare media materials to help educate the public about the need for, and availability of, family planning. An even more important need, HSU feels, is to teach family planning in primary schools; it must be integrated into the curriculum and inculcated in students from early years. To this end he has organized a group of specialists to work out inclusion of small family norms in primary textbooks.

Taiwan today has a population of approximately 14,000,000—compared to 6,000,000 in 1946 - and some 45 percent are under the age of 15. However, as a result of the family planning program, and based upon the 1964-68 rate of decline, the school-age population will be 986,307 fewer in 1984 than it would have been otherwise. HSU comes up with these figures in the paper he did with K.T. Li, Minister of Economic Affairs (1968 Ramon Magsaysay Awardee for Government Service "for vigorous, rational guidance of Taiwan's economy"), entitled "The Effect of Population Pressure on Economic Development and Some Solutions." The productive population will be only 136,860 fewer. Based on the cost in 1968 of US$25 per primary pupil per year and US$37.50 per junior high pupil, the savings in educational costs alone will be US$136,000,000 in 20 years' time. Every US$l spent on family planning will save US$50 in expenditures on education and job creation. Moreover, without family planning, by 1974 Taiwan would move from a grain surplus nation to a grain importing nation, with a serious loss in foreign exchange.

HSU, through his "organizational acumen, professional competence and convincing philosophy" has guided and pushed to fruition many of the major plans that have moved Taiwan into the modern era. He has helped create a healthy citizenry and a growing agricultural and industrial economy. By 1965 Taiwan had, according to Jacoby, "one of the lowest annual death rates in the world—6.5 per 1,000 population, and a notably healthy, vigorous and mobile work force." Life expectancy had increased by more than 13 years. The daily nutrient availability had risen from 1,277 calories in 1945 to 2,297 in 1963, and protein from 24.31 to 58.75 grams. By 1967 Chinese experts were serving as advisors for the WHO abroad, and health personnel were being sent by that organization to Taiwan for training. HSU himself had been invited by the WHO to represent the Western Pacific Region at a conference on community development in India in 1957, but had declined; he felt he was more needed in Taiwan.

HSU has written on rural health, nutrition and family planning in the little time he has had to spare from his administrative activities. He has served his government as a member of the Family Planning Committee of the Provincial Health Department and as one of three top policymaking advisors in helping resolve the problems of the Labor Insurance Administration and in reorganizing several hospitals.

For his family HSU has difficulty arranging a regular allotment of time but his wife and their two daughters—Kai, aged 28, and Lo, aged 24— respect his commitment to public health service. The family religiously attends and tithes to the church of their Christian denomination.

Colleagues find that the combination of his dedication, competence and unflagging energy makes HSU "a dynamic initiator, coordinator and pusher." His motto, one of them says, is "to forget what was accomplished yesterday, to ponder over what has not been to his fullest satisfaction and to do the best he can today so that a better tomorrow will be created for him to work more effectively and for people to live more happily."

September 1969
Manila

REFERENCES:

China Yearbook, 1967-68. Taipei, Taiwan.

"Family Planning and Population Study," Taiwan's Health. Taipei: Department of Health, Taiwan Provincial Government. 1965.

HSU, Shih-chu. From Taboo to National Policy. 1969. 11 p. (Mimeographed.)

______. Major Achievements of Health Program of Joint Commission on Rural Reconstruction in 20 Years. June 1968.

______. Presentation made to Group Discussion. Transcript. Ramon Magsaysay Award Foundation, Manila. September 1,1969.

______. "Progress of Family Planning Action Program in Taiwan up to 1966," Economic Review. Taipei: Bank of China. May-June 1967, 14 p.

______. "Summary Report of Present Status of Family Planning Programs in East Asia," Chinese Medical Journal. Taipei. Vol. 15, no. 2, June 1968.

Jacoby, Neil H. U.S. Aid to Taiwan, A Study of Foreign Aid, Self-Help and Development. New York: Frederick A. Praeger. 1966.

JCRR General Report XVI. 1965.

Li, K.T. and S. C. HSU. "Effect of Population Pressure on Economic Development and Some Solutions." Paper presented at Conference on Population Program in East Asia. Taipei. May 1-7,1968, 27 p.

Ravenholt, Albert. "Public Health Amidst China's Civil War." Letter from Canton, China. May 23, 1949. Institute of Current Affairs. New York 1949, 19 p.

Interviews with and letters from colleagues and others knowledgeable about the work of Hsu Shih-chu. Visits to rural health centers.