The Asia-Pacific Journal | Japan Focus Volume 12 | Issue 18 | Number 1 | Article ID 4112 | May 02, 2014

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Yellow Blood: Hepatitis C and the Modernist Settlement inJapan 黄色い血　日本におけるC型肝炎とモダニズムの決着法

Vivian Blaxell

Précis:

Japan has one of the highest rates of hepatitis Cvirus infection in the industrialized world. Thisendemic and the challenges it poses for thefuture of Japan’s healthcare system stem,ironically, from the formation of a modernistsettlement beginning in the late 19th century.Modern techno-scientific solutions to politicalproblems inadvertently provided millions ofopportunities for hepatitis C to spread in ruralcommunities, among leprosy communities, thetraumatized postwar community and into thenational blood supply.

Late on the morning of March 24, 1964, EdwinReischauer, President Kennedy’s ambassadorto Japan, stepped through the front door of theU.S. Chancery building in Tokyo and headedtowards a waiting Cadillac that would take himto a meeting with Kim Jong-pil, a South Koreanpolitician and founder of the South KoreanCentral Intelligence Agency. Suddenly, a youngJapanese man wearing a raincoat and thick-lensed spectacles darted up and stabbedReischauer in the right thigh with a 6-inchkitchen knife. The wound was deep and bledprofusely: Reischauer’s femoral artery hadbeen severed. Embassy officer, John Ferchak,used his necktie to make a tourniquet, probablysaving the ambassador’s life. Four aides quicklybundled Reischauer into the limousine and thecar took off for the nearby Toranomon Hospital.There, Japanese surgeons worked for fourhours to repair the damage to Reischauer’s leg.In the course of the surgery, he receivedseveral blood transfusions.

The next day, Reischauer released a statementto the press in which he said in part: “I wasborn and grew up in Japan, and now that I havereceived Japanese blood, I finally feel I havebecome half Japanese.”1 But the transfusionshad not only made Reischauer half Japanese,they had also infected him with the hepatitis Cvirus (HCV). He had been given what theJapanese were calling “yellow blood.” Threeweeks later, recovering at Tripler Hospital inHonolulu, he displayed all the symptoms ofacute hepatitis. In retrospect, this was almostcertainly the acute phase of HCV infection, butsince the hepatitis C virus was still far beyondthe limits of scientific knowledge and theincubation period for hepatitis was notsupposed to be so long, U.S. Army doctorsdiagnosed mononucleosis. Twenty-six yearslater, becoming half Japanese caught up withthe founding father of postwar Japanesestudies: after many years of debilitating illnesscaused by chronic HCV infection, Reischauerd i ed o f HCV - re l a t ed c i r rhos i s andhepatocellular liver cancer. In the end,becoming more Japanese killed him.

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In 1964, HCV infection via direct blood-to-bloodcontact with contaminated blood washappening wherever medicine could affordtransfusion technology and wherever bloodproducts and hypodermic syringes were in useas therapies or therapy delivery systems.Although the hepatitis C virus probablyoriginated in West Africa in the late 15 th

century, its global sweep and pandemic statusin the world today are both intimately linkedwith progression of the modernist settlement:the dualistic epistemological structure ofmodernity in which science and technology aredivided from and purified of culture andpolitics. In the late 19th and early 2th centuries,this Platonic, post-Enlightenment settlementproduced public health programs in NorthAmerica and in Europe that were then exportedinto colonized territories as pure sciencewithout reference to their engagement with thepolitical practice of imperial hegemony. If theresults of unwitting introduction of Europeaninfectious diseases into 17th, 18th and early 19th

century America and Australia were genocidalfor indigenous populations and cultures, thedepoliticized delivery of public healthvaccination, fertility management and diseaseeradication programs in colonized or subalterncommunities between 1918 and 1989 was amodernist vehicle for both demographic anddisease outcomes that would not becomeapparent until decades later.

Perhaps this latter consequence of a modernistsettlement is nowhere more apparent than inthe political epidemiology of hepatitis C virus inJapan, where the political problem posed by thepossibility of domination by the Euro-Americanpowers between 1854 and 1945 was counteredby resort to intense techno-scientific solutionsincreasingly set apart from social and culturalmatters as time went by. Amongst thesesolutions were a nationwide public healthproject, a pharmaceutical research andmarketing project and adoption of medicaltechnologies for delivery of public healthservices and pharmaceutical products. From

these solutions came Japan’s 21st centuryhepatit is C endemic. Among wealthyindustrialized states, Japan has one of thehighest rates of chronic hepatitis C virusinfection: about 2.3 percent of the populationbear the virus whereas in the United States,HCV infects about 1.8 percent; in nations suchas Germany and Australia, 1 percent or less livewith chronic hepatitis C infection. Japanese arefour times more likely than Americans todevelop liver cancer,2 and more than threequarters of all cases of primary liver cancer inJapan are caused by chronic hepatitis C virusinfection.3 Since liver cancer is very difficult totreat, the great majority of people diagnosed donot survive without liver transplantation.Hepatitis C infection also produces a host ofother disabling syndromes and conditions:cirrhosis; acute fatigue; lymphoma; depression;cognitive deficit; blood and skin disorders. Theeconomic, personal and social burdens ofchronic hepatitis C virus infection are thus veryheavy.

Working back from the current endemic, wecan track a political epidemiology of HCVinfection in Japan that comes directly from thelocal modernist settlement. In the period fromthe arrival of Perry at Edo to the surrender in1945, Japan’s modernizers were remarkable forall the qualities noted in modernists by thehistorian of science, Bruno Latour: daring;research; innovation; tinkering; youthfulexcess; increasing scale of action; acceleration;multiplication of modernizers; creation ofstabilized objects independent of society.4 Andyet there were sometimes catastrophicconsequences from modernist techno-scientificsolutions to the problem of how to keep Japanout of the clutches of the West and elevate it tothe status of modern world power. One of themost admirable of these modernists was SensaiNagayo, but his solutions also led to the spreadof hepatitis C virus in Japan. In 1871, Sensaiwas an eminent physician practicing inNagasaki, but he was called to Tokyo and askedto join the Iwakura Mission, a group of

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scientists, and policymakers charged withscouring the world for technologies, practicesand ideas that might be brought back to Japanand used to construct a modernist settlement.

Sensai Nagayo, the father of public health in Japan.

In Germany, Sensai encountered the science ofpublic health expressed in the complex Germanconcept of Gesundheitpflege or “Hygiene”which at the time was also quite new toEuropean modernists. “I heard ‘sanitary’ and‘hea l th ’ everywhere and, in Ber l in ,‘Gesundheitsphlege.’” Sensai later wrote. “ButI did not really understand these words.Eventually I came to understand that thesewords meant not only protection of the citizens’health, but referred to the entire administrativesystem that was being organized to protect thecitizens’ health -- a system that relied not onlyon medicine but on physics, meteorology, andstatistics, a system which operated through thestate administration to eliminate threats to lifeand to improve the nation’s welfare.”5

Much enthused by his discoveries and chargedwith modernizing Japan, Sensai tookGesundheitpflege and the rest of the packageback to Tokyo with him. Initially, the newpublic health solution was directed at control ofepidemic infectious diseases, such as cholera.In 1875, the government appointed Sensaihead of Eiseika, a new Central Sanitary Bureauwithin the Interior Ministry. From there, heturned the imported Gesundheitpflege complexinto a series of Japanese techno-scientificsolutions dedicated to making the young nationstate richer and stronger. In 1877, he issuedscientific guidelines for prevention of choleraand began to promote national vaccinationprograms. Local Eiseika were set up and Sensaipopulated each Japanese ken and fuadministrative district with an eisei-iin orSanitary Officer. Sensai also played a leadingr o l e i n p r o d u c t i o n o f a J a p a n e s epharmacopoeia, thereby putting control of thescience of drug compounding in the domain ofgovernment and, by regulating imports ofdrugs, promoted the science and technology ofdrug design and production in Japan: Japan’spharmaceutical industry began here in thisparticular modernist solution.6 By 1895, theEiseika had also mastered the science ofstatistics, presenting the health of Japan insophisticated sets of graphs and tables.

Even so, the modernist settlement was notreadily accommodated in Meiji Japan, thanks toanxiety associated with the idea that whilescience was intrinsically Western, Japan’s goalwas to be free of Western hegemony. But,victories over China in 1895 and over Russia in1905, colonization of Taiwan and Korea, alongwith a sustained explosion of heavy industrialdevelopment and associated techno-scientificmassification during World War I, quelled thisanxiety and made possible a modernistsettlement involving the separation of pureuniversal sciences and technologies fromculture and society in Japan. It was during thistime too that the public health system and itstechnologies were turned on schistosomiasis

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(also known as bilharzia), inadvertentlytriggering the spread of the hepatitis C virus.Schistosomiasis is a disease once endemic toseveral local areas in Honshū and Kyūshū. It iscaused when the schistosome trematode, afluke worm which breeds in water snails,enters the human body and lays eggs there,causing a range of serious and sometimes fataldiseases affecting the liver, the gut and/or therenal and genital organs. Among diseasescaused by parasites, schistosomiasis is secondonly to malaria in terms of the number ofpeople it makes ill, and it is still endemic inparts of Africa and Asia. In Japan, FujiiYoshinao, a physician practicing in wet ricerural areas of Hiroshima, descr ibedschistosomiasis in 1847 and gave it the name“Katayama disease.” By the end of the 19th

century, public health authorities knew thatschistosomiasis was endemic in the areas ofHiroshima Prefecture adjacent to the Takayariver, along the tributaries of the Fuji river inYamanashi between Tokyo and Shizuoka, andaround the Chikugo river in the Saga/Fukuokaregion of Kyūshū. Hundreds of thousands,perhaps millions of Japanese sickened and diedfrom the disease.

By 1978, however, schistosomiasis had beencompletely eradicated in Japan. Its banishmentwas a great victory of the modernist settlementin Japan, but it also broke down centuries ofbarriers to spread of the HCV virus. In theroughly four hundred years since the ancestorhepatitis C virus emerged in 1476 in what isnow the West African republic of Guinea-Bissau, HCV had been relatively confined in theworld by its requirement for direct blood-to-blood contact for transmission. Although it islikely that gory battlefields and the bloody,dirty ministrations of military surgeonsprovided opportunities for spread of HCV, andsome sort of hepatitis epidemic was widelyreported during Napoleon’s campaigns inEgypt and during the American Civil War, thespreads were highly localized and wellcontained; the means for endemic spread were

simply not available. So too, in Japan, wherethe virus probably entered between 1880-1889,perhaps from an American ship,7 but at firstlacked the means for great horizontaltransmission. The resolution of the modernistsettlement in public health science andtechnologies, however, dismantled barriers toHCV endemicity. By 1918, modern drugdelivery technologies, such as hypodermicsyringes and intravenous injections, whichmultiplied the number of opportunities forblood-to-blood contact, were in ever wideninguse in Japanese hospitals, in doctors’ officesand even in homes.

These modern tools in modern infection controlprograms were used on a massive scale totackle schistosomiasis in Japan, therebyopening up millions of opportunities for thevirus to spread horizontally. In 1917, JohnChristophersen, a British physician working inBritish Sudan, had discovered that repeatedintravenous injections of antimony sodiumtartrate killed the eggs of the schistosome ininfected patients. Within a few years, Britishpublic health authorities had put in place a vastprogram of repeated intravenous antimonysodium tartrate injections throughout bothEgypt and the Sudan. Starting in 1923, publichealth authorities in Japan followed suit. Usingantimony sodium tartrate at first, and then alocally developed drug called Stibnal, theEiseika (Sanitary Bureau) and health officialsat tacked schis tosomias is wi th suchthoroughness that by the 1970s, public healthofficials had given more than 10 millionintravenous injections to treat the disease inJapan.8 The schistosomiasis eradication projectwas a testament to Japan’s modernity, butsomething went invisibly wrong: public heathworkers delivering schistosomiasis intravenousinjections used and reused glass and steelsyringes and needles. These were either notsterilized after each use or, if they weresterilized, were not sterilized in a way thatdestroyed the hepatitis C virus. Witlessly then,the modernist techno-scientific solution for

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schistosomiasis relentlessly spread HCV. By the1930s, hepatitis C virus saturated communitieswhere schistosomiasis once flourished. Andfrom these localized zones of endemicity, thebolus of infections spread out from Saga,Hiroshima and Yamanashi, into adjacentcommunities.

Perhaps hardest hit by this spread of HCV wasthe incarcerated community of “lepers”9 inJapan. By the time HCV found it, the Japaneseleprosy community was already muchtransformed by science and technology, andalthough these transformations have beendiscussed and examined at length in bothJapanese language literature and in westernaccounts, to understand how hepatitis C andleprosy were brought together by themodernist settlement in Japan, it is necessaryto recapitulate what happened with leprosywhich until the 1980s, was mienai byō in Japan:the disease that cannot be seen. This problemof vision leprosy shared with chronic HCVinfection, except that HCV infection is bothasymptomatic until the end and could not beseen by science until after 1989, while leprosycan be so painful ly visible that it hashistorically been hidden away. If any societycould find a way of thinking that makes anoseless face beautiful, it is Japan where nodesof culture are organized around appreciation ofthe beautiful and around making the sad andthe ugly seem lovely.10 But the horrible visibilityof leprosy was recalcitrant, unredeemable in itsugliness. It had to be concealed, eyes had to beaverted. Thus, from the time of leprosy’s firstrecorded appearance in 8th century Japan,governments sought to strictly regulate it.“Lepers” were usually obliged to live outsidethe village, the castle town and the great city:the disease was often viewed as a kind ofpunishment for sin, unskillful conduct and itskarmic consequences. Nonetheless, before the1850s, “lepers” were also a part of the overallcommunity and autonomous leprosycommunities were a common feature of life inTokugawa Japan. Members o f these

communities exploited their status as karmicsinners to maintain autonomy and to survive.As Susan Burns writes: “They supportedthemselves by soliciting alms house-to-houseseveral times a year: as they moved from hometo home collecting offerings of rice, goods andcash, the ‘lepers’ announced themselves withthe call ‘monoyoshi’, signifying that they werebringing fortune to those who showed themcompassion.”11

This careful mix of seen and unseen, sin andforgiveness characterizing much of leprosy lifefell apart quickly and in parallel with the fallingapart of the Tokugawa state upon theunregulated arrival of mid-19 th centurymodernity on Japanese shores. As bakufupower broke down after the shogun succumbedto demands for treaties and trade with theUnited States and the European powers, so didthe power to discipline the visibility of leprosyand the movements of Japan’s 500,000 to 1.5million “lepers” decline. Support systems forleprosy communities also stopped functioning.“Lepers” hit the road seeking alms and food,and with the whole land in a great andfracturing confusion, the shogun’s many andrigorously policed internal barriers to travelthrough the Japanese archipelago could nolonger inhibit “leper” movement.

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The horrible visibility of leprosy in Japan: Date and sourceu n k n o w n . F o u n d h e r e(http://cirrmoka.wordpress.com/tag/japan-egeszsegugy/).

Leprosy now appeared unregulated and“lepers” appeared in great conglomeratednumbers in cities. People with leprosy walkedthe streets willy-nilly. They gathered at templesand shrines to beg for alms, displaying “thehorrific morbidity of leprosy for the first time:the severely disfigured faces and nodulatedbodies, the ceaseless groaning of a man withpainful neuralgia, and the labored breathing”12

of those whose throat and bronchi were filledwith leprous nodes.

Opening to the modern world tore up theexisting contract between Japanese “lepers”and the state, setting “lepers” free, makingthem visible. Yet, as modernity began to settleon the land the unregulated display andmovement of leprosy could not be allowed tostand. The problem was fundamentallypolitical: “lepers” on the streets were a sign ofJapan’s lack of modernity and until that lackwas resolved, unequal treaties and vulnerabilityto Western hegemony could not be overcome.The solutions were techno-scientific and whenthey were delivered, they seemed almostcompletely divorced from and purified of the

political problem. By the end of the 19th centuryleprosy was in abeyance in Europe and NorthAmerica and when it was not, it was strictlyand scientifically secluded. In Europe,Australia, and the United States, incarcerationcorrected the problem of visibility, provided ascientific solution to the threat of contagionand made administration of medical andbehavioral technology to the body of the“leper” more manageable. Now these solutionswere to be part of the modernist settlement inJapan and they were to be spearheaded byexpatriates who believed that the scientific wayto deal with “lepers” was to hide them.

Foremost among expatriates pushing forremoval of lepers from sight in Japan was a tallEnglish spinster: Hannah Riddell. Imperious,independent and fond of luxury, Riddell cameto Japan as a missionary when she was 35 yearsold.

Her posting was to the city of Kumamoto inKyushu, and it was at Kumamoto in 1891 thatHannah Riddell first saw leprosy and wasquickly struck with a complex urge tomodernize Japan by removing “lepers” fromsight, incarcerating and regulating their everymovement and moment. Her encounter cameduring a visit to the splendid Nichiren secttemple of Honmyō-ji north of the city. At thetop of the two hundred steps leading up to themain temple hall and the tomb of KatōKiyomasa, 16th century lord of Higo and hero ofthe 1592 to 1598 Japanese attempt to conquerKorea, Riddell came upon leprosy and itsbearers. In her retrospective accounts of thisinitial sighting, it is all about the visibility ofleprosy and the stain the lepers at Honmyō-jimade upon beauty: “It was in the spring aboutten years ago that I came to this temple for thefirst time. That day happened to be one of itsannual great festivals. The sky was clear andbright and the cherry blossoms were at theirbest for quite a distance on either side of theroad. Under the beautiful blue sky and thelovely blossoms, one saw the most wretched of

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scenes -- men, women and children sufferingfrom leprosy. Numbers were crouching oneither side of the road, some were blind, somehad no noses, some had hands without fingers,others feet without toes. These poor sufferersdisplayed their own wretched condition so as toattract the attention of the passers-by to theirbegging” she writes.13 Almost immediately, aneed to hide and regulate the “lepers” ofKumamoto possessed Riddell to the near-exclusion of all else. With determination andleadership somewhat unusual for a Victorianwoman, Hannah Riddell raised funds from bothexpatriates and local Japanese nobility, leasedland and built a hospital for 40 “lepers.” OnNovember 12, 1895, Kaishun Hospital opened.

Hannah Riddell

In Japan, Riddell is regarded as something of aleprosy savior; a woman who lifted “lepers”from a cruel and disordered life on the streets,protected them in her hospital and promoted ascientific approach to the disease and itsmanagement. And it is true that she wascentral to the modernist settlement aroundleprosy. But no matter how compassionate herapproach, Kaishun Hospital and the sciencebehind it were also the opening experiment in awhole techno-scientific project involvingleprosy in Japan that was exceptionally unkind,indeed barbaric. “We cannot hope to bebeautiful to look at, but we can try to leadbeautiful lives”14 one of Riddell’s patients said,but those lives would have to be led with theirbeauty unwitnessed. Riddell was no scientist,nor was she a technocrat, but her ideas aboutthe science of controlling the contagion ofleprosy became part of the solution. Patients atKaishun Hospital needed government passes togo into Kumamoto, and permission fromHannah Riddell to leave the grounds.Paradoxically, Riddell also insisted that leprosywas hereditary and proselytized her viewpointamong Japanese policymakers who adopted thefaulty science without much sign of self-consciousness about the deep contradictioncreated by putting contagion and geneticstogether. Riddell put in place methods forkeeping genetic transmission of leprosy undercontrol: all Japanese “lepers” were to beprohibited from sexual intercourse andreproduction for two generations.

Riddell drew powerful supporters for hersolutions for leprosy in Japan. These men metin 1905 at the elite Bankers’ Club in Tokyo toraise money for Riddell’s work, but the meetingconcluded with a call for the government tocontrol and regulate lepers in the waysrecommended by Riddell. In 1907, a firstversion of the Leprosy Prevention Law waspromulgated requiring all “lepers” who werewithout the care and support of non-leprouspeople to enter and stay in official leprosysanatoria. The first five of thirteen public

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leprosy sanatoria were set up in Tokyo, Aomori,Osaka, Kagawa, and Kumamoto; more likeprisons than hospitals, they were built inremote places or, when not remote, encircledby high fences or moats. Quickly, Japanese“lepers” were moved into these sanatoria, oftenby force, and in later years the law wasexpanded to require all Japanese with leprosyto live in one of the thirteen governmentinstitutions and two private sanatoria.

In these places, “lepers” were intensivelywatched, worked, treated with whatever drugswere made available by Tokyo, disciplined andmanaged. The institutions themselves weretechno-scientific solutions delivered by themodernist settlement in Japan, and so were thepatient management policies aggregatedaround the Leprosy Prevention Law. That thesolutions responded to the political problem ofhow to look modern in Japan was almostentirely elided by a discourse about publicsafety and duty of care. And the techno-scientific solution concealed the catastrophiceffects of the science of leprosy on “lepers”themselves. Castrations and abortions wereperformed across the sanatorium system: 33percent of male “lepers” were castrated; 23.6percent of women were forced to medicallyterminate their pregnancies.15 Suicide rateswere very high. Going beyond the sanatoriabecame almost impossible for “lepers” andeventually for their non-leprous families. Forexample, after their father and older brotherwere deported to a sanatorium, Murata Naokoand Nakamura Hideko were shunned in theirOsaka community. Without the incomeprovided by the men of the family and in acommunity where they were increasinglyinvisible, the two girls left school before theyturned 13 and went to work in another townwhere their connection to leprosy wasunknown.16

Emperor Showa visits Nakakoma Village (now KaiCity) in Yamanashi Prefecture, Oct 1947, anddiscusses the schistosomiasis endemic in the village.S o u r c e : W o r l d W a r I I D a t a b a s e(https://apjjf.org/admin/site_manage/details/ww2db.com/image.php?image_id=20248).

Into this solution came the consequences ofanother modernist solution: hepatitis C virusspread by intravenous treatment o fschistosomiasis entered the leprosy sanatoria,where it became endemic and caused hundredsof deaths from cirrhosis and liver cancer. It is along, slow drive from the city of Okayama tothe island of Nagashima, not so much becausethe distance is great but because the island isstill out of the way with no railway station, noferry from a major city, no public bus service,and kilometers from the nearest freewayentrance. There is a bridge to Nagashima now,but until 1988, the crossing was only by boat.This Inland Sea area of Japan is almost alwaysbeautiful with slow and silky sea and hundreds

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of steep green islands in the sun. Nagashima isbeautiful too, but it is remote. The governmentbuilt two leprosy sanatoria here: first Aiseien in1930, and then Oku-Kōmyō-En in 1938. Thesedays, Aiseien houses both an historical archivemeticulously and compassionately managed byTamura Tomohisa, and about 300 people whoused to have leprosy; in 1955 there were 1,701patients here.

Oku-Kōmyō-En is turning itself into a carefacility for aged Japanese, especially thosesuffering from dementia. It now houses about200 people who once had leprosy, but in 1960there were 968 patients. Those who remainhoused in these two institutions are old; somehave lived their whole lives here. Others leftwhen the leprosy laws changed but returnedbecause life in the mainstream community wasnot what they had hoped for. Who knows whathorrors they saw or experienced? What we doknow now is that many of them are infectedwith hepatitis C virus.

The presence of HCV in the leprosy sanatoriawent unseen until the 1990s; the virus was wellbeyond the ontological horizon until the late1970s, only suspected for most of the 1980suntil a group of researchers working for ChironCorporation in California detected it in 1989and techniques for seeing the virus particle,along with tests for the presence of active virusand for counting the amount of virus in theblood stream became available a few yearslater. In 1996, however, a study of 229 leprosypatients in two leprosy sanatoria showed that18 percent of them had active HCV infection,very much higher than the percentage ofJapanese in the general population positive forHCV.17 Researchers theorized a specialcomorbidity between leprosy and HCVinfection, a possible biological or pathologicallink between the two diseases, but the storywas more complex than that. In 2010, newinformation about leprosy, HCV and modernitycame to light at Oku-Kōmyō-En on Nagashima.Between 1940 and 1980, medical officers at the

sanatorium had routinely performed autopsy onalmost all of the approximately 1,000 Oku-Kōmyō-En patients who died during thoseyears. At autopsy, they harvested samples ofliver tissue. These they preserved usingformalin, then archived. The collected tissuesamples then remained available for researchat the sanatorium pathology archive. Beginningin 2006, they were reviewed, re-sampled andembedded in paraffin for optimal preservation.Around 2008, a team of researchers made tworemarkable discoveries about the history ofpatient deaths at Oku-Kōmyō-En. First, theteam found a steep increase in patient deathscaused by cirrhosis of the liver after 1960, andsecond, it observed an equally sharp increasein patient deaths caused by liver cancer after1970.

National Sanatorium Oku-Komyo-En

Seeking to explain the causes of theexceptionally high rates of liver cirrhosis andliver cancer at Oku-Kōmyō-En, the team quicklyturned its attention to the liver tissue samplesagain, this time choosing 48 samples frompatients who had died of cirrhosis or livercancer between 1940 and 1980. Using amicrotome and changing its glass bladebetween each slice, the team cut each liversample into five micro-slices from which totalRNA was extracted. Since chronic HCVinfection had been the principal cause of liver

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cancer in Japan for a number of years, the teamtested the samples for genetic remains ofhepatitis C virus. HCV has six genotypes,identified by Arabic numerals, and multiplesubtypes within each of the six genotypesidentified by the Roman alphabet. The researchteam found HCV-1b and HCV-2a in more than70 percent of all 48 samples.18 Hepatitis C virushad been killing patients at Oku-Kōmyō-En fordecades.

Because the time between initial infection withHCV and full-blown cirrhosis and liver canceraverages between twenty and thirty years, andbecause cirrhosis and liver cancer were presentin samples taken from patients who had diedafter 1970, the team at first speculated that thevirus had been introduced into the leprosycommunity on Nagashima in the 1940s. But, asubsequent study of the tissue archive by thesame researchers revealed three HCV-positivesamples of cirrhotic liver tissue from the1940s.19 This meant that the first patients atOku-Kōmyō-En to die of diseases caused byHCV infection probably contracted the virusbetween 1915 and 1925, ten years or so afterHannah Riddell’s solution for the problemposed to modernity by leprosy had beenadopted and elaborated by the nationalgovernment and just a few years after theEiseika had started mass intravenous injectionsfor schistosomiasis in regions not far from Oku-Kōmyō-En. As Japanese modernity settled forscientific solutions to political problems, andsegregated technology and science fromsociety and culture, localized consequenceswere becoming national with devastatingeffects for the leprosy community.

In strict epidemiological terms, the HCVinfestation at leprosy sanatoria probably camei n f r o m t h e b o l u s o f i n f e c t i o n s i nschistosomiasis communities, and then spreadwithin the sanatoria until between 18 and 25percent of patients were infected. Yet again theprincipal technological solution to the health ofentire populations (itself a political problem)

was at fault: hypodermic delivery systems.Health workers used HCV-contaminatedsyringes to inject antimony tartrate and Stibnalin schistosomiasis treatment, and HCV-contaminated syringes were almost certainlythe main transmission technology in the leprosysanatoria. Intravenous inject ions ofChaulmoogra oil (Hydnocarpus wightiana) werea routine, and ineffective, therapy for leprosy,and the first effective drug for leprosy, Prominwas also delivered intravenously. Leprosy canalso cause severe pain, as did intravenousinjection of Chalmoogra oil; intravenousinjection of analgesia was a routine treatmentfor pain in the sanatoria. Disposable syringeswere either unknown or not available in theseplaces for much of the 20th century. TamuraTomohisa, curator of the history museum atNational Sanatorium Nagashima Aiseien on theopposite end of the island from NationalSanatorium Oku-Kōmyō-En, also suggests thatthe HCV infection rate was so high not simplybecause of contaminated syringes but alsobecause Tokyo never allocated budget to theleprosy hospitals sufficient for effectivesterilization and/or replacement of syringes andother instruments used in invasive therapies,such as debridement or cutting away of deadflesh around leprous ulcerations.20 Tamura alsoclaims that already low staffing levels at thesanatoria, caused by prejudice and stigmaassociated with leprosy, were even furtherreduced by miserly funding from Tokyo and theprefectural governments. In the absence ofstaff, patients conducted treatments on eachother, injecting Chaulmoogra oil and cuttingaway dead tissue themselves without infectioncontrol.21 Both leprosy and schistosomiasischallenged the perfectibility of Japanesemodernity and both were subjected to techno-scientific solutions coming from a new publichealth system. These solutions overlapped. Inthat overlapping, a new and considerably moreformidable threat formed: the chronic hepatitisC infection endemic.

Of course, hepatitis C virus had nowhere to go

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from the leprosy sanatoria; like its humanhosts, it was incarcerated there, but beyond thesanatoria, the modernist settlement in Japanmeant that the HCV introduced as a corollaryof programs to eradicate schistosomiasisleaked all over Japan between 1940 and 1980,forming a huge bolus of infections that wouldnot be seen until the last years of the 20th

century. Yet, once the different parts of thisbolus came to light, they could all be trackedback to elements of the modernist settlementand modernization in Japan. Take for example,the story of the Daigo Fukuryū Maru. On March1, 1954 the United States detonated ahydrogen bomb at Bikini, an atoll of 23 islandscircled around a 230 square mile lagoon in thewestern Pacific region of Micronesia. Theexplosion turned out to be considerably largerand more powerful than anticipated.

The Daigo Fukuryū Maru shortly before leaving for BikiniAtoll

Radioactive contamination spread widely in theregion and a plume of lethal fallout swept overa Japanese tuna fishing boat trawling about 100miles east of Bikini: Daigo Fukuryū Maru orLucky Dragon No. 5 . For hours, sandyradioactive ash rained down on the 23crewmen aboard Daigo Fukuryū Maru. By the

next day most of them were ill, nauseated,vomiting, in pain and with inflamed skin: allsymptoms of acute radiation sickness. By thetime the trawler returned to its homeport atYaizu in the Shizuoka area, the crew wereacutely ill with radiation disease. One died inSeptember 1954. The others were hospitalized,treated, and survived. By 2004, however, morethan half of these surviving Daigo FukuryūMaru crewmen were dead from liver cancer orcirrhosis caused by chronic HCV infection. Atfirst, their diseases were put down to alcoholabuse, but by 2010 it was clear that Japanesedoctors had used blood transfusions to treatthe leukopenia caused by the crewmen’sradiation sickness and that the donated bloodhad been contaminated with hepatitis C virus.22

As Dr. Akashi Makoto, director of Japan’sNational Institute of Radiological Sciences,remarks, “Exposure to American nuclear falloutand exposure to HCV are not directly tied, butthe hepatitis C virus infections originated aspart of the Lucky Dragon No. 5 incident.”23

Akashi is on the right track here: the HCVinfections of the Daigo Fukuryū Maru crewmendo indeed refer us to the Cold War. Beyond itsconflict of ideas, the Cold War was a battlebetween two infrastructures. Infrastructureprovides the wide-ranging techno-scientificmodernist solution to the fragmentation of“macro, meso, and micro scales of time, space,and social organization” in modern societies; itforms “the stable foundation of modern socialworlds.”24 Yet, the Daigo Fukuryū Maru HCVinfections and deaths were also consequencesof the late Meiji and Taishō modernistsettlement within Japan which had blindlydelivered an HCV epidemic in its solution toschistosomiasis, itself both a clinical and apolitical problem. From the schistosomiasissolution, HCV entered the blood supply ofpostwar Japan. But the trajectory of the virusfrom prewar schistosomiasis programs to theblood banks and plasma processing factories ofJapan in the 1950s, 1960s, and 1970s passedthrough another techno-scientific modernist

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solution to a political problem that amplifiedt h e e n d e m i c s p r e a d o f t h e v i r u s :methamphetamine.

Formation of a modern research anddevelopment scientific community policed byprinciples of shared assumptions, universalmethods, replicable results and empiricallyobservable outcomes was a vital part of Japan’smodernization: without it there could havebeen no modernist settlement. The modernscience of chemistry and its technologicalrelative, pharmaceutical research anddevelopment, were core parts of thesettlement.

Nagai Nagayoshi: Father of modern chemistry in Japan anddiscoverer of methamphetamine

Nagai Nagayoshi was a leading figure in the

format ion o f chemica l sc iences andpharmaceutical technologies in Japan: he wasalso the discoverer of methamphetamine. LikeSensai Nagayo, the founder of public health inJapan, Nagai studied rangaku (Dutch Learning)and spent time in Nagasaki in the 1850s wherehe built connections with men like Itō Hirobumiand Ōkubo Toshimichi, who would soondominate Japan’s modernization. Like Sensai,Nagai also spent time in Germany during the1870s. He studied at the University of Berlin,now Humboldt University of Berlin. Back inJapan, Nagai bore overall responsibility forestablishing and developing modern chemistry;for Nagai, modernity was to be found in theuniversalism of organic chemistry and in theuses to which it could be put to improve Japan.As professor of chemistry at Tokyo ImperialUniversity, he began a modern chemicalanalysis of ephedra herba, a plant with a longhistory of use in both Chinese traditionalmedicine and its Japanese version, kanpō. In1888, he discovered the alkaloid, ephedrinehydrochloride, which would be synthesized intomethamphetamine in 1893 and into crystallinemeth by Ogata Akira in 1919.25

For several decades, methamphetaminelanguished. To begin with, its only use was asan agent to contract chronically over-dilatedpupils in cases of mydriasis, or “blown pupil.”Then, after World War I, the drug becamecommercially viable as an injectable broncho-dilating treatment for asthmatics26 but asJapan’s military commitments in Chinaexpanded, and after the war with the UnitedS t a t e s b e g a n i n D e c e m b e r 1 9 4 1 ,methamphetamine became a scientific solutionto the po l i t ica l problem of imper ia lpreservation and protection of the Japanesestate. Dai-Nippon Seiyaku Company sold oraland injectable forms of methamphetamineunder the trade name of Philopon (hiropon) tokeep Japanese fighting and producing for theempire and the war to defend it. As JeffreyAlexander remarks: “during the Second WorldWar Japan's military government came to

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consider it [Philopon] a safe, effective stimulantfor tired pilots, signal corpsmen, and munitionsworkers, and it ordered a swift and dramaticincrease in production.”27

After surrender the political problem solved bymethamphetamine changed. Now the stimulantwas used to resolve the anxieties, trauma, andexhaustion produced by the political problem ofdefeat, loss of sovereignty and living in theruins of war under American occupation. By thelate 1940s more than 20 Japanese drugcompan ies produced and marketedmethamphetamine for relief of hypotension,fatigue and sluggishness.28 After manufactureand sale of methamphetamine in powder ort a b l e t f o r m w e r e b a n n e d i n 1 9 4 9 ,manufacturers turned to injectable solutions.Miriam Kingsberg reports that use of thestimulant was very high and she gives asevidence the perhaps not very exemplary storyof twenty-year-old Sakemaki Shūkichi who wascharged with the murder of a young girl whileunder the influence of methamphetamine in1954: “At the time of the murder, Sakemakihad been injecting himself with twenty to thirtyampoules of hiropon (Philopon), a type ofmethamphetamine, daily for two years” shewrites.29 And although Sakemaki’s use mayhave been on the high end of the nationalmethamphetamine usage scale, intense use ofmethamphetamine delivered intravenously washappening all over Japan.

Injecting Philopon (hiropon). Source: Shashin KōhōPhoto Bulletin] May, 1954

Inevitably, the legal use of intravenouslydelivered methamphetamine to solve battlereadiness, worker productivity, exhaustion andwar trauma opened up a way for the relativelycontained boluses of HCV infection around theschistosomiasis communities to spread. Evenafter the government passed an AmphetaminesControl Law in 1951, widespread use ofmethamphetamine did not stop. The strictseparation of science from society, central tothe epistemological structure of the modernistsettlement, now disintegrated. The science ofmaking crystalline methamphetamine went intothe hands of criminal organizations. Meth labsusing base compound smuggled in from Macaoand Hong Kong and run by criminal enterprises

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proliferated in Japanese cities. What is more,one of the core technological devices formodernization of health, the hypodermicsyringe, had already escaped the scientificarena and become popular technology: by thetime methamphetamine was made illegal,Japanese were well-accustomed to injectingthemselves at home with vitamins and otherdrugs, and hypodermic syringes and needleswere available for legal purchase at everyc o r n e r d r u g s t o r e . 3 0 I n j e c t i o n o fmethamphetamine continued.

P e r s i s t e n t i n t r a v e n o u s u s e o fmethamphetamine after criminalization spreadhepatitis C virus even further in Japan; so farand so thickly that it entered the postwar bloodsupply. This final stage of the epidemiologycould have happened earlier had blood beenscientized by modernity earlier than it was. Butin Japan’s modernist settlement, the mysticalsignificance of blood was slow to cross theepistemological gulf between culture andscience. Blood letting had been an untroublingpart of Tokugawa era medicine for centuries,but even though Drs. Gotō Shichirō and ShiotaHiroshige had separately witnessed the almostmiraculous effects of blood transfusion onwounded soldiers in Europe in 1916 and hadseparately brought transfusion equipment backto Japan, the technology triggered someresistance in Japan and failed to catch on. InFebruary 1919, Gotō transfused 300 ml ofblood into a patient during thoracic surgery; inJune of the same year, Shiota performedtransfusion of 200 ml of blood into a patientwith uterine fibroids.31 Other transfusionsfollowed, including one in 1930 on PrimeMinister Hamaguchi Osachi who had been shotat Tokyo Station in an assassination attempt.

By the time of Japan’s attack on Pearl Harborand the beginning of the Pacific War, both theUnited States and the European powers hadcome to regard blood as vital strategicmateriel. The problems of transporting bloodsupplies to the frontline and to preservation

had largely been solved, partly throughdevelopment of plasma powder. As a result,blood supply and transfusion techniques playeda significant role in the Allied victory but,although Japanese scientists found their ownway to powdered plasma, there was no donorbase from which to obtain large quantities ofwhole blood in Japan and by the time the newtechnology became available, Japan’s supplylines to its far flung fronts were too unreliablefor the technology to reach troops. After thewar, however, a rapidly expanding and highlyprofitable business in collection of blood, andsupply of whole blood and plasma products foruse in clinical situations and in new drugformulations, emerged. At the center of thisnew business and its new products were bothAmerican techniques for managing blood andmaking blood products, as well as technologicaland scientific solutions worked out at orabstracted from the work of the infamous Unit731 laboratories outside the Chinese city ofHarbin, then in the Japanese puppet state ofManchukuo, during the war. Dr. Naitō Ryōichideveloped freeze drying technology for use inexperiments on Chinese prisoners and POWs atUnit 731 headquarters there;32 after the war heused the same technology to start a blood andblood products company that grew into a multi-billion dollar transnational business: GreenCross. Kitano Masuji, another member of theUnit 731 team managed Green Cross for Naitō.Like other Unit 731 scientists, Kitano and Naitōwere not prosecuted for war crimes by theUnited States after the war; data from theirexperiments on human subjects were valuablebargaining chips.

It is easy now to forget that until the late 1960sthe Japanese people were not rich. In the first10 years after defeat, they were especiallypoor, often desperate. Green Cross and otherblood collection and processing businesses inJapan paid for donations of whole blood, andgiving blood became quite a business in itself.By the 1980s, Japan used more blood and bloodproducts than any other country. Demand

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outstripped supply.33 Green Cross and theJapanese Red Cross Society had to importblood. Screening was rudimentary, and in anycase, lethal blood borne viruses like hepatitis Cvirus were almost unknown. The HCV endemicin the schistosomiasis communities and amongthe vast numbers of people who injectedmethamphetamine, along with HCV imported inblood from abroad, entered the national bloodsupply.

Cartoon depicting long-term effects of HCV infection onthe liver. Source (http://www.germaniumnet.com/23.htm).

More than 50 percent of Japanese transfusedwith blood developed post-transfusionhepatitis. 34 Although the government wasaware of the problem it did not act until thenews of Edwin Reischauer’s post-transfusionhepatitis caused such a scandal that lawmakershad no choice but to change the system. Paidblood donation was phased out beginning in1964; screening for hepatitis B antigen wasintroduced in 1972.

Even so, Japanese doctors soon discoveredwhat their colleagues in the United Statesalready knew: screening for hepatitis A andhepatitis B viruses was not eradicating post-transfusion hepatitis, but it was not until 1989that HCV was detected and a test becamepossible. In the meantime, the giant business inblood and blood products infected millions of

Japanese with hepatitis C virus: the endemicenabled by development of a public healthsystem as part of the modernist settlement andbegun with the schistosomiasis eradicationprograms in the 1920s and 1930s, thene x p a n d e d b y i n t r a v e n o u s u s e o fmethamphetamines during the war and after,now reached a kind of epidemiologicalapotheosis. The disease once confined to ruralcommunities in marshy areas and to “lepers” ininstitutions could now be found across thenation: between 2 and 3 million Japanesepresently live with this most modern of viruses;millions more are affected by it as familym e m b e r s , c o w o r k e r s , h e a l t h c a r eprofessionals. 3 5

In May 1988, after giving birth to her first sonat a hospital in the city of Ise, Kuno Ikukobegan to bleed. Her obstetrician gave Kunofibrinogen, a Green Cross blood-clotting drugmanufactured using human blood products.Kuno became ill. Her skin turned yellow notlong after her treatment with the coagulant,and although the jaundice left her, she beganto feel chronically ill. In the early 1990s, Kunowas tested and told she had chronic hepatitis Cinfection. As an infant in Nagasaki, FukudaEriko was given Christmassin, a Green Crossclotting agent made from human bloodproducts. At the age of 20, Ms. Fukuda learnedshe had chronic HCV infection; the bloodproducts used to manufacture Christmassinhad been contaminated with HCV. KawadaRyūhei was born hemophiliac. At the age of 10his mother told him that the Green Cross blood-clotting drugs he had been using to keephimself alive had given him both HIV and HCV.Watanabe Ken, cinema actor and star of TheLast Samurai, has chronic HCV infection. Thegreat enka singer, Misora Hibari had HCVinfection. Kōno Yōhei, a former Deputy PrimeMinister and president of the LiberalDemocratic Party, has hepatitis C virus andunderwent a liver transplant in 2002. GreenCross , which had a lready been he ldaccountable for HIV infections caused by its

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blood products, now faced a second scandal todo with hepatitis C virus: the company hadfailed to screen for the hepatitis B antigen,which was a predictor of HCV at a time before1989 when hepatitis C had not yet beendiscovered, but was thought to exist and to beresponsible for millions of cases of what wasthen called non-A non-B hepatitis.

*******

Modernity and its settlement were alwaysbricolage in Japan: ideas and techniques fromthe pre-1868 ancien regime not only persistedbut were networked into modernity alongside,but epistemologically divided from, the new.And, although Japan is usually considered alatecomer to modernity, its modernizers actedwith extraordinary alacrity to settle modernscience and technology for Japan and to setthem off together from any admittedtransactions with any parts of the modernistsettlement other than economics: science andtechnology were heavily linked to economicprogress but were purified of culture andpolitics. Less than 20 years after the MeijiRestoration, a modern, scientific public healthmachine had been started, and indigenousclinical sciences, chemistry and pharmaceuticaltechnologies had begun to take shape. Thesetoo, were epistemologically divorced from otherarenas of the modernist settlement, but werenonetheless used to provide solutions bothformal and informal to political problems:national hygiene indexed modernity; infectioncontrol and disease eradication provided aneffective workforce for a modern state;scientific incarceration removed the ancientblight of leprosy from sight; chemicals helpedextend the empire, preserve the sovereignty ofthe militaristic state, and then made thepostwar world possible in existential terms formany. From these solutions delivered by thequick and effective modernist settlement inscience came Japan’s early hepatitis C virusendemic, which stands today as both achallenge to Japan’s 21st century modernist

settlement and as a symbol of modernistsettlements made in Japan’s past.

This essay owes its existence to TamuraTomohisa, curator of the history museum atNational Sanatorium Nagashima Aiseien, andto Professor Muta Orie. Thank you.

Vivian Blaxell is an Asia-Pacific Journal: JapanFocus associate. She has taught Japanesehistory and politics, Asian history and politics,and political theory at universities in the UnitedStates, Japan, China, Turkey and Australia. Sheworks on Japanese colonialism and has recentlycompleted a book-length study of the globalhepatitis C endemic. She currently lives inMelbourne, Australia and teaches at RMITUniversity.

Recommended citation: Vivian Blaxell, "YellowBlood: Hepatit is C and the ModernistSettlement in Japan.", The Asia-Pacific Journal,Vol. 12, Issue 18, No. 1, May 5, 2014.

Notes

1 Quoted in George R. Packard, Edwin O.Reischauer and the American Discovery ofJapan. (New York: Columbia University Press,2010), p. 205. My account of the assassinationattempt is also taken from Packard.

2 Melissa M. Center and Ahmedin Jemal,“International Trends in Liver Cancer IncidenceRates.” Cancer Epidemiology, Biomarkers andPrevention, 2011, Vol. 20, No. 11, pp. 2362 –2368.

3 Iwao Ikai, Masatoshi Kudo, Shigeki Arii,Masao Omata, Masamichi Kojiro, MichiieSakamoto, Kenichi Takayasu, Norio Hayashi,Masatoshi Makuuchi, Yutaka Matsuyama &Morito Monden, “Report of the 18th follow-upsurvey of primary liver cancer in Japan.”Hepatology Research, 2010, Vol. 40, pp.1043–1059.

4 Bruno Latour, We have never been Modern,

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translated by Catherine Porter, (Cambridge,MA; Harvard University Press, 1993), Location2666 in Kindle edition.

5 Quoted in Ann Bowman Janetta, “FromPhysician to Bureaucrat: The Case of NagayoSensai” in Helen Hardacre and Adam Kern,editors, New Directions in the Study of MeijiJapan. Brill's Japanese Studies Library, Book 6(Leiden, Boston & Tokyo: Brill, 1997), p. 159.

6 Nagasaki University School of PharmaceuticalSciences, Kusuri no rekishi, Nagasakiyakugakushi no kenkyū, Daisanshō kindaiyakugaku no teichakuki. Iryō – Eiseigyōseiseino sōshisha: Nagayo Sensai. [The history ofpharmaceuticals, Research into pharmaceuticalscience history. Chapter 3: The period ofestablishment of pharmaceutical sciences.Nagayo Sensai: Founder of the medical carea n d p u b l i c h e a l t h s y s t e m s . ](http://www.ph.nagasaki-u.ac.jp/history/research/cp3/chapter3-4.html) Viewed 04/13/2014.

7 M. Mizokami, Y. Tanaka, Y. Miyakawa,“Spread times of hepatitis C virus estimated bythe molecular clock differ among Japan, theUnited States and Egypt in reflection of theirdistinct socioeconomic backgrounds.”Intervirology, Vol. 49, 2006, pp. 28–36.

8 Yasuhito Tanaka, Kousuke Hanada, EtsuroOrito, Yoshihiro Akahane, Kazuaki Chayama,Hiroshi Yoshizawa, Michio Sata, Nobuo Ohta,Yuzo Miyakawa, Takashi Gojobori & MasashiMizokami, “Molecular evolutionary analysesi m p l i c a t e i n j e c t i o n t r e a t m e n t f o rschistosomiasis in the initial hepatitis Cepidemics in Japan.” Journal of Hepatolology,Vol. 42, No. 1, January 2006, pp. 47-53.

9 The term “leper” to name people withHansen’s Disease is considered pejorative inboth Japan and elsewhere these days. But“leper” or the Japanese equivalent, raibyōkanja,was the language of the times described in thisessay. “People with Hansen’s Disease” islanguage adopted in the latter years of the 20th

century. I use “leper” in inverted commas to beat once h istor ica l ly accurate and toacknowledge the stigmatizing power of theword.

10 I am thinking here of the beauty found inasymmetrical, rough, and accidentallyimperfect ceramics, or of Mishima Yukio’saestheticization of war and violence. Late onespring night many years ago, I was walkingwith a Sōtō Zen monk through the groves ofcherry trees lining the banks of the Ōi River atArashiyama. The cherry trees were in fullbloom and beneath them lay great middens oftrash left by revelers. I commented on theugliness of it. “However,” my monasticcompanion said, “Is not the trash beautiful too,for it forces the eye to travel up to the blossomsand into the night sky.”

11 Susan L. Burns, “From ‘leper villages’ toleprosaria: Public health, nationalism and theculture of exclusion in Japan” in CarolynStrange and Alison Bashford, editors, Isolation:Places and practices of exclusion. (London &New York: Routledge, 2003), p. 100.

12 William Ng, “The Literary Works of Hansen’sDisease Patients in Japan.” InternationalJournal of Dermatology, Vol. 49, Issue 4, April2010, p. 462.

13 Quoted in Tobumatsu Jingo, Hannah Riddell:Known in Japan as “The mother of lepers(https://apjjf.org/admin/site_manage/details/anglicanhistory.org/asia/jp/riddell1937/text.html).Project Canterbury. Viewed December 20,2012.

14 Quoted in Julia Boyd, 1996. Kindle Location2018.

1 5 Tok ie Takahash i , “Tak ing Soc ia lResponsibility for the Legal Isolation ofPatients with Hansen’s Disease.” Essays 2006.Nagoya Women’s Studies Research Group,2006.

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16 Fukuoka Yasunori and Kurosaka Ai, “Zettaini, kokkara ugoku monka to – chichi to ane gahansen byou ryouyoujo ni shuyousareta shimaino katari” [No way are we leaving here - Sisterswhose father and older brother had been put ina leper sanatorium tell their story] Nihon AjiaKenkyuu [Japan Asia Research, No. 8., March,2011.

17 Katsushi Egawa, Tomo Yukawa, ShoichiArakawa, Takeshi Tanaka, Fumio Tsuda,Hiroaki Okamoto, Yuzo Miyakawa and MakotoMayumi, “Hepatitis C virus antibody, viral RNAand genotypes in leprous patients in Japan.”Journal of Hepatology, Vol. 196, No. 24, pp.397-402.

18 Kazuya Shiogama, Hidemi Teramoto, YukikoMorita, Yasuyoshi Mizutani , RyoichiShimomura, Ken-ichi Inada, Toshio Kamahora,Masanao Makino, and Yutaka Tsutsumi,“Hepatitis C Virus Infection in a JapaneseLeprosy Sanatorium for the Past 67 Years”Journal of Medical Virology, Vol. 82, 2010, pp.556–561.

1 9 Hidemi Teramoto, Kazuya Shiogama,Yasuyoshi Mizutani, Ken-ichi Inada, ToshioKamahora, Masanao Makino and YutakaTsutsumi, “Molecular Epidemiology of aHepatitis C Virus Outbreak in a LeprosySanatorium in Japan.” Journal of ClinicalMicrobiology, Vol. 49, No. 9, Sept. 2011, pp.3358–3360.

2 0 Personal communication via email ,12/28/2012.

2 1 Personal communication at Aiseien,27/05/2013

22 Juntendo University Shizuoka Hospital,Faculty of Medicine, Shiigatakanen uirusu wok i r u ! [ K i l l H C V ! ](https://apjjf.org/admin/site_manage/details/juntendo.org/c&m/03/c&m-03-08.php). ViewedJune 27, 2013.

23 Quoted in Bikini jiken – hanseiki no kokuin: 5/tairyou yuketsu de kanenhasshou [The BikiniIncident – Impressions of half a century: No. 5/Major blood transfusions and outbreak ofh e p a t i t i s ](https://apjjf.org/admin/site_manage/details/shizumin.com/kitahama-machi040305.html)Mainichi Shimbun, March 5, 2004. Viewed June27, 2013.

24 Paul N. Edwards, “Infrastructure andModerni ty : Force , T ime, and Soc ia lOrganization in the History of SociotechnicalSystems” in Thomas J. Misa, Philip Brey,Andrew Feenberg, editors, Modernity andTechnology. (Cambridge, MA: The MIT Press,2004), p. 186.

25 Sato Akihiko, “Methamphetamine use inJapan a f te r the Second Wor ld War :Transformation of Narratives.” ContemporaryDrug Problems, Vol. 35, Winter 2008, pp.717-746.

26 Miriam Kingsberg, “MethamphetamineSolution: Drugs and the Reconstruction ofNation in Postwar Japan.” Journal of AsianStudies, Vol. 72, No. 1, 2013, pp. 141-162.

27 Jeffrey W. Alexander, “Japan’s hiropon panic:Resident non-Japanese and the 1950s methcrisis.” International Journal of DrugPolicy.May 2013, Vol. 24, No. 3, p.

239.

28 Kazuya Shiogama, Hidemi Teramoto, et al,2010, p. 561.

29 Kingsberg, 2013.

30 Alexander, 2013, pp. 238-43.

31 Saito Katsuhiro, “Hiroshige Shiota.”NihonIshikai Zasshi [Journal of the Japan MedicalAssociation], 1965, Vol. 53, No. 1439.

32 Nishiyama Katsuo, “’15-nen sensō’ e no

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Nihon no igaku iryō no katan no kaimei nitsuite” [Participation of Japanese medicine inthe 15 Year War], Shakai igaku kenkyū SocialMedicine Research 2009, Vol. 26, No. 2, pp.11-26.

3 3 S. Sekiguchi, “The Impact of BloodSubstitutes on the Blood Program.” E.Tsuchida, editor, Blood Substitutes: Presentand Future Perspectives. (Amsterdam: ElsevierScience, 1998), pp. 383.

34 Hobyung Chung, Taisuke Ueda, MasatoshiKudo, “Changing Trends in Hepatitis CInfection over the Past 50 Years in Japan.”

Intervirology, 2010, Vol.53, pp. 39–43.

3 5 G o r d o n G . L i u ; M a r c o d a C o s t aDiBonaventura; Yong Yuan; Jan-SamuelWagner; Gilbert J. L'Italien; Paul Langley &Isao Kamae, “Burden of Viral Hepatitis C inJapan: A Propensity Analysis of PatientOutcomes.” Poster session at the 21stConference of the Asian Pacific Association forthe Study of the Liver, APASL 2011, Bangkok,Thailand, February 17-20, 2011. Available here(http://www.kantarhealth.com/docs/publications - c i t a t i o n s / a p a s l _ 1 1 - b u r d e n _ h e p -c_japan.pdf?sfvrsn=12). Retrieved May 3,2014.