In the 4th TUPReP Cross Talk, entitled "Towards a Social History of Infectious Diseases," panelists discussed social changes after the modern era, with a focus on changes in people's perception of infectious diseases. Professor Odanaka began with an overview of the "birth of the 'Other'" in Western Europe after the Industrial Revolution. Professor Takehara then presented Meji-era Japanese public records on public health administration and patient concealment. Professor Kawauchi followed by explaining people’s "fear" of infectious diseases based on examples from the Russian and Spanish Flu. During the following discussion, participants discussed the differences in society in Japan and other countries. They focused on the different characteristics of Japan compared to the West.

•Introduction
"Industrial Revolution, Capitalism, and Imperialism: The Birth of the 'Other' in the West"
Naoki Odanaka (Professor, Tohoku University Graduate School of Economics and Management)
　Albert Camus' "The Plague," which depicts people being tossed about in a plague pandemic, drew attention in japan during the COVID-19 pandemic. Daniel Defoe had previously published the book, "A Journal of the Plague Year," in 1722 based on a plague epidemic in London. Between these two novels covering e same theme, we can see a change in the relationship between people and the plague.

　Daniel Defoe's "The Plague" is a record of an actual London 1665 plague epidemic. . The behaviors of the characters in his work indicate that the so-called elite class fled from the city center and shut down their houses as a precautionary measure against the plague. However, other citizens—in despair that they could not escape the plague—turned to superstitions, such as prophecy and astrology. Defoe himself was a man of deep faith in God. This is evident from descriptions such as "Diseases are the work of God." A prominent feature throughout his work is the strong conviction of the "existence of God."

　Conversely, Albert Camus' 1947 novel,"A Journal of the Plague Year," depicts people in the throes of a fictional plague epidemic in 1940s Oran, Algeria. The plague and the people fighting it symbolized the Nazis and the people relistening them, respectively. In this piece, the elite class deals with the plague by establishing measures to prevent and treat infection, including quarantine, disinfection, and drugs. However, the public perceived the plague as "the Other." They viewed the plague as an "unpleasant visitor who will one day leave because they came from the outside" or "a nightmare that will soon be over."

　The characters perception of the plague changed significantly from "something unknown" to "the ‘Other' that can be subdued." Perhaps it was the discovery of the plague bacteria and its treatment at the end of the 19th century that caused this change the elite class. However, amongst the public and working class, it was the Industrial Revolution that triggered this shift in perception.

　The "commercialization of the steam engine" had a significant role in 18th century England’s Industrial Revolution. Coal fueled steam engine. Since the UK was a country abundant in coal, the people’s perception towards nature shifted from "a source of raw materials" to "an inexhaustible source of energy." In other words, nature was externalized from human beings, and came to be recognized as the "Other," i.e., "an inexhaustible entity, which, when used up, can be found elsewhere."

　The Industrial Revolution also changed the structure of the global economy and society, resulting in the birth of capitalism: a production system consisting of capitalists and workers. This system is based on the equivalent exchange of wages and labor. In reality, in the 19th century, capitalists became richer and workers more impoverished. Marx criticized this as an "unequal exchange." As capitalism spread, capitalists saw workers as inexhaustible source of labor that could be replaced once exhausted. In other words, for capitalists, laborers became "the Other" that they could not sympathize with.

　With the accomplishment of mass production through capitalism, the demand for locations to obtain raw materials and expansion of markets advantageous and monopolistic to a country increased. As a result, imperialists emerged and established colonies around the world. The expansion of colonies indeed enabled mass production and increased profits. However, colonies require further expansion of areas for raw material supply and product markets. This lead to a demand for new colonies. Thus, for imperialists, foreign countries were inexhaustibl. Foreign countries were "the Other" that needed to be absorbed by—yet remain detached from—imperialists.

　Thus, after the Industrial Revolution, the “other" emerged in society as an entity outside of oneself.
In fact, "the other" is a counterpart to oneself; it represents nature for humans, laborers for capitalists, and foreign countries for one’s home country. The "other" is inexhaustible and necessary for the self in the sense that it is taken in and used within oneself. After something or someone consumes an “other", they must then search for more. This relationship between the "other" and oneself has been the Western mindset since the Industrial Revolution.

　If we connect this Western mindset to the COVID-19 pandemic, SARS-CoV-2 was starkly distinguished as something “other” from human beings. However, the "other" is an entity that can be taken in and digested by individuals. In a pandemic, infection prevention measures and medical treatments will thus emerge as means of distancing the pathogenic “other” from humans, leading to the eventual eradication of the disease. In the post-COVID era, a new "other" will likely emerge. Or, from the Western perspective, perhaps we need a new "other" to emerge.

　The discussion so far has touched on the Western mindset after "The Plague" by Defoe. Now we will explore the Western mindset that existed before it. While the existence of God greatly influenced societies before “The Plague,” God’s character and relationship to humans differed significantly. For example, both monotheism and polytheism were prevalent before “The Plague,” but the eventual emergence of anthropocentrism after the 14th shifted society from a neutral, "God-centered" mindset to the envisioning of a human-centered society. Although this shift is regarded today as primarily a departure from the medieval mindset, there is a possibility that it may have led to an ideology that places non-human beings below humans. These issues also warrant discussion.　

•Topic 1: “’Patient Concealment’ Infectious Disease Outbreaks in the Meiji Period: Clues from Reports on Cholera and Dysentery Outbreak Reports”
Kazuo Takehara (Assistant Professor, Tohoku University Center for Northeast Asian Studies)
　Until the Edo period in Japan, people attempted to "pacify" infectious diseases to “weather it out." In modern times, however, infectious diseases have become something that should be "contained." One of the triggers for this change was the introduction of a public health administration based on the western model.

　The institutionalization of the Japanese public health—especially infectious disease control—was led by Nagayo Sensai, who accompanied the Iwakura Mission. The cholera epidemic set the stage for the institutionalization of infectious disease laws. Cholera was a new infectious disease that first appeared in Japan in the 19th century. Outbreaks occurred sporadically beginning in 1877, and it became a major threat due to its high fatality rate. With the recurrence of its epidemics, a legal system was established to prevent its spread. This included the Cholera Disease Prevention Act of 1877, the Infectious Diseases Prevention Regulation of 1880, and the Infectious Diseases Prevention Act of 1897. With the eventual outbreak of dysentery, the public health administration fought simultaneously against both diseases between 1892 and 1901.

　In response to these outbreaks, provincial administration and the Sanitary Bureau of the Interior Ministry published reports on the following characteristics of cholera and dysentery epidemics: trade outlines, legislations, and statistical information. The reports included many survey items to understand the epidemic situation and improve disease-prevention. As people gained more experience with epidemics, the survey items increased, and the reports became more detailed and specific. These reports are important primary sources for understanding infectious disease epidemics and the measures taken to combat them back then.

　According to a cholera report from 1879, there were two major "obstacles for preventive sanitization." The first obstacle was the reliance on old customs from the pre-modern era, such as the practice of praying to Gods and enforcing rituals. The other was patient concealment due to misconceptions about the importance of prophylaxis. The 1890 cholera report included "harmful effects of patient concealment" as a survey item, indicating that the issue was a major concern.

　In the case of dysentery, in particular, concealment was more likely to be encouraged than cholera because dysentery had existed in Japan for a longer time than cholera and has a lower fatality rate. Additionally, the prologed isolation period for dysentery can impact family finances, and many people had developed an aversion to quarantine hospitals.

　According to reports from Kumamoto and Yamanashi Prefecture, economics, medical care, government administration, ideology, prejudice/discrimination, and time all contributed to patient concealment. Once a person was identified as a patient, the cost of medications and labor restrictions due to quarantine caused significant economic damage. Furthermore, quarantine hospitals did not function sufficiently back then due to a lack of facilities, doctors, and nurses. The old belief that epidemics were due to curses of Gods also played a role. There was also prejudice and discrimination within villages due to infection, and patients themselves felt guilty thinking they may have spread the disease to the village. All these factors pushed people to conceal patients. An 1898 article on a dysentery outbreak in Yamanashi Prefecture even stated, "In all prefectures, the greatest cause of spread is patients who conceal their illnesses."

　In response to patient concealment, the government implemented compulsory supervision and monitoring, quarantine hospital improvements, fines, census, and the establishment of public health associations for mutual surveillance and knowledge communication. The establishment of public health associations aimed to develop people's public health awareness via public health lectures. Reports indicate that the cases of patient concealment at the local level decreased.

　The COVID-19 pandemic has had few cases of patient concealment. Some think this was due to the advancement of medical knowledge, improvement of the medical environment, sufficient information disclosure, and the influence of mutual surveillance such as "self-restraint police", and a sense of peer pressure unique to Japan. Case studies by the "Working Group on Prejudice, Discrimination, and Privacy" and the resulting countermeasure-reinforcement may also have helped prevent patient concealment. However, no studies have made international comparisons of the progress of Japanese infectious disease control measures in the Meiji period. For example, patient concealment persisted during the Ebola outbreak in Africa for the same reasons as Meiji-era outbreaks in Japan. This means that the actual causes of patient concealment have not yet been fully overcome. To prepare for future pandemics, we must research past and present patient concealment.

•Topic 2: "How Influenza Epidemics have been Feared: Insight from the Russian and Spanish Flu"
Atsushi Kawauchi (Associate Professor; Tohoku University International Research Institute of Disaster Science)
　Implementation of infectious disease control measures starts with proper fear of infectious diseases. This "proper fear" is based on two factors: fear of infectious diseases and accurate knowledge about infectious diseases. While "proper fear" is an extremely important aspect of infectious disease control, it is difficult to generate in practice. In this session, we compare the "fear" seen in two pandemics that modern Japan has experienced: the Russian Flu and the Spanish Flu.

　The 1890 - 1894 Russian flu was pandemic thought to be caused by the human coronavirus (OC43) or Type A influenza virus. It reached Japan in February 1890 and spread rapidly in the Kanto region from mid- to late- April 1890. Starting with a city-wide outbreak in May, it spread to areas outside of the Kanto region by mid-May. Surprisingly, citizens did not fear the Russian flu during this first wave of the epidemic. Although many people were infected, their symptoms were often not severe and few sought medical attention. Rather, people were more afraid of cholera, which was more prevalent at the time. There were even serious discussions that influenza was a precursor of cholera. When the second wave of the Russian Flu epidemic broke out in Tokyo in mid- to late- November 1890, the mortality rate was higher than in the first wave. However, the administrative response was insufficient. During a time when there was no health insurance and it was impractical for everyone to receive medical care, people began to fear the Russian Flu (influenza), and the only preventive measures they could take were over-the-counter medicines and folk remedies. In the second wave, the Russian Flu came to be known by a variety of names, including "Denbei Flu," "Denko Flu," and "Iwashi Flu." In the fury of the second wave, people tried to rationalize their fear towards influenza by giving it various names.

　On the contrary, the Spanish Flu, which resulted in a pandemic from 1918 to 1920, was caused by the H1N1 Type A influenza virus. It spread to Japan in April 1918. There were signs of an outbreak in May; many sumo wrestlers were absent from the Summer Grand Sumo Tournament, and malignant colds were seen in army garrisons across Japan by June and July. Then, in September and October 1918, an outbreak known as the "pre-epidemic" began. Especially during the latter half of the “pre-epidemic,” high death tolls and mortality rates were recorded. In February 1919, the Japanese government developed countermeasures against the epidemic, starting with the statement entitled, "Matters Concerning the Eradication of the Malignant Flu," which encouraged the avoidance of crowded settings, masking, gargling, and vaccination. These measures were based on the assumption that influenza was a bacterial disease. In addition, the "Precautionary Guidelines for Flu Prevention" were also issued to disseminate accurate knowledge and raise awareness. At the beginning of 1920, the so-called "post-epidemic" outbreak occurred, and the government once again encouraged thorough masking and vaccination. Posters encouraged people to take voluntary measures such as masking. The posters were intended to develop a fearful image of influenza with accurate knowledge. To spark fear, the poster depicts "other" people. This presence of "others" capitalized on the characteristic of Japanese society where people establish individual norms through relationships with others. The posters visually demonstrated that voluntary measures were not only for one's own sake but also for that of others. Additionally, these posters created a new "fear" of attracting negative attention and being singled out if one failed to take voluntary measures. By simultaneously sparking fear in the viewers and providing correct information, the posters cultivated "proper fear" of influenza.

　Again, "proper fear" is based on two things: accurate knowledge and appropriate fear control.
When we consider whether people were able to "properly fear" the COVID-19 pandemic, we find that in terms of knowledge, anti-vaccine groups and occult anti-intellectualist belief, such as “COVID-19 is a cold,” emerged, but their impacts were limited. In terms of fear, people feared not just the disease itself, but quarantine and public sanctions, such as the so-called "self-restraint police" and fear of being singled out. However, in a contemporary society which has undergone massification and become increasingly information-centered, people may have difficulty " fearing properly." If "proper fear" is a necessary preventive measure against infectious diseases, a challenge for historians will be to consider the similarities and differences between society during the Spanish Flu and the modern day.

Discussion

•The Western Perception of Infectious Diseases as "Someone Else's Problem"
　One characteristics of outbreaks in the West is that they considered infectious diseases to be "someone else's problem" and were negligent in developing domestic control systems. For example, cholera spread in mid-19th century Europe due to belief that cholera was an Asian infectious and the plague epidemic was a thing of the past, which led to the outbreak of the disease from India. In the case of the 20th century Spanish flue, overconfidence that infectious diseases could be controlled that came from the pride of overcoming the epidemics of cholera, plague and yellow fever resulted in a delayed respond In the 21st century, with the outbreaks of SARS, MARS, and Ebola, the West provided substantial international aid, but did not invest in domestic systems at all, based on the assumption that infectious diseases happen in other countries. It was in this context that COVID-19 broke out, and the West lost control of the situation. As already mentioned, the belief that infectious diseases are phenomena that happen in other countries and something that can be controlled became a barrier to reinforcing measures against infectious diseases in the West, each time leading to a new epidemic.

　Until around the 18th century, Western Europe lagged behind Asia in many areas, including technology, economy, and society. The Industrial Revolution reversed this situation. But, the fact that the Industrial Revolution took place in Western Europe was due to the fortuitous existence of coal mines and the large US market nearby. This fortuitous coincidence caused the West to perceive themselves as the global leader, and that Asia was lagging behind. Infectious diseases were also assumed to be an issue of " underdeveloped Asia."

　In the early stages of the COVID-19 pandemic, the West predicted that there would be many deaths in their own countries, but this was an oversimplified prediction that most deaths would amongst residents of urban low-income neighborhoods and migrant workers, and that the wealthy would escape to the suburbs. In reality, the disease spread to the affluent classes, and the flustered countries completely failed in their initial response although they opted for lockdowns and other measures. Here again, there existed the mindset that infectious diseases are “someone else’s problem.”

•Introduction to the JACSIS/JASTIS Study from the Perspective of Infection Concealment and "Proper Fear"
　The actual life of the citizens and social conditions during the COVID-19 pandemic have already been investigated in the JACSIS/JASTIS studies. Since these studies have been conducted continuously, they can be used for longitudinal studies. Survey items included patient prejudice/discrimination, vaccine avoidance, conspiracy theories, and other topics related to patient concealment and "proper fear"—which were also addressed in this presentation—and are expected to be further employed in the future.

•How Japanese Society Differs from the West
　The main COVID-19 pandemic prevention measure in Japan was "self-restraint," which succeeded in restricting people’s behaviors without mandates. This success may have been due to the Japanese tendency to "not cause inconvenience for others." On the contrary, this behavior is inconceivable in the West, where the primary concern is whether an individual themselves is infected. Historically, Japanese people have lived in harmony with others. Fear towards infectious diseases among the Japanese perhaps includes the fear of losing this "relationship." This fundamental difference in society is probably the major difference between Japanese and Western approaches to infectious diseases from the perspective of the humanities/social sciences.

　Conversely, however, like the West, the "self-responsibility" argument has also become prevalent in Japan lately. Relationships with "others" are gradually disappearing as well. In fact, in the early stages of the COVID-19 pandemic, many deaths occurred in metropolitan areas such as Tokyo and Osaka, where local connections have weakened. Conversely, fewer deaths occurred in rural areas—considered to be vulnerable due to aging—which still retain local connections. A decade from now, Japan's "relationships with others" are expected to be more tenuous than they are now, which will make it difficult to suppress COVID-19 using the same prevention measures implemented this time.

•To Fear Properly
　Even if information on vaccines, treatment development, the medical and scientific risks of infectious diseases are disclosed to the public, how they react to their fears is a different matter. Scientific knowledge that is 100% accurate will not eliminate fear. Proper control of fear is essential for people to "properly fear" infectious diseases. With the Spanish Flu epidemic, for example, the government succeeded to some degree in controlling fear by sparking the fear of being judged by others using warning posters. However, this method was only possible in pre-war Japan because information sources were limited. Modern society, where information sources abound, faces a different level of difficulty in controlling information. We must rethink how fear can be controlled in future society.

•The Hidden Potential of the Edo Period
　For the past 200 years since the Industrial Revolution, society has been pushing toward modernity, mainly in Western Europe. For Japan, it was a period in which the grounds for modernization were formed in a manner different from the West. For example, "Nishiki-e" (woodblock prints) of the period demonstrate that the "god of plague" shifted a more vulnerable position but was still capable of fighting with medicine. It was also during this period that people in Japan started a movement to break down feudalism. Although there is a general tendency to believe Japanese modernization was driven by external pressure after Perry’s arrival, Japan had already been collecting information from abroad and devising how they should develop. Indeed, the Edo period was not a period of stagnation, but rather a period with the potential for modernization different in nature from Western Europe. Perhaps we should reevaluate the Edo period once again.　

•Connection between the Spanish Flu and World War I (WWI)
　The Spanish Flu was closely related to WWI. While the mobilization of WWI in 1918 triggered the Spanish Flu pandemic, it also helped end it. One factor that brought WWI to a close was the difficulty in mobilizing German troops on the Eastern Front due to the Spanish Flu pandemic. We must consider whether such a relationship between the Spanish Flu and WWI can be found in Japan and its historical, social, and political implications.

•What the Mediterranean Sea Means to Europe
　The Mediterranean Sea, from a world history perspective, functioned as a buffer zone between Europe and the rest of the world, including Asia and Africa. In the early 19th century, The International Sanitary Conference was established in major Ottoman Turkish cities, such as Constantinople, to prevent the spread of infectious diseases—especially cholera—in the Mediterranean region. It was one of the earliest international organizations to pursue international public interest and is one of the origins of the current WHO. However, the conference’s origin lies in preventing infectious diseases from Asia and Africa, the "others," from entering Europe, the “self.”— Here again, we find that sense of "otherness," which emerged during the Industrial Revolution. Thus, we must study history to understand the relationship between the "self" and the "other" in world history and what "globalization" actually means.

　The "Eyes" of Others Needed for Disaster Response
When encouraging Japanese people to change their behavior, it is effective to emphasize not how a behavior will impact them, but how their relationships with others will be impacted. In the case of infectious disease prevention, this "relationship with others" refers to relationship with people in shared spaces. During the Spanish flu epidemic, posters raised awareness using the "gaze of those around you." When considering other disasters beyond infectious diseases, "relationship with others" can also include people with whom one never will live in the same timeline. In the past, building structures were commonly reinforced against earthquakes since they were not the property of individuals, but belonged to the "family" and were to be passed on to the next generation. It is important that Japanese people decide their actions in relation to others when evacuation and behavioral changes become necessary.

•Pandemics and Society Under Surveillance
The pandemic spurred Asian countries to transition to a robust surveillance society. China is said to have completed its transition via further improvement of its security cameras and tracking systems. In addition to China, many other Asian countries, such as Singapore and South Korea, have developed surveillance systems. Therefore, there some people fear that the current pandemic will be "the beginning of a surveillance society" that may be fully established in 50 years.

　In Japan, although police officials and health unions conducted surveillance during the Meiji period, its nature changed over time, and surveillance during the COVID-19 pandemic became extremely lax, limited to self-restraint police. Japan is unique in that it did not transition into a strong government-led surveillance system like other Asian countries. However, perhaps a more heterogeneous surveillance system may have been established in Japan, in which people were exposed to surveillance through social media and other means and were forced to surveil themselves.

•Did Japan Succeed in the Swiss Cheese Model?
　The West tends to adhere to a single solution for each problem. Thus, in the COVID-19 pandemic, they relied on one "dramatic" solution, with the belief such as "vaccines will solve the issue," and consequentially suffered devastating damage. According to the so-called Swiss cheese model, there is no single correct answer to unprecedented challenges like pandemics; rather, every solution is imperfect in some way. However, by combining and overlapping each element, we achieve something closer to perfect. Despite modernization, Japan is said to be the only country in the world where a "mythical society" remains, with a strong presence of Shintoism, Buddhism, and traditional culture. In Japan, with the mixture of various things, the Swiss cheese model may have been successful to some extent.

•Concluding Remarks
　In "Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine," Jim Downs mentions that people generally believe that modern epidemiology originates from John Snow's work on the 19th-century cholera epidemic in the UK. However, Downs criticizes that this narrative was created by the imperialists with the aim of concealing their dark secrets, and that modern epidemiology was actually established through the exploitation of "others" in the context of colonization, slavery, and war. For example, statistics on survival rates during slave transportation and disease outbreaks during wars.
Examining these overshadowed and marginalized narratives that have been historically accepted is key to moving away from Eurocentrism. Taking pandemic prevention measures as an example, the current Western-led framework—in which the development of vaccines is the only correct answer—is unlikely to work for unprecedented pandemics in the future. Unless we reconsider our Western-centered approach which relies on a single measure, we will not be able to survive the next pandemic.

　However, merely criticizing Eurocentrism will not solve the issue. We must study history and consider the true implications of globalization by relativizing modern/contemporary times and Japan. Through this process, the Japanese uniqueness may become apparent.

　We must also remember that the greatest enemy of pandemic response is the elevation of tolerance levels. In the early stages of a pandemic, people react sensitively to increasing cases and deaths. However, people gradually lose interest as the pandemic prolongs, since they become used to such abnormalities. The cholera and SARS epidemics were unforgettable because deaths were concentrated in a short period and many lessons were learned. However, since the COVID-19 pandemic was prolonged an extended time, people's tolerance levels rose, their senses became numb, and the initial sense of crisis was forgotten. The effects of tolerance levels need further verification.