Converging pathways: The institutional integration of medical missionary and indigenous medical professionalism in modern China (1915–1932)

Established in 1886, the Medical Missionary Association of China (MMAC) was the first academic society dedicated to Western medicine in China. In 1915, a group of Chinese physicians trained in Western medicine founded the National Medical Association of China (NMAC), marking the creation of the first Western medical academic community organized by Chinese nationals. In 1932, the two organizations merged and were renamed the Chinese Medical Association. While scholars have already conducted extensive research on the histories of these two associations, questions remain regarding the nature of the interactions between the MMAC and NMAC during the 17 years between 1915 and 1932.1 How have their dynamics, marked by negotiations, cooperation, and competition, shaped the development of modern medicine in China? How does the structural transfer of epistemic power facilitate a merger? These questions require further investigation. From Independence To Cooperation: Building An Internationalized Medical Association. Initially, membership in the MMAC was restricted to foreign medical missionaries in China. In 1896, two female Chinese physicians, Mary Stone and Ida Kahn, became the first Chinese members of the MMAC, opening the door to Chinese participation.2 By 1913, ten Chinese doctors had joined the association, serving in various capacities as full, corresponding, or honorary members. At the 1915 MMAC annual meeting held in Shanghai, at least 10 of 113 formally registered attendees were Chinese physicians, including F. C. Yen, Lien-the Wu, E. T. Hsie, Tsao Li Yui, Mary Stone, Ida Kahn, C. M. Lee, E. S. Tyau, A. M. Wong, and T. K. M. Siaou.3 Although Chinese members comprised less than 8% of the total, the MMAC regarded this as a major breakthrough.4 However, Chinese doctors did not accept the MMAC's dominant position in China's medical sphere. As Lien-teh Wu remarked, "How can we remain indefinitely under a foreign medical association? In every advanced civilized nation, there exists a government-sanctioned medical society which supervises public health policy and mobilizes public support to improve medicine and hygiene."5 In 1915, 21 Chinese physicians, eight of whom were members of the MMAC, established the NMAC, marking a pivotal moment in the history of modern Chinese medicine. This act signified a break from foreign-dominated structures and the beginning of Chinese-led development of the national medical profession. Previous studies have shown that NMAC initially borrowed almost entirely from MMAC in terms of its organizational structure. However, the two associations differed significantly. First, NMAC was officially registered with the central government and constituted an independent and legitimate academic body representing China.6 Second, unlike MMAC's restrictive membership policies, NMAC championed unity, openness, and inclusiveness. It welcomed medical professionals from all nations to raise their academic standards and better serve public health in China. NMAC's first president, F. C. Yen, believed that "medical organizations should have no national limitations" and openly invited MMAC members to join NMAC, emphasizing that "we need their cooperation and stimulation, sympathy and wise counsel".7 Correspondingly, the president of the MMAC, W. H. Venable, also expressed a cooperative attitude toward the NMAC.8 Sixty Western physicians attended the NMAC's first national meeting in 1916, comprising one-quarter of the total membership.9 From 1915 to 1932, the NMAC consistently pursued interaction and cooperation with the MMAC, upholding the principles of friendship and solidarity.10 The two societies held their annual conferences simultaneously and in the same location, allowing members to participate and engage in mutual exchange and discussion of scientific research progress. As editor-in-chief of the National Medical Journal of China (Natl Med J Chin), Lien-teh Wu actively promoted academic collaboration and resource sharing between the journal and The China Medical Journal (MMAC's publication, Chin Med J), and invited MMAC members to contribute articles. Influenced by these efforts, the MMAC relaxed its membership restrictions in 1925 and began accepting more Chinese physicians. Many Chinese doctors held dual memberships in both organizations. By 1929, 93 of MMAC's 649 members were Chinese—a notable increase.5 Moreover, the status of Chinese physicians in the MMAC improved. F. C. Yen served as the MMAC's vice president from 1923 to 1925, while NMAC president W. S. New held a position on the MMAC Executive Committee for eight years. On the side of the MMAC, there had long been a desire to establish comprehensive cooperation with the NMAC in two key areas: the standardization of medical terminology and the translation of medical textbooks. "The two associations should collaborate on matters such as translating medical texts and conducting thorough reviews."4 The association emphasized the need for joint action on translation and quality control—efforts that required Chinese expertise to advance the localization of Western medical knowledge. This longstanding cooperative relationship laid the groundwork for an eventual merger. The MMAC referred to the NMAC as its "sister organization".11 In 1928, following the establishment of the Ministry of Health under the Republican government, the leaders of both associations proposed adopting a system akin to that of Western countries, in which each nation has a unified national medical association.11,12 The MMAC asserted that "The China Medical Association should be to China what the British Medical Association is to Great Britain".11 The NMAC called for the unification of domestic medical associations, and the MMAC was the first to respond, expressing that "this association (China Medical Association) would be ready at all times to offer the closest cooperation to China's government." MMAC president Arthur Woo acknowledged the need for transition: "The membership must become overwhelmingly Chinese, and the management of this association must pass into Chinese hands."11 In 1932, the two organizations officially merged under the name The Chinese Medical Association (CMA). Membership quickly expanded from 794 to over 1500, with one-third of the members being foreign nationals, including hundreds of physicians from Europe, the United States, and Japan.10 This merger marked the transformation of the national NMAC into a professional body of international stature. The CMA became the sole official representative of China's medical community on the global stage — a development hailed as the beginning of "a new era for Chinese medicine".10 Transfer Of Academic Discourse Power. Over the course of several decades, the NMAC experienced rapid growth, particularly after the establishment of the Ministry of Health under the Republican government in 1928. Core members of the association were appointed to key positions within the ministry, further elevating the NMAC's academic status, while the influence of the MMAC within China's medical system began to wane. For instance, the initiative to standardize medical terminology, originally launched and led by the MMAC, gradually came under the control of the Chinese medical community. Voonping Yu, a key figure at the NMAC, played a central role in the project. Many of the early terms introduced by the MMAC were eventually replaced with new terminology endorsed by the NMAC. This structural shift in epistemic authority between the two associations can be empirically observed through a comparative study of articles and authors published in their respective official journals: The Chin Med J, published by the MMAC, and The Natl Med J Chin, published by the NMAC. Chinese Authors in The Chin Med J. The first appearance of a Chinese author occurred in the Chin Med J in 1905, in issue number 6, when Kang Cheng (Ida Kahn) published an article titled "T Self-supporting Medical Missionary Work".13 In 1912, the names of three Chinese authors appeared in the journal, namely Lien-teh Wu, F. C. Yen, and Mary Stone. In total, five articles were published that year, with Lien-teh Wu and Mary Stone contributing two articles each. From 1912 to 1931, the year the Chin Med J ceased publication, Chinese authors published 309 articles, according to incomplete statistics. (Note: The names of Chinese authors in the Chin Med J were transliterated using Wade–Giles romanization, and a small number of names may not have been accurately identified.) As illustrated in Figure 1, the number of articles authored by Chinese writers in the Chin Med J increased rapidly after 1920. A 1927 report noted that while the number of Western members was declining, Chinese membership was rising; that year, 25% of the journal's articles in the first half of the year were authored by Chinese contributors.14 This trend continued to grow steadily; by 1930, the number of articles published by Chinese authors peaked at 40. Among the Chinese contributors, K. C. Wong was the most prolific, with 17 articles, followed by Lien-teh Wu (16) and Tou-yan Lai (14). Other contributors included senior officials from the Ministry of Health—J. Heng Liu, F. C. Yen, and R. K. S. Lim—as well as prominent Chinese physicians such as K. K. Chen, M. Yang, and Voonping Yui. It is worth noting that most of Wong's articles focused on the cultural history of Chinese medicine. For instance, the first article in Issue 8th of the 1927 volume was his piece titled "Hua To"—a position of prominence typically reserved for the most significant academic work in an issue. For research with outstanding academic merit, the editor of the Chin Med J made a special evaluation of this article and suggested that K. C. Wong continue to write an article analyzing why Chinese medicine did not develop after the Middle Ages. The editor believed that this phenomenon was similar to the history of medieval medicine in Europe.15 Likewise, the first article in the first issue of the Chin Med J in 1928 was authored by Chinese physician J. Hua Liu, titled "Foreign Bodies in the Air and Food Passages Among the Chinese", which was the first scientific research paper submitted by a Chinese doctor.16 Since then, Chinese authors have occupied an increasingly central place in the academic content of the Chin Med J.Figure 1: Number of articles published by Chinese authors in Chin Med JComparison of Chinese and English-language articles in The Natl Med J Chin.The Natl Med J Chin was launched in 1915 as a bilingual journal. The first issue featured 57 and 52 pages in Chinese and English, respectively, indicating an approximately equal balance between the two languages. As Figure 2 shows, during the early years, the Chinese section of the journal consistently exceeded its English section. This discrepancy stemmed from several factors: the scarcity of original English submissions; the presence of translated Chinese articles; and the inclusion of news briefs, translated summaries, and association updates in the Chinese section, which often made it 50 pages longer than its English counterpart. From 1919 to 1928, the Chinese and English sections were more balanced in length, although the Chinese section was noticeably longer in 1924 and 1926. However, between 1929 and 1931, the Natl Med J Chin exhibited a marked shift toward English dominance. During this period, the number of Original Research articles, Case Reports, and Clinical Notes and Devices in English significantly surpassed those in Chinese. In 1929, for instance, the journal published only 32 original Chinese articles, whereas the combined number of original English-language Articles and Clinical Case Reports was 59. Furthermore, the society's proceedings were published in English during this period.Figure 2: Page count comparison of Chinese and English content in Natl Med J ChinAdditionally, a comparative analysis of English-language articles published in the Natl Med J Chin and the Chin Med J Figure 3 revealed a clear trend of convergence. While there was a wide disparity in English-language content between the two journals at the time of the Natl Med J Chin's founding, the gap narrowed significantly from 1929 to 1931.Figure 3: Comparison of English-language articles in Natl Med J Chin and Chin Med JWhat is especially noteworthy is that despite the Chin Med J being a monthly publication (12 issues per year) and the Natl Med J Chin being a bimonthly publication (six issues per year), the two journals published nearly equal numbers of English-language articles annually by this period. This pattern not only reflects the increasing academic writing capacity of Chinese medical researchers but also indicates that their research ability had reached an internationally recognized standard. It further demonstrates that by this time, the Natl Med J Chin had attained a significant level of internationalization. A New Landscape in Chinese Medical Development. After 1928, the MMAC, primarily composed of foreign physicians, came to a sober realization: "No one can deny that the future of Chinese Medicine is in the hands of Chinese themselves, and Chinese will eventually be the official language of the profession in China." Arthur Woo, Presidential Address, Chin Med J, 1929, 43: 159 Although the MMAC attempted to participate in the Republican government's public health administration and sought to influence the structure of its health system—suggesting that China would do well to draw lessons from European models—it ultimately admitted: "The solution of this all-important question, we seek the cooperation of the NMAC."17 This acknowledgment was grounded in the fact that the NMAC had close ties to the Ministry of Health of the Republic of China. Many senior officials at the ministry were NMAC members; Vice Ministers J. H. Liu, F. C. Yen, Lien-teh Wu, and W. S. New served as government advisors. Voonping Yui played a key role in standardizing medical terminology. These figures were not merely medical leaders but also architects of China's public health system. Furthermore, the NMAC not only cooperated with the government from the top down but also actively submitted policy recommendations from the bottom up.18 In 1928, the NMAC petitioned the Ministry of Health to reform its medical education structure. Some members openly criticized the ministry's irrational policies.19 In his essay "The Future of Our Association," Lien-teh Wu emphasized that while the NMAC must collaborate with and serve the government, it also bore the responsibility to critique and advise the state, thereby preserving its independent spirit.20 Although the MMAC did not directly participate in shaping the governmental health system, its earlier work in public health and medical education laid the foundation for the creation of a new medical order in Republican China. Building on this foundation, the NMAC actively advanced the modernization of Chinese medicine. This transformation took concrete form in the following areas: Rural healthcare construction. The MMAC long promoted free medical care in rural China. In 1929, with funding from the Rockefeller Foundation, the MMAC Annual Conference sponsored a rural health demonstration in Ding County led by the Peking Union Medical College. With support from the Shanghai municipal government, F. C. Yen established a rural health demonstration on the city's outskirts. Rural health care was soon incorporated into the core agenda of the Ministry of Health. State Medicine. In 1927, the MMAC proposed adopting a European-style health administration model known as "State Medicine" to address the acute shortage of doctors in China. Liu elevated this concept to a top priority in the Ministry of Health, while Yen emerged as an active promoter and practitioner of State Medicine in China. Public Health campaign. As early as 1915, the MMAC established a Public Health Committee, with F. C. Yen serving as an executive member.21 Before 1932, both the NMAC and MMAC, in collaboration with the Ministry of Health, played instrumental roles in promoting public health nationwide. Medical education standardization. Most NMAC committee members were employed at medical schools and hospitals governed by the MMAC, providing them with rich professional experience. F. C. Yen served as chair of the Medical Education Committee of the NMAC. The president of the NMAC, H. P. Chu, also played a major role in helping the Ministry of Education formulate standardized medical curricula. Infectious disease research and control. Chinese and foreign physicians utilized Chin Med J and Natl Med J Chin as platforms to introduce recent European advances in bacteriology. Their research addressed a wide range of infectious diseases, including plague, schistosomiasis, tuberculosis, leprosy, hookworm disease, smallpox, cholera, and syphilis. In addition, the NMAC took the initiative to establish rules regulating medical ethics and safeguarding physicians' rights. As President W. S. New noted, the Ministry of Health's medical administration policies were well conceived, but it was the NMAC that deserved credit for advancing the new landscape of modern medicine in China: "The progress made in modern Chinese medicine could not have been achieved without the contributions of our Association."22 Different Paths, Same Destination. In 1915, at the founding of the NMAC, President W. H. Venable of the MMAC predicted at the annual meeting that "Chinese must be increase, we must be decrease."23 Echoing this sentiment, the NMAC consistently emphasized cooperation with the MMAC and advocated learning from its experience to promote the development of Western medicine among the Chinese. History has borne out this trajectory: from 1915 to 1931, the growth of the two organizations showed a clear inverse relationship; as the academic influence of the NMAC rose rapidly, the scholarly vitality of the MMAC gradually declined. Despite fundamental differences in their nature and missions, decades of interaction and collaboration between the two made their eventual merger, shaped by political and cultural factors, a historical inevitability. In 1932, the two groups merged to form the CMA, symbolizing the localization of Western medical knowledge and the rise of a nationally representative profession. The merger illustrated how negotiation and mutual respect enabled different institutional paths to lead to a shared goal: the modernization of Chinese medicine. The two ultimately arrived at the same destination via different paths. Conflicts of interest None.