Modernisation of the system of traditional Korean medicine (1876–1990)

Health Policy 44 (1998) 261 – 281

Modernisation of the system of traditional Korean medicine (1876–1990) Annette Hye Kyung Son * Department of Economic History, Uppsala Uni6ersity, Box 513, S-751 20 Uppsala, Sweden Received 5 March 1998; accepted 17 April 1998

Abstract For the past two centuries or so, the emergence and growth of scientific medicine has resulted in the gradual replacement non-scientific medical practitioners with scientific medical practitioners at the field of public health in most Western countries. The key factor behind this transformation has been the official policy that has encouraged practitioners of scientific medicine while at the same time suppressing and ignoring practitioners of non-scientific medicine. The case of the Republic of Korea (henceforth called Korea) reveals, however, a small discrepancy from this general trend, i.e. the coexistence of practitioners of both non-scientific medicine and scientific medicine. This article explores the modernisation of the system of Traditional Korean Medicine from 1876 to 1990 in an attempt to answer why the Korean health care system has a dual system of medical care and argues that the dual system of medical care in Korea was shaped by the conflicts and tensions between herbal doctors and Western trained doctors throughout the various stages of historical development. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Modernisation; Traditional Korean medicine; Herbal doctors; Modern Western medicine; Western-trained doctors

* Tel.: + 46 8 3890950; fax: +46 8 7595975; e-mail: [email protected] 0168-8510/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0168-8510(98)00027-X

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1. Introduction For the past two centuries or so, the emergence and growth of scientific medicine has resulted in the gradual replacement of non-scientific medical practitioners with scientific medical practitioners in the field of public health in most Western countries. The key factor behind this transformation has been the official policy that has encouraged practitioners of scientific medicine while at the same time suppressing and ignoring practitioners of non-scientific medicine [1]. The case of the Republic of Korea (henceforth called Korea) reveals, however, a small discrepancy from this general trend, i.e. the coexistence of practitioners of non-scientific medicine and practitioners of scientific medicine. Before we proceed, it is necessary to make some adjustments in the terminologies utilised in this article in order to foster understanding of the ensuing discussion. In the Korean health care system, the terms are better understood as ‘modern Western medicine’ and ‘traditional Korean medicine’ and herbal doctors and Western-trained doctors respectively. The reason for this is a simple fact that scientific medicine was introduced to Korea by American missionary doctors and Japanese Western-trained doctors, at the end of the nineteenth century. Since then, the Korean government’s official policy has followed a similar pattern, i.e. on one hand promoting modern Western medicine while on the other hand suppressing and ignoring traditional Korean medicine. As of 1990, 10% of the registered doctors in Korea were practitioners of traditional Korean medicine [2]. Furthermore, the medical practices of traditional Korean medicine are independent of those of Western-trained doctors. This is what makes the Korean health care system unique in comparison with health care systems in most Western countries. However, the historical development of this unique system is not well understood. In short, the purpose of this article is to explore the modernisation of the system of traditional Korean medicine in an attempt to answer why the Korean health care system has a dual system of medical care, in which practitioners of traditional Korean medicine and practitioners of Western medicine work independently of each other. In doing so, the focus is placed on the process of how the practitioners of traditional Korean medicine have succeeded in perpetuating their tradition in spite of a suppressive official policy during the course of modernisation of the Korean health care system. This article is mainly descriptive. It covers the period from 1876 to 1990, which in turn is divided into three phases: (i) traditional Korean medicine in a period of transition (1876–1944); (ii) reinstatement of traditional Korean medicine (1945 – 1983); (iii) inclusion of traditional Korean medicine in the National Medical Insurance System (1984–1990). The article concludes with a discussion of the exploratory findings. The sources utilised in this article is classified into two categories. The first category includes two Korean publications, one ‘The 40 Year History of the Korean Oriental Medical Association’, published by the Korean Oriental Medical Association (KOMA) in 1989 and the other ‘The 85 Year History of the Korean Medical Association’, published by the Korean Medical Association (KMA) in 1993. The Korean Oriental Medical Association is the central interest organisation

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for herbal doctors while the Korean Medical Association is the central interest organisation for Western-trained doctors. The first publication ‘The 40 Year History of the Korean Oriental Medical Association’ deals with both the historical development of traditional Korean medicine and the activities of the Korean Oriental Medical Association from the time of its establishment in 1952 to 1989. By comparison, the second publication ‘The 85 Year History of the Korean Medical Association’ deals with the both historical development of the organisation from 1908 (the first professional society for Western-trained doctors was founded) and the organisation’s role in the development of the Korean National Medical Insurance System and other health care matters of the Korean population. Examination of both publications are important in two respects. The first is to understand the different attitudes that existed between these two groups of doctors towards the development of the health care system in Korea. The second is to maintain a balance between conflicting opinions from these two different groups of medical practitioners. The second category of sources utilised in this article consists of official publications from the Korean government, some vernacular daily newspapers and other literature. The idea behind the active utilisation of secondary sources is based on Theda Skocpol’s recommendation. She contends that ‘if a topic is too big for purely primary research –and if excellent studies by specialists are already available in some profusion – secondary sources are appropriate as the basic source of evidence for a given study’ [3]. As specified above, we begin with describing the transformation of the Korean health care system, at the turn of the last century.

2. Traditional Korean medicine in the period of transition (1876–1944) From 1876 to 1948, traditional Korean medicine was characterised by that of marginalisation. During this time, Korea entered into a process of modernisation under direction of the imperial Japanese government and also experienced postcolonial political and social instability. Nevertheless, the medical reform made during this period was not able to totally replace practitioners of traditional Korean medicine. In part, this was due to the insufficient supply of Western-trained doctors. It was also due to the elderly herbal doctors’ continued effort to pass on knowledge of traditional Korean medicine to the younger generation. In the following, we will see how the marginalisation of traditional Korean medicine proceeded from the year 1876.

2.1. Arri6al of Western medical practice to Korea The first practitioners of Western-medicine in Korea consisted of two foreign groups; one group from Japan and the other group from North America [4]. According to the Kanghwa Treaty of February 16, 1876 between the Chosun Dynasty of Korea and Imperial Japan, several Japanese military Western-trained doctors began practising their professions at the modern hospital in Pusan. Pusan, a port city, located closest geographically to Japan, was the place where Japanese

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merchants were allowed to engage in free-trade. Japan later expanded its medical activities when they established modern hospitals in two other port cities, i.e. Incheon and Wonsan, and Seoul where the Japanese consulates were located [5]. These hospitals were on the whole reserved for the Japanese military and their family members. The number of Koreans who were treated in these hospitals were insignificant [6]. On the other hand, the signing of friendship and commerce treaties between Korea and several Western imperial powers during the 1880s led to the arrival of Christian missionary doctors. In an effort to spread Christianity, these missionary doctors, mainly from the US and Canada, treated not only the traditional elite class but also the general population and in most cases, free of charge [7]. The expansion of modern Western medicine into Korean society was extremely slow. Thus, for most Koreans, traditional Korean medicine remained as their main source of medical care. Under these circumstances, modern Western medicine was provided with a golden opportunity of showing its effectiveness to the Korean people.

2.2. Traditional Korean medicine put to the test On December 4, 1884, a coup d’e´tat was staged against the conservative factions in the Chosun Dynasty government, by a group of progressive scholars and officials, with the help of Japanese troops stationed in Seoul. The aim of the progressives with this political incident, was to accelerate the modernisation of Korean society through the removal of a number of leading conservatives within the government [8]. In this aborted coup d’e´tat, a great many soldiers and a number of the conservative members were wounded by guns and by swords. The treatment of these wounded soldiers by Horace Newton Allen, an American missionary doctor, made a strong positive impression on the Korean public with regards to the efficacy of modern Western medicine. He was also summoned to the Royal Palace to treat a high-ranking official, named Min Yo´ng Ik for serious stab wounds inflicted by an assassin. At that time, 14 herbal doctors of the Royal Court had already tried to save his life, however, his condition went from serious to critical. In this situation, Dr Allen was called to treat him and was able to save his life after 3 months of medical treatment. This so pleased Emperor Kojong, that he permitted Dr Allen to build a hospital, called the Kwanghyewon, the Hospital of Extended Grace, where he could practice Western medicine. The hospital opened in February 1885. The hospital, Kwanghyewon, subsequently replaced the two Traditional public medical service institutions, the Hyeminso and the Hwalinso. Dr Allen was appointed as a physician to the Royal household, as well as the head of the Kwanghyewon [7]. The impact of this appointment on the Confucian scholar-officials and the herbal doctors was immense. The superiority of Western science was an eye-opener for the Confucian scholar-officials. For the herbal doctors of the Royal Court, it was considered a disgrace not to have been able to save the life of a wounded high-ranking official and subsequently to be considered subordinate to the foreign physician. From this time on, the number of progressives who considered tradi-

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tional Korean medicine to be ‘a legacy from old times’ began growing and a movement to learn Western science, foremost Western medicine, started to emerge among the young yangban elites.

2.3. Medical care system reform Changes within the medical care system continued in 1894, when the Korean government of the Chosun Dynasty undertook the far-reaching Kabo reform. This reform was implemented under the direction of the new Japanese minister to Korea and marked a radical departure from the past. There were two reform measures that had adverse impacts on practitioners of traditional Korean medicine. The first was the abolition of the Confucian-oriented national examination and the second was the separation of the Royal household from Affairs of the State [9]. The abolition of the state civil service examination for herbal doctors caused the whole profession to lose their official status as herbal doctors. Separation of the Royal household from the Affairs of the State led to a series of new organisations being established. The two traditional royal medical service institutions, i.e. Naeu´iwon and Jeonu´igam, were placed under the jurisdiction of the newly created Department of Royal Household Affairs, and the two traditional public medical service institutions were replaced by a new hygiene section which in turn was placed under the newly created the Department of Home Affairs. The state hospital, Kwanghyewon was replaced by a new state hospital, called Kwangjewon (The Hospital of Widespread Relief) and placed under the jurisdiction of the Department of Home Affairs [5]. In January 1900, the Department of Home Affairs issued a decree dealing with medical doctor’s qualification and registration. This became the first modern legal provision, concerning the status of medical doctors since the abolition of the medical civil service examination in 1894. What is important in this process is that there was no clear distinction made between traditional Korean medicine and modern Western medicine [5]. For example, Western-trained doctors were assigned to official posts of physicians to the two royal medical service institutions. In some cases, the practitioners of traditional Korean medicine were appointed as heads of the hygiene section as well as of the modern state hospital. Pharmacies for both types of medicines coexisted in this modern state hospital. Furthermore, the practitioners of traditional Korean medicine still played the main role in public medical services during this period of history [10]. In summary, it can be said that the reformed medical care system was an attempt to modernise the Korean health care system, in which both practitioners of traditional Korean medicine and practitioners of modern Western medicine coexisted. It represented an institutional measure by which both traditional Korean medicine and modern Western medicine could meet the various medical care needs of the Korean people. For instance, herbal medicine was used for the treatment of patients while modern Western medicine was applied for prevention and sanitation purposes [5]. Unfortunately, this coexistence did not last long, as the Japanese imperial power began to exercise an increasingly greater influence over Korean health policies.

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2.4. Loss of the administration basisfor traditional Korean medicine After the Japanese victory in the Russian–Japanese War (1904–1905), the Japanese government accelerated its actions in the annexation of Korea. According to the Ulmi Treaty signed between the failing Korean government and the Japanese government in 1905, Korea became a Japanese protectorate. Although the Korean monarch was permitted to keep his throne, all real power, including medical administration, was vested in the office of the Japanese Residency-General [11]. Following this treaty, the modern state hospital, Kwangjewon was closed and the Korean hospital Taehanbyungwon, was established in its place by the Japanese Residency-General. No practitioners of traditional Korean medicine were allowed to practice in this hospital. The medical administration in the hygiene section was brought under the control of the Japanese Police Bureau and all medical administration posts were occupied by the Japanese officials [5]. Overnight, the medical administrative system was transformed into a Western system under which only Western-trained doctors were allowed to practice. In one blow, traditional Korean medicine, which had developed along with the evolution of Korean society for over thousands of years, lost the administrative base for its medical services.

2.5. First professional organisation for traditional Korean medicine Amidst the Japanese policy for the marginalisation of traditional Korean medicine, as discussed above, a movement to perpetuate traditional Korean medicine was launched by the practitioners of traditional Korean medicine. This movement had two aims. The first was to establish educational institutions for traditional Korean medicine and the second was to establish a professional organisation for the practitioners of traditional Korean medicine. In 1904, several herbal doctors of the Royal Court, in alliance with some herbal doctors in private practice, petitioned the Emperor Kojong for the establishment of a Korean medical school. The Emperor granted their petition and a medical school, named Tongjeu´ihakkyo was thereafter founded. From April 1905, a course on traditional Korean medicine was offered to 40 students. However, due to the lack of financial resources as well as interference from the Japanese Residency-General, the school was forced to close in 1907 [10]. In October 1909, the Society for Korean Doctors was founded by a number of young herbal doctors. The objective of the society was to promote the traditional Korean medical tradition. The number of herbal doctors who joined the society was 170. According to a 1908 investigation, conducted by the hygiene section of the Home Affairs Department, there were 2593 herbal doctors throughout Korea [10,12]. Among their activities were lectures on traditional Korean medicine given on their own initiative. However, their activities were not allowed to continue under the suppression of the Japanese authorities and over the course of time, they were forced to suspend medical education as well as their own society meetings [10].

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2.6. Degradation of traditional Korean medicine The marginalisation of traditional Korean medicine was undertaken more systematically during the Japanese colonial period (1910–1945). As soon as Japan annexed Korea, the newly arrived Japanese colonial authorities embarked on an ambitious program to create modern facilities and institutions that were based on their experience of modernisation under Meiji reform of 1868 [13]. The Japanese authorities, very proud of their advanced knowledge of modern Western medicine, looked down with disdain upon the prevalence of herbal medicine in Korea, and in doing so, denying its worth as an honourable profession. At that time the actual medical care at the private level was carried out by Korean herbal doctors, though the state medical care system was predominantly operated under the system of Western medicine since 1894. Although they attempted to stamp out all forms of the Korean identity, including the practice of medicine, the Japanese colonial authority soon came to realise that they were unable to obliterate the Korean herbal doctors as the supply of Western-trained doctors was limited. According to an investigation conducted in 1908, Korea had approximately 360 Western-trained doctors of which only 66 were Korean. In contrast, there were 2593 herbal doctors [12]. This situation forced the Japanese authority to modify their plan to prohibit practitioners of traditional Korean medicine from medical practice throughout Korea. Thus a temporary arrangement was implemented in order to relieve this acute situation. They issued two distinct regulations in 1913; one for herbal doctors, the other for Westerntrained doctors. The regulation for herbalists gave Korean herbal doctors licenses to carry on their medical practices. On the other hand, the regulation for doctors specified that only Western-trained doctors were given the authority to take responsibility for public medical service [5]. The consequence of these two separate regulations on medical care practitioners was the total exclusion of herbal doctors from the public medical service. This measure was considered by herbal doctors as a degradation of their medical profession. In the field of private medical service, a dual system of medical care had began to emerge; Western-trained doctors serving Japanese residents in Korea and a few carefully selected members of Koreans who lived in urban areas, while Korean herbal doctors serving the rest of the population who lived in rural areas. This situation did not manifest any substantial changes throughout the rest of the Japanese colonial period [14]. After the above-mentioned institutional transformation, the number of prominent Korean herbal doctors who left the medical profession increased as they were unable to endure the Japanese contempt for traditional Korean medicine and its practitioners, while at the same time the number of persons who received licenses to practice traditional Korean medicine reached an all time high of 5813 persons. This is because, according to clause 2 in the regulation on herbalists, anyone over the age of 20 years and who had been engaged in medical practice for more than 2 years could apply and receive a license. This ill-formulated measure by the Japanese colonial authorities resulted in further deterioration in the quality of traditional Korean medicine. An important reason was that some of those who were able to

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get licenses in time were often not professional herbal doctors but individuals who had some connections with the medical field, such as herbal medicine dealers [10]. The provisional measure was even further transformed in the course of time. The Japanese colonial authorities issued permanent licenses to those who applied in the first year. From 1914 to 1943, they issued licenses which were only valid for a 5 year period. The regulation dealing with herbalists was finally discarded in 1944 when the Japanese colonial authorities felt confident that the supply of Western-trained doctors was sufficient enough in order to deal with the medical problems of the Korean population. Traditional Korean medicine reached yet another serious crisis and totally disappeared from the state medical administrative and legal system [10]. 2. Z Herb doctors" strategies to preserve traditional Korean medicine Regardless of the official policy of the Japanese colonial authority on traditional Korean medicine, the movement to preserve traditional Korean medicine continued, at the initiative of leading herbal doctors. Some of them organised meetings, issued medical journals on traditional Korean medicine and established educational institutes in which herbal doctors could offer lectures on traditional Korean medicine to those who were interested. All these activities were organised on the initiative of individual herbal doctors, thus these activities could not proceed on a continuous basis, but were interrupted intermittently on account of either financial difficulty, or direct or indirect suppression by the Japanese colonial authority. The activities of the Society for Eastern-Western Medical Research established in 1934, for the continued development of traditional Korean medicine deserves to be mentioned. When the society acquired information on the Japanese colonial authorities' plan to abolish the license system for herbalists, the society decided to produce as many herbalists as possible before the issue of licenses for herbalists came to a complete stop. The society drafted a proposal to the Japanese authorities, stating their willingness to educate herbalists to fill places in 300 doctorless villages in Kyunggi-do Province. All education expenses were to be borne by the society. This proposal met with a positive response, thus the Institute for Herbalists in Kyunggi-do Province was established in 1937. Altogether 300 herbalists, 50 students each year, were educated until 1944 [10]. What is interesting to note is that the teaching staff in this institute consisted of not only herbal doctors but also of Western-trained doctors who showed a considerable interest in maintaining the tradition of Korean medicine. The medical practitioners from this institution came to play an important role in keeping traditional Korean medicine alive after Korea's independence from Japan in 1945.

3. Reinstatement of traditional Korean medicine (1945-1983) The modernisation task of the Korean health care system was succeeded by independent Korean authorities. In the following we will see the recurrent attempts of government authority in alliance with Western-trained doctors to proscribe

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traditional Korean medicine, under the pretext of health care system modernisation. We will also see the collective struggle of practitioners of traditional Korean medicine to perpetuate traditional Korean medicine. However, we begin with a short description of the medical system transformation that took place during the 3 years US Army Military Government in Korea.

3.1. Reemergence of traditonal Korean medicine (1945 – 1948) Independence from Japan in 1945 gave new hope to the herbal doctors who had survived the harsh colonial rule. Although the new health authorities in the US Army Military Government in Korea were also scornful of traditional Korean medicine and its practitioners, they did however implement some measures which were favourable for the further development of traditional Korean medicine. The most important administrative reform was the establishment of a section that administered traditional Korean medicine, within the Department of Health and Welfare [12]. In spite of the establishment of the traditional Korean medicine section, the health authorities continued to deride practitioners of traditional Korean medicine. In this situation, a group of herbal doctors assembled in October 1945, to discuss the future development of traditional Korean medicine. Their aim was to regain their degraded social and legal status in the medial profession as well as to educate younger students. The meeting bore fruit and the Korean Society for Herb Doctors was founded on November 3, 1945. On October 10, 1946, the society established the Institute for Oriental Medicine. In addition, the Society for Oriental Medicine was also founded with the aim of promoting traditional Korean medicine in May, 1947. These societies were short-lived due to the social and political unrest during this period. Traditional Korean medicine, however, survived this new crisis because of the wide spread interest among various educators in the establishment of educational institutions for traditional Korean medicine [10]

3.2. Herbal doctors’ numerical inferiority in the health policy making process The persistent struggle of elderly herbal doctors to foster and educate younger generations of herbal doctors led to an increased number of herbal doctors graduating from various institutes for traditional Korean medicine nationwide, especially during the few years after the country’s liberation from Japan in 1945. However, no herbal doctors held positions where they could exercise influence on the health policy making process. In contrast, at least six parliamentarians in the First National Assembly and the Minister and the Vice Minister of Health were Western-trained doctors [12]. This situation turned out to be a grave weakness for the continued development of traditional Korean medicine. When administrative power was transferred from the US Army Military Government in Korea to the newly established Korean government in 1948, the health administration was placed under the Social Ministry [5]. The medical practitioners, irrespective of modern Western medicine or traditional Korean medicine, felt that

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it was necessary to separate health affairs from other social matters, while taking the significance of health matters into consideration. This initiative, however, was taken by the Western-trained doctors. The Western-trained doctors succeeded in their efforts to establish a separate health ministry, with the assistance of several parliamentarians whose former professions were those of Western-trained doctors. The posts for the Minister and the vice Minister in this newly independent Health Ministry were filled by two Western-trained doctors. The Health Ministry, organised under their leadership, consisted of three departments and one section. To the Korean herbal doctors’ great disappointment, there was no separate department or section for the administration of Korean medicine [12]. When the new Central Government Law was implemented in February 1955, the two separate ministries of Health and of Social Affairs were reintegrated and became known as the Ministry of Health and Social Affairs [5]. As their former professions revealed, the Health Ministry personnel and the parliamentarians were oriented more towards the westernised modernisation of the Korean health care system rather than through the promotion of traditional Korean medicine. Evidence of this Western oriented preference was soon demonstrated when the Second National Assembly was opened on June 19, 1950. Two different legislative bills on the Medical Law were presented to the National Assembly with the sole intention of blocking herbal doctors from gaining official recognition as medical practitioner. The first legislative bill excluded herbal doctors from the category of medical practitioner while the second legislative bill contained a clause in which herbal doctors were downgraded which meant that practitioners of traditional Korean medicine came under the control practitioners of Western medicine. When these legislative bills were disclosed to herbal doctors, their disappointment was immense [10]. It is rather ironic that the proscription of traditional Korean medicine, which had been initiated by Japanese colonial authority, was followed by the newly established Korean authority. The main difference between the health policies of the Japanese colonial authority and the newly established Korean authority was that the Japanese colonial authority were only able to downgrade the practitioners of traditional Korean medicine, while the Korean authority attempted to totally outlaw traditional Korean medicine from the Korean health care system. In any event, the health policy of the fledgling Korean government seems to have revealed a serious defect. It is important to recall that while the majority of clinics or hospitals were located in the cities, over 70% of the Korean population lived in rural areas, where transportation networks were undeveloped and private medical care therefore was provided predominantly by herbal doctors. Thus the health policy of the fledgling Korean government may have had the good intention of facilitating the modernisation of the Korean health care system under the system of Western medicine, but it lacked a clear understanding of how medical practice carried out in reality.

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3.3. Impro6ements in the legislati6e climate The practitioners of traditional Korean medicine and its aspirants immediately entered into action to deter the passing of the bills on the Medical Law. Some 120000 petitions, signed by the herbal doctors throughout the country were sent to the National Assembly [10]. In addition, the representatives of traditional Korean medicine lobbied intensively in order to get an opportunity to participate in the legislative process in the National Assembly. As a result of their coordinated effort, they finally succeeded. During the 2 days of debate that followed, both Western-trained doctors and herbal doctors were given the opportunity to present their respective positions. In short, the practitioners of Western medicine argued that the herbal doctors should not be included in the category of medical practitioners because that Korean medicine was ‘traditional’ and thus had no scientific base. Some of them went so far as to claim that to include herbal doctors in the category of medical practitioners would discredit the Korean health care system. By contrast, herbal doctors argued that herbal doctors should be included in the category of medical practitioners as the use of both type of medicine were beneficial in dealing with different health problems. They further argued that a dual system of medical care would beneflt the Korean population in the long run. The result of the final voting was the establishment of a dual medical care system in which practitioners of traditional Korean medicine and practitioners of Western medicine work independently of each other [15]. Soon after, practitioners of traditional Korean medicine established the Korean Oriental Medical Association whose major purpose was to perpetuate traditional Korean medicine and its practitioners [10].

3.4. Recurring impediments for traditional Korean medicine Although the herbal doctors regained their legal status, the development of traditional Korean medicine was not without further obstacles. The two following episodes illustrate some of the impediments traditional Korean medicine has been confronted with. Korea suffered enormously from all kinds of communicable diseases following the three decades after the liberation of Korea from Japan in 1945. For example, before and after the Korean War, over 40000 Koreans were infected by smallpox [15]. Japanese encephalitis resulted in a considerable number of deaths, from August through October. The numbers who contracted Japanese encephalitis amounted to over 1000 cases, and casualties from this disease ranged from 300 to 500 each year. As in the cases of other communicable diseases, most of the victims were poor. However, the casualty rate from Japanese encephalitis showed a tremendous decrease from about 50% in the early 1950s to about 20% in the late 1950s [16]. This remarkable achievement satisfled the practitioners of Western medicine with their efforts to control the communicable diseases. They were also convinced that their scientific biomedicine excelled over traditional practitioners’ herbal medicine in controlling various communicable diseases. Under these circum-

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stances, a Western-trained doctor wrote a featured article ‘Japanese encephalitis and modern Medicine’ in Yonhap-Shinmun, one of the vernacular daily newspapers. In this article dated July 26, 1959, he made a sweeping claim on behalf of his colleagues that the remaining 20% of casualties depended on the fact that patients sought ‘unscientific’ herbal treatment instead of ‘scientific’ biomedicine. This article by a Western-trained doctor may have been intended to introduce the effectiveness of Western medicine to the general public. However, the way he expressed his viewpoints was strong enough to insult herbal doctors as the article appeared to show contempt for herbal doctors as well as to disparage traditional Korean medicine in general. This is followed by a counter-argument, titled ‘Japanese encephalitis and traditional Korean medicine’ which appeared in the same newspaper 19 days after the above-mentioned article was published. A representative of the herbal doctors presented cases where herbal medicine was successful in the treatment of encephalitis while Western-trained doctors were able only to diagnose the illness but were unable to cure it. The author also inquired why the effective treatment of Western-trained doctors was not available during the time when the disease was prevalent during the beginning of the 1950s and requested scientific evidence for the argument that the remaining 20% of casualties were due to herbal treatment. He added that if the argument by the Western-trained doctor turned out to be true, all herbal doctors were honourbound to resign their medical practice. After this article was published, the public attitude toward traditional Korean medicine improved to a certain extent. The dispute between the herbal doctors and the Western-trained doctors over the superiority of their own medicines was settled for the time being. However, in the early 1960s, a similar controversy broke out again, this time over the treatment of tuberculosis. Various public information materials—films, posters, and pamphlets — that were designed to enlighten the public about the control of tuberculosis showed some scenes that disparaged herbal doctors. For instance, these materials often categorised the herbal doctor as shamans. They exhibited great contempt for the herbal doctors who considered themselves as members of the same honourable medical profession as Western-trained doctors. This issue took three years to be resolved after intensive protests from herbal doctors [10].

3.5. Consolidation of traditional Korean medicine In the meantime, the efforts of the elderly herbal doctors to educate the younger herbal doctors continued. The Institute for Oriental Medicine, which was founded in 1946, offered a 2-year course in training herbal doctors. In order to enhance the quality of the herbal doctors, the board members of this school encouraged a plan to provide a 4-year training course equivalent to that of other universities. The plan was finally accepted by the Ministry of Education on March 5, 1953. Following this decision, the Institute for Oriental Medicine was automatically closed after producing a total of 36 graduates, 20 graduates in 1950 and 16 graduates in 1953. Instead, the Seoul Oriental Medical University was established on April 1, 1953 with 60 students in each academic year. Although the curriculum of this university con-

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sisted basically of subjects on traditional Korean medicine, some prerequisite subjects in Western medicine, such as physiology, pathology, hygiene, anatomy as well as diagnostics, were also included in the curriculum. The university changed its name to the University of Oriental Herb Medicine on March 10, 1955 in order to appeal to a broader public. One more important reason for the name change was to follow international trends, as well as to enhance its scholastic level, i.e. comparable to Western medicine [10].

3.6. Go6ernment’s effort to modernise the Korean health care system Pressure to revise the Medical Law of 1952, requiring the proscription of herbal doctors on the ground that traditional Korean medicine was unscientiflc, recurred in the early 1960s. The legislative bill was supported by the Minister of Health and Social Affairs and 11 parliamentarians whose former professions were those of Western-trained doctors, and the Korean Medical Association and the Korean Dental Association [10,12]. Even though the Korean Oriental Medical Association protested strongly against the legislative bill, the situation was unfavourable. Amidst this legislative process, a coup d’e´tat was launched by a group of military off cers on May 16, 1961. From this day to December 17, 1963, all political activities were forbidden and all political powers were concentrated in the Supreme Council for National Reconstruction. The Council immediately declared a state of national emergency throughout the country. After the coup d’e´tat, the Supreme Council for National Reconstruction issued an order that all social and academic organisations should integrate between themselves if they shared similar aims and activities. This ordinance was also applicable to the organisations for traditional Korean medicine. At that time, besides the Academy of Oriental Medicine, which was affiliated with the Association, the Korean Academy of Oriental Medicine operated right up to the coup d’e´tat. A plan was therefore made to integrate the two academies into one. In the early August, 1961, the representatives of the two academies made contact and agreed to integrate under the name of the Korean Academy of Oriental Medicine. It then reshuffled its board members and accepted 107 leading herbal doctors as initial members. The new Korean Academy of Oriental Medicine has maintained an open-door policy. In other words, the academy’s statute specifies that the membership in the academy shall be given not only to herbal doctors, but also to Western-trained doctors who are engaged in research in traditional Korean medicine, as well as to those who have profound knowledge of traditional Korean medicine. As its first task, the academy decided to continue the publication of its defunct journal ‘Oriental Medicine’ [10]. However, this first task was interrupted as the academy joined the Korean Oriental Medical Association in the struggle for the rights of traditional Korean medicine. The deliberation of the legislative bill concerning the revision of the Medical Law of 1952, which was bequeathed from the Second Republic, was resumed within the Supreme Council for National Reconstruction. In October 1961, the council passed the bill which excluded herbal doctors from the category of medical practitioners and decided to close the University of Oriental Herb Medicine. When the decision

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was disclosed to the Korean Oriental Medical Association, the herbal doctors could not hide their shock and dismay. For 3 months, their representatives thus employed every possible means available in their struggle to have this law reversed. For instance, they sent petitions to the Chairman of the Supreme Council for National Reconstruction, to the Prime Minister, and to the Minister of Health and Social Affairs. They also made direct contact with high ranking government officials. Their effort bore fruit thanks to their active lobbying. The Supreme Council for National Reconstruction informed the Association that the Council would begin reexamination of the whole matter. On March 20, 1962, the law was reversed and herbal doctors regained their legal status [10].

3.7. Herbal doctors’ efforts to acquire the same standard of education as Western-trained doctors However, the struggle to establish their legal status did not stop here. They soon discovered a clause concerning the qualification and license for herbal doctors. According to this clause, the herbal doctor’s license should be given to those who studied herbal medicine for the final 2 years of their medical course at a state or public university, with a major in herbal medicine and pass the state qualification exmination for herbal doctor. The herbal doctors found that this clause contained several inconsistencies. For instance, the clause was contradictory to the clause in the constitution that guaranteed the citizens freedom to learn and the freedom to teach. To give permission only to state and public universities and to forbid private universities from offering courses in herbal medicine went against to this clause in the constitution. There was also some suspicion among herbal doctors that 2 years of study in traditional Korean medicine might not be sufficient to acquire profound knowledge of herb medicine. Moreover, ever since this law came into force on March 20, 1962, no state or public university showed any move to follow this clause. On the other hand, the University of Oriental Herb Medicine, which was private, but the only university that had offered courses on herb medicine in Korea at that time, faced the risk of closure since the university did not meet the legal requirement. The herbal doctors were united in their belief that the clause as described above, would effectively shutdown the education of herbal doctors and thereby stop the development of traditional Korean medicine. The representatives of the herbal doctors, with support from the Korean Academy of Oriental Medicine, came into action again to revise the clause in the law. They produced a statement which pointed out the inconsistencies between this clause and that found in the constitution. Their statement was published in two leading vernacular daily newspapers, Hankook Ilbo and Dong-a Ilbo on July 20, 1963. Also they sent a recommendation to the health policy-making authority and a petition to the Chairman of the Supreme Council for National Reconstruction. During this process, they met strong resistance from the Minister of Health and Social Affairs who was himself a Western-trained doctor. In the end, the clause was revised on November 25, 1963 and the revised law came into force on December 13, 1963. Thereafter the University of Oriental Herb

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Medicine changed its name again to the Oriental Medical University with the length of courses expanded to 6 years in length. Thus, the herbal doctors flnally acquired the same educational standard as Western-trained doctors and dentists [10]

3.8. Paramedical practitioners ‘outside’ official medical care system Nevertheless, the debate on the dissolution of dual system of medical care and subsequently the creation of a single system of medical care under the system of Western medicine had taken place intermittently throughout the 1960s without any noticeable progress. One example that deserves mention is related to the legislative bill dealing with the institutionalisation of paramedical practitioners, such as acupuncturists, moxicauterists, bone-setters, and massagers. In early January 1965, the bill was drafted by individual parliamentarians who were subjected to pressure from these paramedical practitioners. Based on their failure to stop the institutionalisation of herbal doctors, the Western-trained doctors this time mobilised in a more systematic way. For example, the Western-trained doctors built up a special fund in order to finance their activities and to assist those working to obstruct the legislative bill from becoming law. They sent a petition, as well as 5000 letters, signed by individual Western-trained doctors to the President of Korea and the Speaker of the National Assembly [12]. What is interesting to note in this process is that the Western-trained doctors’ efforts to consolidate their professional competence vis-a-vis other forms of medical practice were also supported by the herbal doctors who had evolved by now as the sole authority on traditional Korean medicine [10]. Thanks to this unified endeavour, the legislative bill was finally defeated. The consequence of this Western-trained and herbal doctors’ victory was that many capable acupuncturists began working outside the medical establishment. This remains as one of the critical issues within the Korean health care system.

3.9. Failure to establish a unified system of medical care The discussion on the creation of a unified system of medical care continued in the 1970s while the Korean government was preparing its plan to implement the National Medical Insurance System. In the middle of the 1970s, there were 2788 herbal doctors throughout Korea, their ratio to the Korean population being about 1–12500. Traditional Korean medicine still responded to the medical demands of relatively large sections of the population in rural area that had no access to modern medical care [15]. This situation posed a great problem for health policy makers who had committed themselves to modernising the Korean health care system into one that was based on modern, ‘scientific’ Western medicine as is found in many advanced countries but not on traditional and ‘unscientific’ Korean medicine. Under these circumstances, the dispute between both types of practitioners entered into a serious phase in August, 1977. Two organisations representing Western medicine (the Korean Medical Association and the Korean Pharmacists Association) sent ‘a recommendation dealing the integration of medical care’ to the

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Ministry of Health and Social Affairs and the Ministry of Education. The cosigned recommendation contained the following arguments: Up to this time, medical care in Korea is divided into traditional Korean medicine and modern Western medicine and this dual system of medical care was an obstacle to closer cooperation between the two forms of medicine. These two medicines had developed separately and were subject to separate legal provisions and separate educational systems. This has caused great financial waste in the administration and education of health care. Moreover, due to the separate nature of the two systems of medical care there were some cases where sick patients were not helped at all as they were shuffled between both types of medical institutions. Nevertheless, there were some cases where Western biomedicine failed to cure but Korean herb medicine succeeded. For this and other reasons, it was important to integrate the dual system into a single system of medical care, in order to improve the health of the Korean population [12]. As early as 1974, a task force had been assembled to deal with the integration of a dual system of medical care within the KMA. The resulting recommendation was the outcome of 3 years of research by the task force team. The task force came up with the following solution to the problem of the dual system: (1) create a unified medical education program which includes subjects on both Korean medicine and Western medicine; (2) offer a new medical doctor’s license to those who graduate from the revised medical education curriculum; (3) establish a special department for traditional Korean medicine within general hospitals; (4) offer a refresher course for all doctors in order to entitle them to receive a new medical doctor’s license [12]. On the whole, the herbal doctors were of the opinion that the recommendation made by the KMA and the Korean Pharmacists Association was a trick to strike out traditional medicine by subordinating traditional Korean medicine to Western medicine. The representatives of traditional Korean medicine convened a board meeting immediately and adopted ‘a Statement of Objection’ regarding the integration of medical care proposal. They sent this statement to the leading daily newspapers and other journals as well as to the Ministry of Health and Social Affairs and other related organisations. The statement issued by the KOMA detailed among other things, the background of the dual system of medical care and expressed their skepticism toward the possibility of integrating the two systems of medicine as these two types of Medicine address health problems in completely different ways, i.e. a holistic approach in traditional Korean medicine and an engineering approach in Western medicine [10]. After this statement was published, the dispute between these two medicines discontinued for a time. No specific steps were taken by the government to resolve this dual system of medical care. On the other hand, the situation resulted in the implementation of the National Medical Insurance System, covering only medical care provided by the Western-trained doctors in 1977.

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4. Inclusion of traditional Korean medicine in the National Medical Insurance System (1984 – 1990) Up to now we have seen the repeated attempts of Western-trained doctors to outlaw the practice of traditional Korean medicine and later their changed attitudes toward traditional Korean medicine. We have also seen the herbal doctors’ persistent struggle to maintain the independence of their profession. In the following, the government’s policy to include traditional Korean medicine in the National Medical Insurance System is described. This marked a complete turnaround of the existing official policy towards traditional Korean medicine. As mentioned above, the National Medical Insurance System covered only the medical care provided by Western-trained doctors. For this reason, the clinics and hospitals began to be crowded with insured patients, regardless of the degree of their health problems while the number of Koreans who visited herbal doctors began to radically decrease. To halt this trend, the government implemented a project to include partial medical care provided by herbal doctors to be covered under the medical insurance benefit, beginning December 1, 1984 [15]. Initially the project was carried out at 26 herbal doctors’ clinics in two towns over a period of 2 years. The insurance coverage of traditional Korean medicine was expanded to the rest of the country from February 1, 1987, A recent official government report illustrates the rising utilisation of the traditional Korean medicine among Korean population. The oriental medical institutions providing medical insurance benefit have increased from 2760 oriental clinics in 1987 to 33 oriental hospitals and 3528 oriental clinics in 1990. The number of patients who have been treated by traditional Korean medicine was increased from 458781 cases in 1987 to 1408093 cases in 1990.

5. Unresolved problems For the last two decades or so, the number of herbal doctors who have utilised modern medical equipment such as the electro-pulse recorder, the blood pressure gauge, and the like have also increased in step with the ever-increasing demand for oriental medical care. The utilisation of modern medical equipment was a result of a modern trend to be scientific in every respect of life in general and in medical care in particular. Nevertheless, Western-trained doctors were of the opinion that herbal doctors were utilising this medical equipment ‘illegally’. Accordingly, Westerntrained doctors sent a recommendation to the government requesting them to take steps to control the herbal doctors’ utilisation of Western medical equipment. Even after the government issued an order for herbal doctors to stop utilising Western medical equipment, they continued using this medical equipment [12]. Herbal doctors believe that this accusation by Western-trained doctors represented a narrow-minded attempt to protect their own vested interests and that it should be the duty of herbal doctors or Western-trained doctors to utilise all forms of medical equipment in order to provide the best optimal treatment to patients (interview with Cho, Y.A., the President of KOMA, 25 August 1996, Seoul).

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In any event, what is discernible from this dispute between the herbal doctors and the Western-trained doctors is that the latter have always been more enthusiastic than the former about the plan to integrate the two systems of medicine. It is certainly questionable to why they have been so anxious in dealing with the question. As described above, the Western-trained doctors once considered traditional Korean medicine as unscientific and repeatedly attempted to outlaw practitioners of traditional Korean medicine. They were very proud of Western medicine and believed that Western medicine could solve all medical problems. However, during the last two decades or so, they have come to realise that many modern sicknesses such as diabetes and various cancers require medical techniques that were beyond the capabilities of Western medicine. Moreover, their colleagues in other advanced countries have shown an increased interest in introducing traditional medicine into their medical treatment. In the case of Japan, the number of physicians employing traditional medicine increased from 19.2% in 1976 to 42.7% in 1982 [17]. However, the Korean Western-trained doctors, who repeatedly tried to outlaw the practitioners of traditional Korean medicine since it was considered to be unscientific, could not utilise the traditional medical technique used by the herbal doctors. In fact, the majority of Western-trained doctors had not paid much attention to traditional Korean medicine at all. As shown above, there existed a persistent prejudice against traditional Korean medicine among Western-trained doctors. The tendency has been more visible especially among the younger generation of Western-trained doctors. They have been proud of utilising various sophisticated medical equipment, while being utterly scornful about the effectiveness of herbal medicines. They have not made any effort to understand the logic behind traditional herbal medicine. They have often pointed to the outmoded theories and unscientific ambiguities in the language used by herbal doctors. In view of these negative attitudes prevalent among Western-trained doctors, they would not dare to employ traditional Korean medicine in their medical treatment, or they may have not wanted to be ‘dirty players’ like the herbal doctors who utilised Western medical equipment ‘illegally’. The enthusiasm among the Western-trained doctors to integrate the two systems of medical care can thus be easily understood. In any event, the dispute between western-trained doctors and herbal doctors is still ongoing in Korea and the integration of the dual system of medical care in the Korean health care still pose a problem for health care policy makers in the Korean government.

6. Summary and conclusion The body of this article has focused on some key episodes during the modernisation process of traditional Korean medicine, that is, the official policy to modernise the Korean health care system and the struggle and effort of herbal doctors to perpetuate their own medical tradition. As explored in detail above, the modernisation of traditional Korean medicine took place amidst expansion of the system of Western medicine in Korea. As both types of medicines have different medical

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traditions, especially with regards to their respective practitioners, it was necessary to explore the changes made to the Korean administrative and legal systems as well as the transformation o f their educational institutions (see Table 1). This article has also shown how the Korean state health policy suppressed and were inconsistent when dealing with traditional Korean medicine. It is, however, possible to contend that the systematic marginalisation of traditional Korean medicine occurred in two phases. The first phase took place under the Japanese colonial authorities. The Japanese authorities degraded herbal doctors, by legislating separate legal provisions for Korean herbal doctors and Western-trained doctors. However, their attempt to marginalise traditional Korean medicine had limited success. In part this was due to the insufficient supply of Western-trained doctors. It was also due to the continued effort of elderly herbal doctors in transferring traditional knowledge to the younger generations. The second phase took place under the newly established Korean government, whose political elites committed themselves to facilitating the modernisation of the Korean health care system. They attempted to proscribe herbal doctors, by removing them from the category o f medical practitioners. Their attempt was unsuccessful due to the active lobbying o f the Korean Oriental Medical Association. As o f 1990, the proportion of herbal doctors amounted to only 10% of total medical practitioners in Korea. Even this low proportion of herbal doctors would not have been possible without the indefatigable struggle o f herbal doctors against official authorities and Western-trained doctors to keep their traditions alive in spite of numerous obstacles. What is unique in the Korean health care system in comparison with the health care systems around the world is that practitioners o f traditional Korean medicine and practitioners of Western medicine provide their medical care service independently of each other, yet both are officially recognised by the government.

Acknowledgements i

I am grateful to Dr Ake J. Ek and Minnie Tubai for their comments and Susan Eng for language assistance.

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