Performing national independence through medical diplomacy: tuberculosis control and socialist internationalism in Cold War Vietnam

Abstract

This article explores medical diplomacy as a means of navigating distinct but related nation-building and internationalist projects during the Cold War. It examines how medical professionals from the Democratic Republic of Vietnam (DRV) utilized their expertise to bolster foreign relations and assert national independence. This article focuses on how three tuberculosis (TB) specialists – Đặng Đức Trạch, Phạm Ngọc Thạch and Phạm Khắc Quảng – adopted, adapted and circulated techniques of TB control, including a modified version of bacillus Calmette–Guérin (BCG) vaccine. Amidst these endeavours, these medical-doctors-cum-diplomats navigated various forms of internationalism while soliciting medical assistance. Their roles within the DRV's state apparatus were prominently showcased from the 1950s to the 1970s, particularly at international gatherings such as the conferences of Ministers of Health of the Socialist Countries (MOHOSC). Because of the political complexities inherent in socialist internationalism, these conferences provided a crucial platform for dialogue among socialist nations when other avenues were limited. Consequently, the DRV's medical experts cultivated goodwill and garnered political support, despite encountering mixed results in their TB control initiatives.

In July 1962, Đặng Đức Trạch (1930–2004) travelled to the German Democratic Republic (GDR) port of Rostock. Trạch, then director of the Bacteriological Services at the National Institute of Hygiene and Epidemiology in the Democratic Republic of Vietnam (DRV, 1945–76), had come to East Germany to defend his concours d'habilitation.¹ Another purpose of Trạch's visit was to attend the Seventh Ministers of Health of the Socialist Countries (MOHOSC) Conference, which was focused on tuberculosis (TB) control and had been held in Weimar the previous month.²

From Rostock, Trạch sent a letter summarizing his experience at the conference. Trạch's letter provides an insider's perspective on the role of medical diplomacy in mediating the relationship between nation building and socialist internationalism. It also offers insight into how medical experts dealt with broader tensions among socialist states, including the Sino-Soviet split. Finally, Trạch's observations reveal how both individual and collective, as well as colonial and postcolonial, methods informed the main TB control techniques: vaccines, surgical interventions, chemotherapy and sanitoria.³

My article explores the DRV's Cold War medical diplomacy, or its use of biomedicine and its experts to simultaneously gain access to medical assistance and advance state interests in international settings.⁴ It asks how Vietnamese medical doctors, in particular Đặng Đức Trạch, along with Phạm Ngọc Thạch and Phạm Khắc Quảng, engaged with nation building and internationalism through their efforts to control (prevent and treat) TB in the DRV from 1945 to the late 1970s. These medical experts asserted DRV independence in matters of tuberculosis control without precluding additional medical assistance. Their efforts took place in the context of the DRV's broader medical exchanges, including material assistance, friendship hospitals, education and training, and conferences. Through these exchanges, it is possible to chart the channels and directions through which medical and political influence travelled in an imagined socialist community.

The TB specialists Trạch, Thạch and Quảng sought not only to advance control of the disease but also to enhance the DRV's international standing by doing so. In the socialist community, the DRV was viewed as a ‘younger brother’ that had to struggle for recognition and equality. Thus medical diplomats viewed biomedicine and politics as complimentary projects. On the one hand, evolving foreign relations among socialist states affected how TB control techniques circulated. Socialist internationalism, or the project of creating a unified socialist bloc, influenced how medical assistance was given and received. On the other hand, when traditional venues for building socialist internationalism broke down, conferences and other forms of medical exchange at times kept political discussions going.⁵

In the 1950s, the DRV depended on medical assistance from the Soviet Union (USSR), the People's Republic of China (PRC) and the Eastern bloc states. As tensions grew between the USSR and the PRC, the DRV began to chart an independent path in TB control. A key performance of medical independence in a framework of socialist internationalism happened at the 1962 MOHOSC conference held in Weimar. This conference, and others like it, helped define the terms of assistance and create the structures within which DRV experts could act. While efforts to control TB had mixed results, the DRV's medical diplomats kept the aid flowing: no small feat during the Sino-Soviet split. Starting in the 1960s, Vietnamese medical doctors also began to exert influence over the biomedicine of other nations. By then, Indonesia had asked the DRV for help with typhoid vaccine production, Phạm Ngọc Thạch was training Lao medical personnel, and the DRV had become an exporter of medical assistance to the African continent.⁶

Building on recent histories of the links between biomedicine and nationalism forged in colonial South East Asia, my article follows North Vietnamese medical doctors abroad as they sought to fashion the DRV's global status in a decolonizing world.⁷ While the DRV was not a theatre state in a Geertzian sense, I argue that its medical doctors performed an important role in state theatre, or the rituals and pageantry necessary to make the state visible and reinforce its existence to others, both at home and abroad.⁸ Like scientific and medical diplomats from other Asian socialist countries, DRV experts collapsed the categories of medicine and politics and inserted biomedicine into various internationalisms as they choreographed TB control.⁹ Moreover, to the extent that Vietnamese doctors acted out the traditions of colonial medicine, their actions demonstrate the stagecraft and statecraft inherent in all biomedicine. In this way, my analysis heeds the call for more histories of medicine that are postcolonial not only in time but also in approach.¹⁰

The push of the World Health Organization (WHO) for the BCG vaccine certainly affected medicine in socialist countries. Yet the WHO's role in the internationalization of health is not the only story to be told about TB in medical exchange.¹¹ Medical diplomats, and the diseases they studied, did not stick to the contours of an imagined bipolar world consisting of socialist and capitalist camps. The boundaries of their activities followed different imperatives and they were willing to accept aid from many sources: in other words, political and medical theatre was an imperfect fit for social and microbial realities.¹² In this paper, I therefore explore the meaning and significance of medical exchanges among socialist countries that have been largely absent from conversations about scientific and medical diplomacy during the Cold War.¹³

Colonial legacies

TB is a very old disease that has affected humans for tens of thousands of years.¹⁴ Bệnh lao, as the disease is now called, has long had a place in Vietnamese culture as one of the four incurable diseases of traditional medicine. After the French conquered the kingdoms of Đại Nam, Laos and Cambodia, creating French Indochina (1887–1954), their medical doctors began to study disease in Vietnamese society. Some found useful the tools of the new microbiology that was being promoted by their compatriot Louis Pasteur (1822–95). Although the German Robert Koch (1843–1910) had used a microscope to isolate the bacillus that causes TB in 1882, the French colonial state did not require the collection of data on this disease until well into the twentieth century. It appears that TB accounted for a heavy disease burden, especially in urban settings. It was referred to as a social disease by the French, putting it in the same category as syphilis and other venereal diseases. As in Europe, some famous Vietnamese intellectuals, including Phan Châu Trinh (1926), Vũ Trọng Phụng (1939) and Thạch Lam (1942), died young of TB.¹⁵

Until the invention of antibiotic drugs in the 1940s, TB was indeed an incurable disease. The only way to treat it was through rest, a healthy diet and mechanical means such as resting the lung by collapsing it.¹⁶ For this reason, prevention was key to TB control, although some medical doctors advocated for the BCG vaccine, especially when administered to children. Starting in the 1920s, Indochina had a relatively high rate of vaccination compared to France. This rate stemmed in part from the work of Albert Calmette, co-inventor of BCG, at the Pasteur Institute (PI) in Saigon. These control efforts were self-interested and coercive, and while Pastorians provided the vaccine to the Indochinese government for free, they did so in the hopes of demonstrating its utility, especially vis-à-vis efforts of European competitors. As in Algiers, Pastorians rarely sought, or received, the consent of their native test subjects.¹⁷

The colonial era also witnessed the first Vietnamese people to be trained in biomedicine. One such expert was the lung specialist Phạm Ngọc Thạch (1909–68).¹⁸ Thạch published his medical thesis in Paris in 1935 on the relationship between TB and disorders of the nose and pharynx. At ease in French culture (he married a French woman, with whom he had two children), Thạch broke with France partly as a result of a colonial policy that did not prioritize Vietnamese health. Medical doctors such as Thạch played a key role in the anti-colonial, nationalist movements in Indochina. Later, as the first minister of health of the fledging DRV, Thạch was well positioned to be a medical diplomat.¹⁹ He adopted a pragmatic approach to colonial-era disease control in a decolonizing context. He did not dismiss treatments for TB introduced by French medicine out of hand. Instead, he sought to scale up the distribution of the BCG vaccine and extend the reach of sanatoria outside their urban concentrations. Furthermore, for both practical (cheapness, durability and portability) and ideological reasons (national pride), he developed a modified version of BCG that, as will be discussed, was adapted for conditions in poorer tropical countries.²⁰

New nation, new health

In the late 1940s, the newly established DRV was heavily dependent on other socialist countries for medical assistance. Moreover, it was largely geographically isolated until the People's Republic of China (PRC) was established in 1949. By the final two years of the First Indochina War (1946–54), however, it was receiving about 110 tons of medical aid per year from the USSR and the PRC largely across the DRV's northern border. It also sent initial classes of ten and fifteen medical students, respectively, to those two countries.²¹ Establishing medical diplomacy among the DRV, the USSR, the PRC and the Eastern bloc was aided by a shared epistemological approach that sought to socialize biomedical knowledge. Medical doctors in these countries thought that such an approach not only was the politically correct thing to do but also offered a chance to improve the health of their fellow citizens and strengthen their nations.²² These socialist countries specialized in different kinds of assistance for the DRV. For example, the Soviet Union sent experts in a range of diseases with a particular emphasis on malaria. Chinese experts on biological and chemical weapons were welcomed after the PRC accused the US of engaging in such warfare during the Korean War. Over time, the Eastern bloc states, including the GDR (1949–90), came to lead the effort to control TB.²³

The destruction of the Second World War, including a famine in 1944 and 1945, had promoted the spread of disease in the DRV.²⁴ Starting in 1946, the First Indochina War made measuring TB infection rates, let alone dealing with them, difficult. During the war, treatment for TB was largely limited to military personnel; the first hospital with a speciality in TB was established in Cao Bang in 1952. It served soldiers with 120 beds and fifty staff, who, thanks to the Soviets and Chinese, had access to streptomycin and eventually isoniazid. Over the next two years, that capacity increased slowly. One newly trained specialist was Nguyễn Đình Hường, a military medic, who was sent to the PRC to take a crash course in TB control. He later managed the TB Prevention Institute's dispensary and eventually became the institute's director.²⁵ By 1955, around 13 million people in northern Vietnam were served by three hundred beds, including 120 beds in Hanoi at Bach Mai Hospital, supervised by Phạm Khắc Quảng, along with beds at provincial hospitals.²⁶

The practices of TB control in socialist countries remained variable. Both the DRV and the GDR, for example, drew on a rich tradition of social medicine that viewed TB as a disease of poverty.²⁷ During the Cold War in the GDR, TB policy ‘came to encompass, paradoxically, more “individualized” care of the sick and more “social” (environmental) studies’.²⁸ Meanwhile, well into the 1970s, the DRV continued to rely on public-health measures, coercive when necessary, such as mass vaccination campaigns and placement in rural sanatoria. This approach was largely driven by poverty, by lack of access to chemotherapy and proper surgical settings and by wartime conditions. Unlike the Germans, among whom memories of the 1929 Lübeck disaster shaped views of BCG for decades, Vietnamese medical doctors promoted BCG vaccination.²⁹ Because the DRV did not yet have the necessary capacities to produce the vaccine itself, it relied on freeze-dried doses delivered from the USSR, or the ‘Murinus–Praha’ variant given by Czechoslovakia.³⁰ Live BCG, however, was hard to keep effective in places with warm, humid climates and without effective cold chains. Thus, before 1960, vaccination campaigns had limited reach and only 100,000 children had been vaccinated.³¹

In response to this situation, DRV medical experts sought a more portable version of BCG that would enable its transport and use outside urban areas. Phạm Ngọc Thạch oversaw the development of a vaccine that was heated to 43 °C. This heat-killed variant showed, according to DRV researchers, results almost as good as live BCG and was more rugged. Four years later, the DRV claimed that 15 million people, a majority of its population, had been vaccinated. How much of this process was voluntary is difficult to determine but, partly as a result of this accomplishment, Thạch was invited to serve on the executive board of the International Union against Tuberculosis.³²

Stages for medical assistance

After the end of the First Indochina War in 1954, the DRV faced challenging domestic and international conditions. During the three hundred days of unrestricted Vietnamese movement that followed the Geneva Accords, southern Vietnam remained a potential refuge for disgruntled medical personnel from the north.³³ Moreover, by the end of 1955, Ngo Dinh Diem had consolidated his rule over the southern Republic of Vietnam (RVN). The DRV therefore had to build socialism and medical care in the north, while simultaneously supporting the National Liberation Front (NLF) and their opposition to Diem's rule in the south.³⁴

While the DRV gained some advantage from its role in negotiating the budding Sino-Soviet split of the 1950s, socialist internationalism was a fraught arena.³⁵ Recognizing the instability of foreign aid, Phạm Ngọc Thạch emphasized the importance of local prevention efforts over machines and modern hospitals. In this way, domestically producing the BCG vaccine contributed to a show of national independence. Such nationalism in medicine echoed the barefoot-doctor movement and the tu/yang distinction in science in the PRC that were happening at a similar time and for similar reasons.³⁶ But despite these efforts, the DRV remained dependent on medical assistance from the PRC and the USSR. In a report dated August 1954, the cabinet director for the Ministry of Health, Nguyễn Văn Tín, estimated that the PRC would deliver 125 tons of medical supplies in the last quarter of that year and a little over fifty tons at the beginning of the next.³⁷ Managing the material aid from the PRC, the USSR and the Eastern bloc states remained a key function of the DRV's medical diplomacy.³⁸

This medical assistance took a range of forms: studying abroad, visits of experts and conferences, along with transfers of material and medicines. The DRV supervised the exchange of students and experts through various offices, including the Department of Experts (Cục chuyên gia), part of the Office of the Prime Minister (Phủ thủ tướng).³⁹ In 1956, the DRV established the Department of External Relations (Phòng Liên lạc y tế nước ngoài) in the Ministry of Health, which kept track of medical exchanges.⁴⁰ In 1957, the Soviet Union sent teams totaling over seventy professors, medical doctors, nurses, technicians, administrators and translators. Meanwhile, East Germany sent ten delegates, Hungary five, Bulgaria fifty, and Czechoslovakia thirty-seven. The time that these delegates stayed varied from ten months to two years.⁴¹ Even with such successful exchanges, the logistics of ordering, sending and receiving material assistance remained tricky.⁴² Nguyễn Văn Tín's 1954 report discussed the many problems of the PRC's assistance order forms, including the mixing of languages (and medical terms) and the delays in transporting vaccines.⁴³ Slowdowns were also a problem for assistance arriving from the Eastern bloc states, especially after it had reached the DRV port of Hai Phong on Polish boats.⁴⁴

One of the most successful cooperation projects, and a key site for displaying TB treatment, was the institution that became known from 1961 to 1989 as the Vietnamese–GDR Friendship Hospital (Bệnh viện Hữu Nghị Việt-Cộng hòa Dân chủ Đức). Reconstruction was a priority at the end of the First Indochina War. As the French pulled out of Hanoi, a group headed by thoracic surgeon Hoàng Đình Cầu (1917–2005) managed the takeover of medical facilities, including the hospital popularly referred to as Phủ Doãn in the city center. From 1954 to 1955, Cầu became its director before heading to the Soviet Union for further medical training.⁴⁵ In 1955, the GDR agreed to help rebuild the hospital and, over the next year, experts from the GDR, the USSR, Hungary and Cuba trained the staff.⁴⁶ Confusion arose, however, when it came to naming. In a July 1956 letter from the GDR minister of health, Luitpold Steidle, to the DRV minister of health, Hoàng Tích Trí (written Hoang Tik Tschi), Steidle called the hospital ‘Wilhelm Pieck’, a reference to then president of the GDR. As Young-sun Hong states, this name erased ‘the agency of the Vietnamese themselves’, and perhaps originated with the medical doctor Richard Kirsch, head of the medical mission to the hospital.⁴⁷ Meanwhile, DRV correspondence of the time continued to refer to the hospital by its popular name, Phủ Doãn. In 1961, the hospital received its long-term name, the Vietnamese–GDR Friendship Hospital; in official documents, it was referred to as the Vietnamese–German Friendship Hospital (Bệnh viện Hữu Nghị Việt Đức).⁴⁸ This friendship hospital, like others in South East Asia, served as a setting for medical and diplomatic action.⁴⁹

Although the building and staffing of friendship hospitals could be marked by competition, the DRV's archives contain many stories of positive encounters.⁵⁰ The surgeon Wolfgang Bethmann, who directed the East German mission to the Vietnamese–GDR Friendship hospital after Kirsch, viewed the two states’ relations as good.⁵¹ And in terms of medical expertise, Soviet bloc states were viewed as excellent places to train Vietnamese medical personnel and to receive treatment for DRV officials.⁵²

The late 1950s saw some advances in TB control in the DRV. Under the guidance of Phạm Ngọc Thạch, Vietnamese doctors adopted a regime consisting of antibiotics such as isoniazid, combined with ‘Filatov’ stimulation and acupuncture from specialists in ‘Eastern medicine’. The biggest step forward was the founding of the TB Prevention Institute in 1957. This institute was built on the resources of Hospital A, established for cadre and state officials the previous year, to carry out the vision of Thạch, its first director.⁵³ He argued that hospital beds and pharmaceuticals were not enough to deal with TB. Instead, a broad social policy, one based on community outreach, disease prevention and personnel training, was necessary. Thạch called for the TB Prevention Institute to carry out epidemiological studies. On paper, it had an impressive staff of 410 personnel, including eighty-five party members, and it was a part of the International Union against Tuberculosis.⁵⁴

In the early 1960s, the DRV was trying to avoid war with the United States and had adopted a pragmatic approach to managing the ideological tensions both among socialist countries and between the communist and capitalist camps. It remained willing to engage with sympathetic medical doctors in France and the US.⁵⁵ Thus the DRV accepted help with TB control from both socialist and capitalist countries and it developed a guarded relationship with the World Health Organization (WHO). In 1949, the Soviet Union and almost all of its socialist allies pulled out of the WHO, but by 1956 many of these countries had rejoined.⁵⁶ During the 1960s, the DRV sent delegates to international conferences attended by both socialist and capitalist countries.⁵⁷ Although wary of the WHO's influence, Vietnamese medical experts sought to implement a socialist vision of health that was complemented by the organization's resources and technical capacities.⁵⁸

While mortality in urban neighbourhoods was relatively low, morbidity rates remained steady or worsened due to the migration and poor living conditions caused by wartime disruptions. According to statistics published by Phạm Ngọc Thạch, between 1958 and 1960 from 1 to 2 per cent of the population had an active case of TB. This meant that 30 per cent of the Vietnamese aged under five living in urban areas had been exposed to TB; the rates of exposure were 20 per cent of the Vietnamese in the countryside and 10 per cent among other ethnicities, mostly residing in the highlands. By the time they reached age thirty, 95 per cent of urban Vietnamese and 85 per cent of rural Vietnamese had been exposed to TB.⁵⁹

Independence on display

The MOHOSC conferences constituted one of the longest-running, and most influential, sites of medical diplomacy. In a series of meetings that started in the 1950s, the health ministers met to develop common approaches to health. The MOHOSC conferences also offered a stage for newly formed socialist countries to negotiate tensions in socialist internationalism and to perform their national independence. In a report on activities undertaken since the Sixth MOHOSC Conference held in Budapest in 1961, the DRV noted that it had sent medical assistance to Laos, Mali and Guinea.⁶⁰ Finally, the MOHOSC conferences were useful sites for building broad political solidarity among socialist countries. Such solidarity was exhibited during the Vietnam War era when the DRV used medical conferences to gain support for its cause.⁶¹

Delegates to the Seventh MOHOSC Conference, held in 1962 in Weimar, GDR, focused on TB. At this conference, DRV representatives presented their country's achievements regarding this disease, including five years of progress brought about by establishing the TB Prevention Institute and adapting sanatoria to the conditions of poorer countries. These representatives also highlighted the heat-killed BCG vaccine that had allowed the DRV to effectively ramp up its vaccination programme.⁶² Taking place from 13 to 15 June, the conference involved formal presentations (plenary sessions and round tables), field trips and private dinners. It was attended by medical doctors, heads of institutes and other TB specialists, with Russian and German as the official languages. For DRV attendees, travel to the GDR involved multiple plane and train rides. In terms of financing, sending countries paid travel expenses, and the receiving country paid for in-country expenses.⁶³

The conference's attention to TB was no accident; Eastern bloc states, including the GDR, had built medical expertise in the control of this disease. The gathering in Weimar offered a chance for participants to develop a common vocabulary and consolidate medical experience and knowledge. This venue also enabled medical doctors to keep up to date on the latest developments. DRV delegates sent home books and journals to supplement those regularly provided by the USSR and other socialist countries.⁶⁴ The build-up to the conference involved an exchange of letters among the ministers of health. In his letter of invitation to his counterpart, Phạm Ngọc Thạch, the GDR minister of health, Max Sefrin described the conference's main purpose, which was to discuss five issues related to TB control:

1. 1 the principles, methods, and stages of preventing TB;

2. 2 the methods of preventing TB, including BCG injections and the use of chemical substances;

3. 3 the widespread use of X-ray examinations among the people … [as] the basic method to uncover TB sufferers;

4. 4 the inpatient and outpatient treatment conditions for TB sufferers; and

5. 5 the inpatient and outpatient methods used to improve the health of TB sufferers working in medical, social, and educational fields.⁶⁵

Sefrin also indicated that three additional topics would be covered: the unification of nomenclature and definitions in the keeping of statistics, bovine TB, and the training of mid-level personnel for TB prevention. Writing in July 1961, Sefrin asked for a copy of the Vietnamese presentation by the beginning of February 1962 so that it could be translated into Russian and German in preparation for the conference. Sefrin mentioned the possibility of visits to TB-related locations, such as sanatoria and hospitals, and tours of Weimar's cultural heritage, including its links to Schiller and Herder. Around September, Sefrin wrote that he would send a draft programme.⁶⁶

Sefrin saw this conference as a chance to build socialist internationalism, and he recognized the importance of medical exchange in advancing research. ‘Because cooperation among socialist countries in scientific medical research cooperation’, he wrote, ‘has a very special effect, we very warmly welcome a group of scientific cadres from your ministry, including the people who have responsibility for planning and undertaking coordination of medical research cooperation’.⁶⁷

In early May 1962, Phạm Ngọc Thạch replied to Sefrin that the DRV delegation would include himself, Nguyễn Văn Trong, secretary of the Department of External Relations in the Ministry of Health, and two researchers from the National Institute of Hygiene and Epidemiology, Hoàng Thủy Nguyên, head of the Virological Services, and Đặng Đức Trạch, head of the Bacteriological Services.⁶⁸ The thirty-two-year-old Trạch had begun his biomedical education with the Viet Minh, studying with Minister of Health Hoàng Tích Trí in the resistance zone during the First Indochina War.⁶⁹ From 1956 to 1959, Trạch went to the GDR to complete his postgraduate studies in applied microbiology at Humboldt University's Microbiology Institute, with a focus on bacterial vaccine production and standardization. He tested the effectiveness of the newly developed heat-killed BCG vaccine on guinea pigs and mice over three years.⁷⁰ While Trạch was training in the GDR, the Pasteur Institute of Hanoi merged with the Microbiology Institute to form the National Institute of Hygiene and Epidemiology. It was this institute that, from about 1959, manufactured the BCG vaccine.⁷¹

The meeting of health ministers had initially been scheduled to take place in Weimar. At the last moment, however, these plans were adjusted, and, for the first time, the conference was divided into two meetings: a specialist medical meeting focused on TB that took place in Weimar, and a diplomatic meeting of the MOHOSC that ended up in Berlin at the end of the following year. Sefrin explained that the conference was not long enough both to address the scientific discussions of TB and to attend to the medical exchanges that had taken place at previous MOHOSC conferences. Indeed, some later MOHOSC conferences followed this model of dividing up these activities.⁷²

Trạch, however, offered an alternative explanation. He suggested that political tensions among socialist countries had changed the conference organization and location. ‘According to those in the know’ (‘theo lòi [sic] nói của một số nguòi [sic] am hiểu’), wrote Trạch, the sudden shift was partly due to the ‘issue of Albania’ (‘vấn dề [sic] An-ba-ni’). In the late 1950s, Albania grew increasingly critical of the Soviet Union's leadership over issues such as the denunciation of Stalin's rule, leading to a public split in the early 1960s. Because the 1963 MOHOSC conference was scheduled for Tirana, which ‘might be inconvenient’ (‘có thể fiền fức [sic]’), the countries involved needed time to discuss the situation. Thus the 1962 meeting of the ministers of health was postponed and the Weimar portion of the conference officially became known as the ‘Conference of Socialist Countries to Combat TB’ (Hôi Nghi [sic] các nước Xa Hôi Chu Nghia [sic] chống bệnh Lao).⁷³

The vocabulary for the state's biomedical performance was itself subject to debate. During a round table on ‘Terminology and nomenclature’, participants discussed whether it was possible to standardize TB-related terms. Without going into particulars, Trạch noted that delegates disagreed over the strengths and weaknesses of Soviet versus WHO terms. Agreeing on whether one set of terms was possible, or even desirable, proved difficult as well. The Chinese delegate even stated that disagreement existed among medical schools within China, so that he could not represent a national perspective. Meanwhile, the Vietnamese proposed two nomenclatures, a simple one for epidemiology and a more detailed one for the clinic. In the end, a German medical doctor proposed an international centre for coordination to simply gather information that individual countries could apply to local conditions. Even then disagreement continued, as a Czechoslovakian delegate argued for Prague, while a Soviet expert overruled him, stating that Moscow was a more appropriate site for the centre.⁷⁴

Keeping assistance flowing

The 1962 conference was one moment in a longer dialogue about medical exchange. For poorer countries such as the DRV, such meetings kept vital medical and technical assistance flowing from other socialist states. Bilateral agreements, negotiated and sometimes signed at these conferences, ensured the continued training of medical students. More broadly, medical experts performed a socialist world at these venues, and subsequently brought home an idea of socialist brotherhood. For these reasons, the conferences had a greater impact than the limited number of participants suggests.⁷⁵ During the Sino-Soviet split, these conferences could also be a site of ideological conflict and potential contamination. According to Trạch's letter, the Democratic People's Republic of Korea (DPRK) delegates kept to themselves.⁷⁶

International conferences also gave individuals the opportunity to bolster personal relationships. In 1962, Trạch met with Herbert Landmann, the East German medical doctor who served as the vice director of the Berlin-Buch TB Research Institute. Trạch and Landmann discussed GDR aid to the DRV, medical beds in particular, and the involvement of the Red Cross in this aid. Landmann raised the issue of a DRV friendship prize (Huy Chương Hữu Nghị), and argued that, while several other doctors had pitched in to support the relationship between the two countries, among East Germans he had made the biggest effort. According to Trạch, Landmann said, ‘I am the person who tried [to do] the most’ (‘Tôi là người cố gắng nhất’). Despite the very Western attitudes of orientalism, condescension and criticism of superstition that existed among Eastern bloc experts, many of them successfully contributed to medical exchanges.⁷⁷

Trạch's notes and other conference documents reveal the range of epistemological approaches to TB adopted in the socialist world. Generally, delegates emphasized the need to address environmental (often meaning social) determinants of health. Both the DRV's and the GDR's approaches to TB included mass campaigns for mobile chest X-rays and radiography.⁷⁸ In other words, prevention took priority over treatment. However, as the PRC's 1962 presentation on isoniazid for mass treatment shows, the Chinese recognized the importance, and effectiveness, of curative drugs and individual treatment. Such an approach based on chemotherapy was not available to the DRV.⁷⁹ According to Trạch, the DRV presented two of its TB control successes. The first was the domestic production of heat-killed BCG, which allowed the DRV to go from four million vaccinated people before 1960 to 15 million by 1964 and 20 million by 1967, representing a majority of the population.⁸⁰ The second success was that the DRV had solved an intractable problem for countries with developing economies, namely how to establish sanatoria at the commune level. Comrades from fellow socialist countries offered their congratulations and encouraged Trạch to publish the results.⁸¹

At the end of the 1962 conference, participants drew up a list of recommendations, which focused on three activities: treatment, including chemotherapy and lung collapsing; prevention, including BCG and sanatoria; and rehabilitation. The DRV did not uncritically adopt Soviet bloc approaches to TB – it stuck, for example, with the use of heat-killed BCG vaccine until supplies ran short in the 1970s. In this way, the DRV acted as a discriminating consumer of foreign medicine, turning to outside help only if something was not available domestically. Nor did the other socialist states drastically change their position towards treatment and prevention of tuberculosis as a result of their interactions with DRV health care. The GDR, for example, continued to rely on chemotherapy and machines to treat TB.⁸² Even though influence in medical knowledge flowed in both directions, it moved slowly and was sometimes blocked.

The limits of the MOHOSC conference were clear to the delegates. They were not able to agree on standard techniques and discussions of bovine TB and the formation of an anti-TB cadre was shelved for later.⁸³ Trạch also reported that several delegates complained of the lack of time for specialist discussions about TB. The ministers of health conferences, even those focused on a specific disease, were not very effective at exchanging medical knowledge or developing medical science, at least in the short term. Instead they served as a safe space to create the terms of exchange by at least addressing the difficulties faced in compiling and translating medical vocabulary and in defining medical ideas and practices in the socialist world. Significant exchange about tuberculosis continued among socialist countries in the following years.⁸⁴

Encore, health conferences

Developments in the 1960s and 1970s further underscored the links between medicine and geopolitics.⁸⁵ After the 1962 conference, North Vietnam continued to struggle against TB and to build its relations with Eastern bloc countries. The diplomatic portion of the Seventh MOHOSC Conference was held in December 1963 in Berlin.⁸⁶ Despite more than one year to organize, uncertainty surrounded the conference and invitations were sent out at the last minute. One of the purposes of the conference was to sign cooperation plans for 1964 and coordinate medical publications and documentation.⁸⁷ Arguments offered for such actions included the need to promote socialist internationalism and to grow the national economy. With increased development, the argument went, there would be more opportunities for cooperation in medical science and health protection.⁸⁸

The landing of US combat soldiers at Danang in 1965 cast the DRV, at least in its leaders’ eyes, as a leading actor in the global communist revolution. This ‘vanguard internationalism’, as Tuong Vu calls it, encouraged DRV political leaders to be both nationalistic and unrealistic.⁸⁹ At the same time, these circumstances presented renewed urgency for international medical assistance.⁹⁰ In October of that year, Max Sefrin, then chairman of the newly formed Vietnam Commission in the GDR's Afro-Asian Solidarity Committee, led a delegation to the DRV. With Đặng Đức Trạch as a translator, Sefrin learned about both the health effects of the fighting and the downing of American aeroplanes. He emphasized solidarity in a speech he gave celebrating the signing of a new medical cooperation agreement in which TB featured prominently. ‘Increasing assistance [translated as viện trợ] for Vietnam has been the central issue of social activity [hoạt động xã hội] of our country's citizens.’⁹¹ In the following years, the Vietnam War continued to dominate medical exchanges between the socialist states, and the Vietnamese–German Friendship Hospital focused on treating civilians wounded in US bombings.⁹²

The Vietnamese Communist Party sought to achieve national goals through international assistance during these difficult years. The DRV Politburo's report at the 12th plenum of the Central Committee of the Workers’ Party of Vietnam spelled out its position vis-à-vis foreign aid. In Part I, ‘Implementation of the state plan in 1965 and general comments on the implementation of the task of economic diverting in 1965’, the author argued for ‘self-reliance [tự lực] in our own efforts to raise the level of mobilization of human and domestic strength [sức người, sức của trong nước] to meet the immediate task’. ‘At the same time’ the author noted the need to ‘enlist the help of brother countries’ (‘tranh thủ sự giúp đỡ của các nước anh em’).⁹³

The destruction unleashed during the US military's Operation Rolling Thunder (1965–8) caused significant disruption to TB control. These bombings forced the TB Prevention Institute to relocate and break up into three sections, making organization at the commune level challenging. Part of the institute's staff and resources remained in Hanoi, where they performed surgery and tended to the injured. Part of the institute was evacuated to nearby highlands, where staff carried out research on lung diseases and surveyed the health of local populations. The third part of the institute became the Rural Health Union, perhaps the most enduring legacy of this period. The union, the brainchild of Phạm Ngọc Thạch, aimed to increase health through hygiene and disease prevention in the countryside. Vietnamese experts learned lessons about running rural sanatoria, blending traditional medicine and biomedicine, and coordinating efforts between the institute and various localities. These lessons formed the basis of Thạch's last book, Thoroughly Understanding the Guidelines of Disease Prevention in Health Protection Work, which was influential in subsequent decades.⁹⁴

In November 1968, Thạch died while on a medical mission in the south. His passing occasioned an international outpouring of sympathy and reflections on his accomplishments. GDR minister of health Sefrin sent a condolence letter that confirmed his country's continued moral and material support and denounced capitalist, specifically American, aggression.⁹⁵ A Festschrift for Thạch published in Hanoi in 1969 included articles by North Vietnamese scholars celebrating both his biomedical and his political achievements. An emotional letter from Prime Minister Phạm Văn Đồng reproduced near the beginning of the volume explicitly connected the two. Đồng first recounted Thạch's exemplary scientific and personal life and then linked it to his struggles against American war crimes. ‘Comrade Phạm Ngọc Thạch was an international activist’, Đồng wrote,

who had broad relationships with medical experts of socialist countries and several other countries; and these past few years, with the title of President of the Committee to Investigate the Crimes of the American Imperialists in Vietnam, the comrade used all his effort to push forward the world people's movement to prevent war crimes of the American imperialists in our country.

Even Đồng, entrenched in a Manichaean world view as he was, could articulate Thạch's value as a medical diplomat to both socialist and capitalist countries.⁹⁶

After Thạch's passing, the directorship of the TB Prevention Institute fell to Phạm Khắc Quảng (1912–2000). Quảng was also an effective medical diplomat and had played an important part in building the DRV's image abroad. During the First Indochina War, Quảng remained in French-controlled Hanoi and opened his house to clandestine resistance activity, in which his older brother, Phạm Khắc Hoè, played a key role. Starting in 1955, Quảng served on several solidarity and friendship committees, including as the vice chairman, and eventually chairman, of the Vietnamese Fatherland Front in Hanoi. In 1959, Quảng became a member of the Communist Party, and the following year was named vice director of the TB Prevention Institute. In his role as a medical diplomat, he attended several international tuberculosis conferences.⁹⁷

The period from 1969 to 1975 saw some important developments in TB control. Under Quảng's leadership, the TB Prevention Institute gradually resumed its activities in Hanoi. Because men were needed to fight in South Vietnam, the institute turned to women, training a significant cohort of female TB specialists who worked in the field even after the end of the war. The institute persisted, too, in developing TB control techniques appropriate to the DRV context, such as using acupuncture as anaesthesia for lung operations. In 1972, when President Nixon ordered the bombing of North Vietnam, the TB Prevention Institute once again partially evacuated to the countryside.⁹⁸ Efforts to control TB after the communist takeover of Saigon in 1975 continued to have implications for foreign policy. In June of that year, the thoracic surgeon and vice minister of health Hoàng Đình Cầu led the Vietnamese delegation to the Sixteenth MOHOSC Conference, which was held in East Berlin.⁹⁹ In 1976, Phạm Khắc Quảng launched a ten-point anti-TB programme in a newly reunified Vietnam, which had been devastated by over thirty years of war. Quảng was helped in his efforts by the WHO, and experts from Western European nations such as the Netherlands and France.¹⁰⁰

Hoàng Đình Cầu, the chief Vietnamese delegate to the Thirtieth World Health Assembly held in May 1977, recognized the need for international medical assistance. In his speech to the assembly, Cầu outlined the principles for the Socialist Republic of Vietnam's (SRV) health care system.¹⁰¹ In principle number 4, Cầu argued for ‘combining the Government's efforts with active participation of the people – who must take responsibility for protecting their own health – and self-sufficiency with foreign aid’. Nguyễn Văn Trong, still director of the Department of External Relations in the Ministry of Health, also spoke about international medical assistance at the assembly and was likely in the audience to applaud Cầu's words.¹⁰²

Conclusion

My article has examined how supporters of socialist internationalism sought to create a fictitious unity out of a fractured reality to advance particular political projects. It has argued that DRV experts played a key role in such statecraft by staging medical exchanges centred on TB control. The MOHOSC conferences were an avenue for high-level dialogue among socialist allies during a pivotal time for the DRV. Moreover, medical diplomacy was useful for building solidarity with friends and sympathizers in capitalist countries. Medical diplomats circulated their knowledge about TB control to help the DRV state achieve its geopolitical ends: performing a healthy, and independent, nation in a community of socialist countries.

Thạch, Quảng, Trạch and other medical diplomats have been feted not only for their professional accomplishments but also for their contributions to the construction of the Communist Party and the state. Thạch received some of the SRV's highest awards and his name graces a medical university, hospitals and major streets in several cities.¹⁰³ Quảng's former residence at 12 Bà Huyện Thanh Quan in Hanoi now serves as the Embassy of Slovakia, a symbol of the DRV's connections to former Eastern bloc states.¹⁰⁴ And in celebration of World Tuberculosis Day 2021, a street in the capital city was named in his honour.¹⁰⁵ Finally Trạch, as director of the National Institute of Hygiene and Epidemiology, developed a cheap cholera vaccine in collaboration with the Swedes in the 1990s. This bacterial vaccine, which drew from his earlier experience with heat-killed BCG, won him international fame.¹⁰⁶

While the DRV's TB experts proved more successful diplomatically than medically during the Cold War, they viewed their jobs not only as healing bodies but also as creating the framework for international medical alliances. They contributed to political and medical independence through the circulation of TB rates and control efforts. In laying the groundwork for fragile success in TB control, they also performed an independent, international Vietnam for the world to see.¹⁰⁷