what is colonial about colonial medicine

8/10/2019 What is Colonial About Colonial Medicine

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997 Th eSociety

or

h eSocial istoryof edicine

PRESIDENTIAL ADDRESS

What is Colonial about Colonial Medicine? And What

has Happened to Imperialism and Health?

By SH U LA M A R K S *

Reading through the abstracts for the Society's 1996 conference on 'Medicine and

the Colonies' one cannot but be struck by the enormous range and rich diversity

of the offerings, and of the astonishing develo pm ent of the field ove r the last dozen

or so years. Th e catchall title bro ug ht togeth er a glittering array of papers, reveal-

ing the scope and variety of work currently being done on medicine in colonial

settings. Even ten years ago, I think such a conference with so variedaprogramm e

wo uld have been impossible. Certainly w hen I was invited by the W H O in 1978

to participate in a project to look at the impact of apartheid on health in S outh

Africa and began to think seriously about the social history of medicine in South

Africa, it would have been inconceivable.

1

At that time, the secondary literature on the history of health care in South

Africa consisted of a handful of articles and couple of histories of colonial me dicin e

before 1900, and biographies and a utobiograph ies, with such titles as

M y

Patients

were Zulus,

2

or Tropical

Victory.

3

At best these were valuable compilations of

fact, at worst, they were old-fashioned, narrowly conceived and somewhat

triumphalist volumes celebrating the progress of 'European medicine' in South

Africa, the lives and achievements of individual medical men, and the establish-

ment of western medical schools and hospitals.

4

If there were rather fewer

medical discoveries to report than in their metropolitan equivalent, there were

to com pensa te the trium ph of science and sewers over savagery and superstition,

as one might paraphrase much of the celebratory history of colonial medicine in

the early twentieth century. Nor do I think South Africa was much of

an

excep-

tion, either for the rest of Africa or even more broadly for 'the colonies'.

One can perhaps highlight four or five major impulses for the increasing interest

* School of Orie ntal and African Studies, University of Lo ndo n, Th orn au gh Street, Russell

Square, London WC1H OXG.

This isarevised version of what I said atth e M edicine and the Colonies conference. I owe the first

question in the title to discussions with Sally Swartz about her own work on the history of psychiatry

in the Cape Colony. Unless otherwise noted, the references are to papers given at the conference.

1

This led to the W H O monograph, Health

and Apartheid

(Geneva, 1983), which I wro te with the

epidemiologist, Dr Neil Andersson.

2

James B. McC ord with John Scott Douglas, My

Patients Were

Zulus (London, 1946).

3

M .

Gel&nd,

Tropical

Victory: An

Account

of

Medicine

in the History of

Southern

Rhodesia(Oxford,

1953).

4

See for example E. H . Burrow s,A

History

o f

Medicine

in

South Africa

up to

the

End of the

Nineteenth

Century(Cape To w n and A msterdam, 1958); A. P. Cartwright,

Doctors

to the Mines. A History of the

Mine

Medical

Officers

Association

of South Africa

(Cape T ow n, 1971); A. F. Hattersley,

A Hospital

Century. Crey s

Hospital Pietermaritzburg

1855-1955

(Cape To wn , 1955).

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Shula Marks

and chan ging focus in the w riting of the history of colonial medicine over the past

generation: the development of social history and with it the social history of

medicine as an academic subject in Europe and the USA over the last thirty years

or so; the growth of social constructionist analyses in the social sciences under

the influence of Foucault, which have underlined the importance of medical

discourses, and shown their centrality in the evolution of the modern state and its

powers of surveillance; the creativity of medical anthropology and the increasing

recogn ition of the centrality of health and disease as social meta phor and biological

con dition ma de all the m ore u rgen t with the rise of new infectious diseases, such

as AIDs and the resurgence of old ones, such as tuberculosis and chloroquine-

resistant malaria.

5

The extent of this change can be seen not only from the spate of monographs

from the 1980s on a variety of aspects of'imperial medicine', but also from the

publication in 1988 of two watershed collections on the history of 'imperial

medicine': Roy MacLeod and Milton Lewis's Disease, Medicine and Empire. Per-

spectives on Western Medicine and the Experience ofEuropean Expansionand David

Arnold'sImperial MedicineandIndigenous Responses.

6

Both these volumes reflected

the growing interest in imperial medicine as a distinct area of research, although

as David Arnold warns in the introduction to his account of the polemic and

practice of medicine in colonial India, Colonizing the Body we should be wary of

establishing too rigid a barrier between colonial and metropolitan medicine:

It would be pointless to deny that much of what is described here in a colonial context

has its precedents and parallels in nineteenth century Europe particularly Britain itself and

was by no means unique to India. . . . the diverse array of ideological and administrative

mechanisms by which an emerging system of knowledge and power extended itself

into and over India's indigenous society [was] in many respects characteristic of bourgeois

societies and modem states elsewhere in the world. . .

.

There

is

indeed

a

sense in which all

modern medicine is engaged in a colonizing process. . . . It can be seen in the increasing

professionalization of

medicine

and the exclusion of 'folk' practitioners, in the close and

often symbiotic relationship between medicine and the modern state, in the far-reaching

claims made by medical science for its ability to prevent, control, and even eradicate

human diseases.

7

These observations are borne out in Hilary Marland's fascinating paper to the

conference on the Dutch Catholic midwifery school which opened in the small

town of Hee rlen in the south of the N etherlands in 1913. Marland shows that o ne

of its purposes was to send 'missionary' midwives into poor, Catholic regions, to

rid the po or w om en they delivered of dang erous, superstitious and dirty practices,

as well as to eliminate their traditional attendants.

8

O ften, wh at is read as chara c-

5

For a most valuable if brief account of recent trends in the historiography o f medicine, see

Gert Brieger, 'The Historiography of Medicine' in W. F. Bynum and Roy Porter (eds.)

Companion

Encyclopaedia

o f the

History

o f

Medicine

(London and New York, 1993), vol. I, pp. 22-44.

6

Published in Lond on and N ew York, and Manchester, respectively.

7

D . Arnold , Colonizing the Body. State Medicine and Epidemic Disease in Nineteenth-Century India

(Berkeley, Los Angeles and Lon don , 1993), pp. 9- 10 .

8

'Th e Missionary Midw ives: Colonizing Dutc h C hildbirth Services at H om e and A broad,

1913-1940' .

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What is Colonial about Colonial Medicine? 207

teristic of 'colonial medicine' then may be characteristic of biomedicine more

generally. As Heather Bell remarked in her paper on yellow fever in the Anglo-

Egyptian Sudan: 'the distancing of scientific interest from patient experience

occurring in this story resulted less from the colonial context than from the

methods of laboratory based medicine. '

9

If, however, there is a large a degree of overlap, what if anything,is specifically

colonial about colonial medicine? This is not an easy question to answer. As Roy

MacLeod and Milton Lewis remark in the introduction to Disease, Medicine and

Empire,

the re is

as

yet no 'c oh ere nt ag enda, let alone an agreed theoretical basis' to

the field of imperial or colonial medicine. What they are concerned with is to

show how 'medicine served as an instrument of empire, as well as an imperializ-

ing cultural force in its el f Th us, for MacL eod an d Lewis, imperial me dicine is

about 'the experience of European medicine overseas, in colonies established by

conquest, occupation and settlement. '

10

Do ubtless the formulation of this agenda is established by virtue of their vantage

point in the Antipodes: from an African or Indian perspective there are perhaps

different priorities as Dav id A rnold's in trod uc tion to his not dissimilarly titled c ol-

lection suggests. Th ere is a fair degree of overlap, but h ere ind igeno us experiences

and agency take a more central position. For Arnold the focus is on the impact of

western medicine on indigenous healing practices, as well as on the indigenous

experiences of, and responses to, western medicine. Many of the papers for the

1996 conference develop further those topics in the collections which have both

reflected and shaped our field of endeavour.

Some of the themes encompassed by 'medicine and the colonies' was also very

helpfully set out in the agenda of the conference organizers. They called for papers

dealing with military medicine and colonial conquest; race and colonial medicine;

missionary medicine; indigenous practitioners and colonial rule; colonial medical

profession; alternative and irregular Western practitioners in the colonies;

nursing in the colonies; colonial hospitals and extra-institutional care; the history

of psychiatry in the colonies; 'tropical' and 'temperate' medicine; and the role of

international health care in the colonies and ex-colonies.

11

Despite the absence of a chronological or geographical frame in the call

for papers, the hundred years between roughly the mid-nineteenth and mid-

twen tieth century formed the focus of the majority of the papers to the conference.

This is wh ere most recent research has been conce ntrated.

12

Nor is this emphasis

9

'Yellow Fever Research in the Interwar Anglo-Egyptian Sudan'.

10

R . M acLeod and M . Lewis, 'Preface' , in MacL eod and Lewis (eds.)

Disease,

Medicine and

Empire,

p. x.

11

S S H M , Gazette,13 (1995), 5.

12

Looking throug h the back num bers of the Society's journ al, Social History of Medicine,for

example, there is not a single article either on the Americas in the colonial period or the Caribbean.


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208 Shula Marks

pure coincidence, for this century both marked the heyday of European empires

and saw the emergence of an effective and apparently all-conquering bio-

medicine, each the product of Europe's technological revolution. And while

recent historians are by no means as sure as their forebears that medical advance

accounts for the markedly redu ced Euro pean mortality in the tropics in the m id-

nineteenth century, this reduction and the growing belief in human adaptability

to climatic variation were essential preconditions for the expansion of empire, as

Philip Curtin has shown.

13

As the reference to Curtin's

Death by Migration

serves to rem ind us, perhaps the

most overw helming fact of empire, o ne wh ich is perhaps so obvious that we tend

to take it for granted, was the enormous movement of peoplessailors and

soldiers, slaves and settlers, merchants and missionariesthat the expansion of

Europe entailed. Curtin's concern is with the impact of disease on the agents of

empire, colonial soldiers, in the nin eteen th century. Yet the expansion of Euro pe

overseas had a far more dramatic disease impact on the non-immune populations

of the New World: American Indians from the late fifteenth to sixteenth century,

Australian A borigines and Pacific Islanders from the late eighteen th cen tury.

As Mark N athan C oh en, has remarked:

overwhelming historical evidence suggests that the greatest rates of morbidity and death

from infection are associated with the introduction of new diseases from one region of

the world to another by processes associated with.. . transport of goods atspeedsand over

distances outside the ranges of movements common to hunting and gathering groups.

Small-scale societies move people among groups and enjoy periodic aggregation and dis-

persal, but they do not prove the distances associated with historical and modern religious

pilgrimages or military campaigns, nor do they move at the speed associated with rapid

modernformsof transportation.

14

The effects were clearly most dramatic in the first colonial encounters, as both

Alfred Crosby and William McNeil have shown.

15

In our concern with the

heyday of empire we should not forget that in some parts of the worldthe

Americas, the Caribbean, the Dutch East Indies, the Cape Colony, parts of

India,colonial medicine has a history stretching back to the sixteenth and

seventeenth centuries.

16

It would be unfortunate ifasa result ofthischronologi-

cal foreshortening we were to lose a sense of the momentous demographic

onslaught of early colonialism or neglect the very important continuities between

the earlier and later colonial history of medicine.

13

See P . C urt in, Death by Migration. Europe s

Encounter

with the

Tropical

World in the Nineteenth

Century(Cambridge, 1989).

14

M . N . Cohen ,

Health and the Rise of Civilization

(Ne w H aven and Lon don, 1989), p. 137.

15

Alfred W . Crosby Jr.,

The Columbian Exchange.

Biological

and Cultural

Consequences

of 1492

(Westport, C N , 1972) and Alfred W . C rosby Jr., Ecological

Imperialism. The

Biological

Expansion of

Europe, 900-1900

(Cam bridge, 1986); William H . M cNe il, Plagues

an d

Peoples (Harmondswor th ,

1979). For the impact of African pathogens, brought by the slave trade, see Kenneth F. Kiple (ed.)

The African

Exchange:

Towards

a

Biological History

o f

Black People

(Durham, NC and London, 1988).

16

M ichael W orbo ys also points to the neglect of these areas in his contrib ution on 'Trop ical

Diseases', in Bynum and P orter,

Companion

Encyclopaedia,vol. I, p. 52 8.



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What is Colonial about Colonial Medicine?

209

As Crosby puts it, the

colonial histories of Old W orld pathogens . . . [provide] the most spectacular example of

the power of the biogeographical realities that underlay the success of European imperialists

overseas. It was their germs, not these imperialists themselves, for all their brutality and

callousness, that were chiefly responsible for sw eepingasidethe indigenes and opening the

Neo-Europes to demographic takeover.

17

H ave w e really said the last wo rd on these 'catastrophic . . . epidem ic invasions of

virgin popu lations' which, M cN eil has argued, were of 'key significance . . . in the

complex of factors sustaining Europe's expansion'?

18

Microbes continu ed to accompany the mov em ent of me n and manufactures o n

the world's seaways into the n inetee nth and twe ntieth centuries. Th e era of indus-

trial capitalism witnessed what Eric Hobsbawm has called 'the greatest migration

of peoples in history': from the m etropo le to the colonies and betwee n and with in

the European empires men (and some women) moved with their pathogens and

parasites, to beco m e w orkers o n the m ines and plantations and factories of em pire .

And while epidemic disease continued to devastate more isolated communities,

as Do nald D en oo n's paper to the conference incidentally rem inded us,

19

th e

expansion of colonialism and the colonial city brought their own harvest of

disease, as the many papers on public health, epidemic disease and colonial rule

bore witness.

20

In 1992 Charles Ro sen berg set out the areas which he felt had been o f conce rn to

professional historians of m edicin e ov er the past couple of decades. O f these, ' pe r-

haps the most widely influential', according to Rosenberg, has been an interest in

'the way disease definitions and hypothetical etiologies can serve as tools of social

control, as labels for deviance, and as a rationale for the legitimation of status

relationships.' This in turn has been associated with the swing towards a social

constructionist view of disease and is an aspect of the wider concern with the

17

Crosby,

Ecological

Imperialism, p. 196.

18

McNei l ,

Plagues

and Peoples,p. 21 0. For further reflections on the processes involved, see A. W .

Crosby, 'Hawaiian Depopulation as a Model of the Amerindian Experience' in Terence Ranger and

Paul S lack , Epidemics and Ideas. Essays on the Historical Perception of Pestilence ( C a m b r i d g e , 1 9 9 2 ) ,

pp . 175-202.

19

'Divorce and Remarriage. Western Medicine and Anthropology in Melanesia' .

20

Kate Lowe and Eugene McLaughlin, 'Sanitation, Social Conditions and Epidemics in the Colo-

nial City: Explaining the Absence of a Public Health Policy in Hong Kong, 1877-1920'; Ijima

W ataru, ' O n the Prevalence of Malaria in Colonial Taiwan and Japanese Imperial M edic ine'; D avid

Killingray, 'A Ne w Imp erial Disease : the Impact of the Influenza P andem ic of 1918 on the British

Colonial Em pire'; Joyce Kirk, 'Co ntrollin g Sana : African W om en , Bub onic Plague, Colonial Law

and the African General Workers' Strike in Port Elizabeth, South Africa, 1901'; Myron Echenberg ,

'The Dakar Bubonic Plague Epidemic of

1914

and U rban Public H ealth Policy in Colonial Senegal' ;

Pamela Wood, 'Cesspools, Swamps and Stinks: Margins and Miasma in the 19th Century Colonial

Settlement of Dunedin, New Zealand'; Kohei Wakimura, 'Diseases and Imperial Health in India and

Taiwan ' .



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210

Shula Marks

relationship between 'knowledge, the professions and social power' in the social

sciences.

21

It is indeed with these issues that many of us concerned with 'medicine and the

colonies' are at present eng aged. In m any ways this emphasis in colonial m edicin e

is not entirely surprising. After all, the colonial context provides a particularly

fertile gro un d for e xplo ring th e relationship o f med icine and its discourses to issues

of colonial pow er and co ntrol, as M egan Vaug han has most elegandy suggested.

22

Med ical discourses in turn draw us to the very heart of wh at Frederick C oo pe r and

Ann Stoler have recently termed the 'tensions of empire': 'tensions' which are

'particular to die universalizing claims of European ideology and the particularistic

nature of conquest and rule, the limitations posed on rulers by the reprod uction of

difference as much as the heightened degree of exploitation and domination that

colonization entailed.'

23

As a spate of recent work makes clear, western biomedicine has undoubtedly

played a major role, both in making universalizing claims, and in creating and

repro duc ing racial and gend ered discourses of difference.

24

The historical connec-

tions be tw een biological science and racial science can hardly be doub ted, and the

study of race, gender and 'difference' has be co m e a veritable grow th ind ustry. By

the late nineteenth century, notions of racial difference intersected with newer

Social Darwinist anxieties in the metropoles about the declining fitness of the

'imperial race', reductions in fertility and birth rates, as well as high infant and

maternal mortality, and led to the upsurge of interest in m oth erho od and an in ter-

est in eugenics.

These ideas influenced even those dominions like New Zealand, which were

least affected by racism in the inter-war years, at least at a conscious level, and

where we can see the influence of eugenics in a perhaps somewhat less sinister

light. As M ilton Lewis poin ted ou t in the 1988 collection 'rising interest in infant

health.was in part a result of fears that an unfit m etrop olitan peop le (including th e

wh ite Dom inions) w ould b e unable to defend and develop imperial possessions.'

25

Similar themes emerge from Philippa Mein-Smith's paper to the conference on

'Go od N ew Zealand Milk, 1890s to 1960s' w he re the interlocking configurations

of political economy, colonial dependence and cultural constructions of whiteness

and fitness were brilliandy illustrated, and Linda Bryder's analysis of the relative

failure of New Zealand's Plunket Society to address Maori infant health. In setder

21

Charles E. Rosenberg, 'Introduction. Framing Disease: Illness, Society, and History', in C. E.

Ros enberg and Janet Golden (eds.)

Framing

D isease. Studies in

Cultural History

(New Brunswick, NJ,

1992), p. xv.

22

Me gan Vaugh an, 'H ealing and Curin g: Issues in the Social History and Anthrop ology of

Medicine in Africa',Social History

of Med icine,

7 (1994), 289.

23

Frederick Cooper and Anne Laura Stoler (eds.)

Tensions

of Empire.

Colonial Cultures in

a

Bourgeois

World (Berkeley, Los Angeles and London, 1997), p. xi.

24

For the most influential, see, for example, George Mosse,

Towards

the

Final

Solution. A

History of

European Racism (N ew Y ork, 1978); Nan cy Stepan, The Idea of Race in Science: Great Britain

1800-1960

(London , 1982); Sander Gilman,Difference andPathology:Stereotypes

o f Sexua lity,

Race and

Madness (Ithaca, NY , 1985).

25

M ilton Lewis, 'Th e Health of the R ac e and Infant Health in N ew South Wales: Perspectives

on Medicine and Empire' , in MacLeod and Lewis (eds.)

Disease,

Medicine

and Em pire,

p. 302.



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What isColonial about Colonial Medicine? 211

society, as in B ritainitself eugenic concerns led to increasing concern with infant

welfare, and maternal responsibility.

If, in the dominions, 'good, white milk' was believed to be necessary for good,

white settler stock, in tropical Africa, as Megan Vaughan has remarked in

Curing

theirlib,

'the power of colonial medicine lay not so much in its direct effects on

the bodies of its subjects . . . bu t in its ability to prov ide a natura lized and path ol-

ogjzed account of those subjects.'

6

Moreover, this 'pathologizing' of the 'other'

is not simply a matter of

history.

The resurgence of medicalized racial discourses

in our own day, as the media treatment of AIDS and the Ebola virus so clearly

reveal, and the 'repolitization of the notion of racial difference', lend a certain

urgency to our consideration of scientific racism.

27

Indeed in answering the ques-

tion 'What is colonial about colonial medicine' the temptation is to give the

priority to questions of race and eugenics. Yet the current search for a 'criminal

gene' among the 'underclasses' in the metropole suggests that here too the

dialogue betw een ho m e and em pire is far from simple.

This pathologized account is perhaps most marked in the responses of colonial

doctors to the problems of gender and madness, as Vaughan suggests in her bril-

liant discussion of colonial discourses around syphilis and madness.

28

Th e slippage

between the mad and the bad, the black and the feminine has deep roots in

European thought, and historians concerned with the discourses of colonial

medicine have, like their European and American counterparts, have found the

history of madness and of venereally transmitted diseases fruitful fields of investi-

gation.

29

On these many readings, 'racial anxiety' is clearly as intimately bound up

with metropolitan as with colonial concerns. And most relate racial discourses to

specifically nineteenth- and twentieth-century concerns. This is also a central

argument in Kenan Malik's thought-provoking new book, The Meaning of Race.

For Malik, the contemporary meanings of race emerged out of the paradox of

the Enlightenment belief

in

equality, and the difficulties in the way of

its

realiza-

tion in capitalist society. R ac e, he asserts, 'deve lop ed initially as a response to class

differences within European society, and was only later applied to difference

26

M e g a n V a u g h a n , Curing their lib. Colonial Power and African Illness (Cambr idge , 1991) , p .2 5 .

27

K ena n M al ik , The Meaning of Race. Race, History an d Culture in Western Society (Bas ings toke,

1996) ,

p . 7 .

28

V a u g h a n , Curing their lib, chs

5

and

6 .

See, also,

fo r

e x a m p l e ,

H .

D e a c o n ,

' A

His tor y of Medica l

Institutions on Robben Island, Cape Colony, 1846-1910', (unpublished Ph.D. thesis, University of

Cambridge, 1994); S. Swartz, 'Colonialism and the Production of Psychiatric Knowledge at the

Cap e, 189 1-1 920 ', (unpublished P h.D . thesis, U C T , 1996); K. Jochelson, 'T he C olou r of

Disease: Syphilis and Rac ism in South Africa, 19 10 -19 50 ', (unpub lished D . Phil, thesis, Univ ersity of

Oxford, 1993).

29

There were no fewer than four papers on colonial madness at the conference; this contrasts as we

shall see with the virtual exclusion of discussion of the industrial diseases which took a far larger toll

of life and limb in the m ines and plantations of the colonie s. See Lynne M arks, 'Sexuality, Ge nde r and

Religious Insanity in Canada, 1850-1900'; Cathy Colebourne, 'Gender and Patients in the Lunatic

Asylum in Colonial Australia'; Waltraud Ernst, 'Gender, Madness and Colonialism: the Case of

Female European Asylum Inmates in 19th Century British India'; and S. Swartz, 'Marking the

Lunatic Body: Rac e and Gender in the Management of the Insane, Cape C olony , 1891-1 920. '


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between Europeans and non-Europeans, and hence became marked by colour

differences.'

30

Yet th e dialogue is surely m ore com plex if on e takes a long er and m ore dialogic

view o f empire. Ra cial ideas, if no t systematic racism, had a more com plex aetiol-

ogy, generated as they were in the long conversation between Europe and its

colonial wo rlds, from th e late fifteenth cen tury. Th us, Stoler and C oo pe r suggest:

Aswe begin to look at the similarities and differences in social policy in Europe and the

world it made colonial, itisclear that the resonance and reverberation between European

classpolitics and colonial racial policies was far more complicated than we have imagined.

. . . If there were places where the European languages of

class

providedatemplate for how

the colonized racial 'residuum' was conceived, sometimes the template worked the other

way around. The language of class itself in Europe drew on a range of images and

metaphors that w ere racialized to the core.

31

In his paper to the conference, Jorge Canizares deals with the beginnings of this

'intricate dialogue' in Latin America. As he shows, from the very beginning of

their colonial enterprise 'Spanish intellectuals deployed secular and naturalistic

explanations to justify th e exploitation of the Am erindian lab our force'. H e

argues, m oreo ver, that these justifications 'neve r really disappeared from Spanish

colonialist discourses', although they underwent a variety of intellectual shifts

from the sixteenth and to the nineteenth centuries.

32

Echoing some of Nancy Stepan's arguments about eugenics in Latin America,

and suggesting some o f the dee per roots of its racial tho ug ht, Canizares m aintains

that in Spanish America 'local white elites (creoles) . . . sought to contradict

the Spanish views of American degeneration by manipulating the very medical

discourses used by the peninsulars to justify their rule for the m etro po lis'. 'Local

scholars argued that the American stars caused Indians to be sloths' and Creoles to

be more intelligent than their 'peninsular brethren'. 'This. . . allowed the Creoles

to represent America as their ow n paradise and . . . to colonize the past of the

peoples they were subjugating'.

33

Julyana Peard's paper on medical ideas in nineteenth-century Brazil fitted well

with Canizares's arguments for Spanish America. Peard maintains that while in

the first half of the nineteenth century the Brazilian elite replicated European

especially Frenchmedical ideas and practices in order to prove they were

'civilized', by the 1860s a gro up of doctors k no w n as the Tropicalistas eme rged in

opposition to develop 'a distinctive medicine of the tropics'. At the heart of this

new medicine was a rejection of environmental determinism and ideas of tropical

degeneracy. This enabled them to reformulate notions of disease in the tropics,

and thus 'to reconceptualize Brazil as a nation with the chance of becoming an

advanced civilization in the tropics'.

34

30

M a l ik , Meaning of Race, p p . 7 - 8 .

31

A. L. Stoler and F. Cooper, 'Between Metropole and Colony: R ethink ing a Research Agenda' ,

in Cooper and Stoler, Tensions

of Empire,

p . 11.

32

J.

Canizares, 'Med ical Theories and Views of Ra ce in Colonial Spanish Am erica' .

33

Nanc y Leys Stepan, 'Th e H ou r of Eugen ics': Ra ce, gender and Natio n in Latin America (Ithaca,

1991).

34

'Med icine and Politics in the To rrid Z one : the Pre-Cru z Era in Brazilian Medicin e, 186 0-19 00'.



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Wh at is Colonial about ColonialMedicine?

2 13

Interestingly, the emergence of the 'Tropicalistas' occurred some thirty years

before th e em ergen ce of a systematically defined 'tropical me dicin e' in the British

context, although speculations about the effect of the tropics on health arose with

the earliest encounter of European traders with tropical climes and tropical

peop les. By the late nin etee nth century the diseases w hich attracted mo st atten tion

from British doctors in the tropics werehardly surprisinglythose which took

so large a toll of white lives in Africa and Asia, and it was the conquest of these

diseases which of course mad e th e pe netra tion of the tropics a possibility: m alaria,

yellow fever, hook-worm. Sleeping sickness, too, which was seen to threaten

the reproduction of the labour force was an early candidate for the practices of

tropical med icine, and, as M ichael W orb oy s has sho w n, is an excellent exam ple of

the divergent medical approaches of different colonial powers in east and central

Africa, 'and the ways these were rooted in different medical approaches and

colonial structures': Belgian, German and British.

35

In the late nineteenth- and early twentieth-century British empire, then,

'tropical medicine' came to have a rather more specialized scientific connotation,

and was readily adopted by the advocates of imperial expansion. While in Latin

America, setder physicians manipulated metropolitan notions of 'tropical

medicine' to assert their own superiority and specialized knowledge, so in Britain

research in to a new ly defined discipline of tropical medicine was used by a small

nu m be r of physicians in order to advance their ow n a uthority and status. As a

result, according to W orboy s:

The investigation and teaching ofthe etiology and treatment of tropical diseases was de-

veloping in an environm ent and culture totally different from the tropics. Work on etiol-

ogy became exclusively scientific, based upon parasitological studies and the germ therapy

of disease. The clinical treatment of these diseases took precedence over prevention and

epidemiological studies on disease incidence and control. In the metropolitan situation,

remote from the practical problems of the tropics, the study of tropical diseases became

increasingly preoccupied with scientific problems rather than the problems of poor

health.

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214 Shula Marks

inheritance, the social and economic aetiology of most Aborigine of ill-health

was obscured.

37

What this suggests is that, as in the case of eugenics, we need to look for the

shape and substance if not the genesis of tropical medicine in specific colonial

imperatives in the dialogue between me tropo le and colony.

IV

Th e dev elopm ent of arguments around eugenics and tropical medicine are perhaps

more easily traced in colonies of settlement than in the tropical colonies them-

selves. Nevertheless, at a broader level, colonized peoples also engaged in a

comp lex set of contestations, negotiations and adaptations in their enc ou nter w ith

western biom edicine. And , while by the late ninetee nth century W estern medical

practitioners had co m e to believe in the single 'universalizable tru th' o f their ow n

understanding of health care, and to show little tolerance for alternatives, non-

Western medicine whether Chinese, Ayurvedic or African, showed itself far more

tolerant and accepting of new ideas.

38

Much new work is about the very complex responses of indigenous people to

colonial medicine, and indeed a considerable number of the conference papers,

celebrate indigenous agency and the bricollage of indigenous medical practice.

Indeed the entire history of healing in Africa, as elsewhere, contradicts the con-

fident jud ge m en t of Jo hn Fitzgerald, the S up erinten den t o f Grey's Hospital in the

Eastern Cape in 1876, that 'it is impossible that ignorance and superstition can

long compete with science and skill in the treatment of the sick'.

39

Far from the

struggles over medical hegemony ending in the triumph Fitzgerald predicted and

in the 'erasure' of indigenous subjectivity which some post-colonial writers

lament, many of the conference papers reveal instead the varieties of successful

resistance to, and the selective incorporation/adaptation and manipulation of,

Western medical traditions by colonized peoples.

40

For the most part, at least in

Suzanne P arry, 'R ace , Tropical Medicine and C on tro l ' . For a similar account o f the function of

'tropical medicine' in Papua New Guinea, see Donald Denoon with Kathleen Dugan and Leslie

Marshall, Public

H ealth in Papua New Guinea. Medical

Possibility

an d

Social Constraint

1884-1984

(Cambridge, 1989).

8

Arthur Kleinman, 'What is Specific to Western Medicine?' in Bynum and Porter (eds.) Com-

panion

Encyclopaedia,

vol. I, pp. 16-17.

39

Cape House of Assembly, G.64 - '7 7 ,

Annexure to

Votes

and Proceedings,

King Will iam's Town,

Grey's Hospital, Report of the Superintendent of the Native Hospital, for the year 1876, p. 1.

Fitzgerald had honed his skills on the Maori before coming to South Africa. His role in the Eastern

Cape and African therapeutic choice were the subject of David Gordon's paper to the conference

(Transformations in Disease Patterns and Therapeutic Traditions in Colonial Xhosaland,

1847-1891') .

40

See, for examp le, Poornim a Sardesai, 'Indig eno us M edical Practitioners and Colonial R ule in

India: A Study in the Pro duction of Medical Know ledge Systems in Andhra, 1880s-1930s'; Stephen

Feierman, 'The Regulation of Indigenous Practitioners in East Africa'; Biswamoy Pad, 'Siting the

Body: Perspectives on Health and Medicine in Colonial Orissa'; Geraldine Forbes, 'Medical Educa-

tion for Indian Women: the Campbell Medical School Experiment'; Maureen Mulowany, 'The

Therapy of Choice: Medical Alternatives at the Kenya Coast, 1880-1940'; Patricia Jasen, 'Narratives

of Childbirth in the Canadian North' .

atUniversityofHyderabadon

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What

is

Colonial about Colonial Medicine? 215

the short and medium run, the outcome was closer to what Luise White has

recently referred to as 'tantalizing hints of an intellectual community in which

aspects of W estern biomed icine w ere unpack ed, exam ined, accepted and reinter-

preted according to local meanings'.

41

V

All this suggests that the h istory o f medicine in the colonies is often an illuminating

way to examine aspects of the power and limitations of colonialism and its ideas

and discourses.

42

Yet an over-emphasis on the role of 'medicine' as a way of

exploring colonial ideas and discourses and the nature of colonial power, risks

a retreat from a political economy of disease and some of the major issues in

the broader history of medicine and the colonies which concerned historians in

the 1970s and 1980s. In our recent concern with discourses and texts, we may

be in danger of forgetting that there is another history of actual morbidity and

mo rtality, difficult as these may be to de term ine especiallybut no t uniq uely in

colonial situations, and of actual therapeutic practices and institutions, in all their

ambiguities and contradictions.

Demography, the changing patterns ofdiseaseand its social causes as well as its

relationship to political economy, remain crucial areas of enquiry, if perhaps

underrepresented ones in the recent literature. Indeed, when I began working in

this field with Neil Andersson in the late 1970s, the 'political economy' of

medicine seemed to reign supreme. To understand, for example, the impact of

apartheid on health, one had to understand the fundamental social, economic and

political institutions which shaped the disease environment and controlled the

availability of health services and therapeutic choice.

In South A frica, th ere cou ld be little doub t o f the, material basis of muc h of

the disease and ill-health, and its relationship to conditions of production and

reproduction; nor could the patterns of health care delivery be divorced from

the relations of power in society. The great killers were malnutrition and the

nutritionally associated infectious diseases, or diseases associated with poverty

gastro-enteritis, tuberculosis, measles. In the widest sense, we saw in the particu-

larities of Sou th Africa's mineral revo lution, com mercialization of agriculture, and

urbanization the source of mu ch of its preventab le ill-health: apartheid was indee d

the way in w hich the burd ens of that process of capitalist grow th w ere transferred

to the black pop ulatio n, and the rewards reaped by whites, although no t all wh ites

equally. The inequalities in health care/medicine were not a simple reflection of

these conditions but equally could not be divorced from them.

4 3

Given the dominance of this paradigm in the early 1980s, it is perhaps a little

41

Luise Whit e: ' T he y C ould M ake Th eir Victims Dull : Gend ers and Genres, Fantasies and

Cures in Colonial Southern Uganda',

American Historical

Review,

100 (1995), p. 13 95.

42

Vaughan, 'Healing and Curing', p. 289.

4 3

S ee W H O ,

Health

and

Apartheid

(Ge nev a, 1983); also

S .

M arks

a n d N .

A nder s s on , ' I ndus t r i a l -

ization, Rural Change and the 1944 National Health Services Act, ' in S. Feierman andJ.M. Janzen

(eds.),

The

Social Basis

o f Health and

Healing

(Berkeley, Los Angeles and Oxford, 1992), pp. 131 -62.



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216

Shula Marks

surprising that there is so little on the social production of disease and the social

costs of production in our recent work.

44

Indeed, there seems to have been a

certain silencing of class issuesasa result of ou r conc entra tion on discourses aro un d

race and gendera reflection perhaps of broader contemporary intellectual

trends. As Eric Hobsbawm has recently remarked, we seem to be living in an age

in w hich discussion of class has vanished as'the o ld class-based political parties and

movement have been weakened. '

45

And with this seems to have come a kind of

collective amnesia about the importance of class, and a displacement of class

politics by the politics of identity in whic h race, gend er and ethn icity have m ov ed

centre stage.

Yet to dece ntre class issues in the history of me dicine in the colonial wo rld, as

in the metropole, is to leave much unexplored and unanswered. I have already

referred to the complex relationship between class, race and gender in the evolu-

tion of eugenic thought. Can it be that because the discourses of medicine

privilege bodily markers like gender and race, they serve, especially in a colonial

contex t, w he the r consciously or uncon sciously, to occ lude considerations of class?

Is there perhaps a danger that for many ofus, as for imperial doctors the fascina-

tion lies w ith tho se diseases w hic h afflicted Eu ropean s in the tropics and tho se n ew

forms of knowledge constituted around them construed as tropical medicine? Is

there not a danger that we are being lured by the glamour of 'tropical' and

epidemic diseasewhere the evidence is easier to come by and where we, too,

can lay claim to a specialized field and, like the

aficionados

of ' tropical medicine' ,

neglect the more mundane but also the more pervasive killers? After all one does

not have to be a Marxist to recognize that a prime motivation for colonialism (if

not theprime m otivation) has been e cono mic wh ether one understands this

to arise from 'gentlemanly capitalism' or from the need for markets and raw

materials, and that the exploitation of material resources and the expansion of

capitalist mod es of prod uct ion have carried a high social cost. As Gw yn Prins has

pointed out,

the social costs of productive activities may be calculated as openly as the material ones.

Thus part of the cost ofaswitch to cash crops in eastern Tanzania [and ZambiaasVaughan

and Moore have recently shown] is paid in increased perinatal mortality, itself aresult of

increased demands on women's time... colonial development projects in northern Ghana

and increased pressure to useriver-valleyand carried a price of increased onchocerciasis

(river blindness); part of the cost of power and irrigation dams is paid in increases in

schistomiasis [andmalaria];aheavy part of the cost of gold-mining in South Africa was the

wholesale introduction of tuberculosis into African recruiting grounds; part of thecost of

urban growth in Zambia is paid, in the encircling shanty towns, in infant malnutrition,

resulting from ... aculturally induced decline in breast-feeding and degradation of diet to

one offizzydrinks and shop bread.

46

44

As far as I could tell from the abstracts, there were only one or two conference papers devoted

to these issues in the colonies: Harold D rayton's accoun t of the colonial origins of health un de rde -

velopm ent, and slighdy less obviously, Diana Wylie, 'Th e Th reat of Race Deterioration : N utritional

Research in South Africa, 1900-1970'.

45

This is the burde n o f Hobsba wm 's 'Identity Politics and the Left',

New

Left

Review,

207 (1996 ), 40.

46

G. Prins, Re view Article 'But W hat W as the Disease? The P resent State of Health and Healing

in African Studies',Past

a nd

Present 124 (1989), pp. 1 65 -6.



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The current silences are surely significant and raise for me the issue of how we as

social historians of me dicine engage w ith w hat m ust be the most imp ortan t legacy

if not of colonial medicine then of imperialism on health: the continuing and

w ide nin g inequalities in health and health care bo th w ithin and betw een different

countries across the world. It is salutary to recall that, despite the optimism of the

1993 World Bank Development Report that since 1950 'life expectancy has

improved more than during the entire previous span of human history',

47

these

disparities con tinue to wid en. In 1 993, of the $23 trillion global G D P, $18 trillion

is in the industrial countries; only $5 trillion in the developing countries, which

contain 80 per cent of the world's population, while the assets of the world's 358

billionaires in 1996 exceeded the combined annual incomes of countries with 45

per cent of the world's population.

48

In its report the World Bank spelt out the good news: in the mid-century life

expectancy in 'developing' countries for which read 'ex-colonial' countries of

Africa and Asiawas 40 years; by 1990 it had increased to 63 . In 1950 28 o ut of

every 100 children died before their fifth birthday; by 1990 this had fallen to 10.

Smallpox which had killed more than 5 million people annually had been eradi-

cated comp letely, and vaccination had drastically redu ced th e occ urren ce of polio

and m easles.

49

Unfortunately these advances have not been sustained.

1990 was probably a relatively go od year in w hich to measure progress before

the eruption of civil strife and ethnic cleansing which has made a mockery of

health care in large swathes of Africa and Eastern Eu rop e. By the mid -199 0s, social

scientists were less optimistic, estimating that mortality in developing countries'

from AIDS would rise to 1.8 million deaths annually by the year 2000, thus

eliminating the improvement made over the last half century. Nor is AIDS the

only health hazard on the increase. The increase in chloroquine resistance means

that deaths from malaria are no w estimated to d oub le to nearly 2 million a year by

the year 2000 while the number of tobacco-related deaths from heart disease and

cancers are also estimated to dou ble by the first decade of the nex t m illenium to 2

million a year. Figures for TB are also set to rise.

50

Quite apart from the increasing health hazards hanging over the next mille-

nium, however, any sense of euphoria evaporates quite quickly once the 1990

mortality statistics are disaggregated. As the World Development Report put it:

Absolute levels of mortality in developing countries remain unacceptably high: child m or-

tality rates are about ten times higher than those in the established market economies [i.e.

North America, Western Europe including the UK, Japan and Australia]. If death rates

among children in poorer countries were reduced to those prevailing in the rich countries,

11 million fewer children would die each year. Almost all of these preventable deaths area

result of diarrhoeal and respiratory diseases, exacerbated by m alnutrition. In addition every

year 7 million adults die of conditions that could be inexpensively prevented or cured.

About 400,000 women die from the direct complications of pregnancy and childbirth.

47

W o r l d B a n k , World Development Report 1993. Investing in Health (Oxford , 1993) ,

p . 1 .

48

U n i t e d N a t i o n s D e v e l o p m e n t P r o g r a m m e , Human Development Report 1996(N ew Y ork , 1996) ,

2 .

49

W o r l d B a n k , World Development Report 1993,

p . 1 .

50

Ibid. pp. 1-3.



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218 Shula Marks

Maternal mortality ratios are on average thirty times

as

high in developing countries as in

high income countries.

51

Moreover if one begins to disaggregate the global figures for the 'developing

cou ntries', the goo d news looks far

less

go od for certain of these coun tries than for

others. While, for example, life expectancy has increased from 42 to 68 years in

China and from 40 to 61 in the Middle Eastern Crescent, in sub-Saharan Africa

average life expectancy is still only 52 (and set to decline to 47 by the year 2000

as a result of

AIDS);

oragain to choose a single example cited by the World

Development reportwhile in 1960 in Ghana and Indonesia about one child in

five died before th e age of five, by 1990 Indo nesia's rate had dropp ed to o ne child

in ten, while Ghana's had only fallen very slightly.

52

And it will not surprise you

to learn that progress in health is directly correlated to increases in inco me and

to the improved nutrition, housing and education that comes with increased

affluence, although manifestly improvements in public health and advances in

medical knowledge have played a part.

53

According to the World Development

Re por t, eco nom ic indicators seem to be the m ost impo rtant predictors of mo rtal-

ity decline, but surely here is a field crying out for comparison by historians of

colonial medicine familiar with the debate among historians on the relative

importance of a rising standard of living and public health interventions in

explaining demographic change in ninetee nth-ce ntury Britain.

54

Ironically, as the emphasis in our field has shifted from class and political

economy

:

and I am talking mainly of a shift of emphasisit seems that the issue

of inequality in health among economists and sociologists has moved again to

centre stage. As the 1980 Black Report on inequalities in health made clear, the

relationship between mortality and occupational class is 'most unequivocal' even

when controlling for age, gender, race or region. Moreover, this remains true

even wh en con trolling for the effect on he alth of lifestyleed ucation, diet, sm ok-

ing and alcoholor the provision of medical services.

55

Yet health is not only a matter of absolute inco m e. In a recent major analysis of

the evidence, R icha rd W ilkinson has sho wn that in industrial societies w hich have

crossed the epidemiological threshold, 'social, rather than material factors are now

the limiting factors on the quality of life.' Thus while within the same society,

occupational class remains the best predictor of individual differences in mortality

and morbidity, across societies it is inequality itself-and the degree ofsocialdis-

location which inequality signalswhich is of crucial importance. As Wilkinson

puts it, 'once a country has passed the threshold of income associated with the

51

Ibid.

52

World Development Report,

p p . 1 ,2 3 .

53

Ibid., p. 34.

54

Ibid., p. 2.

55

See, for example, Peter Tow nshe nd and N ick D avidson (eds.)

Inequalities

in Health. The

Black

Report,and M . W hitehead, The Health Divide (Harmondsworth, 1992 [joint publication, revised

edition]).

The

Black Report named after its chairman, was the report of a W orking Gro up on Inequa l-

ities in Health set up by the Labour Secretary for State for Health and Social Security, and was

first published in 1980. Th e health inequalities whic h it note d in th e late 1970s had increased by the

1990s.



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epidemiological transition, its whole population can be more than twice as rich as

anoth er with ou t be ing any healthier.' Th us, 'life expectancy is higher in countries

like Greece, Japan, Iceland and Italy than it is in richer countries like the United

States and Greece.'

56

Fascinating as these findings are, here is neither the time not the place to

analyse them in detail. In any case, you mig ht ask, wha t relevance do they h ave to

those of us who are working on colonial societies where for the most part people

did not have the minimum living standards necessary to escape the nutritional,

infectious and epidemic diseases? Clearly we have to be careful in drawing too

precise an analogy between the industrialized world and colonial societies. Yet I

do think a broader set of issues arises out of Wilkinson's work which sheds a new

light on forms o f indigenous healing and indigenous und entan ding s of health and

disease, and gives a new meaning to our undentandings of the universal and the

particular.

Very briefly, Wilkinson argues that unequal economic growth and inequality

bring into lerably high levels of social stressJob insecurity and acripp ling sense of

powerless, broken families, increased violence and accidents, drug abuse, crime

and juvenile delinquency, and, above all, loss of a sense of community.

57

If he

is correctand the argument is supported by a remarkable range of cross

disciplinary findingsthis opens up a wide range of comparative questions for

historians. Not only does it revitalize the dialectical relationship of the biological

and the social, and the epidemiological and the political; it also suggests most

interestingly that biomedicine may well have much to learn from the experience

of those non-Western healers who see the need to treat social disease as well as

individual ill-health, and understand that resolving social tension is part of the

healing process.

56

R i c h a r d W i l k i n s o n ,

U nhealthy Societies. The Afflictions of Inequality

( L o n d o n a n d N e w Y o r k ,

1996) pp. 3 , 2.

57

See , espec ia l ly , Wilk inson ,

U nhealthy Societies,

ch . 8 .


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