Public Health in the British Empire: Intermediaries, Subordinates, and the Practice of Public Health, 1850–1960 2011017811, 9780415890410, 9780203332733

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Table of contents :
Front Cover
Public Health in the British Empire
Copyright Page
List of Tables
Introduction: Amna Khalid and Ryan Johnson
1. The Control of Birth Pupil Midwives in Nineteenth-Century Madres: Sean Lang
2. “unscientifi C And Insanitary” Hereditary Sweepers and Customary Rights in the United Provinces: Amna Khalid
3. “Left in the Hands of Subordinates” Medicine, Language, and Power in the Colonial Medical Institutions of Egypt and India: James Mills
4. Surviving the Colonial Institution Workers and Patients in the Goverment Hospitals of Mid- Nineteenth-Century Jamaica: Margaret Jones
5. “a Laudable Experiment” Infant Welfare Work and Medical Intermediaries in Early Twentieth-Century Barbados: Juanita De Barros
6. Burmese Health offi Cers in the Transformation of Public Health in Colonial Burma in the 1920s and 1930s: Atsuko Naono
7. Mantsemei, Interpreters, and the Successful Eradication of Plague The 1908 Plague Epidemic in Colonial AccraRyan Johnson
8. Medical Training, African Auxiliaries, and Social Healing in Colonial Mwinilunga, Northern Rhodesia (zambia), 1945–1964: Walima T Kalusa
9. The Mid-level Health Worker in South Africa The in-Between Cindition of the"Middle": Anne Digby
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Public Health in the British Empire

Routledge Studies in Modern British History

1 Violence and Crime in Nineteenth-Century England The Shadow of our Refinement J. Carter Wood 2 Revolutionary Refugees German Socialism in Britain, 1840–60 Christine Lattek 3 Marxism in Britain Dissent, Decline and Re-emergence 1945–c.2000 Keith Laybourn 4 The Victorian Reinvention of Race New Racisms and the Problem of Grouping in the Human Sciences Edward Beasley 5 Origins of Pan-Africanism Henry Sylvester Williams, Africa, and the African Diaspora Marika Sherwood 6 Statistics and the Public Sphere Numbers and the People in Modern Britain, c.1800–2000 Edited by Tom Crook and Glen O’Hara 7 Public Health in the British Empire Intermediaries, Subordinates, and the Practice of Public Health, 1850–1960 Edited by Ryan Johnson and Amna Khalid

Public Health in the British Empire Intermediaries, Subordinates, and the Practice of Public Health, 1850–1960 Edited by Ryan Johnson and Amna Khalid



First published 2012 by Routledge 711 Third Avenue, New York, NY 10017 Simultaneously published in the UK by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2012 Taylor & Francis The right of Ryan Johnson and Amna Khalid to be identified as the author of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. Typeset in Sabon by IBT Global. Printed and bound in the United States of America on acid-free paper by IBT Global. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Public health in the British empire : intermediaries, subordinates, and the practice of public health, 1850–1960 / edited by Ryan Johnson, Amna Khalid. p. cm. — (Routledge studies in modern British history) Includes bibliographical references and index. 1. Public health—Great Britain—History—19th century 2. Public health—Great Britain—History—20th century. I. Johnson, Ryan, 1975– II. Khalid, Amna, 1979– RA485.P788 2011 362.10941—dc23 2011017811 ISBN: 978-0-415-89041-0 (hbk) ISBN: 978-0-203-33273-3 (ebk)


List of Tables Acknowledgments Introduction

vii ix 1



The Control of Birth: Pupil Midwives in Nineteenth-Century Madras




“Unscientific and Insanitary”: Hereditary Sweepers and Customary Rights in the United Provinces




“Left in the Hands of Subordinates”: Medicine, Language, and Power in the Colonial Medical Institutions of Egypt and India




Surviving the Colonial Institution: Workers and Patients in the Government Hospitals of Mid-Nineteenth-Century Jamaica




“A Laudable Experiment”: Infant Welfare Work and Medical Intermediaries in Early Twentieth-Century Barbados




Burmese Health Officers in the Transformation of Public Health in Colonial Burma in the 1920s and 1930s ATSUKO NAONO


vi Contents 7

Mantsemei, Interpreters, and the Successful Eradication of Plague: The 1908 Plague Epidemic in Colonial Accra




Medical Training, African Auxiliaries, and Social Healing in Colonial Mwinilunga, Northern Rhodesia (Zambia), 1945–1964




The Mid-Level Health Worker in South Africa: The In-Between Condition of the “Middle”



List of Contributors Index

193 195


1.1 4.1 5.1 5.2

Salaries of Hospital Nursing and Midwifery Staff Death Rates at the Kingston General Hospital for Selected Years Population of Barbados British Caribbean Infant Mortality Rates (per 1,000 live births)

40 86 102 103


This volume is the outcome of a workshop held at the Wellcome Unit for the History of Medicine, University of Oxford, June 5, 2009, “Inside/Outside: Intermediaries, Subordinates, and the Practice of Public Health in the British Empire.” The editors would like to thank fi rst and foremost Professor Mark Harrison, director of the Wellcome Unit for the History of Medicine, Oxford, for providing us with the facilities and encouragement to hold the workshop. Additionally, we would like to thank Ms. Carol Brady and Ms. Belinda Michaelides for their administrative and organizational acumen. We are also indebted to several participants who influenced the contents of this volume. In particular we would like to thank Professor Mark Harrison, Professor David Hardiman, Professor Anne Marie Rafferty, Dr. Sanjoy Bhattacharya, Dr. Sloan Mahone, Dr. Guy Attewell, and Dr. Rosemary Wall. The co-editors have maintained a constant dialogue at every stage of the development of this volume. The result is a genuine synergy where the editors have made equal contributions.

Introduction Amna Khalid and Ryan Johnson

In his report on plague in Bombay in 1896–1897 the municipal commissioner of Bombay, P.C.H. Snow, commenting on the significance of Halalkhors and Bigarries (castes responsible for the sweeping and scavenging of the city) to the sanitary system, wrote: These men . . . form the working basis of the sanitary system, and the slightest hitch in their organization, which is a most elaborate one, or depletion in their numbers, would immediately involve a serious danger. Scattered as they are through every portion of the City in larger numbers, any unrest or tendency to strike among them immediately effects other numerous low caste natives, and any development of panic or alarm straightaway spreads to their immediate surroundings. Among the fi rst to have followed their example would have been the large staff of labourers . . . on whom we are largely dependent for carrying out our struggle with plague . . . It can be imagined, then . . . what would be the result if the whole body of Bigarries and Halalkhors struck work. In a fortnight the City would have to be abandoned, dependent as it is on the hand-removal of sewage and the cart removal of sweepings by these men . . . On these men and their good-will [hangs] the carrying out of every sanitary measure, and even in ordinary times were they all to remove from the town for a fortnight, Bombay would be converted into a dunghill of putrescent odure. I grasped the hard reality of the situation . . . and determined that whatever else happened, the Bigarries and Halalkhors must be kept together at all hazards, as if they struck work and left, half the inhabitants would speedily follow them, and no single measure could be adopted against the plague either then or thereafter, nor could even the Europeans, Parsis, and high caste natives have remained in the City.1 Snow’s anxiety was indeed justified. Bombay sweepers had gone on strike in 1866 and 1889 for a mere ten days and a day and a half, respectively, “causing an inconceivable amount of danger and nuisance.”2 Another strike during a plague epidemic could very well have been the undoing of the second


Amna Khalid and Ryan Johnson

largest city of the British Empire and one of the most significant and active ports in the Arabian Sea. With this particular fear in mind Snow modified the plague segregation orders that were the source of discontent and anger amongst the sweepers; thereby retaining their services in the city and averting a grave threat to one of the main economic hubs of the British Empire. In a similar example, at the conclusion of an epidemic of plague that struck Accra in 1908, the capital of the Gold Coast (Ghana), the governor, John Rodger, commented: When dealing with . . . persons named in the accompanying correspondence, in connexion with services rendered in combating an epidemic, I think that the services of [those] unconnected with the Medical Department should be considered more deserving of special recognition than those of medical officers, and that the services of an unofficial are even more meritorious than those of a Government officer.3 In a display of candor, Rodger paid tribute to the importance of local men and women in the quick and efficient eradication of plague in the city, especially the role of local rulers in organizing and coordinating the large amount of labor required. So grateful was Rodger that he rewarded “subordinate officials” with small monetary sums, and in some cases new housing and accommodation.4 As these examples demonstrate, subordinate and intermediary agents on the ground were central to sanitation and public health practice in the British Empire. They formed the very base upon which the sanitary and health systems were built.5 Furthermore, as the examples suggest, these agents were able to influence and determine not only public health practice, but policy as well. It was the fear of collective action by the Halalkhors and Bigarries that informed the decision of the authorities to modify plague policy. While in the Gold Coast, colonial officials understood the paramount importance of ensuring the cooperation and assistance of local rulers and subordinate personnel. In this respect, colonial officials were obliged to communicate with subject populations through intermediary and subordinate agents, not least because of barriers of language and culture. Yet the historiography of public health in the colonies has focused, with a few exceptions,6 on debates in the upper tiers of colonial sanitary and medical administrations. These debates and professional rivalries in the process of policy making are important and have their place in the story of public health in colonial societies, but they do not capture the practice and implementation of public health policy on the ground. In addition, these accounts tend to portray colonial policy as the result of the imperial exigencies and the interests of colonial administrators, overlooking the manner and degree to which agents on the ground were able to impact policy. This volume, therefore, is the fi rst consolidated study addressing the importance of intermediaries and subordinates in the formation and



practice of public health policy across the British Empire. Our aim is to investigate the duties and responsibilities of these previously neglected medical and non-medical personnel, as well as intermediary agents such as local rulers. In doing so, we argue that colonial policy making was not a top-down process but one that subordinates and intermediaries helped to negotiate and shape. In order to understand how policies were formulated, what considerations went into designing sanitation and public health measures, and how they panned out in practice, it is imperative to take into account the agency of those responsible for instituting them. By shifting the focus to subordinate and intermediary personnel this collection of essays throws into relief a particularly “colonial” aspect of “colonial medicine”: the empire, although governed by British colonial officers, was largely run by intermediary and subordinate staff on the ground. By considering how the subjectivity of these agents influenced the manner in which they discharged their duties, and how this in turn shaped public health policy, this book also highlights the disaggregated nature of the colonial state—and the empire more generally—thereby challenging the understanding of the imperial project as an enterprise conceived of and driven by the center. From local political leaders and interpreters, to medical auxiliaries, nurses, matrons, hospital orderlies, pupil midwives, asylum attendants, and sweepers, the cooperation of intermediate and subordinate personnel was key to the functioning of most colonies’ public health machinery. Although our interest in subordinates and intermediaries is influenced by the initial concerns of the Subaltern Studies project of writing “history from below,”7 we have chosen not to refer to the agents that we are studying as subalterns. The different methods and styles of the many contributors to the subaltern school make it difficult to make generalizations about their approaches. Moreover, the emphases of the project have shifted and developed over time. As Ranajit Guha himself said, the idea of incorporating the subaltern in historical narratives gives “a new orientation within which many different styles, interests and discursive modes may fi nd it possible to unite in their rejection of academic elitism.”8 However, some assumptions are common to the work of the subalternists, such as the elite–subaltern dichotomy that lends itself to the kind of essentialism that risks an overly deterministic reading of history. As Sumit Sarkar has noted, one problem with the subaltern school is its “tendency . . . towards essentializing the categories of ‘subaltern’ and ‘autonomy,’ in the sense of assigning to them more or less absolute, fi xed, decontextualized meanings and qualities.”9 In other words, insufficient attention has been paid to internal variations and diff erences within the category of “subaltern.”10 Moreover, there is the tendency to locate the agency of the subaltern mainly in the act of resistance to domination. And in this domination–resistance framework “resistance itself should necessarily take the virile form of a deliberate and violent


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onslaught.”11 This approach, we believe, tends to reduce subordinate agency and power to acts of resistance, and in so doing risks overlooking other ways in which their agency may be deployed, such as when they use their power to exploit other subordinates. At this point, we would like to clarify what we are not investigating in this volume, primarily practitioners of indigenous systems of medicine, such as healers, diviners, and herbalists.12 Our focus is exclusively on agents implementing Western public health measures in connection with the colonial state. At times, this could include the work of healers, diviners, and herbalist; however, we are not assessing these individuals separate from their interactions with Western medicine and the state. Our categories of “intermediaries” and “subordinates” are broad and not mutually exclusive—indeed, quite often one who is a subordinate is also an intermediary and vice versa. We are aware of the danger of homogenizing these agents and it is not our intention to attribute a common agenda, aim, or consciousness to them as a collective. At the outset we wish to qualify the labels intermediary and subordinate by recognizing the immense diversity of individuals that fell under these umbrella terms. The aim of this collection of essays is to show that whereas British colonial officers were in positions of authority, it was intermediary and subordinate workers that often determined people’s experience of public health. They formed the backbone of the public health system and often wielded more influence and power than their superiors. In this sense, they were not “subordinate” or “intermediary.” If anybody was a subordinate or intermediary in this scenario, it was the colonial official. Nonetheless, we argue that the categories of intermediary and subordinate are analytically vital because they refl ect positions in the administrative hierarchy that determined an individual’s economic and social status; and, perhaps more importantly, their rank as intermediary or subordinate determined the kinds of strategies they used to exert power and influence. Without acknowledging their position relative to colonial officials, we risk not only misrepresenting how they were able to work and function in their daily lives, but also elide the paternalism and many indignities they often endured. Furthermore, the fact that they were employed as lower ranking staff often meant that outright opposition to authority was not viable, thus necessitating other, perhaps more covert, ways of serving their own interests. Secondly, we think the terms intermediaries and subordinates reflect quite accurately their position in the historiography of public health in the British Empire. As noted earlier, historians have focused on debates between colonial officers in the upper echelons of colonial and imperial administrations, with subordinate and intermediary personnel receiving considerably less attention. Therefore, in order to situate these works and the contribution this volume makes, it is instructive to fi rst investigate the key trends in the historiography that have been crucial for



understanding the intermediaries and subordinates explored throughout this volume.

PUBLIC HEALTH AND MEDICINE IN THE BRITISH EMPIRE Historians of public health and medicine in Britain’s former colonies have produced a substantial body of exciting scholarship over the last several decades. What started out as individual explorations around the social history of medicine in colonial contexts has blossomed into what can legitimately be called a field in its own right. Indeed, many different dimensions and aspects of health and medicine in Britain’s empire have been brought to the fore highlighting the complexity of what rightly comes under the banner “colonial medicine.” Early histories of medicine in Britain’s colonies were often celebratory accounts of colonial medical services and “heroic” medical men.13 Charles Rosenberg’s observation that the history of medicine written prior to 1960s was “a professional history, written by and largely for physicians” is borne out in these accounts that were generally authored by colonial medical officers.14 This scholarship declared Western medicine as one of the few benefits European colonial rule conferred on subject populations. By the 1970s, historians challenged this redemptive aspect of Western medicine and the strides made by medical officers in the control of epidemic diseases. A discernable shift was under way as scholars informed by political ecology of disease frameworks criticized earlier studies depicting Western science and medicine as a positive force.15 Instead they argued that political, economic, and social changes engendered by colonization had disrupted existing ecological balances and the health of local populations.16 In the case of Africa, John Ford’s seminal study of trypanosomiasis in East Africa showed that epidemic outbreaks of sleeping sickness in the early twentieth century were the product of environmental changes introduced by colonialism.17 Ira Klein reached similar conclusions by considering how colonial irrigation schemes in Bengal created the conditions for malaria epidemics.18 Several studies followed revealing how European invasion and intervention, rather than improving local health, had actually created conditions for the spread of disease.19 It was also argued that epidemic outbreaks precipitated by colonialism reflected and embodied the crisis of modernization. For example, Steven Feierman emphasized the need to reconsider the disease burden of colonies as the social cost of colonial development projects, drawing attention to how vulnerable sections of society (women, children, and rural inhabitants) bore the brunt of ill health. 20 Rural areas were also more susceptible to epidemic disease when the needs of colonial capitalism triggered massive population migrations. 21 Furthermore, the displacement of subsistence crops by cash crop farming unleashed famines that in turn created favorable conditions for the spread of disease. 22 Whereas in cities rapid


Amna Khalid and Ryan Johnson

urbanization and lack of town planning had set the stage for overcrowding and poor sanitation, similar problems defi ned the experience of plantation and mine workers. 23 These appalling conditions, coupled with infrastructural developments such as irrigation and railways, facilitated not only the movement of army troops and labor but also infectious disease. 24 Overall, single disease histories located in the political, economic, and social context of colonialism constituted a substantial part of the field during the 1970s and 1980s. 25 This trend established that disease and sickness, far from being the “natural” conditions of Britain’s colonies and their inhabitants, were instead the result of changes introduced by colonial rule. Up to now we have been considering histories of diseases, but what of medicine in the colonies? The publication of Daniel Headrick’s Tools of Empire in 1981 led the way for understanding Western medicine in the political context of colonization. Drawing on the usefulness of quinine in the supposed “opening up” of Africa for Europeans, he argues that Western medicine, far from being a benign force, was enmeshed in the political agenda of imperialism and served as a “tool” of empire. 26 Following Headrick’s scholarship, and alongside a political economy-ecology of disease approach, historians increasingly portrayed Western medicine in Britain’s colonies as a subjugating political force that held the potential for social control. The most potent example of this trend was the publication of Disease, Medicine, and Empire and Imperial Medicine and Indigenous Societies in 1988. Both edited volumes framed Western medicine as an “imperializing cultural force,” and argued that Western medicine “reveal[ed] . . . the nature and preoccupations, the ambitions and methods of an encompassing imperialism.”27 Colonial medicine thus came to be seen as a tool serving imperial ends in many different ways. For instance, Radhika Rammasubban argued that colonial medical concerns in British India were limited to the health of the army and European civilians. 28 Disease was considered the major enemy of the state, far outstripping military deaths from combat. In the case of India, historians agree that the health of Europeans and the army were key factors in determining the scope and “enclavist” nature of public health policy. 29 Medical institutions were not set up for the care of the public but to benefit the minority ruling class. 30 The colonial government’s policy was to detach itself as far as possible from the health concerns of the subject population; and, as Mark Harrison has shown, it was prepared to go to extraordinary lengths to adhere to this guiding principle. 31 It has also been argued that the British government’s fi nancial support for the London and Liverpool Schools of Tropical Medicine was “largely an expression of the desire to make the tropics safe for Europeans,” and “for the benefit of the imperial power.”32 Historians of the Caribbean maintain that colonial health policies privileged the medical needs of soldiers and other Europeans in the original “white man’s grave.”33 Indeed, one of the primary reasons for expanding



the gamut of Western medicine in the colonies to include local people was the realization that the majority of troops, drawn from local populations, could not be prevented from interacting with civilians. 34 These concerns formed the basis of institutionalized public health in the colonies. But as David Arnold stresses, although local populations and their health became a concern for colonial governments, “the military remained one of the prime incentives behind wider medical action” and “governments were prepared to commit resources to the protection of the army’s health and sanitation to an extent unthinkable for civilian populations.”35 Furthermore, he maintains that Western medical practitioners were rarely concerned with the ordinary ills of the people, rather “the diseases that preoccupied colonial medicine in the nineteenth century were epidemic diseases, the communicable diseases of the cantonment, civil lines and plantations, the diseases that threatened European lives, military manpower and male productive labor.”36 Diseases that had potentially grave consequences for trade and commerce became the other main impetus for sanitary reform and public health interventions. For instance, the colonial government’s sanitary and medical interventions at Hindu pilgrimage sites in India, and the draconian antiplague measures introduced in Hong Kong, India, and in the Cape Colony, stemmed from international pressure and fears of cholera and plague spreading to Europe via British trading ships.37 As some historians have argued, epidemic outbreaks forced colonial authorities to undertake largescale public health programs, particularly in the tropical colonies, where they were otherwise reluctant to do so.38 This interest in the health of local populations was also informed by the economic logic of capitalism: the need to maximize labor productivity on plantations, mines, and factories. High morbidity rates among workers (including migrant labor) had implications for the colonial economy, thereby necessitating intervention to control disease. 39 For example, Richard Sheridan’s work on plantations in the West Indies shows how political and economic pressures lay behind the provision of medical care and hospitals for slaves.40 The extension of Western medicine to “native” laborers was also used to justify such exploitive practices in the first place. It was maintained that once “natives” had their eyes opened to the curative powers of Western medicine, their hostility towards colonizers and capitalism would abate. This gave grist to the moral mill of “civilizing” the colonies, and fi rmly embedded medicine and public health in discourses legitimizing foreign capitalist rule.41 As Lewis and MacLeod argue, colonial governments “found their credibility as purveyors of European culture and rational government intricately tied to their power to control the spread of disease.”42 Although histories informed by political economy approaches continued to emerge, some historians turned their attention to the cultural processes and mentalities that helped establish imperial dominance. The English translations of Michel Foucault’s Madness and Civilization, The Birth of


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the Clinic, and Discipline and Punish, for better or worse, made his work accessible to English-speaking historians. Furthermore, the publication of Edward Said’s Orientalism in 1978 made for an explosive combination that propelled the trend of exploring colonial mentalities and the discourse of imperial governance. Foucauldian and Saidian theories encouraged historians to investigate the ideological underpinnings of colonial medical discourse thereby revealing that far from being benign and apolitical, Western medical knowledge was an inherently colonizing force.43 In her groundbreaking book Curing Their Ills, Megan Vaughan analyzes medical discourses on “the African” and argues that Western medicine was central to the process of “othering” through the construction of Africans as essentially different and inferior to Europeans in both body and mind. She demonstrates how the impact of Western medicine went far beyond the economic and political spheres, playing a significant role in shaping the identities of colonial subjects and legitimizing interventionist policies.44 The role of medicine in the construction of racial difference, gender, and madness became popular themes of investigation, once again throwing into relief the complicity of medical knowledge in “othering” non-Europeans.45 For example, James Mills argues that madness was seen to reside in the “native” body, and techniques such as autopsy and phrenology were central for rooting out and locating “madness.” As Mills reveals, many of those labeled “mad” and subsequently institutionalized were often individuals who questioned colonial domination and refused to work in its service.46 Engendered in this rendering of colonial subjects who challenged colonial authority as mad was the belief that colonial rule was normal, natural, and necessary. As subsequent studies argued, violent resistance to colonial rule was pathologized and framed as a psychological disorder that could “become infectious, even epidemic.”47 For instance, British liberals explained away the Mau Mau rebellion as a psychological condition precipitated by rapid modernization; the presupposition being that the “primitive” mind, confronted with such modernization, could not cope.48 Built into such accounts is also the assumption that Western medicine was operating as a tool of social control. As Alison Bashford demonstrates in Australia, vaccination was a way for the state to mark and control bodies (all immigrants had to be vaccinated) in order to make them more governable.49 Similarly, Arnold argues that medical intervention opened a way for the regulation of local religion and custom. He maintains that the colonial state’s intervention at Hindu pilgrimage sites to curb cholera was not merely an attack on disease, but “also an assault on Hinduism, one which was all the more authoritative for its invocation of medical science.”50 In a similar manner, Western medical knowledge was instrumental for instituting residential segregation along racial lines. 51 Indeed, experts in the new tropical medicine “declared segregation to be the fi rst law of hygiene in the tropics,” and the justification for the preferential treatment of Europeans was framed against the supposed ignorance of the “native” population. 52



Historians of Southeast Asia have interpreted anti-plague measures as a means to destroy the property, cattle, and desecrate the dead of the local population.53 Thus, understandably, Western medicine came to be seen as a way for the state to regulate and intervene in the lives of the colonized. Western medicine was also used to police and control the bodies and sexualities of those on the edge of society. Socially marginalized groups were often pathologized given that their peripatetic lifestyles transgressed societal norms.54 For example, M.W. Swanson has argued that the Cape government’s emphasis on sanitation in relation to plague policy was engendered by a desire to control such marginalized sections of society.55 Indian prostitutes (catering to the European single men in the army) were constructed as “principle carriers of venereal disease” and were subjected to mandatory examinations, forcible confi nement, and treatment. 56 The resulting Contagious Disease Acts have rightly been viewed as a means to control sections of the indigenous population deemed suspicious by the colonial state.57 In his influential book Colonizing the Body, Arnold demonstrates that the body of the colonized became the “site for the construction of the state’s authority, legitimacy, and control.”58 Drawing on Gramsci’s work he frames Western medicine as a hegemonic force, exploring the ways in which it came to acquire authority over and among Indians. He argues that perceived higher rates of disease were one of the key features that came to defi ne “the tropics.”59 The very idea of the tropics, according to Arnold, was a Western construct that was “particularized through the discussion of disease,” hence classifying “native” culture and environment as essentially distinct and fundamentally different from Europe’s.60 Certain disease came to be seen as originating in specific colonized spaces despite the fact that many were long present in Europe. For instance, cholera became Asiatic cholera; fevers became regionally specific such as Burdwan fever, Congo red fever, Rift Valley fever, West African relapsing fever, Mozambique ulcer, Guinea worm infection, and Bullinus Africanus.61 Furthermore, such diseases were portrayed as inextricably linked to the cultures, practices, and rituals of local populations, thereby constructing them as naturally inferior.62 Colonial medical discourse was thus not distinct from imperial ideology, but central to the process of essentializing and othering Britain’s colonies and its peoples. The framing of Western medicine as a subjugating force and means of social control also necessitated a discussion of local responses to such medical interventions. And the influence of Subaltern Studies, with its focus on writing history from below, lent further steam to the project of investigating such responses to Western medical practices. There was also a move towards understanding how Western medical practice subjugated local medical traditions and systems of healing. The tendency at fi rst was to reduce local responses to resistance exclusively; a focus that emphasized and reinforced the colonizer–colonized binary. As Waltraud Ernst argues:


Amna Khalid and Ryan Johnson This kind of approach conceives of medicine as determined mainly by the agenda of colonialism, at the cost of other social dimensions. It can become incongruously mono-dimensional and hence bad social history. There is more to medicine within a colonial setting than the discourse of colonialism—even when the limelight is not only on governmentality, hegemony and colonial identities but also on their companion counterparts of “resistance,” “ambiguity” and the “subaltern.”63

Presaging Ernst’s insights, historians as early as in the mid-1990s argued that the development of colonial medical knowledge and policies was far more complex than the frameworks of colonizer–colonized and center–periphery allowed for. As we have seen in the case of India, the colonial state was blamed for inadequate public health and sanitation programs, and the extremely limited scope of medical facilities.64 However, this assumption was called into question by historians focusing on the agency of Indians working at the provincial, municipal, and local levels. Given that many sanitary initiatives were thwarted by local politicians and municipal commissions to serve their own interests, it was argued that the colonial state was not entirely to blame.65 And portrayals of an all-powerful colonial state were further complicated by examples of successful vaccination drives in Princely States that deployed measures often more draconian than those of the colonizers.66 Along with calling into question the hegemony of the state, historians started interrogating the all-encompassing category of “the colonized” by demonstrating that not all local men and women had negative attitudes toward the colonial state and Western medicine. Not only had many educated elites cooperated and assisted public health measures, but they initiated drives themselves.67 Even within relatively confined regions, people responded to and made sense of state medical intervention differently. Biswamoy Pati’s study of the way different classes and castes, especially the non-tribal community, interpreted and responded to state medical interventions is an excellent example.68 Indeed, some local men and women used medical measures as a means to serve their own purposes. For example, I.J. Catanach argues that in India, nationalists deployed anti-plague measures to create public panic in order to consolidate support for their political cause.69 Several recent studies have also demonstrated that local men and women trained in Western medicine used their knowledge to bolster their authority and further nationalist ideals.70 And many indigenous practitioners recast their own medical systems along Western “scientific” lines in order to advance their own agendas.71 Importantly, such scholarship highlights the tensions between communities and classes in Britain’s colonies, problematizing scholarship that essentializes colonized populations into a single, monolithic entity.72 The category of “colonizer” has also come under increasing scrutiny. Like the colonized, colonizers were not a homogenous group. Debates and



disputes among policy makers reveal that many colonial medical officers contested official policy on moral grounds.73 As the study of smallpox vaccination policy in India highlights, many colonial administrations were often deeply divided.74 And in the case of psychiatry, certain disorders were used to confi ne and deport “insane” Europeans (those seen as weak and irrational) for fear that their behavior would tarnish the image of British officials and therefore undermine British claims of racial and cultural superiority.75 Furthermore, like the categories of colonizer and colonized, historians have questioned center–periphery models that presupposed the flow of scientific and medical knowledge from metropole to colony. They have demonstrated how colonial conditions and environments were important in the innovation and advancement of Western medicine, challenging assumptions of one-way exchanges between Western and local medical practitioners. In fact, they argue that Europeans often consulted local physicians and considered indigenous medical texts and practices as bodies of knowledge to learn from.76 For example, in their study of tuberculosis in Africa and India, Harrison and Worboys argue that whereas a uniform empire-wide discourse on tuberculosis existed, it emerged through a complex dialogue and exchange of ideas between experts located throughout Britain’s colonies. Therefore, the process of knowledge making and the movement of medical knowledge could never be conceived as a simple diffusion from metropole to colony.77 Inspired by such approaches, studies emerged that emphasized the importance of local factors in determining health policy. For instance, in the case of Ceylon, Margaret Jones shows how, contrary to the idea that Western medicine subjugated local medical systems, the colonial government went out of its way to accommodate vedic practitioners and encourage the study Ayurveda medicine.78 And because local governance was often devolved to local leaders in India and Ceylon, there are several examples of how they determined health policies and implementation.79 The situation was similar in the “white” settler colonies, with dominion medical policy often being more advanced than that of Britain. For example, New Zealand had established a Ministry of Health a full twenty years before the “mother country.”80 Indeed, some settler colonies such as Australia and Canada became significant sites for cutting-edge medical research.81 But even in colonies where Europeans did not settle, colonial outposts provided a more enabling environment for medical research and the development of new ideas that gained currency through informal networks of physicians and researchers across the empire.82 As this review suggests, the study of public health and medicine in Britain’s empire has grown at a rapid rate, benefitting from the various approaches mentioned in this section. Although the emphasis on local contexts remains important, historians are advancing the field still further by arguing that health and medicine in the colonies must be situated within broader international, global, and (more recently) transnational contexts.83 This approach highlights


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the importance of imperial connections, international pressures, and politics that impinged on the specificities of medicine within individual colonies.84 It has been particularly useful in breaking down the notion of Western medicine as progressive and modern versus local healing as traditional and static. The ingrained belief that local healing systems are unchanging is more easily challenged when such systems are placed in global perspective. The edited volume Plural Medicine investigates the extensive dialogue and exchange between local healing and “biomedicine” in India, Africa, New Zealand, and China, revealing throughout that medical systems expose themselves as inherently “mutli-faceted, forever in flux and never purely delineated.”85 Karen Flint’s recent study of traditional healing in KwaZulu Natal also transcends the binary between a static traditional medicine and a dynamic Western medicine by considering the interaction between African therapeutics and Western medicine, as well as the cross-pollination between African and Indian systems of healing. By looking at interactions between non-Western systems, Flint has de-centered Western medicine and made the development of African therapeutics with other systems the main focus.86 In a similar manner, historians of medicine in Britain’s colonies are turning their attention to local healers and other agents such as bonesetters, cauterizers, village midwives, diviners, and herbalists in order to explore the mixing of medical techniques from various systems.87 By focusing on these marginalized systems and healers, such studies are venturing into the exciting new territory of the “subaltern domain of healing.”88 Overall, historians of medicine in Britain’s colonies are moving away from broad analyses at the level of policy formation and rhetoric, and back to considering its practice on the ground.89 A hybrid approach is also emerging that considers a more nuanced understanding of the relationship between colonial mentalities and the practice of public health and medicine.90 There was often a disconnect between the rhetoric of colonial medical policy and what was achieved in practice. Scholars examining the complexity of public health practice in the colonies are demonstrating its fractured nature in terms of both knowledge and goals.91 Regardless of the grand hopes and ambitions of imperial medical discourse, the actual workings of medical policies were contingent on local factors and cultural specificities.92 And perhaps most importantly, in terms of both practice and formulation, it relied on the agency of local intermediary and subordinate workers. However, before moving on to consider these agents, and the chapters in this volume that underscore their importance, it is worth reviewing the extensive and growing literature outside of medicine and public health that considers local participation in empire.

LOCAL PARTICIPATION IN EMPIRE The running of the British Empire by local men and women is increasingly a theme of special interest for historians. A number of studies have



investigated their assistance in imperial and colonial operations, demonstrating how it was crucial to effective rule. Often this participation derived from working within the structures of the colonial state, but those working outside its confi nes, such as religious and commercial agents, were also influential. From local rulers, Western educated elites, interpreters, and clerks to police, soldiers, prison guards, teachers, clergymen, businessmen, and domestic and agricultural workers, scholars have shown that the whole of the British Empire required their cooperation if it were to remain intact. As Heather Sharkey argues in her study of British colonialism in the AngloEgyptian Sudan, “Empire worked on the ground because it relied on vast support staffs of clerks, technicians, teachers, and medics who handled the day-to-day tasks of colonialism.”93 This section reviews the prominent literature on local participation in empire, and for convenience follows what Timothy Parsons identifies as four broad categories: administrative (including local rulers and elites), coercive, cultural, and commercial.94 Arguably the category receiving the bulk of scholarly attention is that of local rulers and elites. For the most part they are investigated in relation to policies of Lugardian “indirect rule,” or various independence campaigns, being framed as either heroic rebels or traitors to larger national movements. One of the fi rst historians to explore this dynamic of local participation is Ronald Robinson.95 Drawing on his influential eccentric, periphery led theories of imperial expansion with John Gallagher,96 Robinson maintains that understanding the dynamics of local collaboration is crucial for explaining the success of the “thin white line”: the rule of a small cadre of European officials over a significantly larger subject population.97 Robinson deploys the term “bargains of collaboration” to describe the manner in which the colonial state negotiated with local rulers and elites to provide the stability and access to resources necessary for maintaining colonial rule. Later, Robinson and Henk Wesseling tempered “bargains of collaboration” with the term “unequal bargains,” to account for the political and material differences that existed in favor of the state.98 For example, Wolfgang Mommsen argues that displays and threats of military force created the conditions necessary for negotiating such bargains.99 Following Robinson, historians have expanded upon theories of unequal dependence and collaboration, drawing into relief the resistor–collaborator dichotomy. For instance, C.A. Bayly in his study of Hindustan just prior to and during the period of British colonization traces out the relationships between local rulers, commercial agents, and merchants, demonstrating how they reacted, adapted, influenced, and resisted the scope of British influence.100 In another important study investigating the establishment and process of British colonial rule in northern India, Bayly uncovers the East India Company’s, and later the colonial state’s, vast network of surveillance agencies and informal social communicators.101 Bayly describes an intricate “information order” largely mediated by Indian agents, and argues that without the military and political intelligence they cultivated,


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the British could not have established economic and political control in the region. As colonial rule intensified, the British, sensing their own vulnerability, strove for less dependence on such networks and the agents that controlled them. But as Bayly demonstrates, the British were never able to do so. Furthermore, given that the “information order” was dependent upon the agency of local intermediaries, the very networks of intelligence vital to the emergence and maintenance of the Indian empire would also become a source of its demise. In their studies focusing on Africa and empire both Edward Steinhart and A. Adu Boahen show how local African rulers moved between collaboration and resistance depending on the political and economic pressures they faced.102 Shula Marks puts forward similar arguments by demonstrating the “ambiguities” of dependence between local rulers, the educated elite, and the state, which allowed for an uneasy, yet effective form of colonial rule in South Africa.103 More recently, James Onley has detailed the nature of colonial rule in British India’s Political Residency in the Persian Gulf. He argues that the effectiveness of the Resident’s rule in the region derived largely from working within local political structures, which resulted in a “collaborative power triangle between the Resident, his native agents, and the rulers that sustained Britain’s informal empire in the Gulf.”104 The British policy of indirect rule, which fi rst arose in India’s Princely States, and more famously throughout large parts of British colonial Africa during the interwar period, is another influential area of the study in relation to local ruler’s and elite’s agency.105 After World War I, several overstretched and underfi nanced colonial administrations sought to devolve authority to “traditional” rulers in order to maintain British political and economic control. Often, these newly appointed “Native Authorities” did not have ancestral claims to power, and only gained legitimacy through their ability to manipulate and serve British interests. For instance, Mahmood Mamdani argues that in South Africa a system of “decentralized despotism” emerged when chiefs, arbitrarily appointed by “Native Councils,” ruled with few checks to their power as long as they supplied the necessary labor and conditions for effective colonial rule.106 Recently, Colin Newbury has revived the work of anthropologists and social scientists investigating the many patron–client relationships established throughout the empire during the nineteenth century and twentieth century.107 Drawing on their fi ndings, he argues that historians can benefit from “a model of relationships between rulers and ruled based on the status differences and reciprocal advantages implicit in the patron–client construct.”108 Newbury maintains that such patron–client alliances are perhaps more analytically useful than formal administrative terms such as “indirect rule” and “collaboration.” According to him, historians of empire should look beyond the specifics of imperial policy, focusing instead on the dialogue established between hierarchical leaders and imperial administrators in the quest for political and material advantages. Rather than



privileging metropolitan policy and political ideals, Newbury’s arguments reinforce the importance of investigating the interface of colonial negotiation when trying to understand the nature of colonial rule. Scholarship focusing on local rulers and elites has been important in terms of understanding local agency; however, historians are shifting their focus back to the work of everyday colonial subjects—an approach pioneered by British labor historians and Subaltern Studies—rescuing them from often monolithic and dualist narratives. They stress the importance of the numerous intermediary and subordinate staffs that composed the administrative infrastructure of empire. The work of these mid- to lowlevel aides was vital to the daily running of empire; and, according to Guha, allowed empire to operate in a state of “dominance without hegemony.”109 However, as Parsons notes, their participation also reveals the “relative fragile inner workings of colonialism.”110 The most common participation in this respect consisted of interpreters, court employees, accountants, postal employees, railway workers, and district office clerks. Within this category interpreters were especially important as they negotiated the many linguistic and cultural barriers standing between European officials and local populations. In this way, they were able to influence the type and scope of colonial policy, which often derived from a desire to further their own individual interests. In their edited volume, Intermediaries, Interpreters, and Clerks: African Employees in the Making of Colonial Africa, Benjamin Lawrence, Emily Osborn, and Richard Roberts maintain that the agency of low- to middle-level African interpreters and clerks is often neglected in favor of local rulers and elites; and that closer investigation into their daily routines is necessary to further complicate standard binaries of collaboration– resistance, colonizer–colonized. Taking up the challenge posed by Frederick Cooper to move beyond resistor–collaborator dichotomies,111 they argue, “Africans who rendered crucial services to Europeans also acquired skills, knowledge and situated authority with which they furthered their own strategies of accumulation.”112 In other words, many African clerks and interpreters were neither passive lackeys of the state nor fervent nationalists bent on ousting their European employers. Lower level administrators, like local rulers and elites, were also keen to accumulate wealth, political power, and status. Coercive mechanisms of the colonial state, namely, the police and army, constitute another important category of local participation in empire. The work of colonial police and military forces was vital given that, “Effective colonial government rested on two basic pillars: firstly, the maintenance of law and order to uphold the authority of the administration; and secondly, the collection of adequate revenue with which to finance the running of the colony.”113 In relation to India and the Indian Ocean arena, Thomas Metcalf argues that “the initial conquests on the ground were the work of Indians, the sepoy soldiers of the Indian Army; and the policing of the conquered


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territories fell to Indian, usually Sikh troopers.”114 In his lucid and ingenious account, Metcalf reveals how Indians in the colonial army and police “helped sustain the fabric of empire.”115 Throughout the nineteenth and twentieth centuries most of Britain’s colonies filled posts in the police and military with local recruits given both the expense and lack of European volunteers.116 Staffing the police and military forces with local recruits, like filling subordinate administrative posts, was less of a financial burden, which was especially important given Whitehall’s expectation that colonies pay for themselves. Many of the first colonial police forces were based on the Royal Irish Constabulary, or the “Irish model.”117 In this case, colonial police officers were expected to carry out similar duties as their European counterparts; however, the role of most colonial armies—the Indian Army being the major exception—was different to that of Western military forces. While they guarded the colonial frontier, and aided neighboring colonies during times of strife, their most important function was to ensure internal peace and enforce unpopular policies aimed at bolstering domestic production and tax collection. Only rarely were they expected to fight and win wars, or defend the colony against invasion by a foreign power.118 Furthermore, unlike their administrative counterparts, those that enlisted in the colonial police and army—sometimes by force and coercion, but generally on their own accord—were predominantly uneducated laborers and agricultural workers from ethnically marginal groups.119 For these individuals, joining the police or military offered more generous pay, and a level of status and power that would be difficult to achieve otherwise. Whereas most local men and women resented the colonial police and army for enforcing alien and autocratic laws, the benefits of working for the state in this capacity generally outweighed such negatives. Given most local constables and soldiers had neither close ties to the people over whom they enforced laws nor a sense of allegiance to a foreign administration that recruited them, they used their positions of power to also bolster their individual wealth, status, and power. Another crucial category of local participation in empire includes the many teachers, clergymen, missionaries, and other educators imparting the cultural and normative values of the colonial administration to subject populations. According to Sharkey, educating local men and women was critical in order to satisfy the demand for semi-skilled and literate employees to fill the many administrative branches of the colonial state.120 The education these individuals received acculturated them to the values and goals of the colonial regime, providing a common worldview conducive to effective rule. In this case, Sharkey argues that cultural technologies such as state-sponsored educational institutions and churches, and the cultural intermediaries who ran them, were perhaps more important than the coercive mechanisms of the colonial police and military.121 Furthermore, missions played a central role in this process, as most of the instructors were clergymen or attached to missionary societies. Although these instructors were first and foremost concerned with their mission and producing converts, they played a significant role in preparing



their students to accept and participate in an exploitive colonial economy. And, as Parsons argues, these cultural intermediaries were perhaps the biggest threat to the stability of the colonial state given “[t]heir familiarity with the legitimizing ideologies of British rule [that] gave them the ability to mobilize African resistance by adapting and reinterpreting Western cultural values to raise doubts about the morality of colonialism.”122 However, Carol Summers reminds us that Africans educated in state-sponsored missions and schools in Southern Rhodesia, modern-day Zimbabwe, did not simply follow patterns of resistance or acquiesce, “and portrayed themselves and acted neither like rebels nor victims.”123 Instead, these “middles took on board new ideas, and created new identities; in short, they acted as individuals”; and in doing so, “they could cripple or aid government and mission initiatives. They could play one patron off against another. They could, in other words, shape the colonial agenda, and block or force revisions on specific colonial initiatives.”124 The many agents and intermediaries working for European commercial firms constitute yet another vital category of local participation in empire; and like the colonial state, European businesses could not function without the skilled and semi-skilled labor of local men and women. They required clerks to supervise accounts, type and manage correspondence, and broker sales, along with the work of tradesmen such as carpenters and mechanics, and others to run shipping, mining, agricultural, and railway posts.125 For instance, Metcalf, investigating indentured Indian workers, or “coolies,” laboring throughout the Caribbean, West Indies, East and South Africa, argues that “the willing arms and backs of hundreds of thousands of Indian laborers alone enabled the empire, and by extension Britain itself, to prosper.”126 He also notes the importance of Indians equipped with money and entrepreneurial skills who took advantage of the numerous trading opportunities that empire held out, especially in regions such as East Africa.127 Overall, whereas this review of the prominent categories of local participation in empire is not exhaustive, it reinforces one important point: the crucial role of intermediaries and subordinates in the running of empire. In addition, all of the points just made pertaining to the categories of local participation in empire apply equally well to those working in medical and public health capacities. However, as noted in the preceding, the role of these intermediaries and subordinates, and their possible influence on the shape and scope of public health policy, has, with few exceptions, been overlooked.

INTERMEDIARIES, SUBORDINATES, AND PUBLIC HEALTH IN THE BRITISH EMPIRE Much of the historiography of public health and medicine in the colonies has focused on policy making within colonial administrations; however, the role of intermediaries and subordinates has not been entirely ignored. Historians have investigated the relationship between elite rulers, the colonial

18 Amna Khalid and Ryan Johnson state, and subject populations in the context of public health programs as well as that of local practitioners of Western medicine.128 For example, Mridula Ramanna has stressed the importance of Indian doctors as intermediaries in propagating the anti-smallpox campaign in colonial India.129 It is only more recently that the role of subordinate personnel in the medical administration of Britain’s colonies has attracted attention. A recent study by Sanjoy Bhattacharya, Mark Harrison, and Michael Worboys sheds light on vaccinators employed for smallpox inoculation programs in British India.130 And James Mills’s work on lunatic asylums in India argues that subordinate personnel in charge of these institutions influenced treatment regimes to suit their own concerns.131 An emerging body of literature on nurses, both European and local, in colonial contexts has investigated their role as intermediaries and “cultural brokers.”132 Maryinez Lyons’s insightful and influential study of medical auxiliaries in the Belgian Congo pioneered the importance of subordinate and intermediary agency.133 This edited volume adds to such scholarship by drawing attention to the significance of intermediaries and subordinates across the British Empire, both local and European, in the day-to-day practice of public health. In most colonies, especially the Crown Colonies and British India, public health initiatives were only made possible by enlisting the help of local men and women. Their work was crucial for a thinly spread colonial administration; and, as noted earlier, colonial officials could not avoid the need to communicate with subject populations through intermediary and subordinate staff due to language and cultural barriers. Atsuko Naono’s chapter on the health service in colonial Burma demonstrates how colonial health operations during the interwar period were successful largely due to the increasing engagement of the Burmese in health service propaganda campaigns. She argues that during the 1920s and 1930s Western public health measures were promoted successfully because the Burmese Hygiene Publicity Officer was able to translate across languages and cultures. James Mills, in his chapter on mental asylums in Egypt and India, also shows the reliance of colonial officials on subordinate staff to translate and interpret daily tasks, and the anxiety that this engendered. Ryan Johnson makes similar observations in his chapter on an epidemic of plague that hit Accra, the capital of the Gold Coast (Ghana), in 1908. Public health authorities were in a particularly poor position to deal with the disease, yet the epidemic was dealt with relatively quickly in part because local interpreters were able to translate government ordinances and ease political tensions between local leaders. Colonial authorities also relied on intermediary and subordinate staff to combat the supposedly “superstitious” and “backward” convictions and traditions of local populations. It was hoped that once subordinates were trained in the principles of Western medicine they would demonstrate its “superiority” to fellow colonial subjects. In his chapter on colonial Zambia, Walima T. Kalusa argues that this was the intention of Kalene Hospital



missionaries and colonial authorities. Similarly, Seán Lang’s chapter on pupil midwives in colonial Madras investigates the training of local women in Western midwifery, with the express purpose of undermining the influence of the “dangerous” and “old-fashioned” dai, the traditional birth attendant. The assumption amongst British medical officers was “that the merest contact with Western science would instantly cause the scales to fall from Indian eyes.” Yet as both Kalusa and Lang show, the aims of the authorities were being constantly undermined. For example, African auxiliaries in Zambia, knowingly or unknowingly, according to Kalusa, transformed the practice of Western medicine by integrating it within Lunda healing practices and understandings of disease; while the pupil midwives in Madras, who were trained with the expectation that upon qualifying they would serve the colonial hospital, left for greener pastures as soon as they received their certificate. It is in this tension between public health policy and practice that the agency of intermediaries and subordinate staff is located. While colonial officers were in positions of authority the actual running of institutions and initiatives was devolved to subordinate staff. Juanita De Barros argues, in her chapter on infant-saving leagues in Barbados, that the “laudable experiment” in infant welfare work was the result of medical intermediaries. Mills demonstrates how the efforts of colonial officials to introduce moral therapy regimes in Indian asylums were undermined and altered by subordinate staff. One of the key questions that arises throughout the volume is: how do we read and understand the frustration of official policy by intermediaries and subordinates? Was it deliberate, or more complicated than this? In order to address this issue, we need to consider the motivations of such agents. Although it is tempting to see the subversion of policy as inherently anti-colonial and anti-imperial, often such incidents were acts of self-preservation and survival. As Margaret Jones notes in her chapter on Jamaica, oppressive colonial institutions afforded opportunities for staff “to survive and even prosper.” Crucially, as Jones’s chapter demonstrates, such acts of subversion must be seen in the context of the socio-economic and political conditions that determined an individual’s intermediary and subordinate status. Similarly, we need to consider local socio -economic and political contexts to understand why intermediaries and subordinates cooperated to achieve policy aims. In his chapter on plague in Accra, Johnson shows how local leaders’ efforts to promote the government’s anti-plague measures were informed by the need to legitimize their social and political positions vis-à-vis other local leaders. In this case, reading the actions of staff only in relation, or isolation, to the colonial state fails to capture the complexity of their position and motivations. Intermediaries and subordinates straddled two cultures, and in order to understand their roles inside the colonial hierarchy we need to take into consideration their positions outside the colonial administration, and how the tension between the two impinged upon and related to their professional lives.

20 Amna Khalid and Ryan Johnson In addition to showing how intermediary and subordinate personnel shaped the practice of public health, the contributions to this volume underscore their significance in the making of policy itself. Even on the lower rungs of colonial administration they were able to shape and influence policy, albeit at times unwittingly. For instance, Jones’s chapter demonstrates how the conduct of subordinate staff at the Kingston Public Hospital and Lunatic Asylum was the catalyst for standardizing policy within institutions across the British Empire. An inquiry into their behavior in response to complaints of neglect and cruelty formed the basis for an empire-wide asylum policy. Whereas the agency of this lower staff would most commonly have been portrayed in the moment of resistance to domination, Jones’s chapter shows how a domination–resistance framework is actually limiting in this case, as it situates their power in the act of defiance alone. Subordinate power at times lay in doing nothing at all, with the perceived threat of “insubordination” itself being sufficient to have an impact on policy. Amna Khalid’s chapter on sweepers in nineteenth-century northern India reinforces this insight by investigating the development of the system of waste disposal under colonial rule. She argues that in order to understand how subordinates were able to influence public health policy, historians need to move beyond the act of resistance as the sole manifestation of subordinate power. Given the absolute indispensability of intermediary and subordinate staff for public health, and the degree to which they were in control on the ground, the labels “intermediary” and “subordinate” may seem entirely inaccurate and unacceptable. But their status in the official hierarchy is significant as it determined the ways in which they could assert their power. Anne Digby’s chapter on South African hospital orderlies and assistants is a potent example in this case. Digby reveals the politics of authority in these institutions, and how subordinate posts, which grew to include tasks of their superiors, threatened European medical practitioners. In the long run, only those posts that ensured their continued subordination to white doctors were retained for subordinate staff. The status of subordinate staff in South African hospitals determined the opportunities available to them, which in turn shaped their professional and social progress. In this case, to deny them the historical status of intermediary and subordinate is to also deny the lower pay, racism, paternalism, and at times violence they endured, if even momentarily, while still managing to run the public health machinery of the empire. Collectively the chapters in this volume emphasize the necessity of considering the role of intermediaries and subordinates in the formulation and practice of public health policy throughout the British Empire. As demonstrated in the review of local participation in empire in the preceding section, this approach has implications for the way in which the imperial project and colonial state is conceptualized; and historians of public health and medicine in the British Empire have much yet to say in this respect. As argued by



Bhattacharya, Harrison, and Worboys, an understanding of the many ways in which local officials often modified, changed, and at times discontinued practices, based on their direct experience and views, brings to the fore the “fractured” nature of the colonial state.134 Their study challenges monolithic representations of the state, colonial officials, and local populations, urging us to contemplate the complexity of colonial governance. Furthermore, an exploration of intermediary and subordinate agency reveals that contrary to the commonly held belief that colonial public health administrations were largely a male affair, women, both local and European, played a considerable part in the making and execution of public health policy. As can be seen from De Barros’s, Jones’s, and Lang’s chapters especially, a significant part of public health provision was in the hands of matrons, nurses, and midwives, who were in positions to determine or alter public health policy and practice. By changing our perspective and considering the roles and significance of subordinates and intermediaries in colonial societies, we are compelled to rethink the nature of the colonial state and those behind its operation. Who knows what other aspects of colonial governance may be challenged by further studies of these agents?

NOTES 1. P.C.H. Snow, Report on the Outbreak of Bubonic Plague in Bombay 1896–97 (Bombay: Times of India Steam Press, 1897), 4–5. 2. Snow, Report on Plague, 3. 3. NA: CO/879/98, Governor to the Secretary of State, July 25, 1908, 186. 4. Ibid. 5. Indeed, many empires have relied on intermediaries for the establishment and maintenance of imperial rule. See Michael Doyle, Empires (New York: Cornell University Press, 1986), 31–50. 6. See the following for a discussion of recent works that consider the role of subordinates and intermediaries in public health in the British Empire. 7. Sanjoy Bhattacharya, “History from Below,” Social Scientist 11, no. 4 (1983): 3. 8. Ranajit Guha, “Preface,” in Subaltern Studies II, ed. R. Guha, vii (Delhi: Oxford University Press, 1983). 9. Sumit Sarkar, “The Decline of the Subaltern in Subaltern Studies,” in Writing Social History, ed. Sumit Sarkar, 88 (Delhi: Oxford University Press, 1997). 10. See also Anand Yang, “Review of Subaltern Studies II,” Journal of Asian Studies 45, no. 1 (1985): 178. 11. Rosalind O’Hanlon, “Recovering the Subject: Subaltern Studies and Histories of Resistance in Colonial South Asia,” Modern Asian Studies 22, no. 1 (1988): 223. 12. See David Hardiman’s project on the history of the subaltern domain of healing at the Centre for the History of Medicine at Warwick University: subalternhealing/. 13. Some examples are: D.G. Crawford, A History of the Indian Medical Service: 1600–1913, vol. 2 (London: Thacker, 1914); Andrew Balfour, The War


14. 15.



18. 19.

20. 21.

Amna Khalid and Ryan Johnson against the Tropical Disease: Being Seven Sermons Addressed to All Interested in Tropical Hygiene and Administration (London: Tindell and Cox, 1920); H. Harold Scott, A History of Tropical Medicine (London: Edward Arnold, 1939); Michael Gelfand, Tropical Victory: An Account of the Influence of Medicine on the History of Southern Rhodesia, 1890–1923 (Cape Town: Juta, 1953); Aldo Castellani, Microbes, Men and Monarchs: A Doctor’s Life in Many Lands (London: Gollancz, 1960); J.J. Mckelvey Jr., Man against Tsetse: Struggle for Africa (London: Cornell University Press, 1973). While being somewhat more critical, the following studies also portrayed medicine in Britain’s colonies in an overall positive light. See Michael Gelfand, A Service to the Sick: A History of the Health Services for Africans in Southern Rhodesia, 1890–1953 (Gweru: Mambo Press, 1976); Ann Beck, A History of the British Medical Administration of East Africa (Cambridge, MA: Harvard University Press, 1970); Ralph Schram, A History of the Nigerian Health Services (Ibadan: Ibadan University Press, 1971); Colin Baker, “The Government Medical Service in Malawi: An Administrative History, 1891–1974,” Medical History 20, no. 3 (1976): 296–311. Charles E. Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge: Cambridge University Press, 1992), 2. For an overview of dependency theory and the political economy of health, see Lynn M. Morgan, “Dependency Theory in the Political Economy of Health: An Anthropological Critique,” Medical Anthropology Quarterly 1, no. 2 (1987): 131–154. Also see R. Jeffery, The Politics of Health in India (Berkeley: University of California Press, 1988). There was a parallel move in Britain’s history of medicine exemplified by Lesley Doyal’s influential work The Political Economy of Health (London: Pluto Press, 1979). John Ford, The Role of Typanosomiases in African Ecology: A Study of the Tsetse Fly Problem (Oxford: Clarendon Press, 1971). For an exposition of the failure of colonial medical programs, also see Randall Packard, White Plague, Black Labor: Tuberculosis and the Political Economy of Health and Disease in South Africa (Berkeley: University of California Press, 1989); and Ian Catanach, “Plague and the Tensions of Empire: India, 1896–1918,” in Imperial Medicine and Indigenous Societies, ed. David Arnold, 149–171 (Manchester: Manchester University Press, 1988); Kenneth Kiple, “Cholera and Race in the Caribbean,” Journal of Latin American Studies 17, no. 1 (1985): 157–177. Ira Klein, “Malaria and Mortality in Bengal, 1840–1921,” Indian Economic and Social History Review 9, no. 2 (1972): 132–160. See T.O. Pearce, “Political and Economic Changes in Nigeria and the Organization of Medical Care,” Social Science and Medicine 14, no. 2 (1980): 91–98; Meredith Thurshen, The Political Ecology of Disease in Tanzania (New Brunswick, NJ: Rutgers University Press, 1984); John Farley, Bilharzia: A History of Imperial Tropical Medicine (Cambridge: Cambridge University Press, 1991); Maryinez Lyons, The Colonial Disease: A Social History of Sleeping Sickness in Northern Zaire, 1900–1940 (Cambridge: Cambridge University Press, 1992); Toyin Falola and Dennis Ityavyar, eds., The Political Economy of Health in Africa (Athens: Ohio University Press, 1992). Steven Feierman, “Struggles for Control: The Social Roots of Health and Healing in Modern Africa,” African Studies Review 28, no. 2/3 (1985): 12. See Shula Marks and Neil Anderson, “Typhus and Social Control: South Africa, 1917–50,” in Disease, Medicine, and Empire, ed. Roy Macleod and Milton Lewis, 257–283 (London: Routledge, 1988); Myron Echenberg, Black Death, White Medicine: Bubonic Plague and the Politics of Health in Colonial Senegal, 1914–1945 (Portsmouth: Heinemann, 2002), chaps. 7 and 9.



22. Marc Dawson, “Disease and Population Decline of the Kikuyu in Kenya, 1890–1925,” University of Edinburgh Centre for African Studies African Historical Demography 2 (1981): 121–138; David Arnold, “Social Crisis and Epidemic Disease in the Famines of Nineteenth-Century India,” Social History of Medicine 6, no. 3 (1993): 385–404. 23. Ira Klein, “Death in India,” Journal of Asian Studies 32, no. 4 (1973): 639– 659; “Urban Development and Death: Bombay City, 1870–1914,” Modern Asia Studies 2, no. 4 (1986): 725–754; Randall Packard, “Tuberculosis and the Development of Industrial Health Policies on the Witswatersrand, 1902– 1932,” Journal of Southern African Studies 13, no. 2 (1987): 187–209; Pamela Wood, Dirt, Filth, and Decay in a New World Arcadia (Auckland: Auckland University Press, 2005); I.R. Phimister, “African Labor Conditions and Health in the Southern Rhodesian Mining Industry, 1898–1953,” in Studies in the History of African Mine Labor in Colonial Zimbabwe, ed. I.R. Phimister and C. van Onselen Gwelo, 102–150 (Berkeley: University of California Press, 1987). 24. See David Killingray, “The Influenza Pandemic of 1918–1919 in the British Caribbean,” Social History of Medicine 7, no. 1 (1994): 59–87; David Arnold, “Cholera and Colonialism in British India,” Past and Present 113 (1986): 118–151; and J.W. Brown, “Increased Intercommunication and Epidemic Disease in Early Colonial Ashanti,” in Disease in African History: An Introductory Survey and Case Studies, ed. G.W. Hartwig and K.D. Patterson, 180–206 (Durham, NC: Duke University Press, 1978). 25. For example, Arnold, “Cholera and Colonialism”; Killingray, “Influenza Pandemic”; Klein, “Malaria and Mortality.” See also Alan Mayne’s chapter on smallpox in Melbourne and Sydney, Shula Marks and Neil Anderson’s chapter on typhus in South Africa and Rodney Sullivan’s chapter on cholera in the Philippines in Macleod and Lewis, Disease, Medicine, and Empire, 219–241, 257–283, 284–300. See David Arnold’s chapter on smallpox in India, Maryinez Lyon’s chapter on sleeping sickness, Terence Ranger’s chapter on influenza and Ian Catanach’s chapter on plague in Arnold, Imperial Medicine, 45–64, 105–124, 172–188, 149–171. There was a similar trend in the medical histories of the metropole. See Richard J Evans, Death in Hamburg: Society and Politics in the Cholera Years 1830 –1910 (Oxford: Oxford University Press, 1987); Paul Slack, The Impact of Plague in Tudor and Stuart England (Oxford: Oxford University, 1985); Margaret Pelling, Cholera, Fever and English Medicine, 1825–1865 (Oxford: Oxford University Press, 1978); Allan Brandt, No Magic Bullet: A Social History of VD in the United States since 1880 (New York: Oxford University Press, 1985). 26. Daniel Headrick, Tools of Empire: Technology and European Imperialism in the Nineteenth Century (Oxford: Oxford University Press, 1981). 27. MacLeod and Lewis, Disease, Medicine and Empire, x; Arnold, Imperial Medicine, 2. 28. Radhika Ramasubban, Public Health and Medical Research in India: Their Origins and Development under the Impact of British Colonial Policy (Stockholm: SAERC, 1982). 29. See David Arnold, “Medical Priorities and Practice in 19th-Century British India,” South Asia Research 5 (1985): 167–183; David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth Century India (Berkeley: University of California Press, 1993), chap. 1. For the medical discourse on hill stations in the nineteenth century, see Dane Kennedy, The Magic Mountains: Hill Stations and the British Raj (Berkeley: University of California Press 1996), 19–29; Mark Harrison, Climates and





33. 34.


36. 37. 38.




Amna Khalid and Ryan Johnson Constitutions: Health, Race, Environment and British Imperialism in India (Oxford: Oxford University Press, 1999), 124–132. Radhika Ramasubban, “Imperial Health in British India, 1857–1900,” 38–60; J.C. Hume, “Colonialism and Sanitary Medicine: The Development of Preventive Health Policy in the Punjab, 1860–1900,” Modern Asia Studies 20, no. 4 (1986): 703–724; Anil Kumar, Medicine and the Raj: British Medical Policy 1835–1911 (Walnut Creek, CA: Altamira Press, 1998). Mark Harrison, Public Health in British India: Anglo-Indian Preventive Medicine, 1859–1914 (Cambridge: Cambridge University Press, 1994), 99–116. See also Phillip Curtin, Disease and Empire: The Health of European Troops in the conquest of Africa (Cambridge: Cambridge University Press, 1988). I.J. Catanach, “Plague and the Tensions of Empire,” 165. According to Susan Abeyasekere, the Dutch East India Company in Batavia had a similar policy focusing almost exclusively on the health of company servants. See Susan Abeyasekere, “Death and Disease in Nineteenth Century Batavia,” in Death and Disease in South East Asia: Explorations in Social, Medical and Demographic History, ed. Norman Owen, 197 (Singapore: Oxford University Press, 1987). Juanita De Barros and Sean Stilwell, “Introduction: Public Health and the Imperial Project,” Caribbean Quarterly 49, no. 4 (2003): 1–11. See Douglas M. Peers, “Soldiers, Surgeons, and the Campaigns to Combat Sexually Transmitted Diseases in Colonial India, 1805–1860,” Medical History 42, no. 2 (1998): 137–160; John Farley, “Bilharzia: A Problem of ‘Native Health’, 1900–1950,” in MacLeod and Lewis, eds., Disease, Medicine and Empire, 189–207. Arnold, Imperial Medicine, 19. Lewis and Bamber have argued that in colonial societies the incidence of venereal disease in civilians was not a matter of state concern even during the twentieth century—it was the health of the military that remained the main concern of the state. Milton Lewis and Scott Bamber, “Introduction,” in Sex, Disease, and Society: A Comparative History of Sexually Transmitted Diseases and HIV/AIDS in Asia and the Pacific, ed. Milton Lewis, Scott Bamber and Michael Waugh, 3 (Westport, CT: Greenwood Press, 1997). Arnold, Colonizing the Body, 254. For sanitary measures at Hindu sacred sites, see Arnold, “Cholera and Colonialism.” David Arnold, “Medicine and Colonialism,” in Companion Encyclopedia of the History of Medicine, vol. 2, ed. W.F. Bynum and Roy Porter, 1402 (London: Routledge, 1993). Ramasubban argues that the cholera epidemics of the mid-nineteenth century were key in shaping public health policy in India in “Imperial Health.” Kiple makes a similar argument for the Caribbean in “Cholera and Race.” Lyons, Colonial Disease; Packard, White Plague; M.W. De Lancey, “Health and Disease on the Plantations of Cameroon, 1884–1939,” in Disease in African History, ed. Hartwig and Patterson, 157–179; Chee Heng Leng, “Health Status and the Development of Services in a Colonial State: The Case of British Malaya,” International Journal of Health Services 12, no. 3 (1982): 397–419. Richard B. Sheridan, Doctors and Slaves: A Medical and Demographic History of Slavery in the British West Indies, 1680–1834 (Cambridge: Cambridge University Press, 1985), chaps. 9, 10 and 11. Note that the quality and effectiveness of medical services was mixed, see 329–337. See Lenore Manderson, “Health Services and the Legitimization of the Colonial State: British Malaya, 1786–1941,” International Journal of Health Services 17, no. 1 (1987): 91–112.



42. MacLeod and Lewis, Disease, Medicine, and Empire, 11. 43. See Michel Foucault, Discipline and Punish: The Birth of the Prison (New York: Penguin, 1977) and The Birth of the Clinic (London: Routledge, 1973); Edward Said, Orientalism (New York: Vintage Books, 1978). 44. Megan Vaughan, Curing Their Ills: Colonial Power and African Illness (Cambridge: Cambridge University Press, 1991). 45. See Sander Gilman, Difference and Pathology: Stereotypes of Sexuality Race and Madness (Ithaca, NY: Cornell University Press, 1985); Nancy Leys Stepan, The Idea of Race in Science: Great Britain 1800–1960 (New York: Macmillan, 1973); Malcolm Nicolson, “Medicine and Racial Politics: Changing Images of the New Zealand Maori in the Nineteenth Century,” in Arnold, ed., Imperial Medicine, 66–104; Sally Swartz, “The Black Insane in the Cape, 1891–1920,” Journal of Southern African Studies 21, no. 3 (1995): 399–415; Sally Swartz, “Colonizing the Insane: Causes of Insanity in the Cape, 1891–1920,” History of the Human Sciences 8, no. 4 (1995): 39–57; Karen Jochelson, The Colour of Disease: Syphilis and Racism in South Africa, 1880–1950 (Basingstoke: Palgrave, 2001); Harriet Deacon, “Madness, Race and Moral Treatment: Robben Island Lunatic Asylum, Cape Colony, 1846–1890,” History of Psychiatry 7, no. 2 (1996): 287–297. 46. James Mills, Madness, Cannabis and Colonialism (London: Macmillan, 2000). 47. Sloan Mahone, “The Psychology of Rebellion: Colonial Medical Responses to Dissent in British East Africa,” Journal of African History 47, no. 2 (2006): 241–258. Also see Dane Kennedy, “Constructing the Colonial Myth of Mau Mau,” International Journal of African Historical Studies 25, no. 2 (1992): 241–260. 48. John Lonsdale, “Mau Maus of the Mind: Making Mau Mau and Remaking Kenya,” Journal of African History 31, no. 3 (1990): 393–421. 49. Alison Bashford, Imperial Hygiene: A Critical History of Colonialism, Nationalism, and Public Health (Basingstoke: Palgrave Macmillan, 2004). 50. Arnold, “Cholera and Colonialism,” 141. See also K. Prior, “The British Administration of Hinduism in North India, 1780–1900” (PhD diss., University of Cambridge, 1990). 51. See Stephen Frenkel and John Western, “Pretext or Prophylaxis? Racial Segregation and Malarial Mosquitoes in a British Tropical Colony: Sierra Leone,” Annals of the Association of American Geographers 78, no. 2 (1988): 211– 228; Philip Curtin, “Medical Knowledge and Urban Planning in Tropical Africa,” American Historical Review 90, no. 3 (1985): 594–613; Susan Parnell, “Creating Racial Privilege: The Origins of South African Public Health and Town Planning Legislation,” Journal of Southern African Studies 19, no. 3 (1993): 471–488; John Cell, “Anglo-Indian Medical Theory and the Origins of Segregation in West Africa,” American Historical Review 91, no. 2 (1989): 307–335. For Southeast Asia, see Norman Owen, ed., Explorations in Social, Medical and Demographic History (Singapore: Oxford University Press, 1987). 52. Walter Myers, “Seventy Second Annual Meeting of the British Medical Association,” British Medical Journal, 1904: 631. 53. Terence H. Hull, “Plague in Java,” in Owen, ed., Explorations, 210–234. 54. See David Arnold, “European Orphans and Vagrants in India in the Nineteenth Century,” Journal of Imperial and Commonwealth History 7, no. 2 (1979): 104–127. 55. M.W. Swanson, “The Sanitation Syndrome: Bubonic Plague mad Urban Native Policy in the Cape Colony, 1900–1909,” Journal of African History 18, no. 3 (1997): 387–410.


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56. Peers, “Soldiers, Surgeons,” 138–139; see also Philippa Levine, “Venereal Disease, Prostitution, and the Politics of Empire: the Case of British India,” Journal of the History of Sexuality 4, no. 4 (1994): 579–602; For Southeast Asia, see Lenore Manderson, “Migration, Prostitution, and Medical Surveillance in Early Twentieth-Century Malaya,” in Migrants, Minorities, and Health: Historical and Contemporary Studies, ed. Lara Marks and Michael Worboys, 49–69 (London: Routledge, 1997). K.L. MacPherson has argued that the primary aim of the system of licensed brothels in Hong Kong was to protect British soldiers and sailors from venereal disease. K. L. MacPherson, “Conspiracy of Silence: A History of Sexually Transmitted Diseases and HIV/AIDS in Hong Kong,” in Lewis, Bamber, and Waugh, eds., Sex, Disease, and Society, 87–98. For a similar argument in the case of brothels in Singapore, see James Francis Warren, Ah Ku and Karayuki-San: Prostitution in Singapore (Singapore: Singapore University Press, 2003), 38, 195. 57. See Mary Murnane and Kay Daniels, “Prostitutes as ‘Purveyors of Disease’: Venereal Disease Legislation in Tasmania, 1868–1945,” Hecate 5 (1979): 5–21; Elizabeth Van Heyningen, “The Social Evil in the Cape Colony, 1868– 1902: Prostitution and the Contagious Diseases Acts,” Journal of Southern African Studies 10, no. 2 (1984): 170–197; Denise Challenger, “A Benign Place of Healing?: The Contagious Diseases Hospital and Medical Discipline in Post Slavery Barbados,” in Health and Medicine in the Circum-Caribbean, 1800–1968, ed. Juanita De Barros, Steven Palmer, and David Wright, 98–120 (London: Routledge, 2009). 58. Arnold, Colonizing the Body, 8. 59. David Arnold, “India’s Place in the Tropical World, 1770–1930,” Journal of Imperial and Commonwealth History 26, no. 1 (1998): 8. 60. David Arnold, “Introduction: Tropical Medicine before Manson,” in Warm Climates and Western Medicine: The Emergence of Tropical Medicine, 1500–1900, ed. David Arnold, 6 (Amsterdam: Rodopi, 1996). 61. Phyllis Lassner, Colonial Strangers: Women Writing the End of the British Empire (New Brunswick, NJ: Rutgers University Press, 2004), 136. 62. Jean Comoroff, “Medicine: Symbol and Ideology,” in The Problem of Medical Knowledge: Examining Social Constructions of Medicine, ed. P. Wright and A. Treacger, 49–68 (Edinburgh: Edinburgh University Press, 1982). 63. Waltraud Ernst, “Beyond East and West: From the History of Colonial Medicine to a Social History of Medicine(s) in South Asia,” Social History of Medicine 20, no. 3 (2007): 509–510. 64. For a more recent example of this argument, see the introduction to Achintya Kumar Dutta and Chittabrata Palit, eds., History of Medicine in India: The Medical Encounter (Kolkota: Kalpaz Publications, 2005), 11–34. 65. Harrison, Public Health, chaps. 7 and 8; Veena Talwar Oldenburg, The Making of Colonial Lucknow 1856–1877 (Princeton, NJ: Princeton University Press, 1984); J.B. Harrison, “Allahabad a Sanitary History,” in The City in South Asia, ed. J.B. Harrison and K. Ballhatchet, 165–196 (London: Curzon Press, 1980). Juanita De Barros has shown how property owners and city officials’ avarice undermined sanitation programs in Georgetown. Juanita De Barros, “Sanitation and Civilization in Georgetown, British Guiana,” Caribbean Quarterly 49, no. 4 (2003): 65–86. 66. Biswamoy Pati, “Siting the Body: Perspectives on Health and Medicine in Colonial Orissa,” Social Scientist 29, no. 11/12 (1998): 19. For another study of epidemic control in a princely state, see T.V. Sekhar, “Public Health Administration in Princely Mysore: Tackling the Influenza Pandemic of 1918,” in India’s Princely States: People, Princes and Colonialism, ed. Waltraud Ernst and Biswamoy Pati, 157–172 (Abingdon: Routledge, 2007).



67. Mridula Ramanna, “Ranchodlal Chotalal: Pioneer of Public Health in Ahmedabad,” in Dutta and Palit, eds., History of Medicine in India, 311–326. 68. Biswamoy Pati, “Siting the Body.” 69. Ira Klein, “Plague Policy and Popular Unrest in British India,” Modern Asia Studies 22, no. 4 (1988): 723–755. 70. Poonam Bala, “Defying Medical Autonomy: Indigenous Elites and Medicine in Colonial India,” and Hibba Augideri, “Colonizing Mother Egypt, Domesticating Egyptian Mothers,” in Biomedicine as a Contested Site: Some Revelations in Imperial Contexts, ed. Poonam Bala, 9–28, 29–44 (Lanham, MD: Lexington Books, 2009). 71. Guy Attwell, Refiguring Unani Tibb: Plural Healing in Late Colonial India (Hyderabad: Orient Longman, 2007); Kavita Sivaramakrishnan makes a similar argument about Ayurvedic medicine in Old Potions, New Bottles: Recasting Indigenous Medicine in Colonial Punjab, 1850–1945 (Hyderabad: Orient Longman, 2006). 72. For class tensions, see Biswamoy Pati and Chandi P. Nanda, “The Leprosy Patient and Society: Colonial Orissa 1870s–1940s,” in Social History of Health and Medicine in Colonial India, ed. Mark Harrison and Biswamoy Pati, 113–128 (Abingdon: Routledge, 2009). 73. Harrison, Public Health, 151. 74. Sanjoy Bhattacharya, Mark Harrison, and Michael Worboys, Fractured States: Smallpox, Public Health, and Vaccination Policy in British India 1800–1947 (Hyderabad: Orient Longman, 2005). 75. Waltraud Ernst, Mad Tales from the Raj: Colonial Psychiatry in South Asia, 1800 –58 (London: Routledge, 1991). Anna Crozier has argued that tropical neurasthenia was used as a means to regulate and control colonial personnel in British East Africa: “What Was Tropical about Tropical Neurasthenia? The Utility of the Diagnosis in the Management of British East Africa,” Journal of the History of Medicine and Allied Sciences 64, no. 4 (2009): 518–548. 76. Deepak Kumar, “Unequal Contenders, Uneven Ground: Medical Encounters in British India, 1820–1920,” in Western Medicine as Contested Knowledge, ed. Andrew Cunningham and Bridie Andrews, 172–190 (Manchester: Manchester University Press, 1997). For the use of indigenous bazaar medicine and materials in eighteenth-century hospitals, see Pratik Chakrabarti, “‘Neither of Meate Nor Drink, But What the Doctor Alloweth’: Medicine amidst War and Commerce in Eighteenth-Century Madras,” Bulletin of History of Medicine 80, no. 1 (2006): 1–38. 77. Mark Harrison and Michael Worboys, “A Disease of Civilisation: Tuberculosis in Britain, Africa and India, 1900–1939,” in Migrants, Minorities, and Health, ed. Michael Worboys and Lara Marks. See also Mark Harrison, “Medical Experimentation in British India: The Case of Dr. Helenus Scott,” in The Development of Modern Medicine in Non-Western Societies: Historical Perspectives, ed. Hormoz Ebrahimnejad, 23–41 (Abingdon: Routledge, 2009). Based on a close reading of over three hundred medical tracts of European practitioners Harrison’s most recent book furthers this argument by showing how European practitioners in the colonies had an impact on therapeutic practices in Europe. Medicine in an Age of Commerce & Empire: Britain and its Tropical Colonies, 1660–1830 (Oxford: Oxford University Press, 2010). 78. Margaret Jones, Health Policy in Britain’s Model Colony, Ceylon, 1900– 1948 (New Dehli: Orient Longman, 2004). 79. Mark Harrison and Biswamoy Pati, “Introduction: Health Medicine and Empire: Perspectives on Colonial India,” in Health, Medicine, and Empire:

28 Amna Khalid and Ryan Johnson

80. 81.

82. 83.


85. 86. 87.




Perspectives on Colonial India, ed. Mark Harrison and Biswamoy Pati, 23–24 (New Delhi: Orient Longman, 2001). Arnold, “Medicine and Colonialism,” 1402. See Neeraja Sankaran, “Stepping-Stones to One-Step Growth: Frank Macfarlane Burnet’s Role in Elucidating the Viral Nature of the Bacteriophages,” Historical Records of Australian Science 19, no. 1 (2008): 83–100; and Alison Li, J.B. Collip and the Development of Medical Research in Canada: Extracts and Enterprise (Kingston: McGill-Queen’s University Press, 2003). Harrison, “Medical Experimentation,” 23–41. For the move towards placing the history of medicine in the colonies in a transnational framework, see Anne Digby, Waltraud Ernst, and Projit B. Mukharji, eds., Crossing Colonial Historiographies: Histories of Colonial and Indigenous Medicines in Transnational Perspective (Cambridge: Cambridge Scholars Publishing, 2010). See Saurabh Mishra, “Beyond the Bounds of Time? The Haj Pilgrimage from the Indian Subcontinent, 1864–1920,” and Sanchari Dutta, “Plague, Quarantine and Empire: British- Indian Sanitary Strategies in Central Asia, 1897–1907,” in Harrison and Pati, eds., Social History of Health and Medicine, 31–44, 74–92; see also Alison Bashford, “Introduction: ‘The Age of Universal Contagion’: Disease, History, and Globalization,” in Medicine at the Border: Disease, Globalization and Security, 1850 to the Present, ed. Alison Bashford, 1–17 (Basingstoke: Palgrave Macmillan, 2006). Ernst, “Introduction: Plural Medicine, Tradition and Modernity. Historical and Contemporary Perspectives: Views from Above and Below,” in Ernst, ed., Plural Medicine, 4. Karen Flint, Healing Traditions: African Medicine, Cultural Exchange, and Competition in South Africa, 1820–1948 (Athens: Ohio University Press, 2008). Projit B. Mukharji, “Going beyond Elite Medical Traditions: The Case of Chandshi,” Asian Medicine 2, no. 2 (2006): 277–291. See also Helen Lambert, “The Cultural Logic of Indian Medicine: Prognosis and Etiology in Rajasthani Popular Therapeutics,” Social Science and Medicine 34, no. 10 (1992): 1069–1076; David Hardiman and Gauri Raje, “Practices of Healing in Tribal Gujarat,” Economic and Political Weekly 43 (2008): 43–50. This project of writing the history of the subaltern domain of healing is headed by David Hardiman at the Centre for the History of Medicine at Warwick University. See research_teaching/subalternhealing/ Recently historians have ventured beyond the lunatic asylum, considering the workings of other medical institutions. See Anne Digby, Howard Phillips, Harriet Deacon, and Kirsten Thomas, At the Heart of Healing: Groote Schuur Hospital, 1938–2008 (Johannesburg: Jacana, 2008); Mark Harrison, Margaret Jones, and Helen Sweet, eds., From Western Medicine to Global Medicine: The Hospital Beyond the West (New Delhi: Orient BlackSwan, 2009); See Samiksha Sehrawat, “‘Prejudices Clung to by the Natives’: Ethnicity in the Indian Army and Hospitals for Sepoys, c. 1870s–1890s,” in Harrison and Pati, eds., Social History of Health and Medicine, 151–172; Simonne Horwitz, “A Phoenix Rising: A History of Baragwanath Hospital, Roweto, South Africa, 1942–1990,” (PhD diss., University of Oxford, 2006); Sanchari Dutta, “Disease and Medicine in Indian Prisons: Confi nement in Colonial Bengal, 1860–1910,” (PhD diss., University of Oxford, 2008). For stress on mentalities see, for example, Mary P. Sutphen and Birdie Andrews, Medicine and Colonial Identity (Routledge: London, 2003); Bashford, Imperial Hygiene; Sarah Hodges, Contraception, Colonialism and Commerce:


91. 92.

93. 94. 95.




99. 100.



Birth Control in South India, 1920–1940 (Aldershot: Ashgate, 2008); Ryan Johnson, “European Cloth and Tropical Skin: Clothing Material and British Ideas of Health and Hygiene in Tropical Climates,” Bulletin of the History of Medicine 83, no. 3 (2009): 530–560. For an emphasis on practice, see Anna Crozier, Practising Colonial Medicine: The Colonial Medical Service in British East Africa (London: I.B. Tauris, 2007); Ryan Johnson, “The West African Medical Staff and the Administration of Imperial Tropical Medicine, 1902–14,” Journal of Imperial and Commonwealth History 38, no. 3 (2010): 419–439; and Atsuko Naona, State of Vaccination: The Fight Against Smallpox in Colonial Burma (Hyderabad: Orient BlackSwan, 2009). Bhattacharya, Harrison, Worboys, Fractured States. See, for example, Lauren Minsky’s excellent study of how vaccination practice in colonial Punjab was shaped by seasonal disease, agrarian production, and the agency of agrarian lower classes. “Pursuing Protection from Disease: The Making of Smallpox Prophylactic Practice in Colonial Punjab,” Bulletin of the History of Medicine 83, no. 1 (2009): 164–190. Heather Sharkey, Living with Colonialism: Nationalism and Culture in the Anglo-Egyptian Sudan (Berkeley: University of California Press, 2003), 1. Timothy Parsons, “African Participation in the British Empire,” in Black Experience and the Empire, ed. Philip D. Morgan and Sean Hawkins, 267 (Oxford: Oxford University Press). Ronald Robinson, “Non-European Foundations of European Imperialism: Sketch for a Theory of Collaboration,” in Studies in the Theory of Imperialism, ed. Roger Owen and Bob Sutcliff e, 117–142 (London: Longman, 1972). See John Gallagher and Ronald Robinson, “The Imperialism of Free Trade,” Economic History Review 6, no. 1 (1953): 1–15; and Ronald Robinson and John Gallagher, Africa and the Victorians: The Offi cial Mind of Imperialism (London: MacMillan, 1961). It is estimated that by the 1930s the proportion of the European colonial administration to the local population was 1:19,000 in Kenya, 1:28,000 in India, and 1:54,000 in Nigeria. Anthony H.M. Kirk-Greene, “The Thin White Line: The Size of the British Colonial Service in Africa,” African Affairs 79 (1980): 25–44. Ronald Robinson, “European Imperialism and Indigenous Reactions in British West Africa 1889–1914,” in Expansion and Reaction, ed. Henk Wesseling, 141–163 (Leiden: Leiden University Press, 1978); Ronald Robinson, “The Eccentric Idea of Imperialism, with or without Empire,” in Imperialism Before and After: Continuities and Discontinuities, ed. Wolfgang Mommsen and Jürgen Osterhammel, 267–289 (London: Allen and Unwin, 1986); and Henk Wesseling, “Expansion and Reaction: Some Reflections on a Symposium and a Theme,” in Wesseling, ed., Expansion and Reaction, 1–14. Wolfgang Mommsen, “The End of Empire and the Continuity of Imperialism,” in Mommsen and Osterhammel, eds., Imperialism Before and After, 333–358. Christopher A. Bayly, Rulers, Townsmen and Bazaars: North Indian Society in the Age of British Expansion, 1770–1870 (Cambridge: Cambridge University Press, 1983). Another influential study by Bayly investigating Indian social history in relation to the British Empire is Indian Society and the Making of the British Empire (Cambridge: Cambridge University Press, 1988). Christopher A. Bayly, Empire and Information: Intelligence Gathering and Social Communication in India, 1780–1870 (Cambridge: Cambridge University Press, 1996).


Amna Khalid and Ryan Johnson

102. Edward Steinhart, Conflict and Collaboration: Kingdoms of Uganda (Princeton, NJ: Princeton University Press, 1977) and A.A. Boahen, African Perspectives on Colonialism (Baltimore, MD: The Johns Hopkins University Press, 1989). 103. Shula Marks, The Ambiguities of Dependence in South Africa: Class, Nationalism, and the State in Twentieth Century Natal (Baltimore, MD: The Johns Hopkins University Press, 1986). 104. James Onley, The Arabian Frontier of the British Raj: Merchants, Rulers, and the British in the Nineteenth Century Gulf (Oxford: Oxford University Press, 2007), 3. 105. Thomas Metcalf argues that the model of indirect rule fi rst devised in the Princely States had an important impact on Frederick Lugard, and the emergence of indirect rule in East and West Africa throughout the twentieth century. Imperial Connections: India in the Indian Ocean Arena, 1860–1920 (Berkeley: University of California Press, 2007), 42–43. 106. Mahmood Mamdani, Citizen and Subject: Contemporary Africa and the Legacy of Late Colonial Rule (Princeton, NJ: Princeton University Press, 1996). 107. Colin Newbury, Patrons, Clients and Empire: Chieftaincy and Over-Rule in Asia, Africa, and the Pacific (Oxford: Oxford University Press, 2003). 108. Ibid., 258. 109. Ranajit Guha, Dominance without Hegemony: History and Power in Colonial India (Cambridge, MA: Harvard University Press, 1997). 110. Parsons, “African Participation,” 257. 111. Frederick Cooper, “Confl ict and Connection: Rethinking African Colonial History,” American Historical Review 99, no. 5 (1994): 1516–1545. 112. Benjamin N. Lawrence, Emily Lynn Osborn, and Richard L. Roberts, eds., Intermediaries, Interpreters, and Clerks: African Employees in the Making of Colonial Africa (Madison: University of Wisconsin Press, 2006), 5. 113. David Killingray, “The Maintenance of Law and Order in British Colonial Africa,” African Affairs 85, no. 340 (1986): 411. 114. Metcalf, Imperial Connections, 2. 115. Ibid., 136. 116. David Killingray and David Omissi, Guardians of Empire: The Armed Forces of the Colonial Powers, c.1700–1964 (Manchester: Manchester University Press, 1999), 7. 117. David Anderson and David Killingray, “Consent, Coercion, and Colonial Control: Policing the Empire, 1830–1940,” in Policing the Empire: Government, Authority, and Control, ed. David Anderson and David Killingray, 3 (Manchester: Manchester University Press, 1991). 118. The exception to this rule was the Indian Army, which was used as much to fight foreign wars and project British imperial strength as maintaining internal peace and guarding the frontier. Killingray and Omissi, Guardians of Empire, 10. 119. Parsons, “African Participation,” 273. 120. Sharkey, Living with Colonialism, 40. 121. Ibid., 41–42. 122. Parsons, “African Participation,” 277. 123. Carol Summers, Colonial Lessons: African’s Education in Southern Rhodesia, 1918–1940 (Portsmouth, NH: Heinemann, 2002), xiv. 124. Ibid., xvii. 125. Parsons, “African Participation,” 281–283. 126. Metcalf, Imperial Connections, 137. 127. Ibid., 165–203. 128. See, for example, Rosemarijn Hoefte, “The Diffi culty of Unhooking the Hookworm: The Rockefeller Foundation, Grace Schneiders-Howard,



130. 131. 132.




and Public Health Care in Suriname in the Early Twentieth Century,” in De Barros, Palmer, and Wright, eds., Health and Medicine in the CircumCaribbean, 211–226; Mridula Ramanna, “Ranchodlal Chotalal: Pioneer of Public Health in Ahmedabad,” in History of Medicine in India: The Medical Encounter, ed. Chittabrata Palit and Achintya Kumar Dutta, 311–326 (Delhi: Kalpaz, 2005); Harrison, Public Health, chap. 7. Mridula Ramanna, “Indian Practitioners of Western Medicine: Grant Medical College, 1884–1885,” Radical Journal of Health 1 (1995): 116–135. In the African context, see John Iliffe, East African Doctors: A History of the Modern Profession (Cambridge: Cambridge University Press, 1998); Adeloya Adeloye, African Pioneers of Modern Medicine: Nigerian Doctors of the Nineteenth Century (Ibadan: University Press Limited, 1985); Adell Patton Jr., Physicians, Colonial Racism, and Diaspora in West Africa (Gainesville: University of Florida Press, 1996); and Anne Digby, “Early Black Doctors in South Africa,” Journal of African History 46 (2005): 427–454. Bridget Brereton has looked at mixed-race medical men trained in medicine in Britain who returned to practice in colonial Trinidad in Bridget Brereton, A History of Modern Trinidad, 1783–1962 (Kingston: Heinemann, 1981), 64–66. Bhattacharya, Harrison, and Worboys, Fractured States. Mills, Madness, Cannabis and Colonialism, 149–163. Anne Digby and Helen Sweet, “Nurses as Cultural Brokers in TwentiethCentury South Africa,” in Waltraud Ernst, ed., Plural Medicine, 113–129. See also Anne-Marie Rafferty, “The Rise and Demise of the Colonial Nursing Service: British Nurses in the Colonies, 1896–1966,” Nursing History Review 15 (2007): 147–154; Simonne Horwitz, “Black Nurses in White: Exploring Young Women’s Entry into the Nursing Profession at Baragwanath Hospital, Soweto, 1948–1980,” Social History of Medicine 20, no. 1 (2007): 131–146. Maryinez Lyons, “The Power to Heal: African Medical Auxiliaries in Colonial Belgian Congo and Uganda,” in Marks and Engles, eds., Contesting Colonial Hegemony, 202–223. See also Walima Kalusa, “Language, Medical Auxiliaries, and the Re-Interpretation of Missionary Medicine in Colonial Mwinilunga, Zambia, 1922–51,” Journal of Eastern African Studies 1, no. 1 (2007): 57–78; and Anne Digby’s chapter on hospital orderlies in At the Heart of Healing. See also De Barros, “Sanitation and Civilization in Georgetown”; Amna Khalid, “‘Subordinate’ Negotiations: The Indigenous Staff, Colonial State and Public Health,” in Harrison and Pati, eds., Social History of Health and Medicine, 45–73. Bhattacharya, Harrison, and Worboys, Fractured States.


The Control of Birth Pupil Midwives in Nineteenth-Century Madras Seán Lang

The annual report of the dispensary at the Madras Government Lying-In Hospital for 1870 contains a small but intriguing detail. A “pariah” woman called Ponee, probably a pauper dalit (“untouchable”), is recorded as having explained why she had chosen to go to the hospital for treatment of what turned out to be an ovarian cyst. She said that someone had pointed out to her in the street another woman, coincidentally bearing the same name, who had gone to the hospital with the same condition and there undergone an ovariotomy under anesthetic. Ponee, the hospital report noted, had “come to the Hospital with the full determination of submitting to the operation, even if it should cost her life”; both women recovered and the two cases were recorded on the same page of the report.1 To the British medical authorities such a tale was extremely encouraging, because it appeared to suggest that Indian women were beginning to recognize the superiority of Western medical care in what was termed “diseases of women and children” over traditional practice, at least in emergencies or cases of severe abdominal pain. If this proved a sign of a general trend, it might suggest that the hospital’s main aim, to establish Western medicine, especially in midwifery, as the norm for all women in south India, was on its way to being achieved. The Madras Lying-In Hospital had been founded in 1840 by a group of British medical officers concerned about the high maternal death rates resulting from the management of labor by dais, India’s traditional birth attendants. 2 The dai fulfi lled a hereditary role of central importance in the religious ritual that surrounded Indian birthing practice. Because childbirth in India was traditionally considered a time of unusually strong ritual pollution, the management of birth was confi ned to low caste women: most dais came from the “barber” caste. Although it was generally agreed even by the most critical European commentators that the dai could provide the mother with good support in natural labor, her complete lack of any sort of formal medical education meant that she was forced to improvise whenever complications set in, often with disastrous results. European accounts of dai practice are full of tales of babies’ limbs or heads being ripped off, mothers’ vaginas being torn open, and of dais binding women’s abdomens

The Control of Birth


tightly or jumping on their stomachs. With only a few exceptions, the consensus among European observers was that the dai was a menace whose influence should be rooted out completely. 3 How to achieve this aim was more problematic. Even with government backing, a single lying-in hospital could hardly make a difference to Indian birthing practice, even within the city of Madras. However, it might have an impact as a midwifery training school, sending properly qualified midwives out into the city and the surrounding area (known in India as the mofussil) where they could operate either independently or attached to one of the numerous civil dispensaries dispersed throughout the presidency. The Madras Lying-In Hospital therefore placed the training of midwives at the heart of its work, which was soon attracting lavish praise and generous support from the Madras government. By the 1870s the Madras Lying-In Hospital was being described in official correspondence as a fi rst-class medical institution that was earning the presidency a worldwide reputation for excellence in the field of female medicine.4 A heavy responsibility for maintaining Madras’s reputation therefore lay on the shoulders of the hospital staff, and especially its pupil midwives, who made up the entirety of its nursing establishment. Tracing pupil midwives in the records is not easy. The surviving records are overwhelmingly from the hospital superintendent, who corresponded with government and oversaw the administration and the surgical work of the hospital but had relatively limited contact with the midwifery pupils. The hospital’s annual reports give overall figures for the midwifery class and categorize the pupils by ethnic group, but give no further information. We have no fi rm evidence of their ages, for example, although we may surmise that most would have been in their twenties or thirties. It was not uncommon for European or Eurasian pupils to be married; indeed, in the hospital’s early days it was expected that most European midwives would be. How they managed to combine the long hours and heavy commitment the hospital demanded of them with any sort of married or family life we cannot tell from the sources. Much of the picture given in this chapter has had to be gleaned or surmised from passing or indirect evidence. Nevertheless, there is enough to enable us to construct a picture, however incomplete, of the life and work of the pupil midwives upon whom devolved the responsibility for carrying out the Madras presidency’s policy on maternity and midwifery.

THE PUPIL MIDWIFE WITHIN THE HOSPITAL, 1844–1881 The Madras Lying-In Hospital was something of an exception to the general rule of nineteenth-century maternity provision. Lying-in hospitals in Britain were usually pauper institutions, sometimes attached to medical schools so that students could gain some practice in midwifery. Until late in


Seán Lang

the century they had a poor reputation, both because of the uncaring attitude of medical students, who seldom took much interest in midwifery, and because of their notoriously high death rate from puerperal, or “childbed” fever.5 Unlike the lying-in hospital in Calcutta, which was attached to the Calcutta Medical School, the Madras hospital was separate from its local medical college. Indeed, in its fi rst years medical students were discouraged from attending it.6 Instead, the hospital’s priority was the training of midwives. So keen was the Madras government on producing a class of trained midwives who would supplant the dai that it attempted to set up training schemes at local dispensaries. However, only one, at the small town of Mannargudi, actually came to anything.7 The main center of midwifery training remained the Madras hospital. It is tempting to see colonial hospitals through Foucauldian eyes as maledominated hierarchical institutions subjecting patients not only to the clinical gaze, but also to the racially driven gaze of the colonial state. Certainly individual labor cases, suitably categorized and analyzed, were presented in the reports submitted by the hospital superintendent to the Madras government. On arrival at the hospital, women were categorized, and in effect defi ned, by race, caste, and religion. Male military medical officers in the service of the Madras government ran the hospital; and the Indian Medical Service existed principally to cater to the medical needs of the Indian Army and medical officers. Even in civil positions, the Indian Medical Service remained subject to military discipline and the demands of military exigency. Subordinate medical staff was expected to obey superiors without question and defiance of orders was regarded as a serious breach of discipline. Even the hospital superintendent was subject to this hierarchical discipline: he was expected to obey the decisions of the governor in council, whatever his personal feelings, and any attempt to get round an unwelcome decision could earn him a severe reprimand.8 However, it would be wrong to overdo the image of the hospital as a symbol of male European dominance. It was an unimpressive building, low, rambling, and badly lit, on a riverside site that was subject to frequent flooding.9 The compound was crowded, not only with women coming in to give birth, but with in- and outpatients attending the hospital dispensary, which opened in 1853, for whom beds in the “native” wards were set aside. It was common for a woman’s family to move into the hospital with her and to cook her meals, for which the hospital paid a daily grant. The hospital was so crowded that Indian women often had to be put into the European wards and extra beds put up on the verandas.10 The impression received by anyone visiting the hospital, therefore, was not of an alien European institution imposing itself on Indian sensitivities but of a building teeming with life that had, in effect, itself been colonized and absorbed by the local community. The day-to-day running of the hospital lay much more in the hands of the subordinate medical staff than it did with the hospital superintendent or the European apothecaries. The latter dealt mainly with complicated

The Control of Birth


labors and combined their work at the hospital in any case with their other duties as officers of the Indian Medical Service. Women coming into the hospital had far more contact with the matron and the pupil midwives, who were the key figures in determining the hospital’s local reputation. On arrival, a woman saw the matron, who assessed her age and state of pregnancy, categorized her by race or caste, and decided whether or not to allocate her a bed.11 Because it was far from uncommon for women to turn up well before term, hoping to enjoy bed and board at the hospital’s expense, the matron had to be prepared to deny a woman admittance and to tell her to come back at a later date.12 The matron generally oversaw the management of natural labors; matron-conducted deliveries tended to have a much lower mortality rate than those conducted by doctors or surgeons, who dealt mainly with life-threatening cases. Confidence in the matron’s ability to deliver babies safely, without risk to mother or child, helped forge a bond of trust between the matron and the women of the community, which could to some extent replicate that between mother and dai.13 Some matrons clearly had a reputation for being caring and supportive. A “Mrs. O’Flaherty,” matron in the hospital’s early years, was so popular and respected that the hospital superintendent petitioned government for a pay rise for her (though, sadly, she was not popular enough for the government to grant it); Mary Scharlieb describes a later matron, a “Mrs. Secluna,” in similarly affectionate and respectful terms.14 It seems plausible that the woman cited earlier, who recommended the hospital to her friend because of the kind treatment she had received, was referring to the hospital matron. Whereas the matron’s role was tied up with the operation of the hospital itself, more important for the hospital’s mission to transform Indian birthing were the hospital’s pupil midwives. Pupil midwives in Madras fell into two categories: in-pupils, who received a small government monthly stipend of Rs 7, and out-pupils, who were either privately fi nanced or supported by a local municipal board.15 The terms of the hospital’s original foundation had stipulated that the intake of pupil midwives should be spread equally between Europeans and Indians, but in practice in the hospital’s early years they were overwhelmingly European or Eurasian; the midwifery school had to be relaunched in 1872 in order to attract a wider range of applicants.16 The government had originally wanted a training course of twelve months but the hospital superintendent, James Shaw, thought this unnecessarily long and successfully lobbied for a reduction of the course to six months.17 The training course on offer at Madras was rather less well organized and structured than the term suggests. The government had originally intended pupil midwives only to be in the hospital to work and to attend lectures during the day. Shaw, however, insisted on their attending day and night, as their certificate was made dependent upon their residence within the hospital.18 The reason is not difficult to see given the pupil midwives made up the hospital’s entire nursing staff. However, this was a heavy requirement


Seán Lang

for women who often had children of their own. Moreover, the government, not having expected the pupil midwives to be resident, had made no provision for their accommodation: they had to bed down where they could, usually on a spare bed in the European wards.19 There does not seem to have been a structured teaching course as such. Apart from occasional lectures from the hospital superintendent, who also conducted their (oral) examinations, the pupil midwives were taught by the hospital matron, who had to fit teaching sessions into her busy working schedule. It seems probable that the training was largely practical with some formal instruction. We know that later in the century, when the midwifery school was better organized, much of the learning was done by rote from a set midwifery handbook, and it seems likely that the same would have been true for the earlier period as well. Teaching by rote requires minimal preparation on the part of the teacher and fits well into an already heavy work schedule. 20 For the length of the six-month course the pupil midwives were in a very vulnerable position, subject to dismissal at any moment by the matron and with a stipend less than half that of nurses at the General Hospital, from which they had to pay for their food and all other expenses. It was a very demanding course, but there was strong competition for places and some women traveled long distances in order to enroll. The main reasons for putting themselves through the rigors of the midwifery school were the status and prospects for lucrative private practice that a midwifery certificate offered. However, understandable though this might have been from an individual point of view, it did not sit well with the Madras government’s hopes that the school would produce a class of midwife who might work within Indian society, especially among women of high caste, and eradicate the influence of the dai. The gap between the government’s hopes and the reality of the school becomes still clearer when we look at the pupil midwives themselves. Pupil midwives, like their patients, are largely invisible in the records. The hospital’s reports enumerate them and categorize them by race but do not name them. It is possible, however, from passing references or from details within the hospital’s reports and correspondence, to construct a profi le of the pupil midwives who worked in the hospital before its move to a new site in 1881. They were of three ethnic groups: European, Eurasian, and Indian. Of the three, the Eurasians were by far the most numerous. Although the school had been set up specifically to train Indians in Western midwifery, Indian pupils do not appear in significant numbers in the hospital’s returns until the midwifery school was relaunched in 1872. European pupil midwives were mostly soldiers’ wives, who had long acted as untrained midwives in the military-dominated society of colonial India. Soldiers’ wives had a generally poor reputation. They were regarded as the common property of the soldiery, often little better than prostitutes. A widowed soldier’s wife would often remarry from within her husband’s regiment to avoid being shipped back to England. 21 For such a woman,

The Control of Birth


therefore, a midwifery certificate, with the possibility of a letter of recommendation from a government institution, offered a highly attractive opportunity to obtain a “character” and to gain a recognized position with a pension. Soldiers’ wives were often called upon to attend officers’ wives in labor. Officers could usually pay well for the woman’s services and a trained midwife might well expect to charge considerably more for her services than an untrained one. Soldiers’ wives were known as robust characters who shared the general attitude of superiority held by “poor whites” towards those they regarded as their racial inferiors. It seems reasonable, therefore, to expect a certain level of brisk efficiency in these pupils. However, they had no intention of working with the sort of pauper women they attended in the hospital any longer than they had to. Women gritting their teeth to get through a demanding six-month training course might make efficient midwives, but they do not necessarily make very caring ones. The largest group of pupils, and the one to which the hospital principally owed its high reputation, were the Eurasians. Eurasians occupied a difficult position within Anglo-Indian society, generally identifying themselves with the Europeans without ever being fully accepted on equal terms. They usually occupied middle management positions within the administration. To Eurasian women, the Madras midwifery school offered a different prospect from that contemplated by European women. Unlike soldiers’ wives, they already had an established position in middle-class society. A midwifery certificate reinforced this by offering the chance of a respectable and responsible position with the possibility of a good income. Eurasian midwives from Madras were in high demand, so they might reasonably hope for managerial positions. Indeed, Eurasian women often appear in the records as hospital matrons. The most likely career open to Eurasian midwives was attachment to government dispensaries, or else in private practice. This could put them in a useful position for spreading the word about Western midwifery among the local population, but it was highly unlikely that a family would call for them in the fi rst instance, except in an emergency. The key figure for realizing the government’s purpose was the Indian pupil midwife. The Indian pupil midwife was in the hardest position of all. She was usually a volunteer, although medical officers put forward some with a particular interest in midwifery. She was at an immediate disadvantage because all instruction was carried out in English, which effectively ruled out any Indian except Christian converts who had attended mission school. Indian Christians were free from rules of caste, which had the advantage of enabling them to work with women of all castes and to undertake any task that might be given them. However, because Christian converts were generally regarded by Indians as renegades, their presence within the hospital, especially if they were ever to dominate the hospital’s establishment, might deter women from attending. Perhaps not surprisingly, given their situation, Indian pupils had a markedly higher failure rate than Europeans

38 Seán Lang or Eurasians. In the fi rst two years after the school’s relaunch, eight out of thirteen Indian pupil midwives failed to complete the training course, compared with only one European out of six and a 100 percent completion rate for the twenty-one Eurasian pupils.22 Nevertheless, British medical officers were convinced of the need for trained Indian midwives if the population as a whole were ever to be converted to Western midwifery. We have no direct evidence of how Indian mothers and midwives interacted within the hospital; however, the absence of reports of friction might suggest that relations generally worked. The overwhelming majority of deliveries were of “pariah” women, who were perhaps less likely than caste women to object to being looked after by a Christian convert or a brusque European soldier’s wife. Relations between the different ethnic pupils are difficult to trace with any exactitude. They were certainly regarded as separate groups in official documentation, and this seems to have been reflected in more practical ways. In 1871, for example, when it was fi nally recommended that proper accommodation be set up for the midwifery pupils, it was taken for granted that European and Eurasian pupils would be housed in the apothecary’s ward, which lay within the hospital grounds, whereas a shed was to be erected for Indian pupils. 23 Given that Europeans usually objected to being treated by Indians unless absolutely necessary, it seems likely that Indian midwives were largely restricted to the “native” wards and that pupils generally associated along ethnic lines. However, by the time the hospital moved to a new site in 1881, this attitude had changed. It was decided “in the interests of good order and discipline that all pupils should mess together.”24 They were already taught together with their European and Eurasian colleagues, so to maintain separate messing arrangements would have looked like deliberate discrimination against the very women upon whom Madras’s midwifery strategy depended. If the hospital authorities feared for good order and discipline, it may indicate some impatience on the part of the Indian Christian pupils with continued segregation. How good was the care offered by pupil midwives? No direct inference is possible from statistics such as mortality rates, because these were largely the result of obstetric operations, which were undertaken by the surgeons. The matron oversaw normal deliveries, though we can suppose that pupils towards the end of their six months would also be entrusted with them. Certainly, the hospital’s popularity and repute would argue for a high quality of care, but with a staff made up entirely of pupils it is not to be expected that everything would have gone smoothly. In 1874 the hospital suffered a major outbreak of puerperal fever and in the subsequent inquiry the sanitary commissioner, William Cornish, criticized the hospital’s policy of relying so heavily upon pupil midwives. They were inexperienced and bound to make mistakes. One woman admitted with a putrid placenta had infected five other women when a midwife used the same syringe on them all. Cornish pointed to the central conundrum in the hospital’s policy,

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The possibility of spreading infection is, I fear, very much increased, when a number of women-pupils, undisciplined and untrained in ordinary nursing, are brought into a Lying-in Hospital to learn practical midwifery. As soon as these women are really qualified for their work, and fit to be trusted, they are replaced by an equal number of undisciplined and untrained hands. 25 Cornish’s suggestion was for European and Eurasian midwives to visit women in their own homes, where, he assumed, they could be treated without fear of infection. He shared the widely held belief that puerperal fever was spread through the fabric of the hospital ward. Although his suggestion was perhaps over optimistic—Indian women were unlikely to call a European midwife in—Cornish had put his finger on the hospital’s central problem: its pupil midwives were in effect being used to staff it on the cheap.

THE PUPIL MIDWIFE WITHIN THE NEW HOSPITAL, 1881–1916 The Madras Lying-In Hospital had long outgrown its cramped and inconvenient riverside site even before the 1874 puerperal fever outbreak lent more urgency to the search for a new ground. One was identified on Pantheon Road, one of the main thoroughfares in the city. Unlike its predecessor, the new hospital was purpose-built, designed on the latest “pavilion” model then in fashion both in India and in Europe, whereby patients were housed in a series of separate blocks or “pavilions” joined by covered walkways. This enabled blocks to be isolated in the event of an outbreak of infectious disease. The pavilion system also allowed, should it be judged necessary, for the segregation of patients of different castes. Madras had not paid much attention to this aspect of lying-in provision. However, as the issue of female medical care in India grew in fashionable popularity in the 1880s increased emphasis was placed on the need to maintain the separation of “caste and gosha” women within European hospitals in India. The Madras hospital had a central administrative block containing one European and two Indian labor wards. This was attached to four detached two-story pavilions, each divided into four separate wards, each with space for four patients. The midwifery pupils had their own accommodation building, although in 1890 a separate block was built for Indian nurse pupils. 26 The new building made an immediate difference to the cultural relations that had pertained in the old hospital. Although women still arrived with their families, they were only admitted a few days before term and their families had to camp out in the grounds instead of setting up around the woman’s bed. Payments for women to prepare their own food were still made, although there were increasing voices calling for the system to be ended. The pavilion arrangement made it easier to

40 Seán Lang supervise individual patients and enormously reduced the overcrowding that had bedeviled the old hospital. The hospital superintendent commented that “administration is simplified, hospital discipline and general control more readily maintained.”27 As at the old hospital, the nursing establishment was almost entirely made up of pupils (Table 1.1). The growth of gynecological work meant that the hospital needed nursing care as well as midwifery, and there was some sharing of pupils between the Lying-In and the General Hospital. Two native nurses were the only qualified personnel below the level of assistant matron. This reliance on midwifery and nursing pupils meant that, just as at the old hospital, nurses and midwives left as soon as they gained the experience that would have rendered them most useful to the hospital. In 1896 Surgeon-Major-General Sibthorpe recommended adding two European or Eurasian midwives to the hospital strength, to which the government assented. The difference in their pay illustrates the different levels of esteem in which each ethnic group was held. The European and Eurasian midwives were to be paid Rs 40 each, whereas the Indian were paid Rs 15. 28 The increased size of the hospital created its own strains. Matrons stayed for shorter periods before leaving for better paid work elsewhere. In 1891 the menial staff went on strike for better wages, and the death in

Table 1.1

Salaries of Hospital Nursing and Midwifery Staff





Head Matron

Rs 125-5-150 (biennial)


Assistant Matron

Rs 50-5-75


2nd Assistant Matron

Rs 50-0-0


Head Nurse and Midwife

Rs 30-5-50 (biennial)+ Rs 15 ration allowance


European Midwifery Pupils

Rs 15 each


European Nurse Pupils

Rs 15 each


Head Native Nurse

Rs 8


Native Nurses

Rs 12 each


Native Midwifery Pupils

Rs 7 each


Native Nurse Pupils

Rs 10 each



Rs 6 each

Source: BLAAS: P/5041 Madras Public Proceedings, January–June 1896, GO no.111. January 22, 1896, Nursing and Midwifery Staff at the Lying-In Hospital, Madras.

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1906 of the hospital superintendent was put down to the administrative strain of running the hospital. 29 Much of the stress was caused by the government’s insistence on economy. Although most requests for equipment were granted, the government was unwilling to sanction anything but the cheapest extensions to the hospital staff. At Rs 15 a month, European midwifery and nursing pupils were cheap. Indian midwifery pupils, at Rs 7 a month, were cheaper still. Low stipends, however, do not attract top quality personnel. By 1894 the superintendent was commenting of the nursing pupils: The majority of women who join the nurse class have no natural liking for the work and are often ignorant, but owing to the small staff they have frequently to be placed in very responsible posts, for which from the amount of knowledge they possess they are unfitted.30 Even more worrying from the point of view of the hospital was the fact that much the same seemed to be true of the midwifery pupils, too. The 1880s and 1890s saw a huge growth in public interest in Indian midwifery, sparked off by the publicity surrounding the visit of the medical missionary Elizabeth Beilby to Queen Victoria in 1881 and the foundation five years later of the Countess of Duff erin’s Fund. Both moves highlighted the need for women doctors to work with Indian women, especially those living in seclusion. In particular, they also drew attention to the conditions in which Indian women gave birth. Other parts of India began to set up their own hospitals and training schemes, many of them based upon the perceived needs of caste women to remain in seclusion. The best known of these was the Pestonjee Cama Hospital set up in Bombay in 1883 by the Medical Women for India Fund, the fi rst such hospital to be established with an entirely female medical staff. 31 Having prided itself for decades on its expertise in the field of female medicine, Madras presidency now found itself being edged out of the picture as the issue caught the fashionable imagination. The Madras hospital, for all its new buildings, looked behind the times with its exclusively male medical staff when compared with the all-female Cama Hospital. Madras opinion responded cynically to news of training schemes set up in northern India for the training of dais directly in Western methods of midwifery; this had been tried in dispensaries in the Madras mofussil and had been found to be ineffective. 32 Madras now found itself being lectured by the government of India on the very issue that it regarded as its own area of expertise. In 1898, for example, in response to an inquiry from Calcutta as to why female students at Madras Medical College received instruction in midwifery in separate classes at the Lying-In Hospital, rather than in mixed classes at the college, as happened at Calcutta, the Madras government revealed its frustration stating:


Seán Lang His Excellency the Governor in Council adheres to the view that has been acted upon in this Presidency for nearly a quarter of a century, that the separation of the sexes is desirable in classes for young persons attending lectures on midwifery. 33

In the very changed atmosphere surrounding women’s health in India in the 1880s and 1890s, it was all the more galling for the Madras government to have to face up to the possibility that the presidency’s much-vaunted reputation for training midwives might be less solidly based than it thought. By the 1890s the number of pupil midwives in training at the Madras Government Maternity Hospital (it changed its name in 1896) grew steadily. Some were given stipends by government, others were put up on scholarships by local boards or by the Countess of Dufferin’s Fund, and some were privately funded. The Madras government took some pride in the fact that women still traveled to Madras from all over India in order to train at the hospital, a point of some irritation to other presidencies. At the start of 1897 there were fi fteen probationer midwives working at the hospital and a waiting list of ninety-four.34 It is not difficult to see the attraction. The course was much better organized than it had been in the early days, and pupil midwives were properly accommodated and enjoyed a more generous stipend. Midwifery did not require the same breadth of skills as general nursing, yet a qualified midwife could set up in private practice more easily than a nurse and earn anywhere between Rs 50 and Rs 100 a year.35 The Madras school had a high reputation and its midwives were much in demand. By 1882 there were eighty-five Madras-trained midwives working in Madras itself and a further 130 in the mofussil and at other presidencies, as well as at Singapore and Burma. Outside Madras itself the heaviest concentration of midwives was at Bangalore, which had an average of twelve midwives in residence at any one time between 1869 and 1881. Other stations normally only had one or two, although in 1875 Ootacamund, the hill station to which the Madras government resorted in the hot weather, boasted four midwives; Dindigul had five.36 By 1888 Madras stations averaged seven midwives each, from eighteen at the Lying-In Hospital at Madura to the single midwives stationed at Ganjam and in the Nilgiri hills. Ten years later this average had risen to ten, with openings also for midwives in the army.37 By 1896 Madras’s midwifery training program was on such a scale that Surgeon-General Sibthorpe carried out a thorough review with a view to establishing the hospital’s midwifery classes as a formal school of midwifery. There appeared to be good reasons for confidence in the quality of Madras midwifery training. The six months of the Madras course compared very favorably with the three months or less that was common for such schemes in England. Moreover, the Madras course was not diluted with general nurse training, as was common in other lying-in hospitals. The type of women now applying for training places had changed since

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the hospital’s early days. Although women from military backgrounds still applied, they were increasingly joined by European women of higher social status, attracted by the newly fashionable status of Indian female medicine. The trend was set by Dame Mary Scharlieb, founder of Madras’s fi rst caste and gosha hospital in 1885, who had begun her career in medicine in 1874 by enrolling at the old Lying-In Hospital as a pupil midwife before applying to the Madras Medical College the following year as its fi rst female entrant. Sibthorpe seems to have considered that the old categorization of European and Eurasian pupil midwives was no longer sufficient or appropriate. However, if the social mix of European pupils was broader than it had been, so too was that of Indian pupils. Because many of these were put up by outside bodies, the hospital had relatively little control over their selection. In Sibthorpe’s review we see for the fi rst time recognition that considerable numbers of Indian pupils would not be able to receive instruction in English. This was a significant departure from the hospital’s earlier practice and almost certainly indicates that these Indian pupils were Hindu. The hospital had enormous difficulty attracting Muslim women as patients, so it seems unlikely that Muslims would account for many of these midwives. Sibthorpe recommended establishing five classes of stipendiary midwifery pupils, arranged according to race, language, whether they were destined for the military or civil service, and whether or not they were also undertaking nurse training at the General Hospital, as follows: midwifery nurse pupil; midwifery pupil; military midwifery nurse-pupil; native midwifery pupil (English-speaking); native midwifery pupil (non-Englishspeaking). In addition, there would be some twenty or so non-stipendiary pupils, certified nurses training in midwifery, and pupils sent up by local boards and by the Dufferin’s Fund. The Rs 20 a month to be paid to European and Eurasian pupils was to cover a uniform, alongside books, dhoby (washing), and mess servants. This is the fi rst mention of midwifery pupils in the hospital wearing a uniform. The Indian pupils’ stipend was only Rs 10, which had to cover their books and mess bills, which might indicate that they were not expected to wear uniform. 38 Certainly Sibthorpe’s categories suggest that the demarcation lines between Indian and European/ Eurasian pupils were now growing stronger rather than weaker; they also suggest a high degree of regimentation. Certainly, high standards continued to be expected. The admissions procedure, for example, was much more stringent than elsewhere in India. In 1911 surgeons in Bombay complained at having to take local women applying to Madras through the hospital’s lengthy application process, which took about an hour to complete and was far more demanding than their own hospital’s procedures.39 However, this rigorous entrance process applied mainly to European and Eurasian applicants. Because many of the Indian pupils were put up by local boards or by the Dufferin’s Fund, the hospital had much less control over their quality. If Indian pupils were of markedly lower caliber than Europeans


Seán Lang

and Eurasians, this too would contribute to the hospital’s internal processes of categorization and segregation. The new hospital’s commitment to teaching some Indian women in the vernacular rather than in English shows the importance it attached to getting its midwives out into the community, working with women in their own home environment. Madras midwives were expected to take on a sort of missionary role for Western medicine, telling women also about sanitation and child care, as was becoming standard practice in Britain. The hope was that the Madras-trained Indian midwife, talking to mothers in their own tongue, would become a much-loved and respected community figure, supplanting the “old-fashioned” and “dangerous” dai. This, however, was to overlook some crucial differences between the two roles. Whereas the dai had usually learnt her craft from her mother, the midwife had been trained, over a much shorter period, at the hospital. The dai’s role was as much one of attendance and company with the mother as it was one of midwifery. Properly speaking, the dai was not a midwife at all in the Western understanding of the term. Her skill came through experience and instinct, whereas the midwife’s training was much more focused on the mechanics of labor, typified by the small midwifery kit she received on graduation, alongside her diploma. Even more importantly, the trained midwife, whether European or Indian, was an agent of the state. Midwives were supposed not only to advise mothers but also to report on the conditions they found. They were responsible for ensuring all births were properly registered and reporting any attempt to cover up a death to the authorities. However friendly a midwife might be, she was bound to be regarded with a certain amount of caution. The state’s expectations of the trained midwife were therefore heavy. In six months, perhaps from a basis of no experience at all, she was expected to adapt to the regimented routine of the hospital; learn the basics of anatomy and gynecology; attend and learn how to conduct normal deliveries; learn how to contain the situation when confronted with complications and emergencies; understand basics of sanitation and childcare; and take on board the legal responsibilities of her role. Moreover, Madras midwives were to pass in most cases directly from the training school to positions of authority and responsibility with no period spent working within the hospital as a fully certified midwife. The pupil midwife was therefore an unusual kind of subordinate in that while in training she was in a very junior position, but the moment she finished her training she was often thrust into a position that offered autonomy and responsibility. The situation was perhaps more analogous to officer training in the army than with nurse training, with the crucial difference that few of the women who enrolled as pupils at the hospital, and especially the Indians, came from the sort of background that prepared them for exercising the level of autonomy and authority a midwifery certificate granted. The course itself did little to prepare women for the leadership role they would be expected to take after qualification. The midwifery handbooks were written in short, easy sections that lent themselves to learning by heart.

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Rote learning, however, is no guarantee of understanding. One writer in 1920, for example, recalled examining a class of midwives at the Dufferin Hospital in Nagpur and finding that, although they were able to give accurate measurements for the female pelvis, they had no idea of the actual length of an inch.40 Labor training was undertaken in a modern delivery room. It bore little resemblance to the conditions of traditional birth in India, usually conducted in an outhouse, its doors and windows sealed, full of smoke from a fire and crowded with the mother’s female relatives and friends. Western doctors, male and female, have left plenty of accounts of how they would stride into the chatti ghar (birthing chamber), take charge, order the windows open and the room cleared. Midwives were in a very different position. Doctors were called in when things had gone wrong, whereas midwives were expected to be present from the beginning. Doctors could take over from dais that had mishandled the delivery, but the midwife was supposed to stop the dai from even starting to attend a delivery that she might well be perfectly competent to handle. It was, to put it mildly, a tall order. The regulatory system set up by government did little to help the trained midwife establish her own role and authority in the community. Midwives at government dispensaries were paid the same regardless of how many deliveries they attended. There was therefore little incentive to go looking for work. The 1882 report on civil dispensaries noted that the midwives at Cuddapah were underpaid and “appear to have attended no cases” and those at South Arcot had “done very little work.”41 The surgeon at Nellore the same year gave a breakdown of cases attended in the past year by each midwife, which ranged from ninety-nine to a mere six.42 A limited system of payment by results was introduced in a rather ad hoc fashion, but this was not enough to transform the situation. In 1895 the average number of deliveries conducted by each midwife at mofussil stations was sixty-nine, but there were considerable variations within that figure, from a top figure of 123 deliveries per midwife at Bellary to only thirty-two among the four Madras trained women at Kurnool.43 By 1901 the two midwives stationed at Vizagapatam were handling 372 cases, whereas the single midwife at Kodaikanal had only attended eleven.44 These reports made alarming reading for the Madras government. Even more worrying were the possible causes for the situation. If it had been merely a case of the stubbornness with which Indian women clung to their traditional practices, it would at least have been no reflection on the quality of Madras training. However, reports also indicated the very poor quality of many qualified midwives and even questioned their moral character, as young women sent on their own to stations far from home. An 1895 report on the large civil hospital at Madura, which maintained its own midwife training school, gave a particularly worrying picture: The District Medical and Sanitary officer reports that, as a rule, these midwives seldom do good work. Young women are trained and sent


Seán Lang to different places where they have no relatives and soon become bad characters. Instead of helping the villagers in labor cases, they get the permission of the people to witness confi nements in the houses and count such cases as having been conducted by them when the barber women actually attend to the cases.45

This might be attributed to the less than adequate training that midwives received at outstations, were it not that similar reports were made about midwives trained at Madras. One doctor stated incredulously: I noticed that the nurse [i.e., midwife] had nothing ready for the delivery, no scissors, no aseptic ligature to tie the cord, no aseptic cotton to wipe the vulva of the woman. How is she better than a barber midwife? . . . She told me that she was trained in the Government Maternity Hospital under Dr. Sturmer. She was in charge of the central ward and she had also worked in mofussil hospitals. I was simply stunned at the degenerated specimen of the diplomaed midwife. It is a well-known fact that we have to fight against the barber midwifery system in this land; but these diplomaed midwives are really a menace to aseptic midwifery. It is a pure deception upon the people.46 It may be doubted that the woman had actually been in charge of a ward at the hospital. Such a position was reserved for a matron. Not only is it difficult to conceive of the sort of woman described here holding such a position, but also matrons were invariably European and Eurasian. However, the woman does appear to illustrate the limitations on the hospital’s capacity to turn Indian women into Western midwives.

CONCLUSION The Madras government’s commitment to midwifery was unusual, not least in that it was designed to address a specifically Indian problem: the loss of Indian women and children at the hands of Indian dais. If this was understood essentially in humanitarian terms when the hospital was founded, by the 1900s the issue was increasingly presented in terms of patriotic duty. Reports on Indian midwifery appeared in census reports and the need to combat the country’s high maternal mortality rate was tied to India’s future as a nation.47 This level of attention necessarily underlined the importance of the trained midwife and of the pupil midwife. The Madras pupil midwife was thus in a strange position. She was a medical subordinate who was nevertheless central to political medical strategy. That strategy aimed at nothing less than the control of Indian birth. Medical officers and government councilors dreamed of a network of midwives coming out of the Madras Maternity Hospital, armed with their midwifery kits, welcomed as saviors

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into the heart of Indian homes while the depraved dai was sent packing. It was always an unrealistic dream, and based upon an entirely false expectation that the merest contact with Western science would instantly cause the scales to fall from Indian eyes. Once that initial contact had been made, it was only a matter of time—and relatively short time at that—before Western midwifery would sweep all before it. This did not happen. Far from impressing families with their midwifery kits, Madras midwives found their little bags made them objects of derision.48 Families called trained midwives in to give the appearance of compliance with official policy, especially because maternity care was clearly in such official favor in the 1880s and 1890s. But it is clear from the annual reports on the dispensaries to which these midwives were attached that in most cases the management of the labor was kept fi rmly in the hands of the dai. This failure might be ascribed to the nature and scale of the task. It would take much larger recruitment and advertising campaigns by the government of independent India to make any inroads into the influence of the dai well into the twentieth century.49 However, the Madras government also miscalculated the extent to which its own pupil midwives would be changed by their training. It was clearly expected not only that Indian pupils would understand and embrace Western medicine, but also that they would somehow gain the confidence that would be needed to carry out their role as the vanguard of Madras presidency’s scientific and cultural offensive. These were unrealistic expectations. Much thought was given to the most effective way of instructing Indian pupils (though the Madras government did supply a midwifery handbook that had been translated into the wrong language for use in southern India), but none at all to the overall planning and cohesion of their course. 50 How they were to gain the more intangible skills that would be needed if they were in any meaningful sense to replace the dai in the hearts and minds of Indian society was not considered. There was a mismatch between government expectations of its midwives and their capacity to meet them. Ironically, Indian midwives, over whose admission and fortunes the hospital had least control and who were least well suited to fulfi lling the role of cultural and medical policeman, were precisely the ones upon whom the heaviest responsibility for wresting control of Indian birth from the hands of the dai chiefly fell.

NOTES 1. Government of Madras, Annual Report of the Civil Dispensaries, 1870, 84. 2. For Madras’s maternity policy see Seán Lang, “Drop the Demon Dai: Maternal Mortality and the State in Colonial Madras, 1840–1875,” Social History of Medicine 18, no. 3 (2005): 357–378; Sarah Hodges, ed., Reproductive Health in India: History, Politics, Controversies (Delhi: Orient Longman, 2006).

48 Seán Lang 3. There is a vast literature on India’s dais and the debate surrounding them. For contemporary accounts see, for example, Norman Chevers, A Commentary on the Diseases of India (London: J. and A. Churchill, 1886); J. Shortt, “Medical History of Woman in Southern India,” Transactions of the Obstetrical Society of London 5 (1864): 103–121; J. Jackson, “Midwifery in the East,” Transactions of the Obstetrical Society of London 2 (1860): 37–47. 4. Madras Quarterly Journal of Medical Science 6 (1863): 183; British Library: African and Asian Studies (hereafter BLAAS): P/1936 Madras Military Proceedings, April 5, 1882, no. 63. 5. See Irvine Loudon, Death in Childbirth: An International Study of Maternal Care and Maternal Mortality, 1800–1950 (Oxford: Oxford University Press, 1992), 273–274; Margaret Tew, Safer Childbirth? A Critical History of Maternity Care (London: Free Association Books, 1998), 196–203; Lara Marks, “Mothers, Babies and Hospitals: ‘The London’ and the Provision of Maternity Care in East London, 1870–1939,” in Women and Children First: International Maternal and Infant Welfare, 1870–1945, ed. Valerie Fildes, Lara Marks, and Hilary Marland, 48–73 (London: Routledge, 1992). 6. BLAAS: P/248/37 Madras Public Proceedings, May 20, 1847, no. 48. 7. For midwifery at Mannargudi, see Madras Quarterly Journal of Medical Science 1 (1860): 177–180; Government of Madras, Report on Civil Dispensaries, 1861; ibid., 1865–1866; ibid., 1867. 8. BLAAS: P/249/30 August 1, 1854, no. 65. 9. J.L. Ranking, Report of the Lying-in Hospital and Dispensary for Women and Children, Madras (Madras: Government of Madras, 1868); Government of Madras, Report of the Civil Dispensaries, 1873–1874; Dame Mary Scharlieb, Reminiscences by Dr. Mary Scharlieb (London: Williams and Norgate, 1924), 33–34. 10. Ranking, Report, 2. 11. BLAAS: P/249/20 Madras Public Proceedings, May 3, 1853, no. 22. For the method of estimating ages, see Government of Madras, Annual Report on Civil Dispensaries, 1876–1877. 12. BLAAS: P/247/43 Madras Public Proceedings, January 27, 1848, no. 5; P/249/82 Madras Public Proceedings, September 28, 1865, no. 157; P/439/1 Madras Public Proceedings, June 22, 1866, no. 130. 13. BLAAS: P/249/20 Madras Public Proceedings, May 3, 1853, no. 22. 14. BLAAS: P/249/20 Madras Public Proceedings, May 3, 1853, nos. 22–23; Scharlieb, Reminiscences, 34. 15. BLAAS: P/272 Madras Public Proceedings, May 31, 1871, no. 149. 16. BLAAS: P/247/53 Madras Public Proceedings, August 4, 1840, no. 7; P/249/30 Madras Public Proceedings, August 1, 1854, no. 65; Government of Madras, Annual Report of Civil Dispensaries, 1870; ibid., 1871; ibid., 1873–1874; ibid., 1875–1876; ibid., 1876–1877. 17. BLAAS: P/249/30 Madras Public Proceedings, August 1, 1854, no. 65. 18. Ibid. Key to Lorimer, October 21, 1852. 19. BLAAS: P/272 Madras Public Proceedings, May 31, 1871, no. 149; P/1038 Madras Public Proceedings, March 21, 1876, no. 48; P/1936 Madras Public Proceedings, April 5, 1882, no. 62: Cornish to Adjutant General, May 9, 1882; P/249/30 Madras Public Proceedings, August 1, 1854, no. 65: Key to Lorimer, October 21, 1852. 20. A. Buchanan, “Midwifery Mechanics,” Indian Medical Gazette 55 (1920): 401. 21. See Pat Barr, The Memsahibs: The Women of Victorian India (London: Secker and Warburg, 1976), 97; Margaret MacMillan, Women of the Raj

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22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32.

33. 34. 35.

36. 37. 38. 39.

40. 41. 42. 43. 44. 45. 46.


(London: Thames and Hudson, 1988), 114; and Jane Robinson, Angels of Albion: Women of the Indian Mutiny (London: Penguin, 1997), 235–236. Government of Madras, Annual Report of Civil Dispensaries, 1872; ibid., 1873–1874. BLAAS: P/272 Madras Public Proceedings, May 31, 1871, no. 149. BLAAS: P/1746 Madras Public Proceedings, July 7, 1881. BLAAS: P/276 Madras Public Proceedings, April 16, 1875, no. 59. H.C. Burdett, Hospitals and Asylums of the World: Their Origin, History, Construction, Administration, Management and Legislation, vol. 6, Hospital Construction (London: J. and A. Churchill, 1893), 223. Government of Madras, Annual Report on the Civil Hospitals and Dispensaries in the Madras Presidency, 1882, 76. BLAAS: P/5041 Madras Public Proceedings, GO 111, January 22, 1896. BLAAS: P/3971 Madras Public Proceedings, GO 9, January 8, 1891; P/7409 Madras Public Proceedings, GO 226 and 227, March 27, 1906. Government of Madras, Annual Report and Statistics up to 1894 of the State Hospitals in the Presidency Town of Madras, 50. For a fuller description of the work and significance of the Cama Hospital, see Mridula Ramanna, Western Medicine and Public Health in Colonial Bombay, 1894–1895 (Hyderabad: Orient Longman, 2002). BLAAS: P/274 Madras Public Proceedings, September 18, 1873, no. 68; A. Lakshmanaswamy Mudaliar, Maternity and Child Welfare: A National Problem, with a Foreword by A.J.H. Russell (Madras: Everymans Publishers, 1922), 94; Madras Medical Journal 1, no. 5 (September 1918): 302; B. Thangamma, “Improvement of Conditions of Child-Birth,” Madras Medical Journal 2, no. 1 (January 1919): 57–60. BLAAS: P/5418 Government of India Medical Proceedings, 1898, nos. 66–67. Government of Madras, Annual Report and Statistics of the Medical Institutions in the Presidency Town of Madras, 1896, Appendix C. BLAAS: P/5041 Madras Public Proceedings, GO 111, January 22, 1896. One Madras-trained midwife charged Rs 150 a time to Europeans and rich Indians and demanded (and got) £100 and her ayah’s expenses before moving to Bombay; see Journal of the National Indian Association, 1883: 166. Madras Almanac and Compendium of Intelligence (Government of Madras: Asylum Press, 1881). BLAAS: P/1936 Madras Military Proceedings, April 5, 1882, no. 62. BLAAS: P/5041 Madras Public Proceedings, GO 111, January 22, 1896. Maharashtra State Archives (MSA): Bombay General Department Proceedings, 1911, no. 1013. In addition to noting a candidate’s personal details, the process involved a physical examination, reading, dictation, and conversation tests, certificates of moral character, and respectability and an assessment of a candidate’s appearance and intelligence. Buchanan, “Midwifery Mechanics,” 401. Government of Madras, Annual Report on Civil Hospitals and Dispensaries, 1882, xvi. Ibid. Government of Madras, Annual Returns (Triennial Report) on the Civil Hospitals and Dispensaries in the Madras Presidency for the Year 1895, 1896, 27. Government of Madras, Madras General Municipal Review, 1901. Government of Madras, Annual Returns 1895, 1896, 28. S. Muthulakshmi Ammal, “A Word about Midwives,” Madras Medical Journal 2, no. 1 (January 1919): 22–56.

50 Seán Lang 47. See, for example, J.C. Moloney and A. Chatterton, Census of India 1911 XII: Madras, Part I, Report (Madras: Government of Madras, 1912); E.A. Gait, Census of India 1911 I: India, Part 1, Report (Calcutta: Government of India, 1912), 215. 48. S. Rozario, “The Dai and the Doctor: Discourses on Women’s Reproductive Health in Rural Bangladesh,” in Maternities and Modernities: Colonial and Postcolonial Experiences in Asia and the Pacific, ed. K. Ram and M. Jolly, 144–176 (Cambridge: Cambridge University Press, 1998); G.T. Birdwood, “Modern Midwifery Practice in India,” Indian Medical Gazette, 1911: 96–99. 49. R. Jeffery, P. Jeffery, and A. Lyon, “Only Cord-Cutters? Midwifery and Childbirth in Rural North India,” Social Action 34, no. 3 (1984): 229–250; P. Jeffery, R. Jeffery, and A. Lyon, Labour Pains and Labour Power: Women and Childbearing in India (London: Zed Books, 1989); M. Bandyopadhyay and S. McPherson, Women and Health: Tradition and Culture in Rural India (Aldershot: Ashgate, 1998); K.H. Brey, “The Missing Midwife: Why a Training Programme Failed,” South Asian Review 5, no. 1 (October 1971): 41–51; Y.N. Ajinkya, The Birth of a Baby (Bombay, 1953). 50. The handbook was a diglot version of Dr Conquest’s Outlines of Midwifery, a popular textbook of the time, published in 1850 in English alongside a Hindustani (i.e., Hindi) translation by Surgeon-General Edward Balfour. Hindi, however, was (and is) little spoken in southern India; the overwhelming demand was for material in Tamil or Telugu. See BLAAS: P/248/61 Madras Public Proceedings, June 4, 1850, nos. 9–10.


“Unscientific and Insanitary” Hereditary Sweepers and Customary Rights in the United Provinces Amna Khalid

The study of debates among imperial and colonial policy makers sheds light on the concerns that determined the scope and nature of written policy, but does not capture the factors on the ground that also affected its formulation and practice. Much of the historiography of public health in the British Empire has focused on policy, and India is no exception. Historians of Indian public health, until quite recently,1 have either examined the creation of policy among high-ranking officials or explained its failure by considering popular resistance to state measures. Although this scholarship is important, it only illuminates part of the picture. The practice of public health in India was contingent, to a large degree, on subordinates implementing policy on the ground. And whereas these agents formed the backbone of the system, they have been marginalized in favor of historical accounts that focus predominantly on the professional rivalries of administrators.2 This chapter draws attention to a group of such marginalized subordinates, namely, scavengers and sweepers, on whose shoulders the public health and sanitation machinery rested.3 As refuse and night soil were disposed of manually in the absence of water flush drainage, the success of sanitary measures depended most critically on the cooperation of these workers. In Victorian Britain night soil was also disposed of manually by scavengers and dust men,4 but their position differed considerably from their Indian counterparts. In India, occupations such as cleaning and sweeping, which involved the handling of fi lth, were relegated to the lowest castes: the “outcastes.” Their social identity was inextricably tied to their low caste status and the only occupations that were open to them were those considered to be physically and ritually polluting. Hence they were tied into a selfperpetuating cycle of social and economic marginalization. Seen as ritually impure by other castes, their touch and in some cases even their shadows were sufficient to defi le a member of a higher caste. Interestingly, sweepers, who were seen as the embodiment of impurity and pollution, were also the ones responsible for sanitation and hygiene. 5 Although sweepers underpinned the sanitary system they seldom figure in colonial records except as statistics or when they take collective action to make their importance felt. Almost all references to sweepers in the

52 Amna Khalid colonial record are negative, often framed in terms of either their “laziness,” “incompetence,” or “recalcitrance.” For instance, in the early twentieth century, when the sanitary administration of Bengal was considering the introduction of a system of “contact beds,” a technique of biologically treating sewage, the sanitary commissioner of Bengal argued against it, reasoning that: In India it is extraordinarily difficult to get any individual, who is either sufficiently intelligent or sufficiently reliable, to be entrusted with the opening and shutting of the valves in a contact bed installation. The ‘sweeper’ of this country cannot be made to understand the absolute necessity of working the beds regularly; a particularly cold night or a heavy downpour of rain, is quite sufficient excuse for not carrying out his duties properly. What can you expect from this class of man, who refuses to do night work, because he reports that he found a devil sitting on the valve handle . . . consequently contact beds should never be installed in places where European supervision is not available.6 Taking the case of sweepers in the United Provinces (UP)7 in northern India, this chapter argues that far from being mere tools for the implementation of policy, these subordinates had power in determining the practice of public health. Moreover, subordinates were able to influence the making of policy itself. This argument challenges scholarship framing colonial policy as formulated at the top and merely implemented by those lower down in the ranks. Instead the making of policy was a process of continual negotiation with subordinate agents. Situated at the very bottom of the administrative and caste hierarchy, sweepers were not passive employees; rather they were agents who strategically navigated the system and used their lowly caste status to further their own interests. On occasion they managed to invert the power balance making their indispensability for the sanitary system palpable. This was possible especially when the threat of epidemic diseases such as cholera loomed large and sweepers went on strike. Therefore, in order to understand the way in which public health measures operated on the ground, we must take into consideration the role of subordinate agents, and how their status was crucial in shaping their actions. The power of sweepers, however, was not limited to acts of resistance. In order to understand how they influenced policy, we need to look at the different ways in which they were able to make their importance felt, at times, without actually taking action. In the case under consideration, it was the perceived threat of a potential strike that was sufficient to override considerations of science and sanitation for policy makers in the sanitary administration. This example further reveals the limitations and inadequacies of the domination–resistance framework in conceptualizing and understanding the power of subordinates. Emphasizing only the moment and act of

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resistance as the sole expression of subordinate power, not only fetishizes resistance, but also overlooks other loci of the influence of subordinates. Drawing on Steven Lukes’s understanding of power as a dispositional concept, this chapter demonstrates that an important locus of sweepers’ power was their capacity to determine the public health policy agenda itself, as opposed to only taking observable action in the form of strikes.8 Therefore, in order to understand why the role of subordinates is significant for understanding public health practice and policy, we need to study not only observable actions and confl ict, but also more subtle and hidden ways in which their position as subordinate staff, and not simply their actions, shaped policy decisions.

SWEEPERS: THE SCAFFOLDING OF THE COLONIAL SANITARY SYSTEM The proliferation and development of urban centers, including port cities, in nineteenth-century India came with all the problems associated with urbanization: overcrowding, the proliferation of slums, pollution, and an increased fear of disease. This necessitated an organized system of sanitation and led to the institution of municipalities. The sanitary demands of these towns and cities far outstripped what the existing communities of sweepers could cope with. But because this growing urbanization was accompanied by rural-to-urban migration a significant contingent of lower caste workers were coming to urban areas.9 The new sanitary infrastructure and municipalities provided opportunities, especially for the lower caste and outcaste migrants, many of whom migrated from the countryside to better their lot in towns and cities.10 For untouchables, employment as municipal servants constituted a considerable change from their position in rural areas where they worked as menial servants for higher castes. Instead, the opportunity to work as employees of the state for monetary remuneration offered some degree of liberation as it undermined the direct caste subordination that they faced earlier. However, it did not translate into upward social mobility as caste distinctions in urban settings did not dissolve. The jobs available to them corresponded to their caste status; they were “concentrated in the menial jobs” and were “slotted into the least attractive positions in the new industrial order.”11Apart from low-paying jobs in factories and on the docks, municipal jobs as scavengers and sweepers were open to these migrants. These positions were poorly paid and reinforced the caste distinction that they had probably hoped to escape in these new settings. As Nandini Gooptu puts it: Occupational divisions along caste lines, prevalent in the rural situation, were . . . being replicated in urban areas, notwithstanding the relaxation of direct caste-domination in employment relations. This


Amna Khalid could generate or accentuate a sense of ritual discrimination among untouchables, especially when juxtaposed against a new experience of independence at work. Thus, while urbanisation opened up new opportunities for them, it also reinforced oppositions and barriers, and perpetuated their historical deprivation.12

However, not all sweepers in a city or town were employed by the municipality. In the case of towns in UP, sweepers were divided into two categories: the hereditary sweepers and the municipal sweepers. The hereditary sweepers claimed a customary and hereditary right to the scavenging for private houses and neighborhoods. Each neighborhood had a sweeper attached to it who was paid by the households (s)he served. Payment was often in kind, such as food or clothes, and at times in cash. There was an implicit understanding among sweepers that each had a monopoly over his/her neighborhood and would not be undercut by the others.13 They functioned as a workers’ union of sorts and because the sanitation of houses and neighborhoods was contingent on their goodwill, they had a signifi cant degree of power over their employers. Colonial records are replete with complaints about how sweepers abused the control their position afforded them. As early as the 1840s William Sleeman noted: [T]he right of sweeping the houses and streets is one of the most intolerable of monopolies, supported entirely by the pride of caste among the scavengers, who are all of the lowest class! The right of sweeping within a certain range is recognised by the caste to belong to a certain member; and if any other member presumes to sweep within that range, he is excommunicated . . . If any house-keeper with a particular circle happens to offend the sweeper of that range, none of his fi lth will be removed till he pacifies him, because no other sweeper will dare to touch it; and the people of a town are more often tyrannized over by these people than by any other.14 These sweepers also laid claim to the night soil they collected (by customary right) and then sold it as manure to farmers in neighboring villages. Sweepers made a considerable part of their earnings selling night soil. During seasons of high demand for manure, the state of conservancy tended to improve as “it was in the sweeper’s interest to collect and sell all the fi lth he could get, and the latrines were cleaned: at other times the work was neglected, unless indeed the nuisance became intolerable and the private employer was willing to pay extra to have it abated.”15 The second category was that of the municipal sweepers, who were direct employees of the municipalities and were responsible for the conservancy of streets and public places.16 Their duties were purely contractual and thereofre did not entail any caste obligation. At least in theory the two

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categories of sweepers were mutually exclusive. However, as we shall see in the following section, this was not always the case. Whereas the main task of sweepers was cleaning and removal of night soil their responsibilities also came to include the collection of public health data.17 The accurate registration of births and (causes for) deaths was vital for the formulation of health policy. Indeed this data formed the basis of preventive medicine. The importance of reporting and registering deaths, especially during epidemics, was recognized as early as 1868: [T]he measure is one of the utmost importance in a sanitary point of view, and without it indeed the basis of all sound sanitary progress must be wanting. . . as regards no disease is such information more important as regards cholera. Here the occurrence of the fi rst case is a matter of the greatest moment to at once be communicated to the sanitary officer who should . . . take measures for preventing the spread of the disease.18 Sweepers were particularly suited for this task as they removed the night soil of each house in every neighborhood. In this manner they were able to access sections of Indian society that administrators could not. Their services in this regard became critically important during the plague epidemic that struck the region in the late nineteenth century. For example, in 1896 corpse inspection was introduced to monitor the spread of bubonic plague—a measure that met with popular resistance. The bodies of the dead were examined by government officials for buboes (usually found in the underarm and groin regions) to determine the cause of death. Often interpreted as a means of desecrating and disrespecting the dead, people would conceal the bodies of the deceased and withhold information. However, sweepers had access to such information by virtue of their daily visits to houses to remove night soil. Moreover, the handling of dead bodies and cremation rituals were considered ritually polluting and were therefore carried out exclusively by the lower castes. Their lowly status enabled them to see things that those higher up did not have access to. In many towns collecting public health data of this nature was an explicit part of the sweeper’s job. And once plague broke out the sanitary commissioner of the province decided to offer monetary rewards to sweepers for reporting deaths in areas where this was not part of their regular duties. As soon as the death rate in any place appeared to be above the usual, sweepers were enlisted to collect information, as this was considered the fastest way to gather intelligence.19 Hardly any records document how the sweepers felt about this responsibility or their work in general. The only document found, a petition fi led by Hira, Bhawani, and other sweepers from Farrukhabad (a municipality in NWP), reveals that they perceived the reporting of births and deaths to be a burden and saw it as a form of oppression, requesting that this should not be required of them. 20 The outcome of this particular


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petition is unknown, but it is clear that sweepers were used extensively for such surveillance work. Thus, with the growing emphasis on hygiene and cleanliness, sweepers became indispensable for the sanitary and public health administration. Although they were at the bottom of the social and administrative hierarchy, not only because of the kind of work they did, but also by virtue of their caste status, they were not entirely powerless. They were aware of how crucial they were for the sanitary system, particularly during epidemics. Times of health crises held the potential for the inversion of the balance of power; sweepers wielded a special influence at these moments, as fear of the breakdown of the sanitary system underscored their importance.21 Indeed, there are a number of instances across northern India when sweepers exercised their agency overtly and took collective action. Sweepers in Delhi went on strike in 1873, 1876, and 1889;22 in Bombay there were two sweepers’ strikes in 1889 and a growing number in the early twentieth century;23 during the Kumbh mela, the large pilgrimage fair of 1879 at Hardwar (a pilgrimage site in UP), sweepers also went on strike when cholera broke out. 24 As Vijay Prashad argues in the case of Delhi, and Jim Masselos in the case of Bombay, these strikes did not often result in improving working conditions for sweepers. Instead they led to the creation of systems that limited sweepers’ ability to go on strike thereby tightening control over them.25 For example, in Hardwar after the strike in 1879 a new system of recruitment was put into place that increased the cost of collective action. 26 However, reducing the power of subordinates to acts of resistance only overlooks another very important locus of their power. We need to reconsider our understanding of power itself in order to see how sweepers were able to influence policy, and move beyond moments of observable “insubordination” as the only expression of their power. Instead we need to consider how sweepers were able to shape policy without taking observable action

SUBORDINATE POWER: THE CASE OF THE UP SWEEPERS In 1865 cholera spread from India to Egypt with Muslim Indian pilgrims traveling to the Hejaz. The following year it reached Europe. 27 In response to this pandemic, the International Sanitary Conference of 1866 was organized at Constantinople, bringing immense pressure to bear on Britain to manage the disease in India, where it was believed to have originated. The conference placed special emphasis upon the role of internal pilgrimages in India in spreading cholera, pinpointing the movement of pilgrims to and from pilgrimage sites in India as “the most powerful of all the causes that tend to the development and propagation of epidemics of the disease.”28 It was believed that the large pilgrimage gatherings (Kumbh fairs) at Hardwar, a pilgrimage site in UP, in the years 1831 and 1855 had been responsible for

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the cholera pandemics in Europe and America in the 1830s and 1860s. 29 In the colonial imagination the perception of these fairs as hotbeds of epidemics was so strong and was taken so seriously that the sanitary commissioner of India declared that the Kumbh mela at Hardwar, was “both in its purpose and consequences . . . an imperial business and not altogether a provincial one.”30 This correlation and association between pilgrimage sites and cholera persisted well into the twentieth century, and in 1912 the government of India ordered the appointment of a committee in UP to investigate the assumption that “large gatherings of pilgrims played a major role in the spread of epidemics.”31 The committee issued a report in 1913, and among other aspects it focused on the nature of conservancy in all the towns in the province. As noted earlier, the waste disposal system was purely manual based on “hand service, cartage and trenching.”32 And although in theory the two categories of sweepers, namely, hereditary and municipal sweepers, responsible for the conservancy of towns were separate, the committee found that, “These two agencies are, however, composed, for the most part, of the same individuals, whose income is made up partly from what they get as private sweepers and partly from their wages as public sweepers.”33 The committee also stressed that the hereditary/private sweepers were in a considerable position of power in that they could avoid work and make the living conditions of people distinctly unsavory. Because they were protected by their hereditary rights, they seldom cleaned private latrines diligently. Moreover, because many private sweepers doubled as municipal sweepers, they entrusted their private work to their wives and children who, according to the committee, did the work more poorly than the sweepers themselves, thereby contributing to the insanitary condition of privies and latrines in private houses.34 During their tour of the provinces the committee recorded: Everywhere the householders complained that the latrines remained untended for days and often for weeks together, and that it is impossible to get the private sweepers to do their work. As a matter of fact the sweeper, protected by his hereditary rights, feels that he is under no control, and both the householder and the local authority are powerless to get anything done.35 This situation was not the result of the lack of any legal recourse. The law provided for action to be taken against sweepers who failed to perform their duties. Section 102 of the Municipal Act of 1900 stated: Should a sweeper who has any customary right to do the house scavenging of a house or building . . . fail to perform such house-scavenging in a proper way and at reasonable intervals, he may impose upon such a sweeper a fi ne which may extend to ten rupees, and upon a second or


Amna Khalid any later conviction in regard to the same house or building, may also direct the right of the customary sweeper to do the house-scavenging of the house or building to be forfeited, and thereupon such right shall be forfeited accordingly.36

But according to the committee this provision was a “dead letter” as the large majority of householders considered going to court as witnesses for such cases socially demeaning.37 Secondly, they feared that lodging a formal complaint against a customary sweeper could result in all the sweepers boycotting the complainant’s household; a risk that could result in great discomfort along with posing a threat to health. Based on its observations, the committee concluded that “the private hereditary sweeper is the most serious menace to the public health” and that “both the householder and the local authority are powerless” in this regard.38 Having identified the hereditary sweeper as the chief threat to public health, the committee proposed two alternatives. The fi rst was to install a system of sewage and to ensure that all private privies be the water flush type connected to the sewers.39 Such a system would dispense with the dependence on private sweepers for house conservancy and thereby free the householder from the “tyranny” of the sweeper, and the local authority from dealing with the public health danger posed by fi lth and excrement festering in private privies. However, the laying out of the basic infrastructure would require considerable expenditure by municipalities and other local authorities and this posed a problem. During Lord Mayo’s time as Governor General (1868–1872), public health was decentralized from the central to the provincial governments. The main motivation for this was financial, as Mayo had to deal with the budgetary deficit created by the previous governor general’s policies. Hence in 1870 his Resolution on Provincial Finance transferred certain expenditures from the central Indian government to the provincial governments, which in turn passed on sanitary expenditure to the municipalities.40 Greater representation was given to Indians on municipal commissions and boards as this was considered a prerequisite if money for sanitation was to be raised by local taxation.41 Accordingly, the burden of shouldering the expense for the water flush sewage system would fall primarily on municipalities that were in no position to raise sufficient funds. Hugh Tinker has argued that the indifference of the majority of Indians towards Western ideas of sanitation, along with members of municipal boards who were not keen on taking initiative in this regard, played a part in limiting sanitary development.42 There is some purchase in this argument, but it also functioned as a convenient excuse for colonial officials to justify overlooking the underdeveloped state of the sanitary infrastructure. Official discourse is replete with statements of the “native” antipathy to hygiene and municipal boards stalling sanitary reform to limit their responsibilities.43 There may be some evidence to support such claims, but at some level these arguments were

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tools in the hands of more senior colonial officials to justify the lack of a sanitary infrastructure. By deploying these arguments, they were doing exactly what they blamed the municipal boards for: they were absolving themselves of any responsibility. In short, the central and provincial governments were reluctant to sanction budgets to municipalities for technological improvements of the sanitary system, especially when the job was being done by sweepers at a much lower cost.44 The committee anticipated that the water flush sewage system would be rejected on monetary grounds, and instead proposed a second alternative: to abolish the system of private sweepers and to place the conservancy of all private houses in the hands of the local authority. According to this suggestion, private sweepers would no longer have a monopoly over the conservancy of private houses; instead the same sweepers would be employed as municipal sweepers. This, it was thought, would limit the power of customary sweepers. The logic was outlined as follows: As a public servant the sweeper receives fi xed wages from the local authority: he has one master and, if his work is not done, he can be punished or dismissed. But a private sweeper has many masters and from each he gets the merest pittance: no one is in a position to exercise any authority over him.45 The committee was keen on this possibility and considered it necessary for public health. C.L. Dunn, the sanitary commissioner for UP, threw his weight behind this recommendation and in its support stated: I may at once say that from a sanitary point of view, I do not consider the scavenging of private houses by customary sweepers at all satisfactory. These customary sweepers are under no control and private houses are this badly conserved. The foul and insanitary state in which privies generally remain is a serious defect in our conservancy system and a constant menace to public health.46 Other officers, like the commissioner of Jhansi Division, were also vocal in their opposition to the system of customary sweepers and declared their methods “insanitary” and “inefficient.”47 Furthermore, hereditary sweepers were making money by selling the night soil they collected to farmers as manure. However, the authorities averred that the manner in which hereditary sweepers collected and transported night soil to cultivators was objectionable as “no proper precautions for its deodorization, etc. [were] being taken,” thereby rendering the system “directly conducive to an insanitary state of affairs within and around the towns, amounting in some cases to a positive danger to the public health.”48 The manner of disposing night soil was “contrary to all sanitary laws,”49 and sweepers were seen as “habitually erring against sanitary cannons.”50 The fact that sweepers


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threw fresh night soil on the fields of the buyers and left it uncovered was said to compound dangers to the health of the population close to the fields. For example, a letter written by the superintendent of the Central Prison of Fatehgarh to the district magistrate regarding this practice, stated: I understand that the sweepers of Fatehgarh have a hereditary right to remove human excreta and rubbish from private houses, but surely this right does not entitle them to carry it exposed on bullocks in bags and deposit it close to habitations. I strongly protest against this practice in the interest of the health of the prisoners under my care and would ask you to kindly take steps to prevent the municipality from continuing this primitive method of disposal of night-soil.51 J.H. Harrison, secretary of the Cawnpore municipality, objected as early as 1882 to the risk posed by the transport of night soil by sweepers. He noted that adjoining most large towns were cantonments and civil stations and hence sweepers were limited in the routes they could take to deposit night soil in pits as trenching it close to cantonments and civil stations was prohibited. This also meant that the night soil usually had to be carried long distances and as a result, “In such cases having often to traverse narrow lanes and crowded streets with the night soil in open baskets—the only appliances these sweepers usually possess—it is easy to imagine how objectionable such a system would be from a sanitary point of view.”52 Moreover, the authorities claimed that fresh night soil was not high-quality manure and to improve its quality, it had to be trenched and treated. 53 Although objections to the methods of hereditary sweepers were articulated in terms of the threat posed to public health, the administration may have been interested in wresting away the control of night soil from customary sweepers for another reason. The refuse collected by municipal sweepers from public latrines was being trenched and treated by the municipalities and then sold to cultivators. It was therefore clear to the administration that the private sweepers were making money by selling the night soil they collected from private houses—an income that could potentially be captured by the municipalities. 54 One officer estimated that in Farrukhabad municipality, which had a population of almost seventy-five thousand, the private sweepers earned Rs 40,000 annually from the sale of night soil. This was primarily because Farrukhabad was situated right next to vast fields where large-scale cultivation was carried out. The exact income generated by the sale of night soil was contested and certain officials claimed it was highly exaggerated.55 However, in 1872 it was recorded that private sweepers had made around Rs 20,000 by selling the refuse to brick-makers and cultivators.56 The commissioner of Agra Division noted that that “even in a less favourably situated municipality of the population of Farrukhabad, an income exceeding Rs. 4000 or Rs. 5000 might be obtained and

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this would be most useful in making the board to dispense with the most objectionable items on the action list.”57 Municipalities were very interested in the potential gains from appropriating the night soil from private sweepers. The municipality of another town, Shahjahanpur, instituted a system whereby it was able to gain access to the night soil collected by private sweepers. The system was hailed as a great success by R. Smeaton, secretary to the government of UP, who recommended all commissioners under him to study this system and see if they could benefit from it.58 It was alleged that the Shahjahanpur municipality was able to address the public health danger posed by the “insanitary” manner in which private sweepers removed and disposed of the night soil without interfering with the alleged rights of customary sweepers. Under this system, which was introduced in July 1887, the municipality bought the night soil from private sweepers, trenched it, and then sold it at a higher price to cultivators. The benefit to the area’s population was articulated in terms of public health: The chief advantage to the municipality, by the present system, is that the chance of prevalence of any epidemic disease has been diminished and the unhealthy smell that used formerly to arise from the uncovered filth in the fields has, by the present arrangement, been entirely destroyed.59 Monetarily, the municipality gained considerably as it made a net profit of over Rs 854. The municipal board claimed that this also benefited the cultivators, as the trenched night soil had higher value as manure. In addition, it claimed that the four hundred private sweepers in Shahjahanpur were happier as they received their money in advance whereas the payment had formerly been made later by the cultivators.60 There seems to be no way of verifying this last claim regarding the sweepers, owing to an absence of surviving documentation. However, in the case of Farrukhabad where the municipality was considering appropriating the night soil of private sweepers, the sweepers displayed considerable resistance. When the proposal to take away night soil from private sweepers was put forth to the Farrukhabad municipal board’s chairman, he said that such a measure would cause “an enormous amount of annoyance and dissatisfaction,”61 and that it could only be contemplated if the sweepers were offered some compensation in return for their right over the night soil. But, he went on to state that “no reasonable award of compensation would satisfy the sweepers for the extinction of their rights.”62 Finally, the committee “deliberately and unanimously condemned it [i.e., the proposal].”63 When the private sweepers of Farrukhabad heard of the proposal, they fi led a formal complaint to the municipal board in which they noted that they were not remunerated by the government for their conservancy of private houses; their only source of income was the night soil they collected and they did not wish for this to be taken away from them.64

62 Amna Khalid Given the degree of opposition by the sweepers and members of the municipal committee, it was fi nally decided that the municipality could not just ignore the rights of the sweepers and appropriate the night soil rather the municipality would compensate the sweepers by buying the night soil from them. After treating it, the municipality would sell it on to cultivators.65 This system was put into place at Farrukhabad and a few other municipalities. It provided a means to fund municipal expenditure along with being what the administration saw as a more sanitary way of disposing of the night soil. But the provincial government did not issue any overarching legislation regarding the rights of the sweepers. Issues relating to private sweepers, their practices, and their rights came up repeatedly for consideration. In 1919, C.L. Dunn, the sanitary commissioner of UP, wrote to the secretary of the UP government, commenting on the state of poor conservancy in municipalities in the provinces and blaming private sweepers, stating that they were their own masters and worked when it suited them. His solution was to abolish customary sweeping and have the municipalities take over the conservancy of private houses, employing customary sweepers as municipal sweepers. And the cost of this system, he proposed, would be covered by levying a small conservancy tax.66 But the rights of sweepers could not be summarily done away with as they had been recognized by law. Before 1900 whatever rights the sweeper had by way of custom were merely between the sweeper and the householder. But in 1900 the Municipal Act for UP was introduced. Modeled on the Municipal Act of Panjab, it incorporated clauses recognizing the customary rights of sweepers and stating that under no circumstances could the municipality take over the conservancy of private houses as this was the domain of the customary sweeper. In case the sweeper did not perform his duty properly, there was a provision for the householder to take him to court and for him to be punished. But an objection was raised: The householder whose house is neglected will apparently, until he has got his judgement, be wronging the sweeper if he makes any other arrangement for cleanliness. And even when the sweeper has been convicted, he will still have his rights to scavenge all other houses, so it will be a long time before he can be turned out of the muhalla [neighborhood].67 Indeed, in one case the system completely backfi red. In response to a few complaints the customary rights of some sweepers were confi scated. Subsequently all the sweepers of the town boycotted the households that had complained.68 Nonetheless, the issue remained unaddressed and the provisions from the Panjab Act were copied into the UP Municipal Act of 1900. When the act was being revised, G.G. Sim, the secretary to the government of UP, suggested that all mention of the customary rights of sweepers be excluded

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from the new act and that none of these rights be recognized. In this manner, the conservancy of private houses could be undertaken by the municipality without breaching the law. However, the committee appointed to consider revisions to the act was reluctant as “strenuous opposition” was anticipated.69 To enable municipalities to take over private scavenging in certain cases, the new Municipal Act of 1916 introduced a clause in section 200(a): the municipal board could undertake house-scavenging of muhallas where the sweeper had a hereditary right, provided the sweeper consented.70 In this manner the committee hoped that municipal boards might arrange to take over private sweepers as municipal sweepers and formally include conservancy of private houses under the responsibilities of the municipality. This clause was tested in Cawnpore, where the municipality arranged to take over the scavenging of a neighborhood. The customary sweepers for that muhalla agreed and were hired as municipal employees at a fi xed rate of Rs 7 per month. The extra expense was to be met by a new house-scavenging tax on the households. The tax was sanctioned by the board and the government, but before the scheme could be introduced, many houses in the neighborhood required structural alterations to their latrines. Orders were duly issued and elicited such strong negative responses from the residents that the municipal board decided it was more expedient to drop the scheme completely.71 In 1919 when the sanitary commissioner of UP considered the recommendation of the Pilgrim Committee to do away with the system of customary sweepers, Lord Meston, the lieutenant governor of the provinces, noted that a mistake had been made in the Act of 1916. He said that by acknowledging the rights of hereditary sweepers, “We have undoubtedly . . . committed ourselves badly.”72 The sanitary commissioner proposed an amendment in the act whereby the rights of hereditary sweepers would be written out. He suggested to the Board of Public Health that municipalities take over the conservancy of private houses and employ hereditary sweepers as municipal ones. The board agreed that such a measure would lead to greater efficiency and circulars were issued to municipal boards to invite opinion.73 Out of the total of eighty-five municipalities, forty-eight strongly opposed the proposal to abolish customary rights. The municipality of Fatehpur reasoned: The sweepers have got, for an immemorable past, customary rights to house scavenging, getting in return some remuneration fi xed by mutual contract between them and the house-holders. This right has been recognised by law and the High Court has held it as a transferable and heritable right which the sweepers can transfer at their will. This is the only temptation that has fi rmly secured their services for the public in general. If this right be abolished and confiscated there is every likelihood that they leave their occupation and adopt some other leaving the world in a realm of vexation.74

64 Amna Khalid The majority of the commissioners were in favor of the change from a sanitary point of view. The commissioner of Jhansi Division condemned the scavenging done by hereditary sweepers as “insanitary, inefficient and not liable to control.”75 Commissioners of Allahabad, Gorakhpur, Meerut, and Lucknow also labeled hereditary sweeping as “unscientific” and “insanitary.”76 However, despite such convictions, few were in favor of abolishing the system as they feared the reaction of sweepers. The commissioner of the Allahabad Division noted that although in principle the system ought to be abolished, this was not feasible for “the sweeper class is restless, municipal administration is generally inefficient and its services unpopular and any interference in their customary rights will tend to make the sweeper migratory.”77 Other commissioners thought that any such amendment would lead to a mass strike by the sweepers; the commissioner of Rohilkhand Division voiced his concern, noting, “The sweeper is in a very strong position and if he had more power of combination and cohesion, might be very dangerous. Excessive powers of punishment and control might very well precipitate a crisis.”78 Another concern related to how Indian society generally would be affected by the abolition of customary sweeping and how the state would be perceived by the general populace. Such a measure would signify more than just a change in the way neighborhoods were administered as it aimed to do away with an established tradition. The deputy commissioner of Pratabgarh was of the view that more than a simple change in legislation would be required to alter such an established system. In his words, “the whole fabric of Indian life is held together by that least tractable of all ties—custom, and the merest executive fiat will not do away with it.”79 A similar sentiment was expressed by E. Blunt, the secretary to the government of UP, when he stated that any rash means of doing away with customary sweeping would challenge tradition as “jujmani [patron–client relations] is a thing to which all castes cling desperately.”80 Although according to the logic of effective sanitation and efficient administration, the customary rights of sweepers needed to be revised, municipal boards were loath to support the amendment. The matter was referred to the Local Self-Government Advisory Committee that met in June 1930. The committee decided that the potential reaction of the sweepers to such a move would be far too strong to warrant the amendment. They therefore postponed reaching a conclusion on the matter indefi nitely.81 While the administration was in agreement that the system of private hereditary sweepers was “bad” and “responsible for the defective sanitation in most of the towns,”82 it was compelled to take into account the possible response of the sweepers. The rights of hereditary sweepers could not be dismissed. It is therefore evident that whereas sanitary policy was a function of the budget allocated for such purposes, the degree of initiative taken by municipal boards, and the responses of the people to proposed measures, it was also shaped, to a considerable degree, by the subordinate

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sanitary staff. How they would react to changes instituted from above was indeed a very serious consideration for those designing policy.

CONCLUSION This chapter has highlighted the importance of sweepers to the sanitary order in British India by examining the various functions they served. The sweepers’ indispensability became even more pronounced during times of epidemic disease as they were able to exercise their agency, drawing attention to their role in society and thereby influencing the making of sanitary policy. But perhaps the most significant conclusion that can be drawn from this case study of the UP sweepers is that without actually going on strike the sweepers had the power to prevent the administration from dismissing their customary rights. Even though the system of private sweepers was not in line with “sanitary principles,” the authorities were reluctant to do away with it. Although there was no actual resistance in terms of a strike, the possibility of sweepers taking collective action was sufficient for policy makers to indefi nitely postpone the decision of whether sweepers’ customary rights ought to be abolished. The power of sweepers in this case actually lay in not acting and showing their preference for hereditary status over contract in this way. This then throws into relief the limitations of the domination– resistance framework that only conceptualizes the power of subordinates as constituted by action, especially the act of resistance. Power in this framework is conceptualized in behavioral terms; in other words, power has to be observable, it has to be exercised. This notion of power is inadequate especially to understand the influence that subordinates may have. Lukes’s view of power, on the other hand, is more useful in this context. According to him, power is “a potentiality, not an actuality—indeed a potentiality that may never be actualized.”83 As the UP sweepers demonstrate, subordinate power is not always overt and observable. The power of the sweepers lay in their capacity to influence decision making without action. It was the perceived threat of a potential strike that prevented the authorities from abolishing the customary rights of the sweepers. Another problem with the domination–resistance framework is that the category of resistance, “impose[s] a teleology of progressive politics on the analytics of power—a teleology that makes it hard for us to see and understand forms of being and action that are not necessarily encapsulated by the narrative of subversion.”84 Resistance only articulates actions as an expression of power if it is exercised for purposes of emancipation. However, in the case of the sweepers, they used their power to defend their customary caste status, which was conventionally seen as conservative and regressive. They were keen to preserve their hereditary status and resist the transformation of their work into a formal contractual relationship. This defense

66 Amna Khalid of traditionalism is a facet of their struggle that the category of resistance overlooks. A broader understanding of power allows us to see the different ways in which subordinates preserve their interests and articulate freedom. Finally, through a discussion of the dual system of customary and municipal sweepers in UP, this chapter has shown that public health measures in India were not always based on “sanitary principles”; the colonial administration was compelled to take into account the will and interests of subordinate workers. Thus colonial sanitary policy was, to some degree, shaped by the concerns and responses of subordinate personnel. Studies that do not take into account either the impact of subordinates or how their status determined the ways in which they could impact policy present only a partial picture of the formulation and practice of public health policy in India.

NOTES The research for this paper was made possibly by a grant from the Wellcome Trust. I am grateful to Mark Harrison, Biswamoy Pati, Margaret Jones and Waltraud Ernst for their comments on earlier drafts. 1. For the recent focus on subordinates in the British Indian context see Mridula Ramanna, “Indian Doctors as Vital Intermediaries: Their Role in Tackling Epidemics in Bombay Presidency, 1896–1920” (paper presented at the conference Epidemics in South Asia: A Review of Medical, Political and Social Responses, University of Burdwan, Burdwan, India, November 2006); James Mills, Madness, Cannabis and Colonialism: The “Native-Only” Lunatic Asylums of British India, 1857–1900 (Basingstoke: Macmillan, 2000), 149– 163; Sanjoy Bhattacharya, Mark Harrison, and Michael Worboys, Fractured States: Smallpox, Public Health and Vaccination Policy in British India, 1800–1947 (New Delhi: Orient Longman, 2005). 2. David Arnold, “Cholera and Colonialism in British India,” Past and Present 113 (1986): 118–151; Mark Harrison, Public Health in British India: Anglo-Indian Preventive Medicine, 1859–1914 (Cambridge: Cambridge University Press, 1994); J.C. Hume, “Colonialism and Sanitary Medicine: The Development of Preventive Health Policy in the Panjab, 1860–1900,” Modern Asian Studies 20 (1986): 703–724; Ira Klein, “Cholera: Theory and Treatment in Nineteenth Century India,” Journal of Indian History 58 (1980): 35–51; Radhika Ramasubban, “Public Health and Medical Research in India” (Swedish Agency for Research Co-operation with Developing Countries Working Paper, 1982). 3. Hereafter, the term sweepers will be used to refer to both scavengers and sweepers. 4. See H. Moule, Town Refuse: The Remedy for Local Taxation (London, 1872). 5. The degradation engendered in their work was further compounded by the poor quality of the equipment provided, often compelling sweepers to handle the waste with their bare hands. These deplorable work condition exposed sweepers to extreme health risks. 6. W.W. Clemesha, Sewage Disposal in the Tropics (Calcutta: Spink Thacker, 1910), 127–128. 7. Before 1902 the region was known as North Western Provinces. Depending on the time period being referred to, this chapter uses both names for the region. 8. Steven Lukes, Power: A Radical View, 2nd ed. (New York: Palgrave Macmillan, 2005), 69–74.

“Unscientific and Insanitary”


9. Oliver Mendelsohn and Marika Vicziany, The Untouchables: Subordination, Poverty and the State in Modern India (Cambridge: Cambridge University Press, 1998), 89. 10. For an exposition of the push-and-pull factors that underpinned the migration of the lower castes from neighboring rural areas to Bombay (prior to the institution of the jobber system) see Jim Masselos, “Jobs and Jobbery: The Sweeper in Bombay under the Raj,” Indian Economic Social History Review 19 (1982): 106–112. 11. Mendelsohn and Vicziany, Untouchables, 89–90. 12. N. Gooptu, “Caste, Deprivation and Politics: The Untouchables in U.P. Towns in the Early Twentieth Century,” in Dalit Movements and the Meaning of Labour in India, ed. Peter Robb, 280–281 (Oxford: Oxford University Press, 1993). Vijay Prashad has taken this argument further using the example of Chuhras, an untouchable caste that migrated from the countryside to Delhi. According to him, the emphasis of colonial offi cials on only hiring certain castes as sweepers was actually responsible for ascribing the connection between modern occupation and caste identity. He shows how Chuhras, who were used to agricultural work, were employed only as sweepers when they migrated to Delhi. This “statutory identifi cation of Chuhras with sanitation” was reinforced when Chuhras established a monopoly over sanitation jobs in the face of competition for jobs other untouchable castes. And so “the state inserted itself into the Chuhras’ lives to adversely refashion their destiny,” and locked them into occupations with which the castes had no work history. Thus what came to be seen as the ‘traditional’ occupation of certain castes was actually a modern formulation of their identities. Vijay Prashad, Untouchable Freedom: A Social History of a Dalit Community (New Delhi: Oxford University Press, 2000), 42–45. 13. Report of the Pilgrim Committee, United Provinces (Simla: Government Press, 1916), 32. 14. William Sleeman, Rambles and Recollections of an Indian Offi cial, vol. 1 (London: J. Hatchard, 1844), 64–65. 15. Report of the Pilgrim Committee, 32. 16. Report of the Pilgrim Committee. 17. AAS: P/5362, NWP Sanitary, A Progs., July 1898, Prog. 133. 18. AAS: P/438/32, NWP General, A Progs., Aug. 1868, Prog. 117, dated September 7, 1867. 19. Prashad notes how sweepers were also used for collecting all kinds of intelligence from the early nineteenth century by the British Resident of Delhi. Vijay Prashad, “Marks of Capital: Colonialism and the Sweepers of Delhi,” International Review of Social History 40 (1995): 7–8. 20. “A petition from Hira, Bhawani, and other sweepers of Farrukhabad, complaining against the Furrukhabad Municipal Board in connection with the sweeping of lanes—forwarded to the Magistrate of the District via the Commission of Agra Division,” NWP Municipal, B Progs., August 1890, Prog. 49, Uttar Pradhesh State Archives [hereafter UPSA]: File 215 A, Box 16. However, in the case of Delhi, Prashad sites a quotation by Charles Metcalfe (the British Resident) that suggests that sweepers actually took pride in their role as informants. Prashad, “Marks of Capital,” 7–8. 21. For another study of how the significance and necessity of the poor and formerly despised sections of society was enhanced during an epidemic outbreak, see Brian Pullan, “Plague and Perceptions of the Poor in Early Modern Italy,” in Epidemics and Ideas: Essays on the Historical Perception of Pestilence, ed. Terence Ranger and Paul Slack, 101–124 (Cambridge: Cambridge University Press, 1992).


Amna Khalid

22. Prashad, Untouchable Freedom, 1–24. 23. Masselos, “Jobs and Jobbery.” 24. See the appendix in Annual Report of the Sanitary Commissioner of North Western Provinces 1878 (Allahabad: Government Press, 1879), 53. 25. Prashad, Untouchable Freedom; Masselos, “Jobs and Jobbery,” 102, 112. 26. Most of the sweepers hired to work at the pilgrimage site during fairs were daily wage laborers who were employed for the fi xed period of the fair. Therefore, if they deserted the site they only forewent their daily wage. After the strike of 1879 a different system of sweeper recruitment was put into place whereby only those sweepers that had permanent jobs with the Hardwar Union Municipality and other neighboring districts’ municipalities were hired. According to this plan, the extra sweepers were borrowed from neighboring districts for the duration of the fair but were paid for their work as part of their monthly salaries from their respective municipalities. In this manner the authorities were able to stem the impulse to strike for the result was the loss of their permanent jobs. AAS: P/3828, NWP General, A Progs., January 1892, Prog. 11, dated May 27, 1891. 27. It was believed that cholera was raging in the Bombay presidency, was taken by Muslim pilgrims to Mecca, and from there spread to Jiddah, Alexandria, Cairo, and then Europe. Tilbury Fox, Cholera Prospectus: Compiled from Personal Observations in the East for the Information and Guidance of Individuals and Governments (London: Robert Hardwicke, 1865), 14–15. 28. A.H. Leith, Abstract of the Proceedings of the International Conference of 1866 (Bombay, 1867), 14. 29. C.L. Dunn and S. Khan, Cholera in Hardwar (Calcutta, 1929), 185; A.C. Banerjea. “Note on Cholera in the United Provinces,” Indian Journal of Medical Research 39 (1951): 17. 30. Annual Report of the Sanitary Communication for the Government of North Western Provinces & Oudh 1891 (Allahabad: Government Press, 1892). 31. Report of the Pilgrim Committee, 2 (Appendix 1). 32. Ibid., 30. 33. Ibid., 30–31. 34. Ibid., 32. 35. Ibid., 31. 36. Ibid., 32. 37. Ibid. 38. Ibid. 39. Ibid. 40. Harrison, Public Health, 105. 41. Ibid., 166. 42. H. Tinker, The Foundations of Local Self-Government in India, Pakistan and Burma (London: Athlone Press, 1954). 43. See, for instance, Letter from Commissioner Jhansi Division to the Secretary of Government, UP, dated May 8, 1926, in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. UPSA, File 416E, Box 326. 44. In the case of Delhi, Prashad has shown that municipal sweepers were locked into very poor working conditions as the Delhi Municipal Corporation (DMC) employed jamadars (people from a caste higher than the sweepers) to supervise the sweepers. These jamadars held powers to hire and fi re sweepers and often abused this to exact bribes and commissions from sweepers in return for not fi ring them. The influence jamadars had over sweepers also had an element of caste oppression: jamadars used social, economic, and

“Unscientific and Insanitary”

45. 46. 47.

48. 49.

50. 51.

52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64.

65. 66. 67. 68. 69.


extra-economic pressure to control sweepers and limit collective action. Prashad (Untouchable Freedom) shows how even after technical solutions were available for the disposal of sewage (such as incinerators) that would have emancipated the sweepers from the tyranny of jamadars, the DMC eschewed such technology because of fi nancial concerns. The subjugation of sweepers by jamadars served the purposes of the DMC at a much lower cost. Report of the Pilgrim Committee, 32. UPSA: File 416E, Box 326, NWP Municipal, A Progs., May 1920, Prog. 12. Letter from Commissioner Jhansi Division to Secretary to Government UP, dated May 8, 1926, in Pilgrim Committee’s Recommendations Regarding Conservancy, in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. UPSA: File 416E, Box 326. UPSA: File 215A, Box 16, NWP Municipal, A Progs., May 1890, Prog. 1. UPSA: File 416E, Box 326, Correspondence between the Superintendent, Central Prison, Fatehgurh and the District Magistrate Farrukhabad, dated August 12, 1916, in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. Emphasis added. UPSA: File 416E, Box 326, Note for the Local Self-Government Advisory Committee, (not dated), in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. UPSA: File 416E, Box 326, Correspondence between the Superintendent, Central Prison, Fatehgurh and the District Magistrate Farrukhabad, dated August 12, 1916, in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. UPSA: File 61A, Box 11, Abstract of Papers received by the GOI on the utilization of town refuse and sewage for agricultural purposes, Municipal Department (not dated). UPSA: File 215A, Box 16, NWP Municipal, A Progs., May 1890, Prog. 2. UPSA: File 215A, Box 16, NWP Municipal, A Progs., May 1890, Prog. 1. UPSA: File 215A, Box 16, NWP Municipal, B Progs., May 1890, Prog. 36. UPSA: File 61A, Box 11, Employment of City Refuse for Agricultural Purposes at Farrukhabad , Municipal Department (not dated). UPSA: File 215A, Box 16, NWP Municipal, A Progs., May 1890, Prog. 36. AAS: P/3598, NWP Municipal, A Progs., May 1890, Prog. 1. AAS: P/3598, NWP Municipal, A Progs., May 1890, Prog. 2. Ibid. UPSA: File 215A, Box 16, NWP Municipal, B Progs., May 1890, Prog. 36. Ibid. Ibid. UPSA: File 215A, A petition from Hira, Bhawani, and other sweepers of Farrukhabad, complaining against the Furrukhabad Municipal Board in connection with the sweeping of lanes—forwarded to the Magistrate of the District via the Commission of Agra Division, Box 16, NWP Municipal, B Progs., August 1890, Prog. 49. UPSA: File 846D, Box 198, revised instructions for the guidance of municipal boards, UP, on the disposal of night soil (1909). UPSA: File 416E, Box 326, NWP Municipal, A Progs., May 1920, Prog. 12. UPSA: File 416E, Box 326, Letter from Secretary to Government of UP to Lieutenant-Governor UP, dated July 25, 1917, in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. Ibid. Ibid.

70 Amna Khalid 70. 71. 72. 73. 74.

75. 76.


78. 79. 80. 81. 82. 83. 84.

Ibid. Ibid. Ibid. UPSA: File 416E, Box 326, Order issued in Government Order on February 1, 1926, in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. UPSA: File 416E, Box 326, Opinions of all Commissioners of Divisions in UP on the Question of Abolition of the Hereditary Rights of Sweepers, dated May 14, 1927, in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. UPSA: File 416E, Box 326, Letter from Commissioner Jhansi Division to Secretary to Government of UP, dated May 8, 1826. UPSA: File 416E, Box 326, Letter from Commissioner Jhansi Division to Secretary to Government UP, dated May 8, 1926, in Pilgrim Committee’s Recommendations Regarding Conservancy, in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. UPSA: File 416E, Box 326, Opinions of all Commissioners of Divisions in UP on the Question of Abolition of the Hereditary Rights of Sweepers, dated May 14, 1927, in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. Ibid. Ibid. UPSA: File 416E, Box 326, Letter from Secretary to Government UP, dated January 2, 1920, in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. UPSA: File 416E, Box 326, Extract proceedings of a meeting of the LSG Advisory Committee held on June 12, 1930, in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. UPSA: File 416E, Box 326, Note for the Local Self-Government Advisory Committee (not dated), in Notes and Orders regarding the Pilgrim Committee’s Recommendations about Conservancy. Lukes, Power, 69. Saba Mahmood, Politics of Piety: The Islamic Revival and the Feminist Subject (Princeton, NJ: Princeton University Press, 2005), 9.


“Left in the Hands of Subordinates” Medicine, Language, and Power in the Colonial Medical Institutions of Egypt and India James Mills

John Warnock was appointed by the public health department in Cairo in 1895 at a time when the city was part of the British Empire. He had been working in the asylum system in the UK for almost a decade and he brought his experience to the task of reforming arrangements in Egypt. Over the twenty-eight years that Warnock was in charge he expanded the institution and built a new hospital, so that by the end almost two and a half thousand Egyptians were being treated at any one time within his domain. He was also responsible for drafting laws on mental illness for Egypt and he set up a department dedicated to lunacy within the colonial ministry of the interior. His accomplishments also included pioneering research into the nature and origins of mental illness in North Africa, particularly related to the local use of cannabis preparations for the purposes of intoxication.1 Warnock’s retirement in 1923 resulted in a memoir published in the Journal of Mental Science in the following year. In it he reflected on his early experiences at the hospital and of his responses to these over subsequent years: Besides the almost complete lack of funds, my total ignorance of Arabic, and the total ignorance of patients and staff of any language but Arabic, prevented my doing anything for some time. I was unable even to tell the servant to shut the door or to ask a patient his name. I had no interpreter. However, after some time I found a patient who could write English and for a while he was employed in translating Arabic letters etc until it was discovered that he interpolated numerous misstatements founded on his delusions. In those days an English or French-speaking clerk was not available. For a time I could only look on and guess at what was going on in most matters. 2 He went on to admit that throughout the years that he spent in Egypt he never bothered to study written Arabic, and that he found it “impossible to learn all the tongues necessary to converse with all the patients and their

72 James Mills friends.”3 By the end of his career his grasp of the vernacular was such that he could only “make my wants known and give orders.”4 Although these retirement recollections provide only glimpses of Warnock’s experiences in the Egyptian asylum, they are suggestive when taken in the context of the wider themes of this volume. The superintendent himself was cheerful enough to report the difficulties that this inability to command local languages produced for comedic effect in the story about the impact of his first clerk’s delusions. However, in other contexts colonial officials were more anxious about the role of locally recruited interpreters and translators who they feared were able to so control communications that the officers were enclosed within a “circle of iron.”5 As officials remained reliant on locally recruited staff to spread their word in local languages and to translate what was being communicated to them by local individuals and communities, they surrendered control over what was said, when, and how. Within the “nodes of power” opened up for translators and interpreters within these lines of communication the personal agendas and understandings of those providing these linguistic services could direct and shape outcomes and ideas.6 In the case of the Abbasiya Asylum, it seems that this enabled a lunatic to control the asylum, or at the very least to “interpolate numerous statements” into the functioning and records of the institution based on a highly individual and particular understanding of the world.7

“LEFT IN THE HANDS OF SUBORDINATES” If Warnock’s story reminds historians that the wider issue of who controlled communications in colonial contexts could often impact on the management of medical institutions there, reports from asylum superintendents in India draw attention to the more practical matters. There, none had the luxury afforded Warnock of devoting all of their time to a single institution. One civil surgeon in India in the 1870s wrote in his memoirs of the tasks that the medical officer of the station was expected to attend: The day after my arrival I took over my duties which included the management of the district jail, containing more than four hundred prisoners, as well as the superintendence of the Arrah dispensary, and several branch dispensaries in different parts of the district, the medical charge of the district police and other civil establishments and a fair amount of private practice in the station and neighbourhood . . . In addition to the various duties pertaining to the office of Civil Surgeon . . . It will thus be seen that the time of a Civil Surgeon in India is pretty well occupied even in an ordinary station like Arrah. In a large station like Patna, where the Civil Surgeon has in addition a lunatic asylum under his charge, and a medical school to superintend the work is much heavier and some of it must necessarily be left in the hands of subordinates.8

“Left in the Hands of Subordinates”


The question remains of who these subordinates were and what evidence there is of their conduct while at work. It is clear that they could be large bodies of staff. At the largest of the asylums at Calcutta the staff in 1880 numbered sixty-nine people, employed to tend to an average daily patient population of 215.9 At the same time, at smaller institutions, such as at Delhi, there were seventy-three patients in the asylum at the end of the year and twenty-five on staff.10 The most senior appointments were usually Indian, so that at Berhampore “the Overseer, Baboo Mohendro Nath Roy, regarding whose character and fitness for the post he occupies I have fully expressed in former reports, continues to perform his duties in an efficient and honest manner.”11 Sometimes other staff members had previous experience of working for the British, and in Bengal it was reported in 1869 that “some of the new men had served in various capacities under the overseer in the horse artillery in former years. A few are Punjabees who have taken their discharge from regiments quartered in this neighbourhood and being contented with the service have summoned others from long distances.”12 Others could also claim experience of colonial institutions, albeit in less celebrated circumstances. The superintendent of the asylum in Rangoon wrote: I have introduced a large convict element into the constitution of the establishment; and I have done so, because in the fi rst place, I consider that by this measure the Chief Commissioner’s instructions to observe the strictest economy in framing my estimates may be closely adhered to; and in the second, because the Asylum will in this way obtain in its minor offices the services of men much more trustworthy, much more intelligent, and much more orderly than any whom it is possible to fi nd amongst the class of free natives of India which alone would be disposed to take service in the institution.13 Such anxieties about the quality of the staff recruited locally were also voiced elsewhere. The superintendent of the Delhi institution complained at one point that “there is not much to be said about the barkandazes and keepers, who, from the smallness of their pay, are generally men who have failed to get employment elsewhere.”14 Efforts were made by British medical officers to impose their ideas and standards on the staff secured for service in the mental hospitals of this period. As early as 1856 the superintendent at the Dullunda Hospital had produced a set of “Rules for the Guidance of the Subordinate Establishment of the Asylum at Dullunda.” This included such stipulations as that which made it clear that all staff were “strictly enjoined invariably to treat the patients with the greatest kindness; to abstain from harsh language, threats, abuse, all acts of oppression, blows or any other acts”; and one that stated that “clubs, sticks, weapons, sharp edged or pointed tools are strictly prohibited from being introduced into the Asylum.”15 The puzzle of how to ensure that all

74 James Mills staff was aware of these rules was solved by the superintendent within the rules themselves, the fi nal one of which insisted that “the overseer will see that the preceding rules are strictly observed and a copy in English and in Bengallee is to be kept suspended in the office. The native Doctor will at the monthly Muster read to the Hospital Establishment a Bengallee translation of the preceding rules.”16 Instructions seem to have been issued elsewhere; the superintendent at Bareilly stated, “I need hardly say that no violence on the part of the attendants is ever allowed, and they understand that a blow, or indeed any kind of harshness or rough usage is visited by immediate dismissal.”17 Some asylums seem to have gone further and devised ways of skilling their staff. For example, the SurgeonGeneral in Madras noted in 1874 that from the asylum at Vizagapatam “a Head Warder, with one female and two male warders, were sent for special training in the Madras Institution.”18 Yet the rules at Dullunda also point to the very distant authority provided by the British medical officer. They stipulated: when the conduct of a Patient becomes violent and dangerous to himself and others, the Hospital Servants will, in the absence of the Super, report the circs to the Overseer who will immediately visit the patient. Should the overseer consider restraint to be absolutely necessary for the safety of the Patient himself or others, temporary seclusion may accordingly be applied. But in such case, the Overseer will report the circumstance to the Superintendent . . . it would also provided for that all complaints relating to the Patients or to the Hospital Servants are immediately to be brought to the notice of the Overseer, who will take the earliest opportunity to report to the Superintendent.19 Such rules were necessary in a system where other regulations, such as those for the mental hospital at Lucknow, stipulated only that “the superintendent shall regularly visit the Asylum at least three days in each week.”20 The question remains, therefore, of what these overseers and their staff were up to while the British medical officer was away from the institution. In many instances it seems that the answer was exactly what they ought to have been up to. Surgeon Major Shircore reported in 1877: Native Doctor Rutoo is well spoken of, having been attached to the Moydapore dispensary for 29 years, and has been attached to the Berhampore Asylum since its opening in 1874. He is well acquainted with all the details of duty, and his willingness to help in the general management of the lunatics renders him a useful officer. 21 Such reports were not uncommon, the superintendent at Cuttack being happy to note:

“Left in the Hands of Subordinates”


the conduct of the establishment during the year has been uniformly good. The darogah has been in charge for the past 15 years and has performed his duties to my entire satisfaction; he possesses remarkable tact in managing the insanes and in keeping the minor establishment up to their work. 22 In his report for the same year the superintendent at Dullunda insisted that: The head clerk, Oparva Narain Bhattacharjee has been indefatigable throughout the year, giving in time of need much more time and labor to the asylum than can be legitimately demanded of him, and never complaining however heavy the additional calls have been or however irregular his hours of rest. 23 Indeed, some on the staff were considered indispensable because of their effectiveness. In 1870 the deputy inspector general of hospitals in Lucknow wrote, “Dr. Cannon reports very favorably of 1st class Native Doctor Luchman Sing; but he is bent with age and disease and I only refrain from invaliding him on account of Dr. Cannon’s assurances as to his efficiency and usefulness, and knowledge of the working of the institution.”24 It was explained in 1874 by Dr. Cannon, by then deputy surgeon general of the Lucknow Circle that: the conduct and qualifications of First Class Hospital Assistant Luchman Singh have always been reported well of by every medical officer under whom he has served, and I quite endorse the opinion of Dr Ray that although old and a sufferer from chronic rheumatism, he is admirably qualified for managing insanes both from his superior tact and good temper, and on this account his services are more valuable in an Asylum than those of a younger and less experienced man. 25 It was not only senior members of the mental hospitals that could attract such praise and gratitude. Major Scriven at Lahore made a point of thanking his staff on the occasion of his return to Britain and emphasized that “not less to be commended are the jemadar, the compounder and the jamadarni. The jemadar, Mirza Hassam Ali, has been here 13 years. He thoroughly understands the work of the institution and we should have had great difficulty in carrying on the work without him.”26 However, there is also evidence that the staff often caused the British medical officers grave concern. This was most obvious where the basic principles of the asylum system of the period were ignored and contravened. These were based on the kind treatment and non-restraint approach of the moral treatment regime. 27 For example, Dr. Payne at Dullunda, the asylum where the system of reading out the rules to the staff had begun in the 1850s, had to report in 1870:

76 James Mills For the fi rst time during an incumbency of ten years I am compelled to report a death from violence. A maniac was brutally ill treated by a peon, and died from the effects of it. The peon was convicted and imprisoned and thus was obtained the only possible satisfaction which can follow the occurrence of such a case. 28 Death was a rare occurrence; however, violent episodes were reported from time to time. In an annual report for the asylum at Waltair the superintendent pointed out that the: conduct of warders and servants has been upon the whole fair, with three exceptions, a male warder, female warder and female cooly who were dismissed and prosecuted for striking patients. I hope these dismissals and prosecutions—in each case a conviction was obtained—will act as a deterrent against the commission of such offence in future. 29 Similarly at Benares the superintendent had to report in 1867 that “one of the two Jemadars was dismissed some months ago for striking a patient.”30 And at Dacca, “the keeper who struck a lunatic in the face with his fist was reported to the police, and a local enquiry was made, but the case went no further for want of legal evidence. He was nevertheless dismissed.”31 The attendants could also frustrate other elements of the British plans for the treatment of the inmates. For instance, putting the inmates to work was an important component in the ideal system, yet the superintendent at Delhi wrote in 1876 that he had met with great reluctance from his staff in trying to set up projects for inmates: “In the treatment of the insane the chief reliance has been put upon healthy occupation and amusement. After a long struggle, and with every kind of opposition thrown in the way by the Asylum establishment, I at last succeeded in starting some manufactures in July last.”32 Medical officers also thought that attention to diet in order to establish physical health in the patient was central to a successful asylum. For example, the superintendent at Delhi reported in 1870 that “the diet has been liberal. Good, well ground wheaten flour chappaties, fit for any breakfast, four each—three in the morning and one in the evening—together with dall and vegetables four times a week, and a stew of meat and vegetables three times a week.”33 He pointed out again in 1872 that “good feeding, great kindness and indulgence of every harmless kind”34 were the central tenets of his institution. His report of 1875 stood in stark contrast to these earlier statements: “I regret I cannot report favourably about the subordinate establishment. The assistant matron, the cook and a keeper have been discharged for stealing the lunatics food and several of the burkundazes and keepers have been fined or dismissed for carelessness or harsh treatment of the lunatics under their charge.”35 In a similar vein Surgeon Major Birch at Hazaribagh in Bengal complained in 1878 that: two cooks have been summarily dismissed for this offence and another was prosecuted, but that pilfering still goes on I fear is the case,

“Left in the Hands of Subordinates”


notwithstanding the measures taken to prevent it. Only a few days ago the Overseer detected two of the cooks stealing the meat which ought to have been issued to the patients. 36 Such instances of disruption tend to catch the eye of historians, and Shula Marks’s study of nurses in the mental hospitals of South Africa is a recent example of an account that notes the “many self-sacrificing and caring mental nurses” but ignores them in order to seek out and linger over “acts of wanton and blatant cruelty.”37 But in the archives of the Indian system such instances are rare and it is as important to acknowledge this and to consider its implications as it is to pick out moments of violence and to dwell on them. No doubt incidents were not reported and complaints silenced, but the overall impression is that the institutions could often be orderly and well-run places. Where this was the case in this period the calm and the order was one imposed and maintained by the Indian staff in whose hands the institutions rested on a day-to-day basis.

CONCLUSION By starting with the question of who exactly wielded power in the stories here it is possible to use the evidence in the preceding to address wider questions about colonialism and about Western medicine in non-Western contexts. The British authorities in both Egypt and India built the hospitals and provided financial resources from taxes levied locally in order to establish mental hospitals. As has been argued elsewhere, they did this for a number of reasons linked to their strategies to dominate and transform the societies that they governed, and it is certainly the case that psychiatry could be viewed as a “tool of empire” for those that set out to build the hospital system. However, what the stories show is that if mental hospitals were such tools, then they were quickly placed in the hands of staff drawn from local communities and societies. Whereas the British medical officer was in charge of the asylums and remained the ultimate source of authority in each, in practice his power was usually highly devolved. At one extreme, institutions like the Lucknow mental hospital would have been subjected to the orders and scrutiny of a British medical officer no more than three or so times a week, which meant that for most of the time its functioning was entirely the business of Indian staff. At the other extreme, institutions like the Abbasiya Asylum in Cairo were under the daily direction of an experienced specialist from Britain. However, even here local staff occupied key roles in the running of institutions based on particular skills, in languages, for example, which only they could provide. That considerable power over these colonial medical institutions rested on a day-to-day basis in the hands of local staff makes problematic any easy statements about colonial medical power. Implementation of the designs of British medical officers will have depended entirely upon the cooperation


James Mills

of the staff of the institutions. Where this was not forthcoming, as in the earlier examples where violence or theft served to undermine efforts to introduce moral therapy regimes based on kindness and good feeding, it is clear that the ambitions of the medical superintendents were frustrated. Just as important, however, are the instances where the staff of institutions worked hard to ensure that the designs of the British medical officers were implemented effectively. No less than the examples where staff did not obey orders, these instances show how contingent colonial and medical designs were on the actions of local staff. Luchman Singh or Mirza Hassam Ali could be the difference between success and failure in the implementation of institutional regimes. In this light it is certainly interesting to think again about what is meant by the “Indianization” of modern medical systems in South Asia. The term has been most readily used to describe the assumption of formal control over institutions that occurred after World War I by Indian doctors that had formally qualified in Western systems. However, it seems that in practice most medical institutions were in the hands of Indian staff from their inception.38 On the other hand, it must also be remembered that the day-today power of the staff to influence and shape the life of the medical institution and to mediate the impact of the doctors in charge was not a feature only of hospitals in India, or indeed of the empire. Over twenty years ago Richard Russell pointed out for asylums in the UK that: the nursing staff were indeed the backbone of the asylum . . . for a brief time during the latter part of the nineteenth century it seems reasonable to suppose that the nursing staff were the most vital part of the whole asylum business . . . it may be that the asylum system upon which the whole lunacy profession rested . . . was being slowly transformed by new ideas brought from below, by the nursing staff, whose origins and attitudes the men at the top were not fully able to control. 39 However, colonial contexts would seem to accentuate the possibilities in this direction. As was clear from Warnock’s assessment of his time in Egypt, language and cultural barriers could make the medical officer even more reliant on his staff and even more distant from both them and the patients for which he was responsible. The question remains of what lay behind the cooperation of the Indian staff. In other contexts historians have talked about the “bargain of collaboration” in which “strategies of accumulation,” “self-aggrandizement,” or “class or proto-class affinities” could shape the positions of colonial intermediaries.40 In the preceding examples in India and Egypt it is difficult to establish exactly what it was that decided whether staff would implement colonial medical regimes within the institutions. The staff that stole food could have been doing so for reasons of self-preservation as they sought to top up meager incomes with additional resources. Those that beat patients

“Left in the Hands of Subordinates”


might simply have been protecting themselves in a context that could be threatening, or could have been manifesting sadistic or violent tendencies. On the other hand, removing meat from patients’ diets or using physical force to tackle the demons that troubled patients could be read as consistent with South Asian belief systems. In this case, it could be that staff were taking the decision to ignore British medical ideas because they felt these less likely to be effective than Indian therapeutic approaches.41 The case of the Egyptian assistant to Warnock, who allowed his personal delusions to affect his translation, reminds historians how localized and personalized the agendas that shaped the operation of colonial medical institutions could be. This local and even personal agency also draws attention to the issue of what to call these staff. It is clear that caution must be shown in collectivizing or homogenizing them. The large numbers of locally recruited staff were usually arranged in hierarchies and often found themselves in strictly defi ned jobs. For example, at the Calcutta institution in 1880 the sixty-nine staff members were arranged in sixteen different job titles that included five different classes of warder. There is no reason to assume, therefore, that all staff thought in similar ways or that they commonly shared agendas, and it is clear from the preceding stories that those in senior positions could be ready to thwart the strategies of those in their charge through a range of disciplinary procedures. This observation also relates to how unsatisfactory terms such as “subordinates” or “intermediaries” seem when talking about these people. First of all, such terms risk retrospective and ahistorical collectivization or homogenization. Additionally, they seem to defi ne these staff simply in terms of location to more important others. This does not seem accurate in light of the conclusions here about the power exercised by those that worked inside these institutions. If anything, the British medical officers in this chapter have appeared to be the “intermediaries.” They were caught between the imperatives of colonial rule and medical practice on the one hand, and the challenges of managing large bodies of staff on the other, employees who were clearly capable of bringing their own ideas and agendas to work. For that reason this chapter has avoided using words like subordinates or intermediaries, and instead has preferred terms like employee or staff. These seem to be more accurate as the evidence considered here suggests that those involved may have sold their labor to the British, but they certainly did not surrender their agency in doing so, and as such often rendered their colonial employers peripheral or powerless within their own institutions.

NOTES 1. J. Warnock, “Insanity from Hasheesh,” Journal of Mental Science 49 (1903): 96–110; see also T. Clouston, “The Cairo Asylum: Dr Warnock on Hasheesh Insanity,” Journal of Mental Science 42 (1896): 793–794.

80 James Mills 2. J. Warnock, “Twenty-Eight Years’ Lunacy Experience in Egypt (1895– 1923),” Journal of Mental Science 70 (1924): 233–261. 3. Ibid. 4. Ibid. 5. Emily Lynn Osborn, “Circle of Iron: African Colonial Employees and the Interpretation of Colonial Rule in West Africa,” Journal of African History 44, no. 1 (2003): 29–50. 6. Benjamin Lawrance, Emily Osborn, Richard Roberts, “Introduction: African Intermediaries and the ‘Bargain’ of Collaboration,” in Intermediaries, Interpreters, and Clerks: African Employees in the Making of Colonial Africa, ed. B. Lawrance, E. Osborn, and R. Roberts, 14 (Madison: University of Wisconsin Press: 2006). 7. Warnock, “Twenty-Eight Years.” 8. J.H. Thornton, Memories of Seven Campaigns: A Record of Thirty-Five Years’ Service in the Indian Medical Department in India, China, Egypt and the Sudan (London: A. Constable, 1895), 168–172. 9. Annual Report of the Insane Asylums in Bengal for the Year 1880 (Calcutta, 1881), 36. 10. Annual Report of the Lunatic Asylums of the Punjab for the Year 1880 (Lahore, 1881), 12. 11. Ibid., 27. 12. Asylums in Bengal for the Year 1869, 5. 13. Extract of letter from IGP British Burma, September 28, 1870, in GOI (Public) Procs April 8, 1871, 38–39A. 14. Asylums in the Punjab for the Year 1876, 19. 15. “Reports on the Asylums for European and Native Insane Patients at Bhowanipore and Dullunda for 1856 and 1857,” Selections from the Records of the Government of India, 28, 63. 16. Ibid. 17. “Annual Reports of the Lunatic Asylums at Bareilly and Benares for the Year 1867,” Selections from the Records of the Government of the NorthWestern Provinces, 59. 18. Annual Report of the Three Lunatic Asylums in the Madras Presidency during the Year 1873–74 (Madras, 1874), 13. 19. “Reports on the Asylums for European and Native Insane Patients at Bhowanipore and Dullunda for 1856 and 1857,” Selections from the Records of the Government of India, 28, 63. 20. Government of Oudh to GOI, August 12, 1868, 3403, in GOI (Public) Procs December 19, 1868, 25A. 21. Asylums in Bengal for the Year 1877, 27. 22. Asylums in Bengal for the Year 1878, 24. 23. Ibid., 15. 24. Annual Inspection Report of the Dispensaries in Oudh for the Year 1869 (Lucknow, 1870), 2. 25. Dispensaries in Oudh for the Year 1873, 3. 26. Asylums in the Punjab for the Year 1880, 3. The jemadar would have been the head of the orderlies and the jamadarni would have been a female cleaner. 27. For a recent discussion of the “moral treatment” system and its origins in British institutions, see L. Charland, “Benevolent Theory: Moral Treatment at the York Retreat,” History of Psychiatry 18, no. 1 (2007): 61–80. 28. Asylums in Bengal for the Year 1870, 12. 29. Asylums in the Madras Presidency during the Year 1877–78, 25. 30. Asylums at Bareilly and Benares for the Year 1867, 47. 31. Asylums in Bengal for the Year 1878, 7.

“Left in the Hands of Subordinates” 32. 33. 34. 35. 36. 37. 38.


40. 41.


Asylums in the Punjab for the Year 1876, 11. Asylums in the Punjab for the Year 1870, 15. Asylums in the Punjab for the Year 1871–72, 5. Asylums in the Punjab for the Year 1875, 3. Asylums in Bengal for the Year 1877, 29. S. Marks, “The Microphysics of Power: Mental Nursing in South Africa in the First Half of the Twentieth-Century,” in Psychiatry and Empire, ed. S. Mahone and M. Vaughan, 67–98 (Basingstoke: Palgrave, 2007). Mark Harrison noted the “Indianisation of the Indian Medical Service” after 1914 and I have used the term when exploring the advent of Indian superintendents of asylums in India between 1914 and 1947. See Mark Harrison, Public Health in British India: Anglo-Indian Preventive Medicine 1859–1914 (Cambridge: Cambridge University Press, 1994), 233; James Mills, “The History of Modern Psychiatry in India, 1858–1914,” History of Psychiatry 12 (2001): 449–451. Richard Russell, “The Lunacy Profession and Its Staff in the Second Half of the Nineteenth Century, with Special Reference to the West Riding Lunatic Asylum,” in The Anatomy of Madness: Essays in the History of Psychiatry, vol. 3, ed. W. Bynum, R. Porter, and M. Shepherd, 312 (London: Routledge, 1988). Lawrance, Osborn, and Roberts, “Introduction,” 29. This argument has been made more fully in James Mills, Madness, Cannabis and Colonialism: The ‘Native-Only’ Lunatic Asylums of British India, 1857–1900 (Basingstoke: Palgrave Macmillan, 2000), 159.


Surviving the Colonial Institution Workers and Patients in the Government Hospitals of Mid-Nineteenth-Century Jamaica Margaret Jones

In 1860 a pamphlet titled Seven Months in the Kingston Lunatic Asylum, and What I Saw There, reputedly authored by ex-patient Ann Pratt, was circulated throughout Jamaica depicting conditions in the island’s asylum. The exposure of these conditions precipitated a major inquiry into the state of Jamaica’s public medical institutions, which ultimately led to an investigation into the condition of such institutions throughout the entire British Empire. In her pamphlet, Ann Pratt described the worst of the practices perpetrated at these institutions, the practice of tanking: I was . . . seized by Antoinette, Julian Burke, assisted by Lunatics, Rosa Lewis, Eliza Scott, and one called Mary. I was stripped; my arms held behind me; my legs extended and forcibly separated from each other; I was plunged into the tank, and kept under the water till all resistance, on my part, ceased; their grasp was then relaxed; I rose to the surface and breathed as if it were my last. Scarcely, however, had I drawn my breath when I was again subjected to the same horrible treatment, with the addition of having my head hurt against the sides of the tank, and my poor body beaten and confused with blows, till the fear of murder prompted them to desist.1 This was the most egregious of what Henry Taylor at the Colonial Office (CO) termed the “most cruel and revolting crimes” perpetrated at the government hospital and asylum.2 The initial response of Governor Darling to this pamphlet was to presume that the allegations were totally groundless and propose an action of libel against the publishers. On the attorney general’s advice, however, Darling reconsidered, given that the hospital’s matron and two nurses had only recently been indicted, even if acquitted, on charges of manslaughter. 3 Although the governor was prepared to leave the issue there, pressure from the CO forced him to hold a public inquiry into conditions at the two institutions. The Commission of Inquiry opened on May 14, 1861, presided

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over by Alexander Fyfe, Robert Hamilton (members of the legislative council), and Alan Ker (a judge on the island’s Supreme Court); it heard evidence from workers at both institutions as well as others who were connected to the hospital as visitors or chaplains, nearby residents, and patients.4 The resulting five volumes of handwritten evidence presents a vivid verbal picture of what life was like in and around the hospital. Hospitals were the fi rst medical institutions to be founded by colonial governments in the British Empire. They were integral to the transfer of Western medicine to the colonies, pivotal in its expansion, and symbolic of the imperial and colonial states’ search for legitimacy. Research on this pivotal colonial institution has until recently been limited, with the nature of the sources ensuring that scholarship is generally focused on their foundation, institutional development, and the trained medical personnel who worked in them.5 In the colonial context, properly trained doctors and nurses were in short supply. Far more important in maintaining a colonial hospital’s day-to-day running were the untrained nurses, attendants, and wardens. This chapter explores their agency and the often ambiguous nature of their role as revealed by the 1860 scandal at the Kingston Public Hospital (KPH) and the Lunatic Asylum in colonial Jamaica. The sources used are the annual reports of medical directors, correspondence between the colonial and imperial governments, and a commission of inquiry. All of these reports and correspondence are skewed towards the viewpoint of the state and its bureaucracy; commissions of inquiry were generally only set up when things went wrong, and often to obscure rather than expose government responsibility. Therefore, the 1861 Commission in Jamaica, although providing a rich seam of evidence for understanding the day-to-day operation of the KPH and Lunatic Asylum, presents a very negative portrayal of the subordinate agents working there in its pursuit of mitigating government responsibility. Jamaica was the largest colony in the British West Indies, with full emancipation from slavery achieved in 1838, and the Crown Colony government instituted in 1867. As late as the 1930s one CO official described the British West Indies as the slums of the empire. A part-time government medical department was established 1867, but CO fi les indicate that it proved very difficult to recruit medical officers to the island because of the low pay and poor conditions of service.6 And the medical service itself was not converted to a full-time one until the 1930s. Most of the population in practice accessed Western medicine through the poor law system, small parish hospitals, and the government-funded KPH and Lunatic Asylum. The care provided at these institutions in the nineteenth century was basic at best and inhumane at worst. In 1938 the medical director, Thomas John Hallinan, claimed that the Jamaican government medical services bore the “indelible” imprint of slavery.7 Jamaican-born doctors were employed in the government medical service, but they were primarily of European descent. As any medical training had to be acquired in the UK, U.S., or Canada, the


Margaret Jones

profession was accessible only to the better off. But following the growth of a Jamaican middle class of African descent in the twentieth century, they too began entering the profession in greater numbers.8 However, the directorship of the medical service remained in British hands throughout the colonial period; and it was not until the establishment of the University of the West Indies in 1948 that medical education was available within Jamaica itself. The provision of Western-trained nurses followed a trajectory of fits and starts, initiatives and failures. The fi rst attempt at nurse training in Jamaica was unofficial. In the 1850s the charitable Lady Barkly’s Hospital for Women set up a nurse training school in conjunction with the KPH. The intention was that its nurses would gain experience on the wards, and in return, they would offer their services for free. This initiative was shortlived. It is not clear whether the Lady Barkly’s Hospital withdrew their nurses because of the appalling conditions in the hospital or they fell afoul of medical politics and were asked to withdraw. Thereafter the Lady Barkly itself folded.9 A nursing school was set up at the KPH in the late 1870s but the numbers it trained remained small until its expansion during the interwar period. In 1946 the Jamaica General Trained Nurses Association was established to advance the status of the profession, and in 1951 Nurse Registration was finally achieved, with a training school established at the University College Hospital, Kingston. Therefore, the major burden of caring for patients in the nineteenth century (if not well into the twentieth) fell upon those with no medical training. This chapter, based on the 1860 Commission, provides some insight into who they were, what their role was, and how they fulfilled it. However, it should be emphasized that this is a mere snapshot. And perhaps most important, the evidence has only come to light because of a huge failure in the system. How typical it was is a matter for conjecture. However, the scandal at the KPH and the Lunatic Asylum generated an empire-wide investigation into conditions in colonial hospitals the results of which suggest that although the hospital in Jamaica may have been the most glaring example of how appalling these institutions could be, it was by no means unique.10 Those who cared for the inpatients on the wards were variously described as nurses, medical attendants, and servants; and almost all in the nineteenth century had little or no medical training, instead learning what they needed while working in the wards. In the running of the hospital they were also supported by other hospital workers, such as porters, dressers, cooks, and wardens. Much of the work in the nineteenth-century hospital was domestic rather than medical. Therefore, matrons, nurses, and attendants were expected to keep patients clean, fed, and cared for, medicines administered, and order and discipline maintained. The 1861 Commission determined that even these basic standards were not met as workers and inmates adopted alternative strategies to survive within the problematic and somewhat hostile environment of the KPH and Lunatic Asylum.

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THE JAMAICA HOSPITALS INVESTIGATION There is a large question mark over the motivations of all participants in the investigation of the hospital and asylum; it was clearly intricately intertwined with local medical and general politics. The chief protagonist making the allegations over the hospitals’ conditions was a Jamaican-born doctor, Lewis Bowerbank (a member of the fi rst short-lived Central Board of Health, 1854–1855), who had been agitating for the reform of the hospital since the mid-1850s. The roots of the “Hospital controversy, in all its malignity,” according to James Scott, the chief medical officer at the hospital, derived from Bowerbank’s failure to get a position at the hospital after the death of its previous medical officer, his brother-in-law, physician Alexander Campbell.11 Additionally, Bowerbank seemed to have acquired much of his evidence from the warden at the hospital, Richard Rouse.12 That Rouse had previously been dismissed by Scott arguably provided motivation for his allegations. Even Bowerbank was unable to decide on Rouse’s probity. He was “a most highly respectable man,” he stated, but then went on to say that he “was living in concubinage at the hospital,” and that he was “acting as a pimp for some of the Medical Officers” (a contradiction that Scott later seized upon).13 Another physician, Alexander Fiddes, depicted Rouse as a “tailor . . . an intelligent man and one who could do his duty if he liked” but who was also “self-opinionated” and “talkative” and “not very easy to keep in order.”14 However, it should be noted that Fiddes succeeded Scott at the hospital after the latter’s dismissal.15 The evidence is thus extremely adversarial and disentangling the hyperbole, distortions, and lies from something that might approach reality cannot be definitively accomplished. Because the commissioners were members of the colonial establishment themselves, they would have had a vested interest in playing down the scandal. However, the fact that they ultimately accepted much of the evidence and that both Scott and a “Dr. Keech” were subsequently dismissed, suggests that there was some truth in the allegations.16

WITNESS EVIDENCE Bowerbank’s charges opened the proceedings and he presented a graphic description of unsuitable and decrepit buildings, unsanitary conditions, neglect, cruelty, and mismanagement. As evidence for his allegations he cited the increasing death rates at the hospital from its establishment in 1793 to the early 1850s. Table 4.1, taken from his evidence, illustrates the changing character of the hospital from an institution for Europeans to the main hospital for the black and mixed-race population that swelled from the 1840s after the arrival of immigrant indentured labor from South India and China. The substantial increase in the numbers admitted resulted in an overcrowding that contributed in no small part to the poor conditions.


Margaret Jones

Table 4.1

Death Rates at the Kingston General Hospital for Selected Years


Numbers treated


% Death rate

Period 1 (Patients: poor and transient Europeans, mainly white) 1793












Period 2 (Patients: less Europeans, more colored and black) 1838–1839
























Period 3 (Patients: mainly colored, black, and Indian immigrants ) 1847–1848








1849–1850 (cholera epidemic)
















Source: NA: CO 137/359, Evidence of Dr. Lewis Bowerbank, May 15, 1861, 86–87.

Even the best-regulated hospital in the nineteenth century was, according to the 1861 commissioners, a “melancholy abode of languor and depression.”17 Nonetheless, the KPH fell far short of even this in the “indifference to the comfort and feelings of patients, and want of attention to their cases.”18 This judgment rested in part on the almost unanimously negative accounts of the nursing provided by witnesses. Bowerbank led this onslaught: the “persons employed within the hospital were untrained and inexperienced,” he claimed.19 “Any person answers as a nurse and no particular qualification is necessary”; with few exceptions they were “altogether illiterate, neither reading nor writing.”20 Similarly, the nurses and keepers at the asylum were not appointed on account of their previous experience: “none of them knowing anything about the proper treatment of the insane”; they were “unfit for so delicate and responsible an office.”21 Scott, the medical officer in charge of the KPH at the time, when

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questioned, was forced to agree with Bowerbank that the nurses “should be a more respectable and intelligent class of person.”22 In corroboration of this is evidence showing how some individuals came to be employed as nurses. Maria Robertson was a washerwoman at the hospital before she became a nurse.23 Robertson, the only female night nurse, whereas formerly “a very attentive person in the sick room” was now, according to Bowerbank, “superannuated and incapable of much exertion” and employed only because she was the aunt of a medical officer at the hospital.24 Ex-patients were employed as nurses, most notably the two male night nurses, both of them, according to Bowerbank, had “sore legs,” were illiterate, and, in addition to their night nurse duties, also acted as watchmen and gatekeepers to the hospital and asylum. They came on duty at 6 p.m. and left at 6 a.m. Moreover, he claimed, they also hired themselves out as day laborers. These were the men, Bowerbank pointed out, who “are put to nurse yellow fever patients, to look after British sailors engaged in British ships.”25 Not only ex-patients were used as carers; inpatients also acted as assistant nurses, a “practice,” Bowerbank argued, “fraught with mischief and condemned in all well-conducted institutions” given that they were “retained as quacks and mountebanks on their fellow patients.”26 There was, for example, Alexander Robertson, another nurse and “sore-legged man,” who had been a patient in the hospital for seven years. While acting as nurse, Rouse claimed that Robertson was “very intimate with the nurse in the A and B ward . . . they used to quarrel and curse each other in the wards.”27 He was “given his beef and allowed to go to all parts of the hospital.”28 Patients were also selected to act as assistants in operations. 29 If operations were carried out indiscriminately around the wards, as Bowerbank claimed, then it seems entirely feasible that patients might be roped in to help.30 Even more disturbing was Bowerbank’s and Rouse’s allegation that inmates of the Lunatic Asylum were employed as keepers and nurses over their fellow sufferers. A lunatic had been regularly employed at the asylum, claimed Bowerbank, “to superintend the others, to punish the females when riotous or fighting.”31 The man, “an epileptic, was a drunkard and of a ferocious temper.”32 Scott did not deny that patients were used as assistant nurses, but claimed it was not a problem. “When a patient is convalescent and is kind, active and intelligent, I see no harm whatever in his rendering occasional aid to his fellow patients who may be very sick, particularly at periods when the nurses may be temporarily absent—probably procuring nourishment.”33 Alexander Robertson, for example, with his “chronic leg ulcer” was “steady, attentive and intelligent.”34 A “Dr. Magrath” (Scott’s predecessor) had “appreciated his services” and found them “valuable.”35 Other employees of the hospital present a similarly mixed profile. The porter of the female ward was a patient and received 4/6d in payment; “old Good,” another patient, opened the gate during the day for extra bread and


Margaret Jones

1½d daily; and patients who acted as barbers received 2/- a week.36 The dresser who succeeded a “Mr. Harrison” (who had been dismissed for drunkenness) could “neither read nor write,” and when he was absent from his post, his duties “were fulfilled by a little boy.”37 The present male superintendent of the Lunatic Asylum, a “Mr. Roberts,” was an “old soldier” who had been dismissed by his previous employer for the Kingston and St. Andrew’s Water Company because “brandy under his charge had been stolen.”38

PATIENT EXPERIENCE With this motley group of workers, how did the patients fare? There is some evidence of acceptable and compassionate treatment, and of resistance to the general harsh ambience of the institutions. One patient, Allen Alexander, was prepared to testify to the inquiry that he had no complaints about his care while he was in the hospital. But he added, “they knew I was connected to a printing establishment.”39 Pratt, whose experience of “dunking” discussed earlier sparked the inquiry, praised nurse Mary Bell, who “to her everlasting credit” on being called upon by Judith Ryan, the wife of the asylum’s former superintendent, to tank Pratt, refused, “stating she had not the heart for such work.”40 It “was a short time,” Pratt added, “till this Asylum was denuded of this humane woman.”41 Nurse Mary Donaldson testified at an earlier hearing before the Inspector of Hospitals that she had disobeyed orders from Ryan to tank Pratt: “I had not the heart to duck Ann Pratt.”42 She also gave Pratt a book: “the book the Minister baptize Prudence child with,” because Pratt had asked for a book to comfort her.43 However, the evidence was overwhelmingly negative. Again Bowerbank presented a catalogue of cruelty and neglect. None of the nurses, servants, or laborers, he claimed, employed during the day remain at the hospital at night, “including even the head nurses who surely ought to superintend the entire nursing of patients.”44 In terms of the personal care of patients his list is damning. “Little or no attention is paid to personal cleanliness, the patients confined to bed have not had their hands and faces washed, or their hair combed. If the person himself cannot do it then it is not done for them.”45 Patients were not bathed regularly, “only when their offensive smell or dirty appearance offends the nose or eye of the MO.”46 Asylum inmates fared even worse. “Frequently when a patient is helpless from disease and is dirty the nurses if directed to clean them will bring one of the night tubs with water in it, and then take the broom with which the yard is swept and scour the body . . . of the poor unfortunate.”47 In addition, “Meals were badly cooked . . . served at irregular intervals and no nourishment is given between meals.”48 There was no “clock to regulate the hours for meals . . . or the administering of medicines.”49 For those who were bedridden, food was “often put down and allowed to become cold and miserable.”50 In the Lunatic Asylum, food was “poured down the throat of the lunatic using the

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long spouted mug in doing so.”51 Food was also, he asserted, “stolen by the nurses and servants,” and in the asylum “the serving of gruel and tea for the weak and ill are left entirely to the caprice of the servants who often keep it for themselves or throw it away rather than give it to the patients.”52 Patients had “to do much for themselves”; some “getting up in the night to assist themselves have fallen and injured themselves and died shortly afterwards.”53 And, “During the night little food, nourishment or medicines can be given to patients . . . patients in the male Hospital were heard shrieking and screaming out for the nurse who after a long period made his appearance only to abuse and curse the sufferer.”54 Nurses were allowed to absent themselves from the hospital “for the purpose of nursing sick friends and relatives”; serious mistakes were made in the administration of medicines, “wrong medicines have been given and in some cases the overdose of an active agent has been administered.”55 The list is seemingly endless, and the nurses at the asylum were a “self-willed set of people, perfectly independent, regardless of all authority or if spoken to or found fault with threaten to leave or do leave.”56 They were “quarrelsome”; they often fought; they beat the inmates with “sticks, ropes and broomsticks”; some of them drank and procured food and drink for their charges.57 Although many of Bowerbank’s stories come across as anecdotal, there is some corroboration from other witnesses. Another surgeon interviewed by the commissioners, James Gibbs, recounted his experience when he was visiting a patient who was complaining to him, “he was much troubled by bugs,” and that: During the conversation I saw a tall fair lady who was employed as a nurse . . . the lady approached a patient (Mr. White a sailor) and said “you must take your medicine now,” she had a small tray in her hand, and as she came up with the medicine she put her finger into the mug and stirred it, and wiped her finger on her gown. I said to the young man “Is this the way in which the medicine is given?” He said I generally stir the medicine with a spoon myself. I believe the nurse is still there.58 Asked if he was aware that medicines were not given during the night, he replied, “Miss Lewis the night nurse knocks up patients about 5 am to give it so that the doctor doesn’t fi nd out about the neglect.”59 Caroline Smith, who went to the hospital to care for her mother-in-law, also had a tale of neglect for the commissioners. She was at the hospital from eight in the morning “until the candles were lit, going from ward to ward reading to the patients.”60 The hospital was not popular with lower orders, she stated, because: [T]he people were not attended to . . . [and] I have seen people in the John Crow ward lying on the ground with a bit of cloth under them, and the place has been so offensive that crows have hovered around it.

90 Margaret Jones My mother-in-law was in the institution because I had not the means to support her and I have gone there and found her in filth and when I called on a nurse to clean her she said it was not the time . . . I told her that I would report it . . . there was a lady from Spanish Town lying in her own filth and I have called attention of nurse to it and she has said it is not time to clean her, and I have said that the proper time was when she needed it. The flies were all around her . . . She was unable to feed herself and there was nobody to feed her and she remained there with the nourishment at her side. The so-called nurses were busily employed carrying pails of water . . . the nurses were not kind, some were better than others.61 Reverend F.H. Almon asserted that the hospital was “wretchedly mismanaged,” that the recovery of the fever patients was hindered by the condition of the ward and by the “want of proper nursing.”62 There was always a “most offensive smell” in the female ward so much so that he “had often when reading to stand by the door to get fresh air.”63 The deficiencies of the other workers were similarly highlighted. For example, according to Rouse’s second statement: The porters, nurses, cook, labourers can’t describe what they are . . . they do as they like, come to work late, live in the streets while the patients require their assistance . . . they were under my supervision but my hands were tied I can neither take in nor discharge them . . . The porter acts as doctor turning patients away before the doctors get to see them . . . the cook gets the diet as he pleases . . . he is not to be spoken to and is very disobedient—the labourers abuse the patients commonly and sometimes patients are desperately rude . . . the bed maker will not make the beds. . . . The institution is not being properly managed, nurses, labourers and others are very impertinent when spoken to respecting their business. If you order them not to leave a ward or business, they tell you plainly—Who pay me to fasten myself in the ward?64 Accusations of drunkenness also abound in the sources. Alexander de Graffe, a contractor to the hospital, was asked whether to his knowledge any of the nurses drank. He replied in the affi rmative that “two thirds were drunkards,” but added that he did not think that the new inspector of the hospital, a “Mr. Trench” (appointed in 1859), “encourages this now.”65 Given the picture painted here, it is no wonder that when the Reverend George Brooks advised a sick parishioner, Charles Pyne, to go to the hospital, the man “threw his hands up in horror and with an expression of disgust in his face, exclaimed that he would rather die where he was than go to such a place.”66 Pyne had been there a year ago and that had been enough for him. When he was there, he complained, “the patients were treated like hogs, in the ward where he was . . . that no matter how ill they might be,

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they had to be their own nurses.” He expressed especial dislike of Keech, who he said “just looked into the ward, said one or two words and went away again.”67 However, Brooks concluded by stating that as Pyne was “literally starving he was forced to agree and died soon afterwards.”68 In mitigation of the nurses’ conduct it should be noted that their duties were extensive, their conditions of work appalling, and their wages miserable. As Bowerbank pointed out, their duties were more those of a servant than a nurse: “they are expected to rub the floor and to carry out every menial duty, to carry out dead bodies.”69 One of the Lady Barkly nurses, Mary Cunha, whilst agreeing that the people at the hospital were “not nurses at all” and that “with a few exceptions they were very rude to patients,” accepted that their tasks were far too onerous: “the nurse who was in charge of the wards had to clean them and to do everything else and they could not attend to the patients at all.”70 There was general agreement among the witnesses on both sides of the dispute that the wages of the nurses were too low and that there were far too few of them. The Reverend Duncan Campbell commented that there was only one night nurse, which led to the “constant complaints of patients . . . that they had to assist in nursing at nights just as they were getting well.”71 Additionally, when he asked one nurse why feverish patients were “tied down with sheets,” he was told that “the nurses could not attend to them.”72 As he suggested, “I do not think this would have been done had there been a greater number of nurses.”73 But then he accepted that “a proper class of persons cannot be procured at the present rate of wages.”74 Bowerbank noted that all the workers, nurses, servants, and laborers were “miserably paid” and that on such “miserable pay it is impossible to expect such persons to perform duties faithfully.”75 Scott had no argument with this judgment: “I should say that 9s a week is too small an amount for the payment of each nurse” (compare that wage with the payments reputedly given to some ex-patients for ad hoc tasks noted earlier).76 If they were paid more, he argued, it would be possible to get a “more respectable and intelligent class of person.”77Given this low remuneration it should come as no surprise that they sought to supplement their wages with other moneymaking schemes.

A HOSPITAL OR A HIGGLING OPPORTUNITY? Higgling is the Jamaican word for how many Jamaicans, even today, make a living. The lack of secure, stable, and reasonably paid employment opportunities means that many of them have more than one job, seek commercial opportunities, and utilize their own smallholdings to get by. If that is true today, it was even more necessary in the colonial society of the nineteenth century. One of the most interesting revelations of the hospital inquiry, aside from the perhaps more predictable picture of squalor, neglect, and


Margaret Jones

inhumanity, is the window it opens up for an understanding of how the lower classes, both white and black, sought to survive, or even prosper, in this very uncertain environment.78 Hence, the other set of allegations was made against those who had anything to do with the hospital and asylum related to such moneymaking activities. This applied from the top downwards. At the top, the colonial government funded the hospital to the tune of £8000 per annum. This represented a considerable commercial opportunity for those who had the means to benefit from it.79 The hospital commissioners (the management board of the KPH and Lunatic Asylum) were accused of securing advantageous contracts for themselves to supply goods to the institutions. Henry Taylor at the CO accepted that three of the commissioners “are accused on strong grounds of receiving dishonest profits from the funds of the institution,” and that “Messrs Salom and Taylor obtained contracts for supplies to the institution under false names . . . by tendering in a fictitious name at a low price and afterwards the price was doubled, or nearly doubled, by the authority of the board.”80 This corruption led to the disbandment of the KPH’s commissioners in 1859 and their replacement by D.P. Trench as inspector of the hospital and asylum. For under that “objectionable constitution,” as the 1861 hospital report pointed out, seven commissioners had been appointed, three of whom were members of the executive commission, which meant that as the executive committee, they “were to hear and determine in one capacity, complaints brought against them in another”—a system clearly open to abuse.81 The opportunities for personal advantage for those lower down the scale operated at a much more basic level and in a variety of ways. At the very bottom there was the petty pilfering of food and other stores. Patients and nurses exchanged food and bartered it between themselves and those outside through the windows of the hospital; “portions of night nourishment are regularly and systematically purloined and taken from the institution every evening.”82 Nurse Maria Robertson’s job was to take the ration of sugar and arrowroot to the asylum for the patients, but “everyday she had to remove two spoonfuls of the sugar and arrowroot and put them in separate mugs,” in consequence of which “the patients’ nourishment was short.”83 David Ryan, the asylum’s former superintendent, and Judith Ryan’s husband, “regularly received stores brought to him from the Hospital and the Lunatic Asylum by patients, inmates and other servants.”84 The Ryans were accused of making a very lucrative living out of the hospital. Rouse claimed that when they had come to the asylum they were in “indifferent circumstances”; while officers there “they rapidly acquired wealth and now possess some property.”85 Witnesses stated that the Ryans used the hospital grounds to keep pigs and poultry. Rouse, for example, claimed Judith Ryan kept “two sows which roam about the place, they breed and make a stye under the fever ward.”86 “She also keeps turkeys, ducks, poultry . . . they mess everything about the place.”87 Furthermore, he said, she took “candles, soap, bread, and beef to feed her dogs and hogs.”88

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Edward Jordon, the warden who succeeded Rouse, concurred with this. There were “turkeys, hogs, fowls, and horses about the lawn. Mr. Trench instructed me to write to Mr. Milford [the steward] to remove his poultry and Dr. Keech and Mrs. Ryan removed the hogs they kept there.”89 Both the Ryans used patients and servants to sell their goods and poultry for them in the town’s markets and to work on their pen; inmates of the asylum were employed by David Ryan to “erect fences” and do “carpenters and masons work.”90 Judith Ryan “sold quantities of dry goods and articles of apparel made up by the lunatics which were carried out and higgled by the servants and washerwomen.”91 The Ryans’s and Scott’s clothes were washed and ironed by the asylum’s washerwoman. “I have seen Mrs. Ryan’s pantaloons, vest and children’s gowns on the lines” as Rouse so graphically recounted.92 “If a lunatic is a good washerwoman, ironer, housecleaner” then Rouse claimed that Mrs. Ryan would “manage to keep her in the asylum.”93 For example, the “very good seamstress” Sarah Carter was refused release for that very reason.94 Asylum inmates were also used as domestic servants to the Ryans and the doctors; a practice that Scott admitted to on the grounds that such “light work” provided some occupation for them.95 There is no doubt that the Ryans had sufficient income to lend money, most notably to Scott himself, who made no attempt to deny it: “It may be true that I have borrowed money from the parties mentioned . . . but it by no means follows that any undue or mischievous influence resulted there from.”96 At the very least it raised a big question mark over his defense of Judith Ryan. His statement that “she was a naturally kind woman” provoked Henry Taylor into the sarcastic comment of “she was kind enough to lend him money.”97 There was also the suggestion that nurses who owed the Ryans money would not be dismissed whatever they did: “the nurses say if they borrow money from the matron they won’t be discharged until they’ve paid it back.”98 Mary Barnett, the matron of the female hospital, was also apparently using the hospital as a base for a business. Bowerbank claimed that she “had been in the habit of disposing of gowns and dresses to the nurses and that her daughters make them up” and that she had been “in the habit of employing patients and others to go out of the institution to purchase goods and perform other services for her.”99 James Gibbs agreed that she had been retailing cloth in the hospital for many years.100 She of course denied it, only admitting that her “daughters on several occasions took up some articles at the shops for the accommodation of the nurses” but that there “was no regular dealing kept up by them.”101 Then there was the steward Caleb Hall’s ice cream–making enterprise. He was accused of “expending much of his time in the fabrication of ice creams” using port wine and ice from the hospital, and of making free use of the malt.102 He admitted to having purchased a “five minute freezer” but the only ingredient he had used from hospital stores was a “few grains of coarse salt.”103 He was “not aware that port wine can be used to improve

94 Margaret Jones ice-cream” and as to the malt accusation, his defense was that the “testing of the malt, wines and liquors before being issued from the stores forms a very material portion of my duty as purveyor.”104 At the very bottom of the pile were the patients. Even those patients who were there for strictly medical reasons could be resident in the hospital for many weeks, if not months, and in some cases years; so that they tried to make their stay as palatable as possible was understandable. Hence they would act as assistant nurses or undertake other tasks for extra food and spending money. Given Bowerbank’s statement about the hospital food, fi nding ways of supplementing that diet was probably a matter of survival, and the bartering and selling of food made good sense. Similarly, given their environment, so too did the procurement of strong drink. That nurses procured rum in the local grogshops was perhaps entirely reasonable, especially at a time when alcohol was frequently used for medicinal purposes anyway.105 The hospital also operated as an almshouse, and no one disputed that. The aged, chronically sick, and infi rm sought admission, as Charles Pyne did, as it was the only alternative to starving on the streets. It was hard to refuse admission to such people, argued, Scott, but not from humanitarian concerns: “if we did and they died soon after the inquest verdict would be ‘died of old age accelerated by being refused admission to the public hospital.’”106

CONCLUSION The 1860 hospital scandal, like other such crises, provoked the imperial government into being unusually proactive and resulted in one positive initiative. Henry Taylor’s reaction at the CO was to question whether such “abuses and evils” existed in the other colonies.107 To that end in 1863 he sent a circular dispatch from the secretary of state to all colonial governors, the opening sentence of which made quite plain what had inspired the initiative: Certain evils and defects which have recently been disclosed in the Public Hospital at Kingston Jamaica, and flagrant abuses and cruelties of long-standing which have been detected in the Lunatic Asylum of the same place, have suggested to me the expediency of making enquiry into the state of similar institutions in other colonies.108 Replies came in from thirty-three colonies detailing the conditions in thirty-nine hospitals and twenty-eight asylums. As a result of this information a report was compiled and sent out a year later with a set of suggestions to be followed in all colonial hospitals and asylums. The object of curative hospitals and asylums, the report pointed out, was that the “greatest possible proportion of patients should be cured and in the shortest possible

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time,” and in the case of asylums “the normal condition and rights of the insane should be infringed upon in as small a degree as may be consistent with efficient management.”109 To this end the report outlined “three cardinal conditions” it was necessary to secure in order to achieve the preceding. They were, fi rstly, “sanitary efficiency.” Secondly, the management of hospitals and asylums should be in the hands of those who had the “necessary knowledge”; who were “in a position to give the necessary attention” to the institution, and who could be “readily made responsible to some other superior authority.”110 The third condition was effective visitation and inspection procedures supplemented by detailed written reports from those in charge of each institution and summary reports from the hospitals inspector or chief medical officer of a colony. These were for the scrutiny of the imperial government and for circulation to all colonies with the aim of spreading the best knowledge and practices throughout the empire.111 These hospital returns and the accompanying summary reports from the principal medical officers of the colonies formed the basis for the annual medical reports that became the main source of information for the imperial government on medical institutions and public health. They were instrumental in the construction of an overview of the health problems of the empire to which, if purely at fi rst for economic reasons, the imperial government’s attention was increasingly drawn. In Jamaica the outcome is less certain. As a result of the 1861 Commission, funding for new premises and improvements was provided at last for the Kingston institutions. How far hospital conditions in Jamaica improved generally is difficult to ascertain but certainly Bowerbank continued his campaign for reform of the island’s medical institutions. In 1872 he provoked another government inquiry into the conditions in the smallpox hospitals during the epidemic of that year that revealed similar examples of neglect and outright cruelty.112 Furthermore, reports of the parish poorhouses to which the chronically sick, infi rm, and aged resorted suggest that the same kind of conditions continued in those into the early decades of the twentieth century.113 Like poor law institutions at the metropolitan centers, the KPH and Lunatic Asylum operated as multifunctional institutions in which their nominal role was at risk of being subsumed within their other tasks. Research on European poor laws has shown that admission to the poorhouse/workhouse was one amongst many strategies employed as a survival mechanism by the working population living in a state of constant insecurity due to unemployment, sickness, and death. It was an alternative or additional strategy to other means such as begging, theft, and prostitution. The KPH and the Lunatic Asylum to some extent replicate this pattern in the uses to which they were put.114 Patients were provided with food and lodging and even employment. Subordinate workers were given the means to make a living and perhaps to prosper. Reading through the evidence of the inquiry, the impression is gained that everyone within these institutions,

96 Margaret Jones whether patient or worker, and limited as they were by circumstances, were utilizing the situation as much as possible to their own advantage. Thus, whereas the inquiry revealed a catalogue of inhumanity and suffering, it also pointed to the agency of those at the lowest levels of colonial society. This agency was overt as has been seen, but it was also more subtly subversive in that their actions had the, albeit unintended, consequence of influencing colonial policy at the highest level. The imperial government was forced to take notice and instigate policies that in turn amounted to an admission that, even if in a limited way, it had a responsibility for the welfare of its colonial subjects.

NOTES 1. National Archives, Kew (hereafter NA): CO 137/350/118, Seven Months in the Kingston Lunatic Asylum and What I Saw There, 9. It was very unlikely that Pratt wrote this pamphlet herself; she was described in the sources as an illiterate mulatto woman. It was more than likely composed by Dr. Lewis Bowerbank. 2. NA: CO 137/365, Draft of dispatch, Henry Taylor to Governor Eyre, August 14, 1862; NA: CO 137/364, Report on the Management of the Public Hospital, November 20, 1861. For further discussion of tanking at the Lunatic Asylum, see Margaret Jones, “‘The Most Cruel and Revolting Crimes’: The Treatment of the Mentally Ill in Mid-Nineteenth-Century Jamaica,” Journal of Caribbean Studies 42, no. 2 (2008): 290–309. 3. NA: CO 137/350/118, Minute, Henry Taylor, September 22, 1860; Kemble to Austin, August 8, 1860. 4. NA: CO 137/359, Commission of Inquiry into the Public Hospital and Lunatic Asylum, 1861, 1. 5. See, for example, Mark Harrison, Margaret Jones, and Helen Sweet, eds., From Western Medicine to Global Medicine: The Hospital Beyond the West (New Delhi: Orient BlackSwan, 2009); Margaret Jones, The Hospital System and Health Care: Sri Lanka, 1815–1960 (New Delhi: Orient BlackSwan, 2009). 6. NA: CO 137/339, Governor, Sir John Grant to the Secretary of State, April 8, 1870. H.H. Howard of the Rockefeller Foundation commented in the 1930s that the British West Indian medical service was the “boneyard” of the colonial medical service, where those at the end of their careers ended up for an easy life. The Archives of the Rockefeller Foundation, Tarrytown, New York: RF. RG 1.1. Series 420, Box 4, Folder 8, 1933, Caribbean Region. Present Cooperative Work and Future Plans, 4. 7. NA: CO 950/118, Hallinan, Memorandum on Medical and Housing Conditions, 2. 8. A further complication was that the U.S. medical degree was not recognized in the British Empire. There was much correspondence between the CO and the Jamaican government about who was entitled to practice in Jamaica. 9. NA: CO 137/370, Fourth Report of the Institution for Training Nurses established by Lady Barkly, 1862. 10. NA: CO 854/7/6, Report on Colonial Hospitals and Lunatic Asylums, April 6, 1864. 11. NA: CO 137/361, Examination of Dr. James Scott, June 18, 1861, 130.

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12. Richard Rouse died before the inquiry was set up but left three written statements. The third of which Henry Taylor at the CO was convinced had been written by Bowerbank because of the change in style to a more literate one from the previous two. NA: CO 137/363. Appendices H, I, J. After his death his son also published a pamphlet based on Rouse’s evidence, New Lights on Dark Deeds Being Jottings from the Diary of Richard Rouse, Late Warden of the Lunatic Asylum, edited by his son (Kingston: Gall and Myers Printers, 1860). I am grateful to Len Smith for sending me a copy of this. I have chosen to use Rouse’s written statements to the inquiry rather than this pamphlet, but they largely cover the same ground. 13. NA: CO 137/359, Examination of Dr. Lewis Bowerbank, May 15, 1861, 1; NA: CO 137/361, Evidence of Dr. James Scott, June 17, 1861, 24. 14. NA: CO 137/359, Examination of Dr. Alexander Fiddes, May 20, 1861. 15. NA: CO 137/365, Governor to Secretary of State, March 24, 1862. 16. NA: CO 137/366, Governor to Secretary of State, May 8, 1862. 17. NA: CO 137/364, Report on the Management of the Public Hospital, November 20, 1861, paragraph 33. 18. Ibid. 19. NA: CO 137/364, Examination of Bowerbank, May 16, 1861, 67. 20. Ibid. 21. Ibid. 22. NA: CO 137/361, Evidence of Dr. James Scott, June 19, 1861, 205. 23. NA: CO 137/362, Examination of Maria Robertson, August 20, 1861, 340. 24. NA: CO 137/359, Examination of Bowerbank, May 16, 1861, 69. 25. Ibid. 26. NA: CO 137/359, Examination of Bowerbank, May 16, 1861, 41. 27. NA: CO 137/363, Appendix J, Rouse, Third Statement, 70–71. 28. Ibid. 29. Ibid. 30. NA: CO 137/359, Examination of Dr. Bowerbank, May 14, 1861, 33. 31. NA: CO 137/359, Examination of Bowerbank, May 14, 1861, 91. 32. Ibid. 33. NA: CO 137/361, Examination of Scott, June 17, 1861, 70. 34. NA: CO, 137/362, Examination of Scott, August 20, 1861, 125. 35. Ibid. 36. NA: CO 137/363, Appendix J, Rouse, Third Statement, 41–103, 71. 37. NA: CO 137/359, Examination of Bowerbank, May 16, 1861, 132. 38. Ibid., 134. 39. NA: CO 137/360, Examination of Allen Alexander, May 29, 1861, 379. 40. NA: CO 137/350/118, Seven Months in the Kingston Lunatic Asylum, 10. 41. Ibid. 42. NA: CO 137/351, D.P. Trench, Inspector and Director of the Public Hospital and Lunatic Asylum of Jamaica, Official Documents on the Case of Ann Pratt, August 11, 1860, Examination of Mary Donaldson, No. 4, 38–39. 43. Ibid. 44. NA: CO 137/359, Examination of Bowerbank, May 15, 1861, 33. 45. NA: CO 137/359, Examination of Bowerbank, May 16, 1861, 51–52. 46. Ibid. 47. NA: CO 137/359, Examination of Bowerbank, May 16, 1861, 54. 48. Ibid., 61–63. 49. Ibid. 50. Ibid. 51. Ibid. 52. Ibid.

98 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78.

79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90.

Margaret Jones Ibid., 68. Ibid., 70. Ibid. Ibid., 139–140. Ibid. NA: CO 137/360, Examination of James Gibbs, Surgeon, May 27, 1861, 47. Ibid., 48. NA: CO 137/ 360, Examination of Mrs. Caroline Smith, lady visitor, May 31, 1861, 185–187. Ibid. NA: CO 137/363, Appendix F, Rev. F.H. Almon, Hospital chaplain 1853– 1855, 13–18, 13, 17. Ibid. NA: CO 137/363, Appendix I, Rouse, Second Statement, 35–39, 38–39. NA: CO 137/359, Examination of Alexander de Graffe, May 20, 1861, 314. NA: CO 137/363, Appendix X, Statement of Rev George Brooks, 249–250. Ibid. Ibid. NA: CO 137/ 359, Examination of Bowerbank, May 16, 1861, 68. NA: CO 137/360, Examination of Mrs. Mary Cunha, June 3, 1861, 271. NA: CO 137/360, Examination of Rev. Duncan Campbell, May 24, 1861, 1. Ibid., 11. Ibid. Ibid., 14. NA: CO 137/359, Examination of Bowerbank, May 16, 1861, 140–141. Scott’s salary was £400 per annum and Keech’s £300, the nurse’s wage adds up to £5–8s a year; NA: CO 137/361, Examination of Scott, June 18, 1861, 129. NA: CO 137/361, Examination of Scott, June 19, 1861, 205. It is very difficult to ascertain the race of Jamaicans in the sources. The doctors who had had a recognized medical training can perhaps safely presumed to be white. Bowerbank and Fiddes defi nitely were—as there are photographs of them. Rouse was stated as being black, Pratt as mulatto, Ryan reputedly said that brown people should be tanked before black, which suggests she was white or mixed race. The other nurses and servants at the hospital were most probably black or mixed race. Some of the patients were poor whites, for example, a Scottish woman, “Mrs. Coyle,” who had been in the hospital since 1844. NA: CO 137/362, Examination of Scott, August 20, 1861, 122. NA: CO 137/364, Report on the Public Hospital, paragraph 33. NA: CO 137/365, Henry Taylor, draft dispatch to Governor Eyre, August 14, 1862. NA: CO 137/364, Report on the Public Hospital, paragraph 25. NA: CO 137/359, Examination of Bowerbank, May 16, 1861, 64. NA: CO 137/362, Examination of Maria Robertson, August 20, 1861, 34. NA: CO 137/359, Examination of Bowerbank, May 16, 1861, 134. David Ryan had been the superintendent of the male Lunatic Asylum until 1858 when he fell out with Scott and was dismissed. NA: CO 137/363, Appendix J, Rouse, Third Statement, 41–103, 72. Ibid., 58. Ibid. NA: CO 137/363, Appendix I, Rouse, Second Statement, 35–39, 37. NA: CO 137/360, Examination of Edward Jordon, May 29, 1861, 50. NA: CO 137/363, Appendix J, Rouse, Third Statement, 41–103, 73.

Surviving the Colonial Institution 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109.

110. 111. 112.

113. 114.


NA: CO 137/359, Examination of Bowerbank, May 16, 1861, 135. NA: CO 137/363, Appendix J, Rouse, Third Statement, 41–103, 76. Ibid. Ibid. NA: CO 137/361, Examination of Scott, June 17, 1861, 1–123, 104. Ibid., 1–123, 106. NA: CO 137/361, Examination of Scott, June 19, 1861, 195–203, 203. NA: CO 137/360, Examination of Gibbs, May 27, 1861, 47. NA: CO 137/359, Examination of Bowerbank, May 15, 1861, 130. NA: CO 137/360, Examination of Gibbs, May 27, 1861, 47. NA: CO 137/361, Examination of Mary Barnett, June 25,1861, 265. NA: CO 137/361, Report of Caleb Hall, February 29, 1860. Ibid. Ibid. Marteen the nurse in A and B wards “used to send her children to buy rum for the patients.” NA: CO 137/363, Appendix I, Rouse, Second Statement, 35–39, 37. NA: CO 137/ 361, Examination of Scott, June 17, 1861, 120. NA: CO 137/365, Minute, Taylor to Frederick Rogers, July 26, 1862. NA: CO 854/7, Circular Dispatch from the Secretary of State, January 1, 1863. The questions were devised by Henry Taylor and approved by the Lunacy Commissioners and the Royal College of Physicians. NA: CO 854/7/6, Colonial Hospitals and Lunatic Asylums, 1864, Part III, General Suggestions, 13–22, paragraphs 48–51. The recommendations of the report were based on suggestions of the Lunacy Commissioners; Florence Nightingale’s Notes on Hospitals; the advice of the Royal College of Physicians; and based on the statements of “defects actually existing in the colonial hospitals and asylums” (ibid., paragraph 57). NA: CO 854/7/6, Colonial Hospitals and Lunatic Asylums, 1864, Part III, General Suggestions, 13–22, paragraphs 48–51. Ibid. NA: CO 137/476/43, Report of the Superintending Inspectors Appointed under Law 6 of 1867, to Enquire into and to Report upon the Statements Contained in the Correspondence that Passed between Dr. Bowerbank and the Colonial Secretary, Relative to the Late Out-Break of Small-Pox in the Parish of St. Andrew, 9. See, for example, NA: CO 140/241, Annual Report of the Board of Supervision, 1911. See, for example, Peter Mandler, ed., The Uses of Charity: The Poor on Relief in the Nineteenth Century Metropolis (Philadelphia: University of Pennsylvania Press, 1990); Ole Peter Grell, Andrew Cunningham, and Robert Jűtte, eds., Health Care and Poor Relief in 18th and 19th Century Northern Europe (Aldershot: Ashgate, 2002).


“A Laudable Experiment” Infant Welfare Work and Medical Intermediaries in Early Twentieth-Century Barbados Juanita De Barros

In the fi rst few decades of the twentieth century, a network of home visitors, infant clinics, and “baby-saving leagues” was established in the British Caribbean. Part of a wider public health infrastructure, it represented the desire of imperial and colonial government officials and local philanthropists to reduce the high levels of infant mortality believed to be pervasive throughout the region. Although perceptions of the causes of infant mortality and the nature of the programs crafted in response reflected ideas and practices current in the United Kingdom, they were also influenced by the economic, political, and social realities of colonial life in the early twentiethcentury British Caribbean. This chapter considers the impact of some of these local factors in the case of Barbados with particular reference to the agency of medical intermediaries. In 1912, a meeting held to address the problem of infant mortality in that colony, attended by colonial and local politicians and physicians, ended with the refusal of the “local authorities” to approve a colony-wide infant welfare program. But although Barbados’s decentralized model of public health administration could stymie the introduction of such colony-wide initiatives, it did not entirely foreclose them. Following the failed 1912 meeting, officials in one parish temporarily introduced the same infant welfare measures that had been rejected for Barbados as a whole as an “experiment.” Although its short-lived nature (it lasted only a year) points to the potentially baneful effects of official resistance on such attempts, its very existence suggests that the combined efforts of local physicians, nurses, and midwives could build public health initiatives in the face of entrenched reluctance, ones that could provide a model for future generations. By focusing on the complex roles of auxiliary health workers in initiating such operations, this chapter argues that these intermediaries were central to determining people’s experience of public health and were, in the case of Barbados, the forerunners of reform programs.

WEST INDIAN POPULATIONS AND INFANT MORTALITY Discussions similar to those held in Barbados in 1912 were increasingly common in Europe and its colonies, and in the independent nations of

“A Laudable Experiment” 101 the Americas, in the early twentieth century as politicians and physicians expressed growing concern about the social and economic consequences of infant mortality. In Britain’s Caribbean colonies, physicians tended to assess this problem in the same terms as their foreign counterparts, largely due to the nature of their medical education and their familiarity with contemporary ideas about public health. In the early twentieth century, most physicians practicing in the British West Indies had trained in universities in the United Kingdom, especially in Edinburgh, and some had obtained public health accreditation at the London School of Hygiene and Tropical Medicine.1 Like their counterparts elsewhere, West Indian doctors blamed infant mortality on a range of factors, including intestinal illnesses, malnutrition, venereal disease, and what were seen as the debilitating effects of poverty. They believed that its impact was widespread, affecting the health of nations as a whole.2 West Indian physicians considered the effects of infant mortality to be particularly intense in the Caribbean. B.G. Mason, magistrate and district medical officer for St. Vincent, declared that the phrase a “nation’s health [was] a nation’s wealth” was especially true in the Caribbean where, as he argued, “prosperity [was] as largely dependent on the health and efficiency of the field laborers as it [was] on the introduction of capital.”3 Many of Mason’s contemporaries would have agreed with him. With the initiation of sugar production in the mid-seventeenth century, Caribbean planters relied heavily on massive supplies of laborers to produce the sweet substance. The end of slavery in the British Caribbean in 1834–1838 and a series of crises in the sugar industry only served to further emphasize the industry’s dependence on large numbers of laborers. Sugar production fell in some colonies after emancipation and declined still further following the 1846 passage of the Sugar Duties Act, which ended protected markets for British West Indian sugar. The latter led to a fall in sugar prices and the industry’s contraction in Jamaica and parts of the Windward Islands’ chain. Recovery had barely begun when the arrival of European-produced beet sugar on the world market in the early 1880s resulted in a further contraction, leading to the “sugar bounty depression” that lasted until the early twentieth century. With World War I and fighting in Europe, which destroyed beet sugar producing areas, came renewed demand for British Caribbean sugar and an expansion of the industry in some territories. Throughout these upheavals, the sugar industry continued to dominate the economies of many British Caribbean islands, including that of Barbados.4 In places where sugar production survived as a significant part of the economy, it did so on the backs of workers, specifically on the ability of local oligarchies to secure sufficient numbers of workers at low wages. Planterdominated governments throughout the region attempted to realize this goal by discouraging former slaves from working outside the plantation sector in the hope that doing so would effectively compel them to labor on the estates on terms set by the planters. Thus, they set high prices for vacant land, passed vagrancy laws, and generally tried to limit non-estate


Juanita De Barros

employment opportunities. In smaller islands, such as Barbados, Antigua, and Nevis, planters had considerable success in doing so. But in larger territories like Trinidad and British Guiana (and Jamaica, to a lesser extent), where former slaves could more easily escape the plantation zone by squatting on abandoned land, the plantocracies attempted to obtain the desired large number of dependent laborers by importing several hundred thousand indentured workers, mostly from South Asia. These indentured immigrants supplied the plantations with permanent, inexpensive workers who, when their indentures expired, competed with Afro-Creoles for seasonal labor, thereby ensuring the existence of a cheap and plentiful labor force. 5 These policies contributed to the very labor shortages they were designed to avoid as the case of Barbados shows. There, the low wages imposed on estate workers may have reduced the costs of sugar production and increased planters’ profits, but it could also result in malnutrition, with dire consequences especially for the very young.6 Low wages also encouraged many Barbadians to emigrate and this in turn led to a decline in the population. Barbados’s population shrank between the 1890s and the early 1920s as its men and women migrated to places such as British Guiana and Trinidad and farther afield to the Hispanic circum-Caribbean and the United States in search of work (see Table 5.1). When the U.S. began building a canal in Panama in 1904, the isthmus became the destination of choice, attracting large numbers of Barbadians until its completion in 1914. Colonial officials worried about the combined effects of emigration and high mortality rates on domestic labor needs, particularly on the sugar estates.7 Its rate of infant mortality in particular was considered to be among the highest in the region and remained high until the early 1930s (see Table 5.2).8 According to John Hutson—a locally born physician and Barbados’s long-serving poor law inspector and fi rst public health inspector—Barbados needed to “stem the devastating torrent of infant mortality and keep [its] supply of cheap labor plentiful enough to stand the constant stream of emigration.”9 Not only did emigration to the Panama Canal reduce the number of current laborers, it also ensured a future shortage. Hutson argued that the exodus of “several thousands of working men in the prime of life” led to a falling birth rate.10

Table 5.1

Population of Barbados




161, 594


182, 806


171, 983


156, 812

Source: Lofty, Report on the Census of Barbados 1921, 6, 10.

“A Laudable Experiment” 103 Table 5.2

British Caribbean Infant Mortality Rates (per 1,000 live births)













St. Kitts












British Guiana




Source: Report of the Commission Appointed to Enquire into and Report upon the General and Infantile Mortality (Georgetown, British Guiana: The Argosy Company, 1906), 11 (hereafter Report of the Mortality Commission). For 1912–1916, see Report of the Proceedings of the West Indian Medical Conference (Georgetown: The Argosy Company, 1921), 62. For 1920–1921, see Mason, “British West Indies Medical Services,” 694.

By the early twentieth century, most British Caribbean governments saw child-saving efforts as contributing to their efforts to ensure sufficient numbers of laborers. Following the lead of Britain where infant welfare clinics, milk depots, and networks of health visitors were established in the early twentieth century, some British Caribbean governments and members of the local middle and professional classes began to introduce similar institutions in the 1910s and 1920s, although inadequate funding severely limited their scope.11

THE POLITICS OF HEALTH Hutson and other public health physicians in Barbados called for the introduction of the kind of maternal and infant welfare programs listed earlier, maintaining that doing so would drastically reduce the colony’s rates of infant mortality. They argued that other governments recognized such measures as “an integral part of [the] official public health effort.”12 But in Barbados, efforts to do so were the subject of considerable political debate. To a certain extent this was due to political considerations and the way in which health (and government generally) was administered. With the exception of Barbados, all colonies in the British Caribbean saw the replacement of their nominally representative systems of government by an even less representative Crown Colony system in the 1860s and 1870s. In the Crown Colonies, legislative bodies were composed of nominated members or a mixture of nominated and elected members with the deciding vote held by the governors. Barbados, on the other hand, retained its legislative system, but one that symbolized the unrepresentative, planter-dominated nature of the old system. Its executive was responsible for introducing all


Juanita De Barros

“money bills” and government initiatives that its elected House of Assembly could accept or reject. Affairs at the parish level were administered by elected governments (or vestries) that oversaw road repairs, poor relief, and “sanitary measures,” and were paid for by local taxes. The number of vestry members ranged from six to sixteen, depending on the size of the parish. Voters for both vestrymen and assemblymen had to meet a property qualification, but this was somewhat lower for vestry elections for all parishes except St. Michael. The number of voters remained extremely limited well into the twentieth century; for example, in 1911, the population of 171,983 produced a mere 1986 eligible voters.13 This political structure had implications for the provision of health care in Barbados, including in the realm of infant and maternal health. At the level of the central government, a government-appointed general board of health was responsible for making “rules and regulations for promoting the health of the island and for removing all causes which may lead to the introduction or spread of all contagious, infectious, or other diseases.”14 The colonial government employed a poor law inspector and, as of 1913, a public health inspector.15 For the period covered in this chapter, both offices were held by the same person, Hutson. The colony had a General Hospital in the capital city of Bridgetown that received funding from the colonial government but was administered by an independent board of directors. For the most part medical care for the sick poor in Barbados was administered and fi nanced at the parish level as part of the poor relief system. Poor relief systems based on the British model existed elsewhere in the British Caribbean, but they played a particularly important role in Barbados.16 Under the 1880 Poor Relief Act a central poor law board was established and a poor law inspector appointed to report regularly on the actions of the local boards of guardians, those who administered poor relief in the individual parishes. Members of the local governments or vestries sat on parish health boards, establishing the rates of local taxes used to pay for poor relief.17 Each parish operated an almshouse where the indigent could be housed and the sick poor could be treated provided that they met an eligibility “test.” Essentially, the almshouses operated as hospitals, carrying out the same functions as those of the small district hospitals elsewhere in the British Caribbean.18 The parishes paid for the medicines doled out to the sick poor and for the services of parochial medical officers who saw to the sick in the almshouses, the dispensaries, or in their homes. Sick paupers who met an eligibility test received free care whereas non-paupers were required to pay a fee.19 As Richardson has argued, the “logistical and bureaucratic requirements of gaining almshouse admission in Barbados in 1900 were enough to keep all but the most determined applicants away.”20 This system made some limited provision for poor parturient women. They could give birth in the almshouse and be seen by the parochial medical officer “in case of an emergency.”21 “Deserving” women who gave birth at home with a

“A Laudable Experiment” 105 midwife could apply to the poor relief inspector to have the vestry pay their midwifery fees. 22 Much to the ongoing chagrin of the central poor law board and that of Hutson, the parishes tended to provide medical care for the sick poor as they saw fit, often ignoring the advice of officials like Hutson. 23 In Hutson’s words, this resulted in “a marked difference of policy and great diversity in the details of administration” among the vestries. 24 Some officials defended this “sectional management” as better suited to Barbados than a more centralized system, because it accounted for differences among the parishes and put health administration in the hands of those “most familiar with local conditions.”25 Indeed, as late as 1925, two Barbados based physicians, J.W. Hawkins and A.J. Hanshell, argued in favor of local control over sanitary laws and regulations in general as a “principle” that reflected Barbados’s “English” heritage. They declared that it was the “correct system . . . in an ever British colony like Barbados.”26 Be that as it may, the sources clearly agree with Richardson’s characterization of Barbados’s poor relief system as a “bewildering, redundant, and thoroughly inefficient means of providing aid to the poor.”27

MEDICAL INTERMEDIARIES AND INFANT WELFARE WORK IN BARBADOS In 1911 and 1912, Hutson, parochial physicians such as Norman Boxill, and members of the Central Poor Law Board and the parochial Boards of Guardians met to discuss the problem of infant mortality in Barbados. The meetings demonstrate the effect of the colony’s decentralized governance model on the development of public health and social welfare policies such as those targeting infant mortality. However, the “laudable experiment” in infant welfare work launched shortly afterwards in St. George parish shows that the combined efforts of physicians, nurses, and midwives could initiate local reform efforts that provided a new paradigm. In 1911, Barbados Governor Leslie Probyn called on two noted island figures—the president of the poor law board, W.K. Chandler and Hutson—to suggest the best means to control the “excessive infant mortality of the island.”28 Their conclusion that one of the main culprits was “improper and insufficient food” for infants in the “lowest class of the community” doubtless owed much to Hutson, an Edinburgh-trained physician who was familiar with current thinking about infant mortality. 29 They proposed establishing “an organized system of district nurses and supply of milk to deserving cases,” the cost of which would be split between the colonial government and parish authorities. 30 A subsequent meeting held in 1912 and attended by Hutson, several parochial medical officers, and the heads of the parish boards of guardians debated a series of resolutions based on Hutson’s and Chandler’s recommendations. Specifically, they called for


Juanita De Barros

every parish vestry provide milk for impoverished mothers and to employ “competent women as parish nurses” to visit new mothers to “give advice and assistance,” particularly about the best ways to feed their infants. 31 The representatives of the boards of guardians, who alone had the right to vote on these measures, rejected the proposals. They did, however, agree that registering infant deaths would “assist in controlling the death rate of Infants.” 32 Hutson interpreted this decision as reflecting the attitude of the local authorities and as preventing the executive from taking action on this important matter. In making this observation, he suggested that the two levels of government—the “local authorities” and the “executive” or central government—were at odds over the best way to tackle the problem of infant mortality. Colonial officials like Hutson as well as imperial officials in London regularly complained about the obstreperousness of the “local authorities” in Barbados, especially in terms of sanitation and health policies. They were castigated as miserly and indifferent to the suffering of the masses of the population.33 However, the extent of the difference between “local” parish officials and those in the colonial government is uncertain. Many had been born on the island and were of similar social backgrounds, and they tended to hold the same views about the purported moral and cultural failings of the African-descended population. Indeed, reading the poor law reports from the late nineteenth and early twentieth centuries reveals what Gordon K. Lewis tellingly referred to as the “social climate of indifference to mass suffering.”34 Physicians such as Hutson and Boxill—the parochial medical officer for St. George parish—present an interesting contrast in this respect. Although medical knowledge certainly did not immunize physicians from contemporary race, gender, and class-based biases—in fact it often underlay them—it did introduce men like Hutson and Boxill to ideas about public health and social welfare that were at odds with the social climate of indifference described by Lewis. Like most British Caribbean–based physicians in the early twentieth century, both men had studied in Edinburgh (Hutson also received training in public health at Cambridge University) and they also corresponded regularly with their professional colleagues in Britain and throughout the British Caribbean.35 They supported the introduction of infant welfare programs established in early twentieth-century Britain, such as providing milk for poor newborns and establishing networks of district nurses to “advise” new mothers about the best ways to feed and rear their infants. In doing so, they represented poor women as ignorant mothers in need of advice by physicians such as themselves and trained nurses and midwives. This perspective echoed that of their metropolitan colleagues but it also intersected with long-standing views in the Caribbean about the purported poor parenting skills of black men and women and their alleged indifference to their children’s welfare. For example, when Boxill began offering free medical care for infants and advice for new mothers in his

“A Laudable Experiment” 107 parish in 1909, he expressed the hope that it would help eradicate the ignorance he believed contributed to infant deaths.36 Although the sources do not state explicitly whether these women were of African descent, the fact that the overwhelming majority of women in St. George parish were either black or mixed race during this period suggests that Boxill’s main concern was with non-white women. According to the 1911 census, 73 percent of the parish’s women were black, 31 percent were described as mixed, and 2.5 percent were white (no census was taken in 1901).37 Something of these views can be seen in the response of Hutson and Boxill to the 1912 meeting addressing infant mortality. As a parochial medical officer, Boxill had attended the meeting. He condemned it as “fruitless” and declared that the problem of infant mortality “[could] not remain as disregarded, not at any rate if those charged with the public welfare deserve[d] to continue to be held worthy of their responsibilities.”38 He subsequently convinced the elected vestry members of St. George parish to institute the same kind of infant welfare scheme rejected by the boards of guardians. 39 The records prevent an easy assessment of the program’s accomplishments as they indicate neither the number of infants born during its existence nor the number of babies that Boxill and the nurses visited, only the total number of visits. But this was considerable (totaling well over five hundred visits), and that number, combined with the over one hundred infants listed as having received free milk, point to a significant amount of activity over the course of the year. According to Boxill, the infant welfare scheme resulted in fewer deaths during a particularly lethal “epidemic of Diarrhoea and Dysentery”; he argued that consequently it had “proven its usefulness and adaptability to an emergency” and had therefore “worked well.”40 Hutson commended everyone involved in “this laudable effort to reduce the infantile mortality of the parish” and called on other vestries to follow suit. Any assessment, of course, must consider the response of the women targeted by the scheme. Unfortunately, the sources are fairly vague in this respect. Boxill believed that the women “welcomed” this initiative, an observation that could well have been true. Under the infant welfare scheme, women saw that their newborns were given free medical care and that some were even given free milk. For poor women in St. George, both were significant.41 Despite this praise, the program ended after a year, defeated when a vestry member moved its cancellation on the grounds that it was “a means of mothers getting support for bastard children instead of getting relief from the father of such children.”42 Boxill condemned the motion as “retrograde,” but it won the support of a majority of the vestry members, its success indicating the influence of negative views of the poor on the colony’s social welfare policies in the early twentieth century.43 Yet Boxill continued to provide free medical care for infants, much as he had been doing since 1909. Several other parochial physicians did so in the years that followed. A system of district nurses employed to visit newborns would not be instituted again until the mid-1920s. But Hutson at least lamented the passing


Juanita De Barros

of the St. George parish scheme, referring to it over the years as an example of what could be accomplished. 44 But the story of the “laudable experiment” concerns more than physicians and colonial politicians. It also involved, in the main, auxiliary health workers, notably nurses and midwives. Indeed, Boxill and Hutson attributed the scheme’s success to the work of the district nurses whom the vestry hired to visit the newborns and advise their mothers. The sources identify only one of the two nurses, a “Nurse Burrowes.” Hutson declared that she was “the most important factor in this system and that no relief of this kind to infants [could] be efficient without her.”45 Boxill in turn complimented “her methods and her tact in performing somewhat delicate duties.”46 These “duties” demonstrated the intertwined professional relationship between a physician like Boxill and a nurse like Burrowes. To a certain extent Boxill determined the nature of her duties. He provided Burrowes with written instructions to guide her interactions with new mothers and stipulated that she refer to him complicated cases with which she was unable to cope. Similarly Boxill controlled one of the key aspects of this program, identifying which infants were to receive free milk.47 Despite working under Boxill’s supervision, Burrowes clearly exercised some professional autonomy. In her visits to the newborns, she was to give “the mothers any advice which seem[ed] to her necessary,” particularly about feeding their babies.48 Boxill’s observation about the tact she exercised in doing so suggests that she decided how to relay this information. Moreover she used her own judgment as to the kind of information she should provide. In addition to advising new mothers, Burrowes provided medical care for their babies. The fact that she was empowered to request “simple remedies” from the almshouse dispensary to treat the infants suggests not only autonomy but also specialized medical knowledge about the most appropriate medicine and how it was to be administered. And in deciding which infants were to be referred to Boxill, she exerted control over access to him, acting as gatekeeper to the infant welfare system.49 Burrowes’ training and years of professional experience gave her the expertise to carry out her various duties. 50 She was a “trained hospital nurse” who, at the time of the St. George parish infant welfare scheme, had held a position of some authority in Barbados’s health system as the head nurse at the St. George almshouse. 51 The sources examined so far do not reveal details about Burrowes, including her personal and professional background. As she held a relatively senior nursing position, she may well have been British born and trained. Although African-descended women had worked as nurses and midwives in the British Caribbean since the period of slavery, by the late ninteenth century and the establishment of formal nurse and midwifery training, senior nurses in the colonial hospitals were invariably British born and trained. Indeed colonial officials consistently preferred to hire whites for supervisory roles in the British Caribbean, and nursing was no exception. For example, when the British-trained

“A Laudable Experiment” 109 head nurse at Barbados’s General Hospital left her position in 1913, she was replaced with a compatriot. In observing that she was to be joined by an assistant head nurse, Hutson noted the preference for nurses with “English training”; two English women were duly sent out. 52 However, whether this policy applied to head nurses and matrons, like Burrowes, who were employed in parish almshouses, rather than in the main colonial hospitals, is uncertain. By the time Burrowes began working in St. George almshouse, formal, hospital-based nurse-training programs targeting West Indian women had already begun in parts of the British Carribean. They started in Jamaica and British Guiana by at least the 1890s and by the fi rst decade of the twentieth century in Barbados. 55 By way of comparison, hospital-based nurse-training programs began in Jamaica in the 1880s and British Guiana by the 1890s. 56 Burrowes’s role in assisting new mothers was short-lived, at least to the extent that it was funded by the St. George vestry. Barbadian women would have to wait until the mid-1920s and the establishment of the Barbados Baby Welfare League before they saw another attempt to institute a system of district nurses.57 However, they could turn to midwives. As was the case throughout the British Caribbean, most midwives were informally trained, so-called “granny” midwives. Physicians and members of the social and political elites often condemned these women as incompetent; their purported lack of skills was seen as placing mothers and newborns at risk. Many of Hutson’s colleagues would have agreed with his argument that their lack of skill could be “positively injurious.”58 Biases in contemporary sources obscure the true nature of the work carried out by these granny midwives, but it is likely that their number included both skilled and unskilled practitioners. Indeed, the willingness of colonial governments in Jamaica and British Guiana to certify and register some informally trained grannies points to an official acknowledgment of their skills.59 The development of formal midwifery programs throughout the region represented an explicit attempt to produce trained, certified midwives with the goal of encouraging poor women to turn to them rather than the “grannies.” Jamaica led the way with the establishment of midwifery training in the Victoria Jubilee Lying-In Hospital in 1887, and British Guiana followed in the late 1890s with the initiation of a hospitalbased and government-supported training program. In both, the goal was to train local women as midwives primarily for the “humbler classes” and to “distribute” the trained midwives throughout the colony. And in both, the colonial governments defrayed some of the costs.60 In Barbados, formal midwifery training began in the early twentieth century, but it occurred only at the parish level. Indeed, the colonial government did not play much of a role in training or regulating midwives before the late 1930s. Despite the observation of the members of the Public Health Commission of 1925 (which included physicians such as Hutson and Boxill) that an “adequate Act for regulating the practice of midwifery [was] required,” such a bill was not passed until 1932.61 Even after it was

110 Juanita De Barros passed the government had not issued rules for the “conduct and training of midwives” as of the late 1930s.62 The relative autonomy enjoyed by the General Hospital from government direction seemed to allow it to determine the extent to which it would become involved in infant welfare work and midwifery training, regardless of efforts by officials such as Hutson. It did not provide midwifery training during the period examined in this chapter, and as late as 1939 did not have a lying-in ward or an antenatal clinic, only admitting pregnant women in case of emergency.63 The refusal of the colonial government and the colonial hospital to establish midwifery training left matters in the hands of the parishes. Hutson encouraged the board of guardians in St. Michael parish to step in. He argued that the presence of a lying-in ward in the parish’s almshouse run by a midwife and the sheer number of women seen there annually made it a natural choice for a midwifery school.64 Following Hutson’s advice a board of guardians in St. Michael began offering a midwifery training program in 1902 in the almshouse. It began slowly, attracting only three students to its second session, but by its tenth iteration in 1914, it had generated 117 certified midwives.65 The program ran until the mid-1930s when it seemed to have ceased operations.66 For the period examined in this chapter, the training course lasted for three months. During that time, students watched births, studied under the almshouse nurses, and attended lecturers given by its medical officers. On completing the course, they were examined by the poor law inspector and then certified as midwives, their names noted in the Official Gazette as certified midwives.67 The training program in St. Michael provided formally trained and certified midwives for other parishes. Some boards of guardians sent students to St. Michael, paying the L5 charged for the course, an amount that included all expenses.68 For instance, in its fi rst year, the parishes of St. Philip, Christ Church, St. George, St. Thomas, and St. Lucy did so. St. Joseph planned to do so as well but then did not send a student. The boards of St. John and St. James both refused, declaring that their parishes had no need for midwives.69 In St. Peter, the board justified its refusal on the grounds that there “would be no means of keeping the midwife in the parish after her training was completed.”70 Some of these women may have been employed by the parish of boards of guardians after their training fi nished, but Hutson suggests that this practice was relatively rare and that parish midwives “generally” were not “permanent item[s]” of parochial expenditure.71 It is likely that most of the midwives worked of their own accord. The sources suggest that at least some midwives chose to use their education as they saw fit, in defiance of official expectations. Thus, there may have been some merit in the concern expressed by officials in St. Peter parish that trained midwives might not return home. Although two of the fi rst graduates of the St. Michael program returned to their own home parishes of St. Lucy and St. Thomas, most graduates remained in St. Michael, the colony’s most populous parish and site of the capital, Bridgetown.72 There

“A Laudable Experiment” 111 they could offer their services “to better class patients, who [were] in a position to pay for them.”73 Even some students whose education was paid by their home parishes chose to remain in St. Michael. The parish of St. Thomas seemed to have been particularly unlucky in this respect. Having paid for and subsequently “lost” four nurses to the charms of other parishes, the St. Thomas authorities decided to force potential students to agree to work for the parish for five years or to reimburse the L5 paid for their training.74 Hutson believed that this problem could be avoided if women were chosen who had “some permanent connexion with the parish.”75 Census reports in 1911 and 1912 seem to bear out these concerns. Although they do not indicate whether the midwives listed in the reports were certified, they do point to the relatively large numbers in the capital city of Bridgetown and the parish of St. Michael. The vast majority of women who identified themselves as midwives were based in Bridgetown or St. Michael (forty-one of fi fty-seven in 1911 and fi fty-three of ninetyone in 1921). According to the census reports, most parishes had at least one midwife in 1911 and two by 1921.76 Physicians like Hutson regularly complained about the inadequate number of midwives. Indeed, the members of the 1925 public health commission observed that the colony lacked sufficient numbers of trained midwives and health visitors needed to staff baby-saving clinics should they be established.77 That parish authorities such as those in St. Thomas complained about losing “their” midwives once their training was completed suggests that these women were locals, born in Barbados as was the vast majority of the population. In 1911, for example, the census report noted that almost 98 percent of the population had been born on the island.78 The sources are silent about the ethnic background of midwives, although some inferences are possible. Most Barbadians were either of African or mixed ancestry, with relatively few individuals of unmixed European descent.79 Thus formally trained midwives could have come from any of those groups. The informally trained “granny” midwives who comprised the majority of assistants during childbirth were doubtless of African descent. Many women turned to them for fi nancial and possibly cultural reasons, choosing attendants who were cheaper and who used familiar birthing methods. Many women, though, were unable to afford this assistance and ended up giving birth unattended. The poor law reports contain frequent references to women forced to give birth outside, in cane fields or near the parish almshouse. Contemporaries characterized this practice as “vagrant midwifery,” an anodyne term that could not come close to relaying the fear that a woman giving birth alone in a field must have felt.80 These accounts indicate a rather obvious truth, that women did not want to give birth alone and that they attempted to fi nd assistance whenever possible, even if that meant setting out alone to reach the parish almshouse. Although the sources do not reveal much biographical information about these intermediaries, their importance is clear.


Juanita De Barros

CONCLUSION This chapter has traced the tentative beginnings of infant welfare work in Barbados, exploring the intersection of colonial political and social realities with contemporary ideas about such public health measures. Although the temporary nature of the short-lived infant welfare scheme introduced in St. George parish in 1912 raises questions about its historical significance, at least some of those who witnessed it in operation believed it to be important. For them, it was a kind of touchstone, an example of what could be accomplished in the future. For historians exploring the social history of health and health workers in the postslavery British Caribbean, the scheme points to the combined efforts of physicians and auxiliary health workers in creating and operating such initiatives. This chapter has emphasized the crucial role of intermediaries in their daily operation. Indeed, although their voices are hard to fi nd in the colonial archive, they were key to the success of such public health and social welfare programs. At the same time their personal needs and desires had an impact on their roles as demonstrated by trained midwives’ defi ance of official expectations and their determination to control the terms under which they would work. This brings to the fore the tension between policy and practice, highlighting the way in which the complex position of auxiliaries influenced implementation, policymaking, and the very nature of the system within which they operated. NOTES This chapter is based on research funded by the Social Sciences and Humanities Research Council of Canada, the Wellcome Trust, and McMaster University. It has benefitted from comments and criticisms offered by numerous colleagues, especially Woodville Marshall, David Trotman, Michael Johnson, Deborah Neill, and the editors of this collection. I also appreciate suggestions from those in attendance at the 2009 Oxford University workshop where I first presented this material. I am, of course, responsible for any errors remaining. 1. For more discussion about this, see Juanita De Barros, “‘Improving the Standards of Motherhood’: Infant Welfare in Post-Slavery British Guiana,” in Health and Medicine in the Circum-Caribbean, 1800–1968, ed. Juanita De Barros, Steve Palmer, and David Wright, 166, 167 (New York: Routledge, 2009); Juanita De Barros, “‘Spreading Sanitary Enlightenment’: Race, Identity, and the Emergence of a Creole Medical Profession in British Guiana,” Journal of British Studies 42, no. 4 (2003): 483–504. 2. The scholarship on infant and child welfare for the post-emancipation British Caribbean is slim but growing. See, for example, Anne Macpherson, “Colonial Matriarchs: Garveyism, Maternalism and Belize’s Black Cross Nurses, 1920–1952,” Gender and History 15, no. 3 (2003): 507–527; Clare Millington, “Maternal Health Care in Barbados, 1880–1940” (seminar paper, University of the West Indies, Cave Hill, November 1995); De Barros, “Improving the Standards of Motherhood.” The Caribbean work has built on the excellent research by British and imperial historians. This includes the following: Deborah Dwork, War Is Good for Babies and Other Young

“A Laudable Experiment” 113

3. 4.


6. 7. 8. 9. 10. 11. 12. 13.

14. 15.

Children: A History of the Infant and Child Welfare Movement in England, 1898–1918 (London: Tavistock Publishers, 1987); Anna Davin, “Imperialism and Motherhood: Population and Power,” History Workshop Journal 5 (1975): 7–65; Kalpana Ram and Margaret Jolly, eds., Maternities and Modernities: Colonial and Postcolonial Experiences in Asia and the Pacific (Cambridge: Cambridge University Press, 1998). G.B. Mason, “The British West Indian Medical Services,” United Empire 13 (1922): 696. For discussions about the health of the British Caribbean sugar industry in the post-emancipation period, see Bonham C. Richardson, Panama Money in Barbados, 1900 –1920 (Knoxville: University of Tennessee Press, 1985), 31–42; Claude Levy, Emancipation, Sugar and Federalism: Barbados and the West Indies, 1833–1876 (Gainesville: University Press of Florida, 1980), 108; Bonham C. Richardson, Economy and Environment in the Caribbean: Barbados and the Windwards in the Late 1800s (Barbados: University of the West Indies Press, 1997), 2; Hilary Beckles, A History of Barbados: From Amerindian Settlement to Nation-State (Cambridge: Cambridge University Press, 1990), 126–132; and Douglas Hall, Five of the Leewards 1834 –1870 (Aylesbury: Caribbean Universities Press, 1971), 127. For a concise summary of some of these developments, see O. Nigel Bolland, “Systems of Domination after Slavery: The Control of Land and Labor in the British West Indies after 1838,” Comparative Studies in Society and History 23, no. 4 (1981): 591–619. Bonham C. Richardson has characterized postslavery emigration from these small islands as a “migration adaptation,” analogous to the attempts of former slaves in the larger territories to remove themselves from the plantation zones. Bonham C. Richardson, Caribbean Migrants: Environment and Human Survival on St. Kitts and Nevis (Knoxville: University of Tennessee Press, 1983), 6. See Beckles, History of Barbados, 132; for an earlier period, see Tara Inniss, “From Slavery to Freedom: Children’s Health in Barbados, 1823–1838,” Slavery and Abolition 27, no. 2 (2006): 251–260. See, for example, Henry W. Lofty, compiler, Report on the Census of Barbados 1921 (Barbados: Advocate Co., 1921), 10, 11. National Archives (hereafter NA): Colonial Office (hereafter CO) 950/567, West India Royal Commission, Second Session held at Bridgetown, Barbados, January 18, 1939, 2. Barbados Department of Archives (hereafter BDA): John Hutson, “The HalfYearly Report of the Poor Law Inspector January–June 1910,” The Offi cial Gazette, November 2, 1914, 16. BDA: Hutson, “The Half-Yearly Report of the Poor Law Inspector, July– December 1907,” The Offi cial Gazette, October 11, 1909, 1719. See De Barros, “Improving the Standards of Motherhood.” BDA: John F. Haslam, Report of the Chief Medical Offi cer for the Year 1st April 1933 to 31st March 1934, 6. This description is derived from the West India Royal Commission Report and Sinckler’s 1914 The Barbados Handbook. Although separated by several decades, both generally agreed about the structure of Barbados government. See West India Royal Commission Report 1944–45 [Cmd. 6607] (House of Commons Parliamentary Papers Online, 2006), 55; see also E. Goulburn Sinckler, The Barbados Handbook (London, 1914), 39, 48, 177. See also Beckles, History of Barbados, 126. BDA: John Hutson, Annual Report of the Public Health Inspector, 1913, in Supplement to “Offi cial Gazette,” June 18, 1914, 3. Ibid.; Sinckler, Barbados Handbook, 39, 42.

114 Juanita De Barros 16. Anna Clark, The Struggle for the Breeches: Gender and the Making of the British Working Class (Berkeley: University of California Press, 1995), 187– 189; Derek Fraser, The Evolution of the British Welfare State: A History of Social Policy since the Industrial Revolution (New York: Palgrave Macmillan, 2003), 47–48, 97–101. 17. Richardson, Panama Money, 26–27, 74–75; Richard C. Carter, “The Almshouse Test: Deterring the Poor under the 1880 Poor Relief Act,” Journal of the Barbados Museum and Historical Society 41 (1993): 140–162; BDA: Report of Commission on Poor Relief. Bridgetown 1875–1877, Pam c72, 35, 44. See also Leonard P. Fletcher, “The Evolution of Poor Relief in Barbados, 1838–1900,” Journal of Caribbean History 26, no. 2 (1992): 170–209. 18. Clarke, “Half-Yearly Report of Poor Law Inspector, January–June, 1905,” 51, 55; NA: CO 28/306/6 no. 37510, Report of the Public Health Commission, Barbados, 1925–1926, 50. 19. BDA: The Ninth Annual Report of the Central Poor Law Board (1888), in Documents Read at the Meeting of Assembly of 4th June, 1889, 13. Millington, “Maternal Health Care,” 7. 20. Richardson, Panama Money, 26–27, 74. 21. Millington, “Maternal Health Care,” 5. 22. Ibid., 7. 23. See, for example, The Ninth Annual Report of the Central Poor Law Board (1888), 1. 24. BDA: John Hutson, “Barbados Poor Law Report January–December 1901,” The Offi cial Gazette, November 28, 1901, 1979; BDA: Third Annual Report of the Central Poor Law Board, in Documents Read at Meeting of Assembly of 29th May, 1883, 2. 25. BDA: J.B. Clarke, Report of the Poor Law Inspector for the Half-Year January–June 1905, in Documents Laid at Meeting of Assembly of 12th September, 1905, 50, 51. 26. Report of the Public Health Commission, Barbados, 1925–1926, 19. 27. Richardson, Panama Money, 26–27, 74–75; see also Carter, “Almshouse Test.” 28. Sinckler, Barbados Handbook, 74, 85. 29. Hutson briefly discusses his medical education in his memoir. BDA: John Hutson, Memories of a Long Life (Barbados, 1948), 35, 36. 30. BDA: “The Half-Yearly Report of the Poor Law Inspector, January–June, 1912,” 2. 31. BDA: Hutson, “Second Annual Report of the Public Health Inspector, 1914,” 3; John Hutson, “The Half-Yearly Report of the Poor Law Inspector, January–June, 1912,” srl.319, 2, 3. 32. Ibid. See also Richardson, Panama Money, 79. 33. Hutson, Second Annual Report of the Public Health Inspector, 1914, 3. Something of these sentiments can be seen in the report by the West Indian royal commission, struck to investigate the causes of labor unrest in the region in the 1930s. See West India Royal Commission Report 1944–45, 56, 57. 34. Gordon K. Lewis, The Growth of the Modern West Indies (New York: Modern Reader Paperbacks, 1968), 228. 35. Sinckler notes that both men studied in Edinburgh. See Sinckler, Barbados Handbook, 80, 81. 36. BDA: John Hutson, “The Half-Yearly Report of the Poor Law Inspector, January–June, 1909,” The Offi cial Gazette, October 1, 1914, 1526, 1537; Hutson, “The Half-Yearly Report of the Poor Law Inspector January–June 1910,” 1742. 37. Boyce, Report of the Census of Barbados, 1911, 14.

“A Laudable Experiment” 115 38. BDA: John Hutson, “The Half-Yearly Report of the Poor Law Inspector, January–June, 1909,” The Offi cial Gazette, October 1, 1914, 1526, 1537. 39. This discussion and its results are detailed in the following: BDA: Vestry Minutes, April 1, 1912, in St. George Vestry Minute Books, 1892–1929, BS 82; BDA: Minutes of St. George Vestry Sanitary Commissioners, April 1, 1912, in St. George Vestry Sanitary Commissioners Minute Books, 1907– 1959, BS 99; “The Half-Yearly Report of the Poor Law Inspector, January– June, 1912,” 3, 16, 17, 25. 40. See BDA: Huston, “The Half-Yearly Report of the Poor Law Inspector, January–June, 1912,” 17, 25, srl-319; BDA: Hutson, “The Half-Yearly Report of the Poor Law Inspector, July–December,” 16, 17, srl-319; BDA: Meeting of the Sanitary Commissioners, July 8, 1912, and Meeting of the Sanitary Commissioners, October 14, 1912, in St. George Vestry Sanitary Commissioners Minutes Books 1907–1959, BS 88. 41. BDA: Hutson, “The Half-Yearly Report of the Poor Law Inspector, January– June, 1912,” 17, 25; BDA: Minutes of St. George Vestry Sanitary Commissioners, October 14, 1912, in St. George Vestry Sanitary Commissioners Minute Books, 1907–1959, BS 88. 42. BDA: Vestry Minutes, March 3, 1913, in St. George Vestry Minute Books, 1892–1929, BS 82. 43. Ibid.; BDA: Minutes of St. George Vestry Sanitary Commissioners, April 14, 1913, in St. George Vestry Sanitary Commissioners Minute Books, 1907– 1959, BS 88. 44. BDA: Hutson, The Twelfth Annual Report of the Public Health Inspector, 1924, 4, 5; BDA: Hutson, Second Annual Report of the Public Health Inspector, 1914, 3. 45. Hutson, “Half-Yearly Report of the Poor Law Inspector, July–December, 1912,” 16. 46. Hutson, “The Half-Yearly Report of the Poor Law Inspector, January–June, 1912,” 3, 16, 17. 47. Hutson, “The Half-Yearly Report of the Poor Law Inspector January–June 1910,” 16. 48. BDA: Minutes of St. George Vestry Sanitary Commissioners, July 8, 1912, in St. George Vestry Sanitary Commissioners Minute Books, 1907–1959, BS. 49. Details about Burrowes’s work can be seen in the following: BDA: Minutes of St. George Vestry Sanitary Commissioners, July 8, 1912, in St. George Vestry Sanitary Commissioners Minute Books, 1907–1959, BS; BDA: “The Half-Yearly Report of the Poor Law Inspector, January–June, 1912,” 25. 50. The research conducted so far has not uncovered any additional identifying information about Burrowes. The details that have been located are from the following: Hutson, “The Half-Yearly Report of the Poor Law Inspector, July–December 1910,” 1803; BDA: “The Half-Yearly Report of the Poor Law Inspector, January–June, 1912,” 25. 51. Hutson, “The Half-Yearly Report of the Poor Law Inspector, January–June, 1912,” 3, 16, 17, 25; BDA: Minutes of St. George Vestry Sanitary Commissioners, July 8, 1912, in St. George Vestry Sanitary Commissioners Minute Books, 1907–1959, BS; BDA: Vestry Minutes, March 3, 1913, in St. George Vestry Minute Books, 1892–1929, BS 82. 52. See BDA: Hutson, “The Half-Yearly Report of the Poor Law Inspector, January–June 1914,” in Documents Laid at Meeting of Assembly of 29th October, 1915, 3; Hutson, BDA: “The Half-Yearly Report of the Poor Law Inspector, January–June 1913,” 3, srl-319. 53. Francis “Woodie” Blackman, Dame Nita: Caribbean Woman, World Citizen (Kingston: Ian Randle Publishers, 1995), 19. 54. BDA: Matron with a Love for Kids, Sunday Sun, May 17, 1984, 16.


Juanita De Barros

55. See the following: BDA: Huston, “The Half-yearly Report of the Poor Law Inspector, July to December 1907,” Offi cial Gazette, October 11, 1909, 1736, 1741 NA: CO 854/33; Francis “Woodie” Blackman, Dame Nita: Caribbean, World Citizen (Kingston: Ian Randle Publishers, 1995); BDA: “Matron with a Love for Kids,” Sunday Sun, May 17, 1984, 16: Pearl Ionic Gardener, “The Development of Nursing Education in English-Speaking Caribbean Islands” (PhD diss., Texas Tech University, 1993); Hermi Hyacinth Hewitt, Trailblazers in Nursing Education: A Caribbean Perspective, 1946–1986 (Kingston: Canoe Press, 2002). 56. Herni Hyacinth Hewitt, Trailblazers in Nursing Education: A Caribbean Perspective (Kingston: Canoe Press University of the West Indies, 2002), 8, 9; Gardner, “Development of Nursing Education,” 68; NA: CO 114/68, Report of the Surgeon General for the Year 1895–96 (Georgetown: C.K. Jardine, 1896), 7. 57. BDA: The Twelfth Annual Report of the Public Health Inspector, 1924, in Documents Laid at Meeting of Assembly of 21st July, 1925, 4. 58. BDA: “The Half-Yearly Report of the Poor Law Inspector, January–June 1901,” The Offi cial Gazette, November 28, 1901, 1981. 59. NA: CO 137/839/2, Protest. “Pursuant to the Notice of Protest given in Council on the Passing of the Third Reading of the Bill entitled, ‘A Law to Further Amend the Midwifery Law 1919,’ Jamaica no. 512; British Guiana, No. 5 of 1886, An Ordinance to Establish a Government Medical Service, and to enforce the Registration of Practitioners in Medicine or Surgery,” in The Laws of British Guiana (1803 to 1921), Volume III (London: Waterlow and Sons Limited, 1923), 40, 41, 43, 44. This is the (1900) amended version of this ordinance. 60. NA: CO 854/33, Charles D. Mosse, January 20, 1896 (encl. 4) in Circular dispatch, M.O. 11087, 2472, 6907/96, General, Chamberlain to All Crown Colonies, June 26, 1896; see De Barros, “Improving the Standards of Motherhood.” 61. BDA: John Haslam, Report of the Chief Medical Offi cer for the Period 1 January 1932 to 31 March 1933, in Documents Laid at Meeting of Assembly of 19 June 1934, 6. 62. BDA: Hutson, The Tenth Annual Report of the Public Health Inspector, 1922, in Documents Laid at Meeting of Assembly of 5th June, 1923, 11, 13; Report of the Public Health Commission, Barbados, 1925–1926, 49; BDA: James D. Alleyne, Annual Report of the Acting Chief Medical Offi cer for the Year 1936–7, in Documents Laid at Meeting of Assembly of 15th February 1938, 6, BDA; James D. Alleyne, Annual Report of the Acting Chief Medical Offi cer for the Year 1935–1936, 4. 63. NA: CO 950/567, General Medical Services of the Colony, 7, 8; NA: CO 950/567, West India Royal Commission, Second Session held at Bridgetown, Barbados, January 18, 1939, 5. 64. Hutson, Barbados Poor Law Report January–December 1901, 1901, 1918. 65. Hutson, “The Half-Yearly Report of the Poor Law Inspector, July–December 1903,” 315; Hutson, Second Annual Report of the Public Health Inspector, 1914, 21, 22. 66. Millington dates the establishment of the school to 1903, but Hutson suggests in a report in 1914 that it was established in 1902. He notes that the second course was offered in the fall of 1903. Millington, “Maternal Health Care,” 11, 12; BDA: Hutson, “The Half-Yearly Report of the Poor Law Inspector, July–December 1903,” The Official Gazette, May 16, 1904, 815; BDA: Hutson, Second Annual Report of the Public Health Inspector, 1914, 21, 22; General Medical Services of the Colony, 8; NA: CO 950/567, West India Royal

“A Laudable Experiment” 117


68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80.

Commission, Second Session held at Bridgetown, Barbados, January 18, 1939, 5. BDA: Hutson, “Half-Yearly Report of the Poor Law Inspector, July–December, 1903,” The Offi cial Gazette, May 16, 1904, 815. By 1914, the course was still three months in length. Hutson, Second Annual Report of the Public Health Inspector, 1914, 21, 22. BDA: Hutson, Barbados Poor Law Report, January–December, 1902, 2111. Hutson, Barbados Poor Law Report, January–December, 1902, 2116; BDA: Hutson, “The Half-Yearly Report of the Poor Law Inspector, July–December, 1903,” 803, 823, 825, 832. Hutson, Barbados Poor Law Report, January–December, 1902, 2116. BDA: Hutson, The Twelfth Annual Report of the Public Health Inspector, 1924, in Documents laid at Meeting of Assembly of 21st July, 1925, 4. Hutson, “The Half-Yearly Report of the Poor Law Inspector, July–December 1903,” 315. BDA: C.E. Gooding, The Fifth Annual Report of the Public Health Inspector 1917, in Documents Laid at the Meeting of Assembly, 7th May 1918, 24. BDA: Hutson, “The Half-Yearly Report of the Poor Law Inspector. July– December 1914,” 18. Hutson, Barbados Poor Law Report, January–December, 1902, 2116. Boyce, Report on the Census of Barbados, 1911, 69; Lofty, Report on the Census of Barbados 1921, 81. Report of the Public Health Commission, Barbados, 1925–1926, 50. Boyce, Report of the Census of Barbados, 1911, 23. Boyce, Report of the Census of Barbados, 1911, 13–14. See, for example, Clarke, “Half-Yearly Report of Poor Law Inspector, January–June, 1905,” 64; see also Hutson, “The Half-Yearly Report of the Poor Law Inspector July–December 1904,” 806; Hutson, “Half-Yearly Report of the Poor Law Inspector, July–December, 1903,” 832.


Burmese Health Officers in the Transformation of Public Health in Colonial Burma in the 1920s and 1930s Atsuko Naono

Scholars have identified various kinds of indigenous involvement in public health in colonial India, whether mobilized by colonial strategies to reduce administrative costs and staff shortages or the rise of nationalism and a national consciousness.1 Likewise, although fewer in number, recent studies have investigated the discourse of indigenous participation in the making of colonial public health in Southeast Asia.2 Yet we still require further examination into how subordinate medical staff, many of whom were indigenous, such as auxiliary doctors, sub-assistant surgeons, and “native” vaccinators, were mobilized and sometimes took leadership roles themselves in implementing colonial medical practices in the field during the late colonial period of the 1920s and 1930s. At that time, new forces, including the internationalization of health, economic depression, nationalist movements, and the rise of new media, were intersecting along the landscape of colonial public health. In Burma, part of British India until 1937, the ways in which the indigenous middle class became involved in promoting public health was somewhat similar to the broader pattern found in the subcontinent. As David Arnold explains, health and medicine were key parts of self-improvement and selfredefinition efforts by the Indian middle class. As part of this “Indian sense of self and nation,” they revisited their own medical system, differentiating it from Western medical science and internalized Western medicine on their own terms.3 In Burma, the indigenous middle class also mediated a balance between local medicine and Western medicine. But perhaps because of the smaller size of the indigenous middle class in Burma relative to that in India as well as the diverse nature of “traditional” Burmese medicine, the push for modernization was more awkward, slower, and was directed by a tiny group of Western-trained indigenous physicians and indigenous officers of international non-governmental organizations present in the colony. They cooperated with colonial administrators who attempted to train indigenous medical practitioners in the rudiments of Western medicine so that they could serve as cheap and effective medical staff in rural areas.4 Thus, they played an important role in attempting to induce the general Burmese population to accept Western medicine as part of everyday health practice.

Public Health in Colonial Burma in the 1920s and 1930s


Although European medical officers in Burma had begun to take steps in the direction of introducing the Burmese to the tenets of Western medicine prior to World War I, progress was slow and efforts were limited to writing a few pamphlets, training indigenous assistants, and setting up a medical museum in one ward of Rangoon General Hospital.5 With the end of World War I, it was no longer possible to ignore the shortcomings of the colonial medical effort. The devastation of the war generated new efforts to foster greater international communication and cooperation regarding public health. This proved embarrassing for some colonial regimes. For example, Mark Harrison argues that the health statistics collected and circulated by new international organizations such as the League of Nations made it possible to quantitatively compare and contrast the health conditions of countries and colonies. As a result, “health became an index of comparative development,” and a major gap was revealed between the touted benevolence of European rule and the realities of colonial neglect of indigenous health.6 Concerned about social and medical disparity, international organizations such as the League of Nations Health Organization and the Rockefeller Foundation broadened their transnational health activities. Some colonial governments such as India’s found this growing enthusiasm to improve popular health useful and encouraged cooperation with its own ongoing work. This chapter examines the intersection of the indigenization of public health propaganda and the collaboration between the colonial government and the Red Cross, one such international organization, in altering the landscape of colonial public health education in Burma.

THE BURMANIZATION OF PUBLIC HEALTH The Burmese themselves would play the leading role in effecting this intersection. In 1923, Burma was granted diarchy, a limited self-rule arrangement in which indigenous ministers were placed in control of some “transferred” ministries in the colony. Whereas the British were unwilling to transfer control of affairs vital to the security of the empire and the economy, they gladly handed over those activities related to the actual betterment of the indigenous population, such as public health and education.7 The transfer of the Ministry of Education, along with it public health activities, again concentrated the control of public health into the hands of Burmese officials and officers. In theory, the civil surgeons’ former responsibilities were formally transferred to a new Public Health Board created in 1922 on the eve of the transfer of powers to the ministry.8 Over the course of the 1920s, increasing numbers of Burmese accepted training in public health education and took over the burden in the districts from the remaining civil surgeons. One of the most important developments in the early 1920s was the emergence of a new space for indigenous involvement in colonial public health through the introduction of new health agencies. The new agencies


Atsuko Naono

included the Hygiene Publicity Bureau of the Department of Public Health (DPH) and the Burma Branch of the Indian Red Cross Society (hereafter Burmese Red Cross). The DPH was responsible for carrying out the government’s decision to promote sanitation, hygiene, and the prevention of other contagious diseases such as plague and cholera by 1920. In 1921, this included propaganda work for mass education in preventable diseases through the issuance of “pictorial posters and pamphlets.”9 When the demand for health propaganda rose, the DPH had to increase the number of trained health officers who would carry out health propaganda work. In 1923, a training school for Public Health Inspectors was opened. In the first year, eleven Burmese, three Anglo-Indians, and several Indian students, all nominated by district councils and municipalities, took the intensive ten-month course.10 One of the most important steps towards Burmanization taken by the DPH was the creation of the post of Hygiene Publicity Officer, the fi rst appointment to this post being on October 10, 1924. This was an attempt by the DPH to centralize its health propaganda work and to organize effective health education activities in the province. Local government required that the appointee had to be a Burman (the indigenous population of the country irrespective of ethnicity was known as Burmese, whereas the members of the largest ethnic group were known as Burman) with the expectation that this would aid in disseminating their message more widely and directly to the indigenous population. The duties of the First Hygiene Publicity Officer were as follows: (a) the preparation of all necessary Health Education material including type lectures, pamphlets, press articles, magic lantern slides, and cinema films; (b) [the] organization of special educative campaigns in the presence of epidemics; (c) the assistance of voluntary health education organizations such as the Popular Health Education Sub-committee of the Red Cross and the various Infant Welfare Societies.11 The Hygiene Publicity Officer’s duties included preparing health pamphlets, leaflets, lectures, and postcard instructions on several health subjects, including the ways to avoid contagious diseases.12 This was the fi rst time that the Burmese medical establishment focused so sharply on the preparation of health educational material under the leadership of a Burmese medical officer. In addition to compiling this educational material, the Burmese Hygiene Publicity Officer visited towns and villages where he gave lectures with lantern slides, showed health films, and distributed health pamphlets and posters. Each Hygiene Publicity Officer carried out intensive health propaganda work.13 Shwe Ge, the third Hygiene Publicity Officer, was particularly active. In 1928, he distributed over a million copies of the Bureau’s publications and 2,346,000 health pamphlets throughout the province. In addition to

Public Health in Colonial Burma in the 1920s and 1930s


this work, Shwe Ge still found the time to contribute health articles to such publications as the Headman’s Gazette. These efforts, led by a Burmese and carried out in the Burmese language, encouraged rural Burmese to set up local health societies in places such as Tavoy, Mergui, Magwe, Thayetmyo, Thaton, and Taikkyi. These indigenous rural health associations often collaborated with the Hygiene Publicity Officer in the promotion of health education, making rural Burmese active participants in the colony’s health activities.14 In some cases, the indigenous grassroots support granted to Burmese medical authorities proved crucial to the continuity of the health propaganda program in the colony. It is true that the official post of Hygiene Publicity Officer was abolished due to the financial crisis brought about by the World Trade Depression.15 Nevertheless, its responsibilities were assumed by subassistant surgeon U Tha Saing. More importantly, U Tha Saing was enabled to carry out the DPH’s health propaganda mainly because of the support of a voluntary work movement emerging from local Burmese health societies such as the Rural Reconstruction League, the Judson College Rural Uplift Society, and multiple youth improvement leagues.16 The work of the Hygiene Publicity Officer thus long outlived the government posting. The Indian Red Cross was also committed to recruiting from the indigenous population and employing indigenous leadership in keeping with its formal national identity. In 1919, the various Red Cross societies of the United States, Britain, France, Italy, and Japan joined together to form the International League of the Red Cross to promote health in peacetime and to develop international coordination of, amongst other things, public health propaganda. The founders of the International League of the Red Cross called for the formation of other “national” Red Cross organizations even at the colonial level. Although India remained a colony politically, when the Indian Red Cross Society was established in 1920 it was accorded the same status in the International League of the Red Cross as British Dominions, such as Australia and Canada. The Indian Red Cross emphasized its indigenous membership, which, by the end of the 1920s, would make up 96 percent of its eighty thousand members and the fact that it was “controlled in steadily increasing degrees by Indians . . . [and] spends all its income in India.”17 Following the model of county branches of the Red Cross in Britain, branches of the Indian Red Cross were organized at the provincial level in the next few years, including the Burma Branch in 1922.18 In 1925, the Burmese Red Cross divided itself into three sections: supplies and comforts; child welfare; and health propaganda. However, in 1927, it reformed itself into four sections: health education; child welfare; Junior Red Cross; and social hygiene.19 The Burmese Red Cross had also contributed a monthly sum of Rs 150 to the Hygiene Publicity Bureau to cover the expenses of distributing health propaganda leaflets, but discontinued this in 1929 when it found that the government merely merged

122 Atsuko Naono the sum into its general fi nances. Instead, it then contributed the same amount directly to the director of the DPH to employ an artist at the Hygiene Publicity Bureau. 20 The Burmese Red Cross’ three main goals were to promote health, prevent disease, and ease suffering among the indigenous population. “Popular health education” was one of its most important functions in the 1920s and through its collection of magic lantern slides, fi lms, pamphlets, and posters in the major Indian vernaculars, it directed health propaganda against the spread of smallpox and plague, as well as other major diseases. In Burma, there was close cooperation between the Burmese Red Cross and the provincial government. The governor of Burma served as its official president, and various colonial medical officers were frequently also officers of the Burmese Red Cross. Sustained by grants from the headquarters, investments, donations, and subscriptions, the Burmese Red Cross helped fund various health projects, sometimes through arrangements that divided the costs between the provincial government and the Burmese Red Cross. It is important to point out that the close knitting of personnel between colonial medical officers and the Burmese Red Cross may have obscured the notion of colonial public health that had thus far been demonstrated in the forceful medical interventions mostly at the time of the outbreak of contagious diseases such as smallpox and plague. The health propaganda and education efforts that were undertaken by these new agencies in order to improve popular health demonstrated a clear departure from the old style of coercive public health operations. Studies of the role of print literature in the dissemination of medical propaganda help to explain Westernization among educated classes in the indigenous population.21 Understanding how colonial medical establishments influenced multilingual or illiterate audiences, however, requires looking at other kinds of media. Lisa N. Trivedi’s recent study of the mobilization of visual aids in Gandhi’s Swadeshi campaign in India, for example, stresses the importance of films and illustrations as vehicles for the spread of nationalist ideas. According to Trivedi, historiography drawing upon Benedict Anderson’s idea of “imagined communities” views the rise of nationalism as contingent on the emergence of print capitalism and the growth of literacy. This model, Trivedi argues, is insufficient for explaining the rise of nationalism in a “multilingual and predominantly illiterate society” like that of colonial India.22 In such societies, one cannot underestimate the importance of visual media in transcending linguistic barriers and conveying propaganda across linguistic lines. Eric Stein, for example, has found that the Rockefeller Foundation’s hygiene fi lms illustrating hookworm prevention for assumed “scientifically and cinematically illiterate” Javanese audiences in the 1930s amounted to a “cinematic carnival.”23 Indigenous audiences reacted to the technician’s attempts to simplify Western medical concepts for easier

Public Health in Colonial Burma in the 1920s and 1930s


transmission to an audience perceived as “irrational” with laughter, accepting the fi lms as comical entertainment; nonetheless, they were influenced by the intended message in the process.24 We should not underestimate the effectiveness of this media in propagating Western medicine even among literate populations. Although the Burmese literacy rate was quite high compared to that of Indians, cinema nonetheless was just as effective as a tool for the dissemination of public health propaganda. The Burma DPH began to make use of the cinema for health education purposes in 1926 at a time when Burmese were becoming very enthusiastic about the new medium.25 The chief architect of this move was physician San Hla Aung, who replaced Tun Aung as Hygiene Publicity Officer.26 San Hla Aung immediately turned to the pioneer of medical education fi lms, the United States. There, health propaganda fi lms provided an ideal venue for many health agencies to educate the general public about necessary but complicated medical discoveries and issues, and encouraged them to adopt hygienic behavior and to seek out expert health advice.27 A major source of American health education fi lms were companies such as Metropolitan Life Insurance, who had recognized early the savings to their business that could be made in the long term by showing private individuals how they could take better care of their health. Also prominent in this effort were social welfare organizations emerging in 1920s America. San Hla Aung was thus able to tap into a rich reserve of American produced health education productions and in 1926 purchased such films as The War on Mosquitoes, Baby’s Bath and Toilet, Malaria, and Unhooking the Hookworm.28 Until he left his post on study leave in late August 1927, San Hla Aung oversaw the initial steps taken by the department in the localization of health education fi lms. In the U.S., health education films were a site of contention for several different interests, including medical doctors, the fi lm industry, and movie critics, who debated, as Martin Pernick has shown, the appropriateness of the production of the medical film in regards to its educational value versus aesthetic concerns and the implications for censorship. In the U.S., these health fi lm debates became a stimulus for dividing entertainment and educational and propaganda fi lms, the latter eventually excluded from regular theatre viewings.29 In Burma, there were additional concerns that foreign health fi lms would either be less entertaining or less meaningful for indigenous audiences. San Hla Aung thus led the department into the local production of Burmese health education fi lms. Encouragement for San Hla Aung’s project also came from the Indian Cinematograph Committee. In 1927, the committee expressed some alarm that India had not kept pace with the development of health education fi lms in the U.S. and Europe, where such fi lms had proved to be a success. The committee also repeated the calls made by the Imperial Conference the previous year to produce “films of sound educational merit” that would serve as instruments of propaganda within the Empire:

124 Atsuko Naono it will be found possible ultimately to evolve a universal harmonious propaganda policy for the whole country in certain subjects of the highest value for the moral and material welfare of its inhabitants. Secondly, there will be no dissipation or waste of resources, no duplication of effort and none of the inefficiency or narrowness of outlook which is the inevitable result of small and local operations . . . Above all, this propaganda work, apart from the quicker and more efficient achievement of its immediate objects, can be made into an instrument of untold value of harmonizing ideals, ideas, customs and practices all over the country. It can, in fact, be made into a nation-building force in the true sense of those words. 30 Further, the committee recommended that propaganda films reflect the peculiarity of each province so that they could raise strong local interests while simultaneously contributing to the sense of a broader, uniform India. According to the committee’s report: Suppose a cholera film is being prepared. Part of this fi lm would have no exclusive connection with Indian conditions, still less with any particular part of India. This part of the film would be . . . studio work which . . . would be done under the best conditions possible in this country and those parts of the film which had to be local and peculiar to Bengal, the Punjab or any other province, could be shot in the required localities, again under the best possible supervision. The result would be that each province desiring a cholera fi lm would get a film of propaganda value, technique, and effectiveness far greater than anything which could have been produced under provincial auspices and this, too, at a smaller cost than if it had been prepared locally [in the respective provinces].31 In 1927, the same year that the Indian Cinematograph Committee expressed its enthusiasm for the local production of educational films, the DPH in Burma, under San Hla Aung’s leadership, began its production of a film on cholera entitled The Village Well and shot it in a Burmese setting. According to the department’s report, “it has proved very popular and it is hoped to extend this branch of activity.”32 From 1927 to 1928, this film was shown twenty-six times to villagers throughout Burma.33 Connected to the application of new media was the establishment of the Harcourt Butler Institute of Public Health (hereafter Harcourt Butler Institute). In 1923, DPH Director E. Bisset asked local government to sanction the necessary expenditure for an establishment that would focus on teaching and publicity as well as on hygiene research, with the Harcourt Butler Institute being formally opened on January 14, 1927. The Institute provided lectures and demonstrations on the subject of public health and hygiene for the benefit of medical and science students from Rangoon University

Public Health in Colonial Burma in the 1920s and 1930s


and the Burma Government Medical School. The Institute’s other activities included the preparation of technical exhibits for the annual Health Week, the storage of Red Cross exhibits and other public health propaganda material, serving as a venue for health associations such as the Burmese Red Cross and the St. John’s Ambulance Association, and the demonstration of health fi lms and lectures on public health matters for the education of the general population.34

HEALTH WEEK One of the most influential avenues to promote health among the general population in Burma was Health Week. This increasingly popular event was organized collaboratively by the Burmese Red Cross and the DPH. The Burmese Red Cross’s Popular Health Education Sub-Committee had organized the fi rst Health Week exhibition in Rangoon in 1924, and this exhibition spread to other towns in the country, including Mandalay and Maymyo in the years that followed. The idea of Health Week was simple. It was meant to educate the population about how to be healthy and what could be done to prevent infection. However, what Health Week demonstrated to the general Burmese population went further than simple health hints. It provided Burmese with a new experience regarding health and created a new social space that made Burmese feel they were part of an international community of health. There were various sections and functions in Health Week. Many were technical exhibits prepared by the Harcourt Butler Institute, such as a display of different types of germs observed under the microscope, comparative models of sanitary and unsanitary latrines, and rubbish cart incinerators. There was even a display of a dirty dustbin with a stuffed crow perched on it and a dead rat by its side.35 Students of the Burma Government Medical School prepared a display of sanitary and unsanitary ways of living. There were also activities such as competitions of health essays and pamphlets for students.36 Each day during Health Week, Burmese pwes (plays), such as on “Good Health and Sanitation,” were staged at the exhibition. These were acted out by students from over twenty schools in 1930, and were directed specifically at children as a means of providing basic instruction in the principles of public health. Among the greatest draws of Health Week were the health fi lms in the Burmese language showing gratis at local cinemas (such as Rangoon’s Madan Theatre).37 Five thousand Rangoon school children attended one film alone in the 1929 Health Week.38 The colorful advertising of commercial medical technology that accompanied the exhibits prepared by the DPH, HBI, and the Burmese Red Cross provided another kind of spectacle. A listing of these displays provides an indication of the scale of exposure to Western notions of cleanliness and health, the prescribed ways to attain a “modern” standard of living, and the


Atsuko Naono

ideals of a new health consumerism. For example, a new Frigidaire refrigerator was displayed to show off Messrs. Watson & Son’s line of automatic refrigeration. Almata Milk Food products, including the Punkt Roller, a new way of treating obesity, 39 and the Punkt friction spray that was used to massage one’s head, as well as various medical soaps were displayed by Messrs. E.M. DeSouza & Co. Cow. Gate Milk Food distributed product samples and pamphlets for free, while the Glaxo exhibition run by Messrs. S. Oppenheimer & Sons, displayed Glaxo baby health care products such as “Ostomalt, Glaxo-ovo, Ostelin (liquid and tablet), and Glaxo Baby Soap.” The main attraction, however, was Glaxo’s mechanical doll that fed itself from a bowl of Glaxo foodstuffs.40 Both European and Burmese nurses staffed the Lever Brothers’s stall showing their soaps and other products. And the Nestle and Anglo-Swiss Condensed Milk Company displayed a mechanical cow in the Lactogen section as well as other products such as Milkmaid condensed milk, sterilized milk, and Danish butter. The New Zealand Co-operative Dairy Company (in the 1932 exhibition) displayed their Anchorian Baby Food, explaining to Burmese onlookers that it was “a purely New Zealand food, which contains natural sources of Vitamin A and D” as well as the Anchor Brand Butter.41 And fi nally the Burma Tube Well Company demonstrated the process of irrigating paddy fields and of draining swamp areas infested by mosquitoes. By including various consumer health products of international companies alongside the technical educational exhibits on hygiene and sanitation, Health Week provided a new experience to Burmese visitors. The popularity of such educational demonstrations and the promotion of specific brands of consumer goods resonate with the “commodification of hygiene” and the consumerism in the colonial world described in Timothy Burke’s examination of Zimbabwe.42 Perhaps also to the Burmese attendees, it may have seemed vaguely similar to the carnival nature of the traditional Burmese festival. By being exposed to these international health products which touted modern scientific value, Burmese may have felt that they were part of the international health community and the Health Week provided such a space. International contributors during Health Week, such as a “Dr. Okayama” in 1932, may have reinforced these feelings. Okayama, a Japanese medical doctor from the Tokyo Dental College, participated and demonstrated dental hygiene in addition to showing off the dental exhibits on loan from his college.43 The success of these efforts appears to have been largely due to the localization of new media. Rather than British colonial officers telling Burmese what to do in broken vernacular or through interpreters, indigenous health officers and nurses were now communicating health information to indigenous audiences in an idiom that the latter could understand. Although it is impossible to know precisely what Burmese thought about the health propaganda in the absence of direct data, indirect evidence suggests that Burmese audiences found such health activities and propaganda informative and

Public Health in Colonial Burma in the 1920s and 1930s


entertaining. The popularity of Rangoon Health Week among the Burmese residents of the city, for example, ensured that it became an annual event, with ever-expanding scope and length. Even with extended hours, reports indicate that it was continually overcrowded and that the exhibitors were kept very busy manning their stalls and displays throughout the week.44 Who were the Burmese attending Health Week and being exposed to Western notions of hygiene and sanitary living? A 1931 article criticizing the effect of Health Week indicated that medical elites involved in it overlooked “the very class of people for whom it is or should be primarily intended.”45 Indeed, the latter were entirely missing from the exhibits during Health Week. According to this critic: It is among the poorest of the community living in the slums of the city that the origin of most epidemics can be traced such as cholera, plague or typhoid fever. We do find a few—a very few indeed of such people present but the great majority of the visitors are people who are comparatively well to do who live in clean surroundings and who are sufficiently well educated enough to know that typhoid germs can be carried about in contaminated food or water, that malarial fever is caused by the bite of a particular mosquito and confers immunity against smallpox. These people live or try to live cleanly and can afford to do so; they can read and have an elementary knowledge of the spread of infectious diseases. Most of them are out to spend a pleasant afternoon . . . But the coolies who live ten to fifteen or more to a room in the slums, the street vendors of fruit and sweets, and the owners of road side eating stalls, are absent or nearly so. The main objects of the health exhibition are thus thwarted from the very start by its not attracting the people who are mostly in need of education and enlightenment on such matters.46 Charles Alexander Innes, the governor of Burma (1927–1932), in taking the opportunity of speaking at the next Health Week, responded rather weakly, even seemingly contradicting himself: A careful watch is kept on the people visiting the Exhibition and we are satisfied that it does attract many of the poorest classes. A visit to the Exhibition in the evening rather than afternoon of a day open to the general public will show that the crowds present are representatives of all classes including the very poorest, and even if it is mostly the middle classes that come, there is great value in getting them interested in public health matters. Knowledge percolates down as well as up, and moreover we want the support of the literate classes of Burma in all we do for public health in Burma.47 By the end of his statement, the governor indicated that the general absence of representatives of the bulk of Burma’s general population was no cause


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for concern. This probably meant that the Burmese middle class and Westerners, not the poorer classes, got together and consumed Health Weeks. The potential impact of the exhibition would have been less dramatic for two main reasons. First, the middle class had developed a familiarity with things Western such as the English language, Western products, Western medicine, and science. Even though the vernacular was also used in film productions, plays, and competitions held during Health Week, its utility for Burmese middle-class children and youth at this time is questionable. Some research even suggests that the Burmese middle class during the 1930s had been given English-language education and familiarized themselves in the Western way of things to the degree that they surprised some Japanese military officers who occupied Burma in 1942. One such officer serving in the education section of the army remembered that he was shocked when he found out that 60 percent of Burmese middle-class students claimed it was easier for them to write in English than in Burmese.48 Second, as international health organizations and commercial health companies defi ned the standards of modern public health, Burmese health officers put on shows that demonstrated how Health Weeks in Burma were just like those you could fi nd anywhere in the West. In fact, there are indications that the organizers were at least partly interested in winning competitions with other colonial capitals over who had the best Empire Health Week (Rangoon won the imperial trophy, the “Bostock Hill Memorial” Shield in 1935, just beating Lagos, Nigeria). 49 Whether these events were directed at middle-class Burmese or at Western observers, most Burmese lived in rural areas too far away to permit exposure to health propaganda at such events as Health Week. These limitations seem to have been missed by Burma’s chief government official, but not by the Burmese officers in the DPH. They realized that if they could not bring rural Burmese into the urban exhibitions, they would have to bring urban exhibitions to the rural areas, making use of new opportunities afforded by Burma’s extensive rail network.

THE HEALTH TRAIN Although new rural health associations were active in supporting the health educational efforts of the DPH, through the distribution of leaflets and the organization of events, they lacked the resources to help the DPH with new mass media. Moreover, whereas Burma did indeed have numerous cinemas, and these were growing in number, they were mainly concentrated in Burma’s two largest cities, Rangoon and Mandalay. Hauling projection equipment around the country was too time consuming and difficult and the DPH did not have the staff to make such an effort feasible. Health films and other public health media thus had a very limited reach in a largely rural colony.

Public Health in Colonial Burma in the 1920s and 1930s


The Burmese Red Cross and the DPH thus sought a means of taking health propaganda and their own recruitment efforts directly to Burmese outside of the major urban areas.50 An opportunity presented itself in 1930. In December 1929, Burma Railways had devoted a train, called the “Advertising Special,” to the purpose of taking the goods of several Rangoon companies around the country to make Burmese aware of their products and hopefully encourage sales. Burma Railways saw the experiment as a success and planned to run another “Advertising Special” in 1930. On this occasion, they suggested the Burmese Red Cross should include a carriage of their own as a kind of traveling health exhibition.51 The June 1930 meeting of the Burmese Red Cross voted to leave the issue of the railway demonstration car in the hands of government health authorities who would make the necessary arrangements with the DPH.52 The Burmese Red Cross saw this as an opportunity to recruit members from among the indigenous population. There were posters identifying the carriage with the “Red Cross Society Burma Branch,” including its peacock logo and the train included a Burmese Red Cross recruitment officer, “his duty being to get as many people as possible to join the society and help in the noble cause.”53 Despite its use for Red Cross recruitment, the same carriage also provided opportunities for the DPH. The number of DPH staff on board demonstrated the train’s superior carrying capacity relative to other modes of transport available at the time, affording a staff of three sub-assistant surgeons, two nurses, two clerks, and two manual laborers. More importantly, the carriage, put under the charge of Hygiene Publicity Officer Ba Kin, also served as a DPH propaganda vehicle. When the train was not rolling, the manual laborers attached to the train circulated DPH leaflets to interested Burmese along the route. The carriage included health-related charts, diagrams, and models of clean and dirty water, clean and dirty lying-in rooms, plague, leprosy, and malaria, all made in Burma. In addition to models designed by Burmese and “meant to appeal to the Burmese,” posters produced by sub-assistant surgeon U Tin covered the health train. His posters included one that expressed the issue of health through an example in Burmese idiom, a poster of Shin Baku, the god of health who was “free of ailments of any kind.”54 He was dressed as a monk, a figure of great moral authority in Burmese Buddhist society. Coupled to the Burmese Red Cross car was a cinema carriage enabling the DPH to hold daily screenings of its films.55 In other words, health staff would take the cinema and health fi lms to the rural Burmese. The health train left Rangoon on December 1, 1930, on the Rangoon– Mandalay and Rangoon–Moulmein lines. It visited twenty towns, attracting the interest of the rural population. It was reported that on average five thousand Burmese visited this attraction daily in addition to fifteen hundred people who watched health films every night until the train returned to Rangoon on December 23. The staff demonstrated the health models to the visitors with

130 Atsuko Naono the cooperation of local health officers, almost certainly Burmese, at every stop. It was so successful that the director of the DPH hoped to do this the following year and also to arrange a similar health education tour by boat.56 The health train was not unique to Burma. Various other colonies also ran health trains or motor vans carrying health models, depending upon the availability of rail or roads. Where there were no metaled roads, such as in the United Provinces (UP), country bullock carts were used to carry magic lanterns and slides as well as a few inexpensive models.57 Sanitary campaigns and health propaganda were even carried by health boats such as one in use in Siam from 1925, targeting over a million river and boat people on the Chaophraya River, and equipped with a cinematographic projector.58 Further, in India and Java, radio propaganda was also in use by the early 1930s in an effort to reach the rural population.59 The health train demonstrated how far the colonial medical establishment in Burma had come since the 1860s when state medical propaganda was limited to printed leaflets. In those days, the higher echelons of the colonial medical establishment had been very hesitant to see public health through Burmese eyes and to develop strategies to encourage voluntary acceptance of western medical treatment turning instead to the court and coercion. 60 In the 1920s however, the new Burmese-led medical establishment clearly found such an effort necessary and even primary in the struggle to promote public health.

CONCLUSION Two main developments intersected to change the face of colonial health operations in Burma in the 1920s and 1930s. First, the end of World War I brought a change in the ways that colonial regimes approached the challenges of health in their colonies. It was cheaper and easier, for example, to indigenize the colonial health administration. Moreover, it made health propaganda work more effective. This shift was also encouraged by new international organizations that pushed for national health awareness, even within colonies. The second development was the availability of a range of new mass media that made it possible for relatively small numbers of health personnel to reach rural, indigenous people. It is difficult to demonstrate conclusively that things would have been any different during the period without increasing local participation, but it seems very likely. The Burmese Hygiene Publicity Offi cer figured prominently in educational activities related to promoting public health procedures in the 1920s and 1930s to a degree not paralleled by any previous British medical officer in the colony. Indeed, it is difficult to see how a British officer in this period would have been able to carry out the translation, across languages and cultures, that was central to the Burmese Hygiene Publicity Officer’s health propaganda efforts.

Public Health in Colonial Burma in the 1920s and 1930s


In comparison to the prewar period, village headmen and other local indigenous officers began to cooperate more frequently with medical staff and used their personal influence to encourage the same cooperation among indigenous villagers.61 The new generation of colonial propaganda worked because Burmanization helped to make Western medicine part of the local medical landscape. It is true that middle-class Burmese probably directed the Health Weeks in the colonial capital, but the health trains (and Burmese health publicity officers) carried essentially the same materials into the interior where they did reach rural Burmese audiences. Health pamphlets and articles written in Burmese, posters that depicted medicine in Burmese idiom, magic lantern slides, lectures conducted in Burmese, and health films played out by Burmese actors and actresses played a major part in efforts to change the health attitudes and habits of Burmese towards Western medicine.

NOTES 1. See Mark Harrison, Public Health in British India: Anglo-Indian Preventive Medicine 1859–1914 (Cambridge: Cambridge University Press, 1994), 166–226; David Arnold, Colonizing the Body: State Medicine and Epidemic Disease in Nineteenth-Century India (Los Angeles: University of California Press, 1993), 284–288; Sunil Amrith, “Political Culture of Health in India: A Historical Perspective,” Economic and Political Weekly, January 13, 2007, 114–116; and Joseph S. Alter, “Gandhi’s Body, Gandhi’s Truth: Nonviolent and the Biomoral Imperative of Public Health,” Journal of Asian Studies 55, no. 2 (1996): 301–322. 2. Chie Ikeya demonstrates the ways in which Burmese mothers were mobilized to symbolize the “hygienic housewife” who was also modern and scientific through an examination of colonial education and consumer culture. Chie Ikeya, “The Scientific and Hygienic Housewife-and-Mother: Education, Consumption and the Discourse of Domesticity,” Journal of Burma Studies 14 (2010): 59–89. Laurence Monnais examines colonial discourse on the Vietnamization of medical personnel including the creation of “auxiliary doctors” (médicines auxiliaries) and “nurse vaccinators” in French Vietnam. Laurence Monnais, “‘Modern Medicine’ in French Colonial Vietnam: From the Importation of a Model to its Nativisation,” in The Development of Modern Medicine in Non-Western Countries: Historical Perspectives, ed. Hormoz Ebrahimnejad, 127–159 (London and New York: Routledge, 2009). 3. Arnold, Colonizing the Body, 241. 4. As in other colonies in British Asia, for colonial authorities in Rangoon, issues of administrative expense, revenue collection, and political control figured more prominently on the scale of colonial concerns than did the betterment of Burmese lives. 5. Supplement to the British Medical Journal, April 30, 1910, 189–190; Atsuko Naono, State of Vaccination: The Fight against Smallpox in Colonial Burma (Himayatnagar, Hyderabad: Orient BlackSwan, 2009), 110–113, 157–161. 6. Mark Harrison, Disease and the Modern World, 1500 to the Present Day (Cambridge: Polity Press, 2005), 145. See also the introduction to Sunil S. Amrith, Decolonizing International Health: India and Southeast Asia, 1930–65 (Hampshire and New York: Palgrave Macmillan, 2006).


Atsuko Naono

7. Michael W. Charney, A History of Modern Burma (Cambridge: Cambridge University Press, 2008), 33–38. 8. Naono, State of Vaccination, 162–163. In practice, however, this change was not immediate. Limited indigenous participation was possible because of the emergence of an urbanized Burmese middle class by the late 1910s, strengthened by Burmese appointments to posts vacated by British officers sent to the Western front during the war, and this class saw the extension of Western medicine as essential to the betterment of the Burmese nation. However, the employment aspirations of members of this class usually focused on law and administration and only a relative few Burmese trained as Western doctors. There was thus initially a paucity of experienced indigenous medical personnel. Indeed, in some districts, the Public Health Board continued to rely upon the services of the local civil surgeon to carry out public health works for some time. 9. Report of the Public Health Administration of Burma for the Year 1921, 4. 10. This course included instruction in Elementary Chemistry, Physics, Anatomy, Physiology, Hygiene and Sanitation, Surveying, Routine Duties of a Public Health Inspector, and Vaccination. Report on the Public Health Administration of Burma for the Year 1923, 39–40. 11. Report on the Public Health Administration of Burma for the year 1924, 32. 12. Ibid. 13. For example, the Hygiene Publicity Officer visited twenty-two towns and villages in 1926 and in 1929, he visited twenty-seven towns and nineteen villages, gave lectures to 56,950 people, and showed health films 125 times. Report on the Public Health Administration of Burma for the Year 1926, 32–33; Report on the Public Health Administration of Burma for the Year 1929, 28. 14. Report on the Public Health Administration of Burma for the Year 1928, 33. 15. Kirtsy Walker, “Historical Perspectives on Economic Crises and Health,” Historical Journal 53, no. 2 (2010): 489. 16. Report on the Public Health Administration of Burma for the Year 1937, 50–51. 17. Offi cial Report of the Proceedings of the Empire Red Cross Conference, Held in London May 19–23, 1930 (London: British Red Cross Society, 1930), 100. 18. Statement Exhibiting the Moral and Material Progress and Condition of India during the Year 1919, 124. 19. Rangoon Gazette Weekly Budget, March 24, 1930, 2; December 29, 1930, 9. 20. Rangoon Gazette Weekly Budget, March 10, 1930, 9. 21. Niels Brimnes, for example, draws attention to the use of multilingual publications in the early vaccination campaign in the Madras Presidency. Niels Brimnes, “Variolation, Vaccination and Popular Resistance in Early Colonial South India,” Medical History 48, no. 2 (2004): 199–228. 22. Lisa N. Trivedi, “Visually Mapping the ‘Nation’: Swadeshi Politics in Nationalist India, 1920–1930,” Journal of Asian Studies 62, no. 1 (2003): 12. 23. Eric A. Stein, “Colonial Theatre of Proof: Representation and Laughter in 1930s Rockefeller Foundation Hygiene Cinema in Java,” Health and History 8, no. 2 (2006): 35. 24. Ibid., 14–44. 25. The number of cinemas in Burma increased from twenty-seven in 1921 to eighty in 1927. The fi rst local production company was opened in 1914 and between 1921 and 1931, fi fty other Burmese fi lm companies were established. Most fi lms, however, would remain foreign imports. Between 1930 and 1932, for example, whereas 188 fi lms shown in Burma were local productions,

Public Health in Colonial Burma in the 1920s and 1930s

26. 27.

28. 29. 30. 31. 32. 33. 34. 35. 36.

37. 38. 39.

40. 41. 42. 43. 44. 45. 46. 47. 48.


over thirty-five hundred fi lms were imported from other countries, 2,482 of them from the U.S. alone. Burma Legislative Council, 12 Aug 1933, 172–3; Tekatho Minwaethan, “Burmese Movie in Retrospect,” Guardian 16, no. 9 (1969): 45; Mann Aung Thein, “Film for People’s Sake,” Forward 6, no. 24 (1968): 8; Report of the Indian Cinematograph Committee 1927–28, India Office Public and Judicial File, L/PJ/6/1747, India Office Records, British Library, London; Emma Larkin, “The Self-Conscious Censor: Censorship in Burma under the British, 1900–1939,” Journal of Burma Studies 8 (2003): 72–73. Report on the Public Health Administration of Burma for the Year 1926, 32. Martin S. Pernick, The Black Stork: Eugenics and the Death of “Defective” Babies in American Medicine and Motion Pictures since 1915 (New York and Oxford: Oxford University Press, 1996), 119. Also, see the utilization of health propaganda fi lms in Africa in Timothy Burke, Lifebuoy Men, Lux Women (London: Leicester University Press, 1996), 53–54, 141–142. Report on the Public Health Administration of Burma for the Year 1926, 32. Pernick, Black Stork, 124. Report of the Indian Cinematograph Committee 1927–28, OIOC/L/ PJ/6/1747, 97. Ibid. Report on the Public Health Administration of Burma for the Year 1927, 33. Report on the Public Health Administration of Burma for the Year 1928, 33. First Annual Report of the Harcourt Butler Institute of Public Health, Rangoon, for the Year 1926, 1; Annual Report of the Harcourt Butler Institute of Public Health, Rangoon, for the Year 1935, 2. Rangoon Gazette Weekly Budget, February 18, 1929, 10. The Burmese Red Cross organized the “essay and pamphlets” competition among students from English, Anglo-Vernacular, and Vernacular schools. This competition became a popular form of propaganda with participating schools increasing from eighty-one in 1933 to 527 in 1936. Report on the Public Health Administration of Burma for the Year 1925, 29–30; Report on the Public Health Administration of Burma for the Year 1932, 55; Report on the Public Health Administration of Burma for the Year 1936, 55. Rangoon Gazette Weekly Budget, February 3, 1930, 15–16. Rangoon Gazette Weekly Budget, February 18, 1929, 16. This roller, like other mechanical devices of the time, was of dubious value. Yoni Freedhoff, “From Plunger to Punkt-Roller: A Century of Weight-Loss Quackery,” Canadian Medical Association Journal 180, no. 4 (2009): 432–433. Rangoon Gazette Weekly Budget, February 15, 1932, 20. Ibid. Burke states “the hegemonic promotion of manners, hygiene, and appearance was increasingly expressed in terms of products and ad slogans” (Lifebuoy Men, Lux Women, 149–150). Rangoon Gazette Weekly Budget, February 15, 1932, 19. Report on the Public Health Administration of Burma for the Year 1925, 29–30. Rangoon Gazette Weekly Budget, January 26, 1931, 8. Ibid. Rangoon Gazette Weekly Budget, February 2, 1931, 18. Takeshima Yoshinari, “Nihon Senryoki no Biruma ni okeru ‘Biruma-ka’ seisaku, The Burmanization Policy under the Japanese Occupation in Burma,” Kyoto Kyoiku Daigaku Kiyou 110 (2007): 33.

134 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61.

Atsuko Naono British Medical Journal, May 30, 1936, 1127. Rangoon Gazette Weekly Budget, March 10, 1930, 9; December 29, 1930, 8. Rangoon Gazette Weekly Budget, December 8, 1930, iii. Rangoon Gazette Weekly Budget, June 16, 1930, 30. Rangoon Gazette Weekly Budget, December 8, 1930, 10. Ibid. Ibid., 3, 10. Shin Baku is also the name of a medical plant in Burmese. Report on the Public Health Administration of Burma for the Year 1930, 46. League of Nations Health Organization, Intergovernmental Conference of Far-Eastern Countries on Rural Hygiene. Preparatory Papers (Geneva: League of Nations, 1937), 3.6. The Executive Committee of the Eighth Congress of the Far Eastern Association of Tropical Medicine, Siam: General and Medical Features (Bangkok: Bangkok Times Press, 1930), 190–192. League of Nations Health Organization, Intergovernmental Conference of Far-Eastern Countries, 3.3. Atsuko Naono, “‘Vaccination Propaganda,’ The Politics of Communicating Colonial Medicine in Nineteenth Century Burma,” SOAS Bulletin of Burma Research 4, no. 1 (2006), 34–44. Notes and Statistics on Vaccination in Burma for 1923–24, 4.


Mantsemei, Interpreters, and the Successful Eradication of Plague The 1908 Plague Epidemic in Colonial Accra Ryan Johnson

When Accra, the capital of the Gold Coast (Ghana), was declared infected with plague on January 11, 1908, the colonial state was neither prepared nor equipped to handle such a deadly and disruptive disease. The epidemic was part of the third plague pandemic, which had emerged in 1894 killing over twelve million in India alone.1 Although the exact source of the epidemic in Accra was never determined, it was more than likely linked to global shipping and trading networks. Prior to the outbreak in 1908, the only known epidemic of plague in West Africa occurred in Grand Bassam in 1899.2 Therefore, when plague struck Accra, both colonial officials and local inhabitants had little knowledge of the disease. In addition, the Gold Coast’s public health infrastructure was suffering from budgetary constraints and various structural problems.3 To make matters worse, members of the recently formed West African Medical Staff (WAMS), especially those serving in the Gold Coast, were protesting overall conditions of service. Therefore, when Accra was declared infected with plague, the Colonial Office (CO) and the colonial government were rightly concerned that it might spread throughout the entire colony. Nonetheless, despite their concerns, the epidemic was dealt with in a relatively quick and efficient manner, with the total number of deaths confined to three hundred West African men, women, and children, of which 156 occurred in Accra.4 Although this was still a terrible toll, arguably the number afflicted could have been far worse. This chapter investigates the successful response to the epidemic, and asks how an inexperienced, ill-equipped, and underprepared colonial government eradicated plague in Accra with relatively little trouble. One way to answer this question is to assess the actions taken by both the imperial and colonial state. Discussed further later, the acting governor, Herbert Bryan, took several initial measures that proved crucial to halting the spread of the disease. The CO, on the advice of Patrick Manson, the “father” of modern tropical medicine and medical advisor to the CO, deployed the respected plague fighter William J.R. Simpson. Accompanying Simpson was J.H. Harran, a medical officer from the East Africa Protectorate with plague experience, and several tons of specialized equipment.


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Within a few months of Simpson’s arrival, the worst of the epidemic had passed. And when the plague was fi nally eradicated in October 1908, the work of Simpson, Western medical technology, and the measures taken by the imperial and colonial state received the majority of praise. Although not discounting the importance of Simpson, medical equipment, and the imperial and colonial state, this chapter argues that the eradication of plague in Accra was only possible with the assistance of the city’s local rulers and Western-educated interpreters; who, along with the desire to restore health to their city, held individual political and fi nancial motivations for assisting colonial officials. Accra’s rulers, or mantsemei—literally “fathers of the town”—were vital to the recruitment and organization of labor required to carry out plague fighting measures, such as rat brigades, destruction of infected dwellings, and the efficient operation of land cordons. One mantse in particular, Alata born Kojo Ababio IV (referred to hereafter as Kojo Ababio), went to great lengths to ensure that his followers cooperated with colonial officials; and, as we will see, he had his own economic and political reasons for doing so. In addition to the mantsemei, this chapter investigates local interpreters, specifically the example of Asere-born physician Benjamin William Quartey-Papafio. The interpretive work of Quartey-Papafio was crucial to stopping the spread of the disease by mediating discussions between colonial officials and local rulers, as well as ensuring posters and other notices were properly translated into the local vernacular. Whereas Kojo Ababio and many of the other mantsemei—such as Daniel Philip Hammond, mantse of Asere, and Taki Obili, the Ga mantse—spoke English, many influential members of their communities did not.5 Therefore, the mantsemei, like colonial officials, relied on individuals such as Quartey-Papafio to bridge linguistic and cultural barriers. Overall, this chapter demonstrates that without the assistance of local leaders such as Kojo Ababio, the workers he organized, and interpreters such as Quartey-Papafio, it would have been difficult, if not impossible, for a distant CO and a thinly stretched colonial administration to implement and carry out extensive plague-fighting measures. Taken together, the agency of local rulers and interpreters in Accra during the epidemic is further testimony to the importance of intermediaries and subordinates in implementing public health measures throughout the empire. Without their assistance, it is doubtful the colonial state could have eradicated plague as quickly and effectively as it did, which was vital for maintaining the already tenuous grasp on control in the region, both politically and economically. Before exploring the epidemic, this chapter provides a brief review of Western public health initiatives in the Gold Coast and Accra, and the problems faced by the medical services prior to the outbreak of plague. This is followed by an overview of Accra’s social and political hierarchy, and the tensions that existed between competing political groups at the time of the epidemic. Next, the chapter examines the epidemic, and the measures

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taken by the colonial government and Simpson. Finally, the agency of Kojo Ababio and the interpretive work of Quartey-Papafio are assessed relative to local struggles over land and power.

PUBLIC HEALTH IN THE GOLD COAST AND ACCRA Prior to formal British colonization, a long dialogue existed between West Africans and Europeans, especially in relation to exploration, commerce, and the slave trade. The most infamous region, the “Gold Coast,” acquired its name through the rich gold deposits mined by the Akan people. 6 From the sixteenth century onwards, the Gold Coast attracted Portuguese, Dutch, Danish, Brandenburg, and British merchants who set up a vast network of trading forts and castles along the coast, with West Africans playing key roles in commercial transactions. After increasing British political involvement from the Bonds of 1844, West Africans fi lled important government administrative posts. David Kimble notes that when the Crown resumed control in 1844, it maintained the merchant practice of employing West Africans, and that “it was not regarded as anything out of the ordinary that a number of Africans . . . were appointed to key official posts.”7 For example, West African James Bannerman accepted the post of Civil Commandant at Christiansborg in 1850, and was appointed lieutenant governor of the Gold Coast later that year. 8 In addition to fi lling top administrative posts, there was an army of West African clerks, tax collectors, and attorneys. And despite increasing racism and exclusion towards the end of the nineteenth century, West Africans, in all capacities, continued the vital work of running the colony until Ghanaian independence in 1957. This aspect of colonial rule in the Gold Coast applied no less to the realm of public health. More than any other region in tropical Africa, British West Africa is perhaps best known for its many talented and Western-trained physicians.9 Whereas mercantile fi rms, missionary societies, and military posts afforded some training in Western medicine and public health, it was after Parliament set up a scholarship scheme in 1853 that West Africans were afforded greater participation in public health matters. By the mid-nineteenth century Western medical consensus held that West Africans were immune to many of the diseases laying waste to British troops, traders, government officials, and missionaries. As a result, Deputy Secretary of War Benjamin Hawes introduced a scholarship to recruit “suitable” West Africans to study medicine in Britain, and thereafter serve as army medical officers in West Africa. The War Office looked to Freetown, Sierra Leone and the Church Missionary Society (CMS) Grammar School to provide candidates; and in 1855 three men, Samuel Campbell, William Broughton Davies, and James Beale Horton—later adding the title “Africanus” when registering for medical school at Edinburgh—were chosen to attain the degree of MD. Horton is perhaps the best-known West African


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physician during this period; despite racism and setbacks, he was promoted to the head of the West African Army Medical Services in 1879, as well as publishing several influential medical and political tracts.10 Other prominent physicians that emerged from what Adell Patton Jr. has described as the Sierra Leone “nexus,” include Nathaniel King (1847–1884), Obadiah Johnson (1849–1920), and John Farrell Easmon (1856–1900).11 Nathaniel King, like Horton, had benefited from connections with the CMS and graduated from Kings College and the University of Edinburgh.12 Yoruba physician Obadiah Johnson had also attended Kings College, and like his predecessors won several prizes and distinctions. John Farrell Easmon, another exceptionally talented physician born in Freetown, had studied at University College, London, and received his MD in Brussels with distinction. After graduation, Easmon accepted a post in the Gold Coast Medical Service in c. 1885; and in 1893 was promoted to chief medical officer. During this time Easmon also contributed to the research and study of tropical diseases, and is credited with coining the term “blackwater” fever in 1884.13 There are several more examples of highly qualified and talented West African physicians, such as Benjamin William Quartey-Papafio, discussed further later. In addition, there was a growing cadre of assistants and aides engaged in efforts to improve public health throughout the Gold Coast and British West Africa. In this case, although Britain’s West African colonies were generally characterized by poor sanitation and health at the end of the nineteenth century—conditions largely created by an invasive British colonialism and commerce—there was a definite trend of increasing West African participation to address these problems. Nonetheless, at the start of the twentieth century, it was maintained by the imperial and colonial state that previously “competent” West African physicians, despite a history of excellence in the practice of Western medicine and public health, were neither “competent” nor capable of becoming so in the future given supposed inherent racial qualities. Such racist rhetoric, spouted as much for economic motivations as inherent cultural constructions of racial difference, was made manifest with the formation of the WAMS in 1902.14 The new service amalgamated the six previously independent medical departments of the Gambia, Sierra Leone, the Gold Coast, Lagos, Southern Nigeria, and Northern Nigeria. The service was explicitly racist, declaring itself open to candidates of European parentage only. The formation of the WAMS as an “all-white institution” was the outcome of several converging factors, including the rise of the “new,” or Mansonian tropical medicine;15 the establishment of schools of tropical medicine in London and Liverpool;16 and Unionist policies of “constructive” imperialism initiated by then secretary of state for the colonies Joseph Chamberlain.17 The new tropical medicine, its concomitant schools, and the WAMS were all part of Conservative ambitions to cultivate the economic potential of West Africa. And perhaps more than any other region of

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Britain’s tropical empire, the West African colonies were considered vital for staving off the aggressive economic and imperial advances of Germany, the United States, and Russia.18 For this reason, British West Africa, especially the Gold Coast and Accra, had witnessed a substantial rise in the European population.19 The maintenance of this population’s health was considered of primary importance if the colony was going to prosper; however, given the region’s poor health reputation, the recruitment of white European medical officers continued to pose difficulties. To resolve this problem, pay and overall conditions of service were improved with the formation of the WAMS, including the stifling of competition from African and Indian physicians for private practice. In addition, members of the WAMS received three months paid training to gain the certificate in tropical medicine at the London School of Tropical Medicine. By staffing the WAMS with white European medical officers, conversant in the principles of modern tropical medicine, the CO hoped that Britain’s West African possessions would rapidly evolve into healthier and more profitable regions of the empire. However, after only two years of its formation, medical officers began issuing complaints and criticisms in the medical press, protesting the amount of non-medical duties, low pay, tensions with senior government officials, and the difficulty they faced in carrying out daily public health measures. Furthermore, the colony suffered from an overall lack of equipment and facilities. Such problems, alongside short tours of service—twelve months on and five months off —had fostered a sense of fatalism and self-interest among medical officers. Rather than focusing on their government medical work, the majority spent considerable time and energy maintaining lucrative contracts with private companies operating along the coast, and searching for other sources of income. Overall, the barring of West African participation in official public health matters, and the lack of equipment and motivation amongst government medical officers, meant that the colony was ill prepared to deal with the emergence of a serious epidemic disease. And when Primary Medical Officer Patrick J. Garland declared Accra infected with plague on January 11, 1908, the situation looked bleak indeed.

ACCRA POLITICS AND HIERARCHY This section is indebted to the scholarship of John Parker; who, in his book Making the Town: Ga State and Society in Early Colonial Accra, has made it possible to understand the complex political hierarchy in Accra prior to and during the epidemic. According to Parker, at the time of the epidemic, the city was divided into seven districts, or akutsei, with each district headed by a local leader, or mantse, symbolized by the stool, or sie; and all of the city’s mantsemei were subordinate to Accra’s paramount


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ruler, the Ga mantse.20 The political structure and hierarchy of Accra’s districts reflect the differing historical alliances forged with European powers. After the Ganyo kron—“true” Ga—were forced to relocate during the Akwamu conquest of the late seventeenth century, they moved into the region that is now modern-day Accra and established links with the Dutch traders already established there.21 So strong was their alliance they named their new settlement Kinka, the Ga translation for Dutch—later renamed Ussher Town after the British took control in 1868.22 The main population of Ussher Town was divided into the Asere and Abola districts; and given the Abola district was home to Accra’s paramount ruler, the Ga mantse, the seat of Ga political power and influence was located in Ussher Town.23 In the decades following the initial settlement of Accra, three more districts, Alata, Sempe, and Akanmaji, emerged to the west of Ussher Town. The rise of the Alata district in particular was outcome of the Ga tradition of incorporating outsiders.24 The Alata and Akanmaji quarters were largely populated by refugees and freed slaves attached to English trading forts. And after falling out with the Abola and Asere, the Sempe—a less powerful faction of the “true” Ga—joined the Alata and Akanmaji, with the region becoming collectively known as Nleshi, or “English” Accra, renamed James Town in 1868.25 The rise of James Town reflects Accra’s history as a merchant and trading city. For example, the founder of James Town, Wetse Kojo, was an ex-slave and servant of the Royal African Company that rose through the ranks of Accra’s political hierarchy given his keen business sense and negotiating skills.26 However, he was an outsider, not descended from the “true” Ga, so could never acquire more political influence than the Ussher Town mantsemei, and especially not the Ga mantse.27 This fact, along with Ussher Town’s and James Town’s differing European allegiances, led to increasing tensions between the two quarters in the decades prior to the epidemic. For instance, Wetse Kojo, more familiar with the British than his rivals in Ussher Town, took advantage of their rule to enhance Alata political and economic power. His successors continued this trend, with hostilities coming to a head in 1880 after a court case concerning land rights, Solomon v. Noy, was decided in favor of the Alata, leading to outright civil war by 1884.28 Throughout the rest of the decade confl ict continued; and when the enterprising Kojo Ababio was installed as mantse of Alata in 1892, he pushed for even further political and economic control. In a demonstration of his resolve, Kojo Ababio, during a ceremony at Christiansborg Castle in front of the governor, declared, “I am not one of King Tackie’s chiefs, I am King of James Town. James Town is an English Town and Ussher Town is a Dutch Town, and English people can’t serve Dutch people.”29 Such confidence derived from his close relationship with the British, who recognized Kojo Ababio as a “modernizer.”30 He was Western educated, spoke fluent English, and established good communication with officials. He also proved to be an effective organizer of labor for several colonial projects,

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such as the Sekondi-Kumasi railway, and built several primary schools that emphasized the English language and values.31 By 1907, tensions between James Town and Ussher Town had once again come to a head over land. In addition, Ussher Town leaders had called into question Kojo Ababio’s assumed status as mantse of James Town, declaring that Anege Akwei, the recently appointed mantse of the Sempe, was the true ruler of James Town. The land dispute of 1907, known as the “Harbour Blockyard Case,” revolved around Kojo Ababio’s ambition to wrestle control of land away from the Sempe in order to establish port facilities. To make matters more complicated, much of the land was near a lagoon. Lagoons are sacred to the Ga, as they are home to the goddess Koole, “the sacred guardian and ‘owner’ of Accra and all Ga lands.”32 Therefore, by 1907, Ussher Town leaders, irritated by Kojo Ababio’s continued lack of respect for the established hierarchy, launched a legal attack. 33 During the Harbour Blockyard Case, the influential Alata lawyer Thomas Hutton Mills represented Kojo Ababio, with the prominent Asere lawyer, Arthur Boi Quartey-Papafio, representing the Ussher Town mantsemei and Anege Akwei. After an articulate testimony by Kojo Ababio, the British-run courts, somewhat aware of his position in Accra’s political hierarchy—which was below Akwei—upheld his status as the mantse of James Town. 34 Emboldened by this victory and obvious British backing, Kojo Ababio set his sights on the remaining land surrounding the lagoon; and when the epidemic hit Accra, he was quick to seize the opportunity that it presented to do so.

THE 1908 PLAGUE EPIDEMIC When Garland fi rst alerted Bryan on January 6, 1908 of “an outbreak of some suspicious disease,” Bryan’s fi rst action was to alert the commissioner of police, who in turn dispatched several local detectives to obtain further information.35 After three days of performing post mortems on recent victims and blood tests on rats, Garland was uncertain if the disease in question was plague. Garland, like many of the medical officers serving in Accra at the time, had little experience diagnosing and treating plague. He also noted how “natives neither reported cases of illness nor death. I afterwards learnt that the native fetish doctors and herbalists had been attending cases and that they charged a fee of £1 . . . hence the natives gave the name ‘one pound’ to this disease.”36 On January 10, however, Garland, after he had managed to pull together the required laboratory equipment and a medical officer with bacteriological knowledge, was able to confidently diagnose the “one pound” disease as plague. The worst hit quarter was James Town, particularly the Alata and Akanmaji districts, both of which were controlled by Kojo Ababio. The death toll, at the time of the city being declared infected with plague, was


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estimated at around ten. However, it was more than likely much higher given large numbers of rats had died in and around the government house and stable yard as early as August 1907. Furthermore, local men and women, out of government distrust, had concealed early cases of illness and death.37 Before announcing that Accra was infected with plague, Bryan, “with a view of getting in closer touch with the natives,” had authorized the employment of former government medical officer, and the fi rst Ghanaian to earn the degree of MD, Benjamin William Quartey-Papafio, the older brother of Asere lawyer Arthur Boi Quartey-Papafio.38 Bryan also established isolation camps; a separate burial ground for infected bodies; the closure of all schools; ordered the rat poison, “Ratin”; and offered employees of European mercantile fi rms accommodation in the newly built lunatic asylum. His next move was to appoint a plague committee composed of Garland (or the most senior medical officer present), the district commissioner of Accra, the commissioner of Police, the secretary for Native Affairs, the attorney general, and Quartey-Papafio. In a move demonstrating the importance Bryan attached to “getting in closer touch with the natives,” it was declared that Quartey-Papafio “shall have power in the event of any vacancy arising from the incapacity, illness, or otherwise of any of their members, to appoint such person, either temporarily or permanently, to fi ll such vacancy.”39 Bryan’s last step, and perhaps his most important, was to call a meeting with the mantsemei of James Town and Ussher Town, as well as leaders of the Mohammedan community. At the meeting, Bryan requested the mantsemei’s “assistance in men and materials,” and reminded them that “this was a matter of life and death; a matter in which their fetish priests could not help them, but in which qualified doctors, both European and native, must be consulted, and their orders implicitly obeyed.”40 For those that could not speak English, Bryan called upon Quartey-Papafio to translate the proceedings, encouraging the mantsemei “to beat the ‘gong-gong’ immediately, and to expound to their people the urgent necessity of complying with the rules.”41 After Bryan fi nished his address, Garland proceeded, “in simple language,” to describe the symptoms of the disease, which were also “translated into the vernacular” by Quartey-Papafio.42 Although paternalistic in tone and content, Bryan’s description of his efforts reveals awareness of the need to gain the support and cooperation of the mantsemei. Bryan noted, “After the Chiefs had returned to the town they at once complied with my directions . . . assembling their people, and explaining to them what they had heard.”43 The results were immediate, as teams of “scavengers” filled rubbish bins, engaged in rat destruction, and continually cleared and burned refuse throughout the night. The CO on the other hand, following Bryan’s telegram of January 11, fi rst stuttered, only leaping into action on the insistence of Manson. Two days after Bryan’s contacting the CO, the Liverpool Chamber of Commerce and the Liverpool School of Tropical Medicine had contacted the colonial

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secretary, the Earl of Elgin, to offer their services and dispatch tropical practitioners Rubert Boyce, William Prout, and Arthur Evans. The CO rebuffed the offer, stating that the outbreak appeared minor and did not warrant their involvement. The very next day, however, Manson sent an urgent telegram to Reginald Antrobus, the assistant undersecretary of state who dealt with all matters concerning Britain’s West African colonies. In the telegram, Manson impressed upon him: [T]hese are very grave telegrams from Accra. Plague in West Africa is a new thing, and no one can say how it will behave under negro conditions. I should think that if it got to Sierra Leone it would wipe it out for a time. The medial officers in West Africa have no experience of the disease. Don’t you think it would be a wise to send Professor Simpson out at once with full powers . . . Prompt action, anyhow, is indicated, for if the disease gets a good hold it would be impossible to stop it.44 In an about-face, and reflecting the growing hostility between the CO and the Liverpool Chamber of Commerce, and the London and Liverpool schools of tropical medicine, Elgin, acting on the advice of Manson, immediately approved the dispatch of Simpson. At the time of the epidemic, Glaswegian-born Simpson was professor of hygiene at King’s College and lecturer at the London School of Tropical Medicine.45 His reputation as a plague fighter had been built in Calcutta where he served as health officer.46 Such was his renown that he commanded £250 a month while working in Accra; a substantial sum considering the average medical officer was on an annual salary of £550. As noted earlier, accompanying Simpson on his journey to Accra was J.H. Harran, a medical officer who had gained experience with plague in East Africa. Simpson had also requested the CO supply him with the latest plague-fighting technology, including a Clayton H disinfecting machine; a Clayton handdisinfecting machine; two tons of sulfur; five thousand doses of Haff kine’s prophylactic; one thousand doses of Yersin’s serum; two thousand doses of rat virus; thirty syringes; and an oil immersion microscope and other laboratory equipment.47 Following the decision to send Simpson, a series of correspondence between Elgin and Bryan ensued. Elgin, informing Bryan of Simpson’s dispatch, stated that, “He will have control over the situation and I am sure he will receive every assistance from medical staff.”48 Bryan was less than enthusiastic. He reassured Elgin that the “outbreak of plague appears to be well under control, departure of Professor Simpson should be deferred.”49 Elgin stood fi rm, noting that “even if there were no more cases . . . I am still of the opinion that his experience would be very useful for advising as to precautions against plague and as to general sanitary conditions.”50 Bryan conceded, and accepted Simpson’s departure, but the exchange

144 Ryan Johnson demonstrates the mounting tensions between the metropolitan “expert” and the colonial “man on the spot.”51 Simpson arrived in Accra on February 2, along with Harran, and was immediately appointed president of the public health committee established by Bryan. In the fi rst of two reports, Simpson acknowledged the important work of the government, stating that Bryan “took [several] steps to combat the epidemic and prevent its spread,” and “that these measures have been attended with success, the shortness of the duration of the epidemic, and the comparatively small number of cases and deaths that have occurred, sufficiently testify.”52 He also acknowledged the quick evacuation of James Town, discussed further later, and the work of Kojo Ababio, “who through a very trying period has done everything that was asked of him.”53 However, the most important measures, according to Simpson, were those implemented upon his arrival, including the fumigation and inspection of cargo, establishing a properly equipped laboratory, constructing a land cordon, and the inoculation of some thirty-five thousand inhabitants with Haff kine’s prophylactic.54 Simpson noted how the inoculation became so popular “people actually struggled and fought with one another to be among the fi rst to be done,” and that he was “inclined to think . . . the inoculations did more than any other measure to save the situation.”55 Next Simpson praised the enforcement of an extensive land cordon, which “no person was allowed to pass through . . . without a passport bearing the impress of his or her thumb mark and . . . stating that the bearer had been inoculated at least a week prior to the date of such passport.”56 Simpson went on to state that the popularity of Haff kine’s anti-plague vaccine was a small victory over supposed African “ignorance” and “superstition.” He also made it clear in his report that the vaccine did not result in “a single accident or ill effect,” and that this “happy result was due to the great care . . . with which the medical officers performed the duty.”57 Simpson continued his support of the vaccine by noting that, “The protective effect of the inoculations even where the pneumonic plague prevailed appeared to be very marked,” and that “the arrest of the disease in localities and villages after all the inhabitants were inoculated was frequently observed.”58 Simpson’s enthusiasm for the Haff kine’s injection, whose efficacy was dubious at best, stemmed from his friendship with Waldermar Haff kine, who, in Simpson’s opinion, had been treated unfairly after the vaccine was linked to nineteen deaths in the Punjab in 1902. 59 Furthermore, rather than being a testament to the growing faith in the “white man’s medicine,” the vaccine’s popularity in Accra was due to the fact that many local men and women traveled long distances for work and food, which was made extremely difficult without the injection and passport. Under pressure to resume shipping and trading lines, 60 Simpson and colonial authorities had announced on May 5, 1908, that Accra and the Gold Coast were free from plague, with the colonial secretary, by this time Lord Crewe, writing to the recently returned Governor John Rodger, “It

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gives me much pleasure to be able to congratulate you and your medical staff and other officers with Professor Simpson on successful suppression of plague epidemic.”61 However, less than a month later, cases of pneumonic plague surfaced in Accra. This second outbreak of plague lasted less than a month, and according to Simpson, “It was easier to deal with . . . because every link in the chain of infection was ascertained, and measures of precision on a large scale were put into operation which checked and controlled the outbreak.”62 Simpson continued, “the rapidity with which the plague machinery had been . . . set in motion reflected great credit on the Medical, Public, Works, and Police staff.”63 Much to his dismay, cases of pneumonic plague emerged in July. However, given pneumonic plague kills its victims much more rapidly than the bubonic version, and in conjunction with Simpson’s, by then, well-oiled plague-fighting machine, the disease rapidly burned itself out, with the plague fi nally eradicated in October 1908. As this account suggests, much of the praise for the eradication of the disease was attributed to the agency of Bryan, Simpson, their medical staff, and the use of medical technology such as Haff kine’s prophylactic. Whereas both Bryan and Simpson mentioned the efforts of non-medical officials, and the work of Kojo Ababio and Quartey-Papafio, their actions were deemed secondary to the work of medical officers and plague-fighting technology. However, a closer investigation of the sources suggests that the cooperation of Kojo Ababio and the other mantsemei, along with the interpretive work of Quartey-Papafio, was central to the successful eradication of plague.

INTERMEDIARIES, SUBORDINATES, AND THE SUCCESSFUL ERADICATION OF PLAGUE After Bryan had addressed the mantsemei at the meeting on January 11, he noted, “The Head Chief of Accra and the Chief of James Town were asked to supply labour, which they did,” and that “the natives worked willingly.”64 As noted earlier, hundreds of laborers were recruited to carry out rat destruction, refuse collection, and later, a land cordon and the destruction of infected dwellings. When James Town was identified as the worst hit quarter of the city, Bryan informed Elgin, “it will be necessary to eject a considerable number of people in James Town from their houses, which must be pulled down. The quarter is hopelessly congested and insanitary.”65 And once again, “The Ga Manche and Manche of James Town were asked to supply labor for the purpose of carrying it away and destroying it, which they did.”66 When Kojo Ababio was made aware of the government’s decision, he was quick to negotiate the terms and location of the evacuation. He informed the public health committee “that the people would do as they were asked . . . and requested that the exact area [of evacuation] might be pointed out.”67 Bryan, visiting Kojo Ababio on the land west of the Korle


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Gono lagoon, stated, “the Chief informed me that his people were anxious to evacuate their quarter . . . and to settle permanently on the land in question, which is stool property, provided they had the support of the Government.”68 Bryan “assured the Chief that he and his people would be encouraged to found a new town, and promised that a surveyor should be sent to lay out the new site.”69 Shortly after the evacuation to the land in question was announced, trouble developed between Kojo Ababio and the Sempe mantse, Anege Akwei. As noted earlier, during the Harbour Courtyard case in 1907, Akwei and the leaders of Ussher Town contested Kojo Ababio’s status as mantse of James Town and his right to land surrounding the lagoon. Bryan informed Elgin that when the evacuation was announced, “there was trouble between the Alata and Sempe people over the evacuation,” and that officials had “paid a friendly visit . . . to Anege Akwei . . . and strongly urged on him the desirability of ready compliance with the committee’s request, and of dropping all private feuds.”70 Nonetheless, tensions escalated at another meeting of the mantsemei, this time to discuss the evacuation of Ussher Town into a stretch of less desirable land. After much discussion, and when the better location of the Harbour Works Quarry was selected, “the evacuation of large parts of Ussher Town . . . was agreed.”71 However, “certain complaints were brought forward . . . and the general attitude of the [Ussher Town] Chiefs and people seemed to be one of friendly distrust.”72 When the mantsemei of Ussher Town were told to evacuate under the threat of force, Kojo Ababio continued to move his people into stool property; however, “on reassembly they proved in a still more hostile mood, and were very noisy in their demonstrations of protest.”73 Such was their anger over the government’s decision to allow Kojo Ababio to evacuate onto the land in question, that “[o]n the termination of the meeting there was considerable noise, and one or two stones were thrown at Dr. Garland and Mr. Church [District Commissioner of Accra], but the arrival of a body of police quelled the disturbance.”74 Months after the evacuation, the people of Ussher Town were still seething with discontent over Kojo Ababio’s brash move into Korle Gono. So much so that they descended upon the new settlement in protest; and according to the commissioner of police, there occurred “a dispute between James Town and Ussher Town as to some land beyond Korle Gono, and a . . . threatened disturbance on Easter Monday, when over 190 Ussher Town people started to visit the James Town evacuation camp, but were stopped by the police.”75 Rather than acknowledge the anger of the people of Ussher Town as the result of long-standing political feuds over land rights, especially after the assault on Garland and Church, colonial officials portrayed their opposition to plague measures as “ignorance” and “superstition.” According to Bryan, “the incidence shows that we cannot depend altogether on persuasion to carry out essential measures to protect the natives against their ignorance and the superstitious advice of their fetish priests.”76 Ussher Town leaders were also

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consistently framed as “backward” by the British (undoubtedly related to the fact that the Ussher Town mantsemei were more accustomed to dealing with the Dutch); and, according to one report, the evacuation, “cannot be said to have been an unqualified success . . . The chiefs and people, from the commencement, seemed lukewarm . . . and progress was consequently very slow . . . forty-one people from the Asere quarter were with difficulty induced to go out to the camp . . . but they quickly vanished.”77 Bryan commented that “if the Ga Manche had loyally cooperated with the Government . . . the plague would have been stamped out in Ussher Town, as it was in James Town.”78 Bryan, by criticizing the Ga mantse and the Ussher Town leaders, was purposely contrasting their actions and demeanor with that of Kojo Ababio. However, he was also acknowledging that the successful eradication of the disease depended upon their cooperation. While the Ussher Town leaders were throwing up opposition to government measures, Kojo Ababio was busy ensuring that the Alata were following the government’s orders, and continued to move into the land west of the lagoon. According to the minutes of the public health committee: The Manche stated that many of the people were desirous of taking up their residence there permanently and asked that a Government surveyor might be appointed to lay out streets for the township . . . the people at the settlement had evidently accommodated themselves to their new surroundings, two licensed houses had been opened, and there appeared to be no shortage of food supplies, and no distress.79 In addition to gaining new land, Kojo Ababio and the people of James Town received considerable praise from the government. For example, the public health committee expressed: [T]heir appreciation of the loyal behavior of Manche Kojo Ababio, of James Town . . . and people of the Alata and Akumaje quarters . . .When the evacuation was agreed to, the Manche set the example by going out at once in person, to Korley Gono, on the far side of the lagoon . . . There can be no doubt that this timely action on the part of the Manche and his people was a most important factor in the arrest of the disease.80 Furthermore, the public health committee declared they were: unanimously of the opinion that Manche Kojo Ababio and the people of evacuated areas of James Town were deserving of special commendation for their loyal co-operation in preventing the spread of disease . . . the voluntary exile of James Town people has subjected them to considerable hardships . . . The committee are of the opinion that their uncomplaining loyalty merits substantial recognition at the hands of


Ryan Johnson the colonial government, and suggest that such recognition should, if possible, take the form of erecting better houses.81

Bryan believed that the money would be a good investment because “[t]he chief of James Town is a man of considerable intelligence, and I feel sure from several conversations I have had with him and his elders that they will take pains to see that suitable houses are built.”82 In the case of Kojo Ababio, it was further decided to provide him with £450 worth of materials to fi nish erecting a house; a substantial sum that made it possible for him to erect a palatial dwelling. Another influential individual working tirelessly behind the scenes, not only to eradicate the plague, but also to calm tensions between the government and the Ussher Town leaders, was Quartey-Papafio. From the start, Quartey-Papafio was the primary interpreter for the public health committee, especially when it came to working with the people of Ussher Town. For instance, during the meeting with the mantsemei, “Dr. Papafio reviewed the situation in the vernacular and explained the method of inoculation, which appeared to have a reassuring effect.”83 And when it was “decided to invite the Ga Manche and Ussher Town Chiefs and elders to a meeting . . . to acquaint them with the provisions of the Infectious Disease Bill . . . Dr. Papafio undertook to personally notify the Manche.”84 As the last example demonstrates, besides translating all notices and ordinances into the local vernacular, Quartey-Papafio was the primary mediator between the colonial state and the hostile Ussher Town leaders. According to the public health committee minutes, “The President [Simpson] asked Dr. Papafio to warn the Ga Manche of the serious consequences which might be entailed by failure to keep his promises to the Government.”85 Quartey-Papafio was born and raised in the Asere district, and he and his family were prominent members of the community; and his younger brother, as noted earlier, was the primary council for the Ussher Town leaders. The Quartey-Papafio family were part owners of Accra’s primary newspaper, the Gold Coast Chronicle, and belonged to a wealthy educated elite in Accra that, while still holding allegiances to their ethnic group, often challenged the authority of its leaders. And when the plague struck, Quartey-Papafio would have worked hard to convince Ussher Town leaders to comply with the government’s measures in the same manner as Kojo Ababio. Being on the public health committee, Quartey-Papafio was well placed to influence plague policy, and aware of the image that the government held of the Ussher Town leaders as backwards and traditional, opposed to the modernizing Kojo Ababio. Whereas there is no direct evidence to demonstrate that Quartey-Papafio convinced the Ga mantse, Taki Obili, to follow government ordinances, the Ussher Town leaders, after initial hostility, did become increasingly cooperative as the epidemic wore on. There is some evidence that Quartey-Papafio was looking out for their best interest at the public health committee meetings. For example, “Dr. Papafio . . . suggested that compulsory evacuation

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should be confined only to those compounds where a case of plague had actually occurred.”86 In this case, his suggestion would ensure that much of Ussher Town would not require evacuation. Although this partial evacuation of Ussher Town did not happen, the government never aggressively enforced it, suggesting that Quartey-Papafio was in a position to influence policy and decisions that the government made during the course of the epidemic.

CONCLUSION After Accra and surrounding villages were declared infected with plague, several important shipping and trading networks were disrupted, along with the local economy. The imperial and colonial state were under immense pressure to restore order, and although the CO dispatched metropolitan medical “experts” and the latest medical technology, this chapter has argued that the plague was only brought under control after Kojo Ababio and Quartey-Papafio were able to organize labor and calm long-standing political tensions. The examples of QuarteyPapafio and Ababio further reveal the centrality of local intermediaries and interpreters; and how, often, the success of public health policy was contingent on their work. In addition, as this chapter has demonstrated, both men were propelled by diff erent economic and political motivations when it came to engaging with the colonial state and public health policy. This leads to an important insight that is often overlooked in scholarship focusing on public health in former British colonies: local political and economic structures often had a great impact on shaping the type of policy that was implemented and how it was put into practice. Rather than focusing simply on local resistance to public health measures, or portraying local communities monolithically, it is necessary for historians of colonial medicine, in all cases where possible, to understand the complex local political, economic, and social contexts they study, and the impact they might have on the scope and practice of public health policy. Furthermore, in order to successfully assess the impact these factors may have on public health policy and practice, it is necessary to explore the agency of intermediary and subordinate agents. Rather than simply framing them as willing collaborators or adamant resistors, it is important to situate them in relation to local political and economic tensions that might be influencing their actions. Perhaps more importantly, it is necessary to investigate possible individual motivations that influence their decision to engage with colonial offi cials. This approach illuminates how local rulers and other intermediaries used the state to expand and consolidate their spheres of influence. In other words, they used the colonial state for their own ends.


Ryan Johnson

NOTES 1. Myron Echenberg, Plague Ports: The Global Urban Impact of Bubonic Plague between 1894 and 1901 (New York: New York University Press, 2007). 2. William J.R. Simpson, Report on Plague in the Gold Coast in 1908 (London: J.A. Churchill, 1909), 2. 3. Ryan Johnson, “The West African Medical Staff and the Administration of Imperial Tropical Medicine,” Journal of Imperial and Commonwealth History 38, no. 3 (2010): 419–439. 4. The disease spread along the coast, hitting villages such as Ninyano, Brewa, and Anamaboe. The cooperation of local rulers and inhabitants in these regions, in some respects, mirrors that of Accra. However, given space limitations, only Accra is investigated in this chapter. William J.R. Simpson, Sanitary Matters in Various West African Colonies and the Outbreak of Plague in the Gold Coast (London: Darling and Son, 1909), 4–5. 5. John Parker, Making the Town: Ga State and Society in Early Colonial Accra (Oxford: James Currey, 2000), 139–141. 6. Harvey M. Feinberg, West Africans and Europeans in West Africa: Elminans and Dutchman on the Gold Coast during the Eighteenth-Century (Philadelphia: American Philosophical Society, 1989), 27. 7. David Kimble, A Political History of Ghana (Oxford: Oxford University Press, 1965), 65. 8. Ibid. 9. See Adeloya Adeloye, African Pioneers of Modern Medicine: Nigerian Doctors of the Nineteenth-Century (Ibadan: University Press Limited, 1985); and Adell Patton Jr., Physicians, Colonial Racism, and Diaspora in West Africa (Gainesville: University of Florida Press, 1996). For a biography of James “Africanus” Beale Horton, see Christopher Fyfe, Africanus Horton: West African Scientist and Patriot (Oxford: Oxford University Press, 1972). For a history of Ghanaian physicians and the medical profession in Ghana, see Stephen Addae, Evolution of Modern Medicine in a Developing Country: Ghana, 1880–1960 (Durham, NC: Durham Academic Press, 1997). For an excellent review of early African doctors in South Africa, see Anne Digby, “Early Black Doctors in South Africa,” Journal of African History 46 (2005): 427–454. And for East Africa, see John Iliffe, East African Doctors: A History of the Modern Profession (Cambridge, Cambridge University Press, 1998). 10. James A.B. Horton, The Medical Topography of the West Coast of Africa (London, 1859); James A.B. Horton, Geological Constitution of Ahanta, Gold Coast (Freetown, 1862); James A.B. Horton, Political Economy of British Western Africa (London, 1865); James A.B. Horton, Physical and Medical Climate and Meteorology of the West Coast of Africa (London, 1867); James A.B. Horton, Guinea Worm, or Dracunculus (London, 1868); James A.B. Horton, Letters on the Political Condition of the Gold Coast (London, 1870); and James A.B. Horton, The Diseases of Tropical Climates and Their Treatment (London, 1874). 11. Patton, Physicians, 59–93. 12. Adeloye, African Pioneers, 48–54. 13. Patton, Physicians, 101–103. 14. Ryan Johnson, “‘An All White Institution’: Defending Private Practice and the Formation of the West African Medical Staff,” Medical History 54, no. 2 (2010): 237–254.

Mantsemei, Interpreters, and the Successful Eradication of Plague


15. See Michael Worboys, “The Emergence of Tropical Medicine: A Study in the Establishment of a Scientific Specialty,” in Perspectives on Western Medicine and the Experience of Scientific Disciplines, ed. G. Lemaine, 75–98 (The Hague: Mouton, 1976); Michael Worboys, “Manson, Ross, and Colonial Medical Policy,” in Disease, Medicine, and Empire: Perspectives on Western Medicine and the Experience of European Expansion, ed. Roy MacLeod and Milton Lewis, 21–37 (London: Routledge, 1988); John Farley, Bilharzia: A History of Imperial Tropical Medicine (Cambridge: Cambridge University Press, 1992), 13–30; Michael Worboys, “Tropical Disease,” in Companion Encyclopaedia of Western Medicine, ed. W.F. Bynum and Roy Porter, 512–536 (London, Routledge, 1993); Michael Worboys, “Germs, Malaria, and the Invention of Mansonian Tropical Medicine: From ‘Diseases in the Tropics’ to ‘Tropical Disease,’” in Warm Climates and Western Medicine, ed. David Arnold, 181–207 (Amsterdam: Rodopi, 1996); and Douglas M. Haynes, Imperial Medicine: Patrick Manson and the Conquest of Tropical Disease (Philadelphia: University of Pennsylvania Press, 2001). In relation to West Africa, see Raymond E. Dumett, “The Campaign against Malaria and the Expansion of Scientific Medical and Sanitary Services in British West Africa, 1898–1910,” African Historical Studies 1, no. 2 (1968): 153–197. 16. Helen Power, Tropical Medicine in the Twentieth Century: A History of the Liverpool School of Tropical Medicine, 1898–1990 (London: Kegan Paul International, 1999), 11–46; and Lise Wilkinson and Anne Hardy, Prevention and Cure: The London School of Hygiene & Tropical Medicine, A 20 th Century Quest for Global Public Health (London: Kegan Paul International, 2001), 1–21. 17. See Robert V. Kubicek, The Administration of Imperialism: Joseph Chamberlain at the Colonial Office (Durham, NC: Duke University Press, 1969); Richard M. Kesner, Economic Control and Colonial Development: Crown Colony Management in the Age of Joseph Chamberlain (Oxford: Clio Press, 1981); Michael Haviden and David Meredith, Colonialism and Development: Britain and Its Tropical Colonies, 1850–1960 (London: Routledge, 1993), 70–114. 18. See E.H.H. Green, The Crisis of Conservatism: The Politics, Economics, and Ideology of the British Conservative Party, 1880–1914 (London: Routledge, 1995), 59–77; and Duncan Bell, The Idea of Greater Britain: Empire and the Future World Order, 1860–1900 (Princeton, NJ: Princeton University Press, 2007). 19. Johnson, “An All White Institution,” 251. 20. Parker, Making the Town, 10–21. 21. Ibid. 22. Ibid., 8–10. For convenience, Ussher Town will refer to Kinka for the rest of the chapter. 23. Ibid., 10–21. Osu, or Danish Accra, to the east of Ussher Town and James Town, is the third major quarter of Accra. 24. Ibid., 8–10. 25. Ibid. For convenience, James Town will refer to Nleshi for the rest of the chapter. 26. Ibid.,13–14. 27. Ibid., 59–61. 28. Ibid., 128–133. 29. Ibid., 140. 30. Ibid., 140–141. 31. Ibid. 32. Ibid., 175.


Ryan Johnson

33. Ibid., 207. 34. Ibid., 176–177. 35. National Archives (hereafter NA): Colonial Office (hereafter CO)/879/98, The Acting Governor to the Secretary of State, February 7, 1908, Africa (West) No. 905, Gold Coast: Correspondence Relating to the Outbreak of Plague on the Gold Coast, April 1909, 22. 36. Simpson, Report on the Plague in the Gold Coast, 15. 37. Ibid., 23. 38. Ibid. In addition to Quartey-Papafio, Bryan recruited Frederick Victor Nayanka-Bruce (referred to only as “Bruce”), who received his MD at the University of Edinburgh. Nayanka-Bruce was also part of the student group at Edinburgh that had protested the foundation to the WAMS as a “whiteonly” service. 39. NA: CO/879/98, At a meeting of the Executive Council, January 11, 1908, 28. 40. Ibid. 41. Ibid. 42. Ibid. 43. Ibid. 44. Later, the CO attempted to recruit physicians with plague experience by placing advertisements in the British Medical Journal, the Lancet, the Times, the Glasgow Herald, and the Scotsman. Glasgow was targeted in particular because of an outbreak of plague that struck the city in 1900. NA: CO/879/98, Sir Patrick Manson to Mr. Antrobus, January 14, 1908, 4. 45. R.A. Baker and R.A. Bayliss, “William John Ritchie Simpson (1855–1931): Public Health and Tropical Medicine,” Medical History 31, no. 4 (1987): 450–465. 46. Simpson had also been part of the effort to halt a plague epidemic in Cape Town in 1901. However, as Myron Echenberg points out, Simpson’s understanding of plague, despite claiming to be an expert, was very poor. In fact, Simpson rejected Simond’s rat flea theory for several years after it was generally accepted, only conceding that infection might occur through rat droppings coming in contact with bare feet. Echenberg, Plague Ports, 279–283. 47. NA: CO/879/98, Professor W.J. Simpson to CO, January 16, 1908, 6–7. 48. NA: CO/879/98, The Secretary of State to the Acting Governor, January 14, 1908, 6–7. 49. NA: CO/879/98, The Acting Governor to the Secretary of State, January 16, 1908, 9. 50. NA: CO/879/98, The Secretary of State to the Acting Governor, January 17, 1908, 10. 51. See Joseph M. Hodge, Triumph of the Expert: Agrarian Doctrines of Development and the Legacy of British Colonialism (Columbus: Ohio University Press, 2007). 52. Simpson, Report on Plague in the Gold Coast, 3. 53. Ibid., 7. 54. Simpson, Sanitary Matters in Various West African Colonies, 3. 55. Simpson, Report on Plague in the Gold Coast, 7. 56. Ibid. 57. Simpson, Sanitary Matters in Various West African Colonies, 5. 58. Ibid. 59. B.J. Hawgood, “Waldemar Mordecai Haff kine, CIE (1860–1930): Prophylactic Vaccination against Cholera and Bubonic Plague in British India,” Journal of Medical Biography 15, no. 1 (2007): 9–19.

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60. Throughout the duration of the epidemic considerable debate concerning ship quarantine practices was sparked after the governor of Sierra Leone had, on his own accord, declared all of the Gold Coast infected with plague. Questions emerged over “modern” quarantine measures that revolved around the Paris Sanitary Convention of 1903, and what constituted appropriate practice during an outbreak of plague. Whereas this chapter does not have the space to consider these debates, they are important to investigate in relation to the rise of global uniformity and standardization of “modern” measures to combat epidemic disease. 61. NA: CO/879/98, Secretary of State to the Governor, May 5, 1908, 108. 62. Simpson, Report on Plague in the Gold Coast, 11. 63. NA: CO/879/98, The Governor to the Secretary of State, July 20, 1908, 167. 64. NA: CO/879/98, The Acting Governor to the Secretary of State, February 7, 1908, 29. 65. Ibid. 66. NA: CO/879/98, The Acting Governor to the Secretary of State, February 22,1908, 47. 67. Ibid., 49. 68. Ibid., 46. 69. Ibid. 70. Ibid., 50. 71. NA: CO/879/98, The Acting Governor to the Secretary of State, March 21, 1908, 98. 72. Ibid. 73. Ibid. 74. Ibid. 75. NA: CO/879/98, The Governor to the Secretary of State, May 15, 1908, 142. 76. NA: CO/879/98, The Governor to the Secretary of State, March 20, 1908, 79. 77. NA: CO/879/98, The Governor to the Secretary of State, July 20, 1908, 170. 78. NA: CO/879/98, The Governor to the Secretary of State, July 25, 1908, 189. 79. NA: CO/879/98, The Acting Governor to the Secretary of State, February 22, 1908, 51. 80. NA: CO/879/98, The Governor to the Secretary of State, July 20, 1908, 171. 81. Ibid. 82. NA: CO/879/98, The Acting Governor to the Secretary of State, March 30, 1908, 109. 83. NA: CO/879/98, The Acting Governor to the Secretary of State, February 22, 1908, 50. 84. NA: CO/879/98, The Governor to the Secretary of State, April 18, 1908, 124. 85. NA: CO/879/98, The Acting Governor to the Secretary of State, March 30, 1908, 103. 86. NA: CO/879/98, The Acting Governor to the Secretary of State, March 16, 1908, 88.


Medical Training, African Auxiliaries, and Social Healing in Colonial Mwinilunga, Northern Rhodesia (Zambia), 1945–1964 Walima T. Kalusa

Prodded by the colonial state after World War II, medical missionaries of the Christian Missions in Many Lands (CMML) at Kalene hospital in Northern Rhodesia’s Mwinilunga district supplanted their training scheme for African auxiliaries with a more scientifically oriented program.1 This came in the wake of the colonial authorities and the missionaries’ own growing dissatisfaction with the older training scheme under which Lunda-speaking medical auxiliaries had been trained since the early 1920s.2 CMML missionaries were particularly keen to replace the old scheme as it had failed to wholly erode pre-existing “pagan” cosmologies of disease and healing among auxiliary graduates. To the missionaries, the tenacity of such cosmologies among the local employees issued not least from the deep-rootedness in African society of “heathen” medical belief systems and associated practices. It also arose from the elementary nature of the kind of training they had hitherto offered to African trainees at the mission hospital.3 Underlying these apprehensions was the widespread assumption in colonial and missionary circles that the medical training program of the interwar period had proved utterly incapable of churning out scientifically minded auxiliaries. Colonial authorities and missionaries worried that auxiliary workers trained during that period hardly appreciated the “objectivity,” “rationality,” and “superiority” of mission-based medicine over African “fetish remedies.”4 Therefore, auxiliaries were often not considered an effective tool in the Christian ideological battle against indigenous cosmologies of disease and praxis. However, to CMML medics, overcoming this problem was essential to undermining local “pagan” belief systems and associated healing rituals that they regarded as barriers to the spread of Christianity. Consequently the need to replace the existing training program with a much more effective scheme capable of imbuing African auxiliaries with greater appreciation of biomedical knowledge became an urgent affair after the war. Medics expected auxiliaries trained under the new scheme to effectively internalize the scientific trappings of Christian medicine and thus appreciate its power. As a result, it was hoped that they would more convincingly persuade their patients to embrace mission medicine.

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From the CMML perspective, this new generation of auxiliaries was to be in the front line of the Christian crusade to annihilate local religious and medical beliefs. From this position, CMML missionaries believed that the auxiliary employees could easily persuade fellow Africans to reject their therapeutic systems in favor of mission-based medicine. 5 CMML evangelists at Kalene Mission Hospital in particular wanted to combat local healing systems that located human affliction within prevailing social relations.6 They held that auxiliaries well versed in bacteriological theories of healing would come to see disease as a function of microbial invasion rather than the consequence of dysfunctional social relationships, as the Lunda people of Mwinilunga believed.7 Furthermore, the missionaries hoped that auxiliary workers would convince fellow Africans to accept that human disease was best treated in isolation from kinship relationships within which the Lunda managed affliction. Thus, the auxiliary was to be the handmaiden in the missionary crusade to decontextualize illness from its social space, ultimately conferring upon African society new medical, cultural, and social identities.8 Like CMML missionaries, European doctors in the colony also shared the concern that auxiliary graduates at Kalene were too poorly trained to appreciate the “superiority” of Western medical power.9 But whereas the former blamed this situation partly on the tenacity of “pagan” medical culture and beliefs, the latter attributed the persistence of such beliefs to the low level of Western education among auxiliary trainees.10 In addition, colonial medical authorities who periodically inspected Kalene mission hospital routinely castigated the CMML’s subordination of medical work to evangelization as yet another cause of the problem.11 Convinced that inadequately trained auxiliaries compromised the colonial state’s efforts to build a satisfactory medical practice in the colony, colonial medical authorities turned into ardent advocates of far reaching improvements in the training of their colonial subjects at both government and mission controlled training centers after World War II.12 Their efforts soon paid off. Barely two years after the conclusion of hostilities in Europe, colonial authorities in the territory devised an ambitious ten-year development plan partly designed to boost African health in hopes of increasing the production of raw materials in colonial Zambia. The plan, bankrolled by the British government eager to rebuild its own war-torn metropolitan economy and to check the rising tide of international anti-colonial agitation, directed substantial fiscal support toward qualitative and quantitative improvement of African health countrywide.13 Consequently, state grants-in-aid for the training of auxiliaries at mission hospitals, such as at Kalene Hill, became commonplace after the war.14 The concern of the colonial state and of the CMML missionaries to train auxiliaries in scientific medicine was driven by mutually shared, if at times tension-ridden, projects. As noted earlier, medical missionaries were convinced that auxiliaries trained in scientific medicine would more

156 Walima T. Kalusa readily internalize its scientific trappings and deploy their newly acquired knowledge to reinforce the CMML crusade against indigenous paradigms of disease and healing. Of singular significance to this chapter, Kalenebased evangelists believed that the new generation of auxiliaries would play a pivotal role in suppressing social healing, which they perceived as one of the strongest fortresses they had to raze down in order to win Lunda souls for Christ.15 On the other hand, colonial authorities enthusiastically hoped that better trained auxiliaries would bolster their efforts to create a more effective medical practice in the territory. To the authorities, African employees steeped in scientific medicine were necessary for the expansion of colonial health services that would in turn win local endorsement for British rule in the aftermath of the war. In sum, then, the new auxiliary was to be a linchpin in the evangelical warfare to refashion African society, and in the imperial rulers’ efforts to bolster the region’s economic potential. Social and medical historians inspired by Michel Foucault’s writings not only stress the centrality of biomedical power in the construction of culture and social control, they also uncritically endorse the perception that nonWestern medical personnel on the imperial frontier uncritically accepted the role assigned to them by their colonial masters.16 Such personnel allegedly appreciated the efficacy of modern medicine, embracing the Euro-Christian bourgeois values that their employers attached to colonial medical interventions in extra-European societies. According to this school of thought, medical auxiliaries regarded themselves as the legitimate spokespeople of scientific medicine in colonial settings; and in so doing they signaled their willing involvement in the Western crusade to subjugate local medical beliefs and African social healing. It is further asserted that auxiliary workers aspired to the European lifestyles, beliefs, and habits of their white employers, and supported the missionary campaign to undermine “pagan” medical cultures.17 From this standpoint, non-European practitioners and auxiliaries of Western medicine on the colonial periphery were little more than obedient agents of “medical imperialism.”18 Relegated to performing menial duties in European hospital regimes so as not to encroach upon the authority of white doctors and nurses,19 they are cast as simple helpers and aides. Undeniably, neo-Foucauldian scholarship has aptly illuminated the subordinate positions non-European medical practitioners of Western medicine occupied in colonial and mission medical hierarchies. But this scholarship has all too often been written from the perspective of white doctors themselves, and not that of the local employees. Thus, although neo-Foucauldian scholars have unmasked the intentions of colonial and missionary doctors, they have scarcely illuminated how indigenous auxiliaries actually practiced modern medicine. Consequently, such scholarship has grossly underestimated their capacity to circumvent the hegemonizing agenda of the imperial authorities and missionaries. 20 Academic discourse that draws its inspiration from Foucault also suffers from other limitations. For instance, it does not take into consideration

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the social context in which medical auxiliaries practiced scientific medicine. African medical auxiliaries did not operate in a social vacuum, and there is evidence to suggest that at times they practiced allopathic medicine in ways that reinforced existing customs and beliefs, even when the auxiliaries themselves did not support such beliefs. 21 If local customs conditioned how medical auxiliaries practiced medicine, so did the shifting disease environment within which the workers plied their trade. 22 Yet neoFoucauldian works have seldom explored how changes in disease environments shaped the work of African auxiliary employees. This creates the erroneous impression that these employees uncritically perceived modern medicine as effective against disease and thus shared their employers’ faith in its alleged effectiveness. This chapter takes issue with the view that stresses the colonizing power of Western medicine and that models indigenous employees in colonial and mission hospitals as no more than cultural conquistadors who assisted their employers to displace African medical beliefs and practices. Acknowledging that after 1945 auxiliaries at Kalene were better trained than their predecessors, this study fi rst questions the popular view in colonial and mission circles that the medical training Africans received at the mission hospital in the aftermath of the war was a purely scientific undertaking. It shows that missionaries at the hospital were forced to accommodate some aspects of Lunda medical culture in order to popularize the work of medical auxiliaries in local villages. Secondly, and more importantly, the chapter casts doubt over the assumption that auxiliaries became “biomedical” agents whose work in colonial and missionowned hospitals was an anathema to African social healing. It insists that despite their scientific training and evident appreciation of Western medical power, auxiliaries in Mwinilunga perceived missionary medicine as more than just a site for reversing physical affl iction. Working in a society with rapidly escalating social inequalities and tensions engendered by postwar colonial policies, African auxiliaries transformed the missionary therapeutic system into a discursive space for confronting and redressing such tensions. Thus, they wittingly or unwittingly became healers of the rapidly fragmenting social body. In this way, instead of displacing the notion that the social was the locus of human disease and suffering, they ended up reinforcing it. African medical auxiliaries reinvented missionary medicine, successfully turning it into an instrument for consolidating interpersonal understandings of disease. This not only frustrated their employers’ efforts of undermining pre-existing healing practices, but demonstrates that African auxiliary workers possessed a form of cultural hegemony over their European employers, notwithstanding the fact that the former enjoyed far less medical authority and power than the latter— another example of how the status and position of many intermediaries and subordinates determined how, and in what ways they could impact and undermine Western public health policy.

158 Walima T. Kalusa EXPANSION OF MISSIONARY MEDICINE The drive to reinvigorate the training of medical auxiliaries in Mwinilunga is best appreciated within the context of the unprecedented expansion of medical services in the colony directly after World War II. As Zeleza Tiyambe and several other writers have observed, Britain emerged from the war with a severely battered economy and a diminished international standing. In response, Britain elaborated a developmentalist agenda to rebuild its domestic economy by mobilizing the productive potential of its overseas empire. 23 Because tapping such resources was contingent on the health of local laborers, Whitehall increasingly committed funds towards the expansion of health infrastructure and services throughout the empire, and especially in Africa. The metropolitan authorities’ concern to improve African health in colonial Zambia was reflected in their enthusiastic support of the colony’s fi rst ten-year development plan in 1947. The plan provided for an expenditure of no less than £1,000,000 on health, the bulk of the funds coming from the Colonial Development and Welfare Fund established after the war. 24 State expenditure on medical services in the territory continued to increase in the 1950s, jumping from £537,436 to £995,199 and then to over £1,000,000 in 1950, 1953, and 1954, respectively. 25 This rise in medical expenditure was paralleled by a proportionate increase in grants-in-aid to medical missions across the colony. Consequently, most missionary societies, including the CMML, improved their medical provisions both qualitatively and quantitatively. For instance, in the early 1950s medical missionaries replaced the sun-dried brick hospital built in the 1920s at Kalene with a modern, burnt brick hospital (still in use today) with 230 beds, numerous wards, and an X-ray plant donated by the colonial state. 26 They also opened additional health centers in many parts of Mwinilunga, including a small hospital at Kamapanda and large clinics at the capital villages of Chiefs Kanongesha, Chibwika, Ntambu. By 1953, they were also running dispensaries at Salujinga and Mwilombi and clinics at Ikelenge twenty miles south of Kalene and at Kanyama ninety miles east of the mission hospital.27 In addition, they were overseeing the operations of newly established or enlarged state dispensaries at Lumwana, Tom Ilunga, and Chief Sailunga’s capital village. 28 The proliferation of village health centers coupled with the scarcity of European medics in the district necessitated the training of local auxiliaries capable of running the centers without the daily supervision of white doctors or nurses. 29 The fact that village dispensaries and clinics were under the control of auxiliary employees added greater urgency to improving the quality of their medical training. This was intended less to uphold modern medical standards at mission-owned dispensaries and clinics than to equip auxiliary workers with medical knowledge deemed essential to the CMML agenda of undermining local healing beliefs. As

Colonial Mwinilunga, Northern Rhodesia (Zambia), 1945–1964


for the colonial state, such auxiliaries were indispensable for effective medical practice across the colony. It was in this context that the CMML invited Sister Hilda Wadsworth, a nurse matron and tutor from England, to reorganize the auxiliary training scheme at Kalene Hill in 1951. Under an arrangement in which the colonial state met her expenses and salary, her major task was to institute a more effective training program in order to produce suitable auxiliary workers to staff the increasing number of state and mission-controlled health centers in the district.30 Wadsworth shared other missionaries’ and officials’ enthusiasm for placing the medical training of Africans on “a sound scientific footing.”31 Averse to local medical beliefs and well versed in midwifery, anatomy, obstetrics, physiology, and gynecology, within three years of her arrival Wadsworth transformed the training of auxiliaries in the district. With fiscal support from the colonial state and the CMML, she built a new training school (still standing today) adjacent to the hospital. Determined to produce auxiliary graduates with a keen sense of microbial theories of disease, she equipped the training school with a state-of-the-art laboratory complete with microscopes, skeleton models, and other equipment. As Wadsworth herself recalled about fi fty years later, this was intended to inculcate in her trainees an appreciation of “biomedicine” and to equip them with techniques essential to identifying and classifying disease-causing organisms.32 Wadsworth did more than just equip her school with scientific technologies. She further overhauled the ad hoc medical curriculum hitherto taught at the mission hospital, replacing it with a two-year curriculum heavily biased towards anatomy, biology, midwifery, pathology, and physiology. 33 Moreover, she initially excluded illiterate candidates from her course, insisting on admitting only young, unmarried men and women with Standard IV education, or higher. Like colonial medical functionaries who routinely inspected her school, she fi rmly held that young, well-educated Africans conversant in English were more likely to comprehend difficult scientific concepts than illiterate trainees of the interwar period. The former could thus be more easily molded into medical professionals, imbued with a deep appreciation of scientific knowledge.34 Indeed, her students had to pass both written theoretical and practical examination. Only upon passing the examinations did Wadsworth deem her trainees adequately qualified to work at Kalene Hill Hospital or at any of its satellite dispensaries and clinics in villages.35 At face value, Wadsworth’s training program appears to have been no less than a scientific endeavor, and she routinely cast it in this light. Her program soon earned several accolades from visiting state medical functionaries, who consistently praised it as a model medical project. It was in this spirit that a colonial medical inspector in 1954 predicted that once trained in sufficient numbers, new auxiliaries from Kalene would quickly undermine the influence of “traditional” healers in the district. He concluded


Walima T. Kalusa

that Wadsworth’s training scheme was worth emulating by other medical missionaries across the territory.36 In hindsight, these comments were informed by the understanding of auxiliaries as agents for undermining local medical belief systems and praxis. But in fact these statements mask the accommodations Wadsworth herself had to make with indigenous healing cultures in order to satisfy local expectations and to win popular recognition and legitimacy for her training project. More ominously, these observations cast African auxiliaries as voiceless workers who passively endorsed the role European missionaries crafted for them. In reality, things were much more complex. In Lunda society, where the respectability of the traditional healer was inexorably tied to age, experience, and trust, Wadsworth soon discovered that her young, unmarried graduates met stiff opposition, if not outright rejection, when sent out to village health centers. Expectant mothers particularly objected to being attended to by unmarried auxiliaries, as their presence at childbirth violated female sexuality (according to local beliefs). Such opposition seems to have been greatest against auxiliaries whose parents or guardians had not worked as auxiliaries at Kalene Hill.37 To abate this opposition, Wadsworth made a number of modifications to her “scientific” training scheme. Although she initially placed a premium upon training very young, relatively well-educated men and women, she soon raised the average age of admission from sixteen to twenty-five. By the late 1950s she even trained older midwives, some of whom had little or no Western education at all. In the same vein, she increasingly recruited auxiliary trainees whose guardians or parents were working or had worked as medical auxiliaries at Kalene. Thus towards the end of the 1950s, more than 50 percent of the twenty-four auxiliary trainees at the mission hospital came from families with a history of medical work in the district.38 Wadsworth justified the bias in favor of these students on the premise that they came from Christian families. As such, her auxiliaries would transform their dispensaries and clinics into the nuclei of evangelization. Wadsworth’s observations were not incorrect, for nearly all her students who trained in the 1950s and 1960s were or became Christian. Most of them also played a key role in establishing “native” CMML assemblies close to their clinics.39 But by admitting to her program older students and by insisting on training the offspring of (former) medical auxiliaries, Wadsworth knowingly or unknowingly subscribed to local constructions of the ideal medical practitioner. She also unwittingly buttressed the local custom of passing the office of healing within specific families, a point that has also been poignantly made by scholars working on African societies in other places and periods.40 For all its scientific trappings, the training of African auxiliaries in postwar Mwinilunga resonated with deep religious and moral overtones. Although Wadsworth wanted her auxiliary trainees and employees to imbibe “biomedical” understandings of disease and healing, she also sought to instill in them the belief that God was “the author of life” and

Colonial Mwinilunga, Northern Rhodesia (Zambia), 1945–1964


as such the source of “good health.” She wanted, therefore, to persuade auxiliaries that God was the ultimate healer, in spite of their appreciation of microbial paradigms of disease and biomedical power. Accordingly, her lectures always began and ended with prayer. Through these lectures and prayers, Wadsworth exhorted the Christian God as the greatest healer, and she sought to inculcate in her students Christian values such as kindness, honesty, and empathy for the sick. Perhaps unknown to her, these virtues were also regarded as the hallmarks of traditional medicine in Mwinilunga. In fact, it was these virtues for which her graduates became renowned in villages, rather than their scientific knowledge of medicine, a point that eventually was not lost on Wadsworth.41 It is clear then, that the medical training that Wadsworth designed at Kalene Hill after World War II was not a purely scientific affair foisted upon passive Africans. Like most other colonizing projects in the empire, her training scheme was not immune to localizing or domesticating forces. Local medical expectations coupled with how auxiliaries were received in villages largely influenced the age, the marital status, and the familial backgrounds of the auxiliaries trained at Kalene hospital from the 1950s onwards. In responding to local expectations by raising the entry age, recruiting married midwives, and training auxiliaries’ sons and daughters, Wadsworth and other CMML missionaries legitimated the training of medical auxiliaries in local terms. This conclusion is neither new nor unique to colonial Mwinilunga. Heather Bell has convincingly shown how British medical educators in the Anglo-Egyptian Sudan appropriated pre-existing ideas of midwifery and used them in training local midwives. She argues that the educators’ accommodation of Sudanese culture—which issued from negotiations between them and their African interlocutors—was central to local recognition and appropriation of Western midwifery practices and medicine.42 In her study of imperial rule in sub-Saharan Africa, historian Karen Fields advances a similar argument. She rightly avers that colonial rulers in the region could not win legitimacy for their rule without deferring to local institutions, practices, or ideas through which their colonial subjects exercised political power and authority. Imperial rulers, therefore, at least tacitly participated in local institutions, appropriating beliefs and practices linked to such institutions. For instance, Fields demonstrates that colonial authorities accommodated ideas surrounding witchcraft—the very aspect of local culture that was considered inimical to their imperial mission.43

AUXILIARIES AS SOCIAL HEALERS If the new medical training program at Kalene hospital was not a purely scientific endeavor, there are indications that its auxiliary graduates also scarcely turned into simple agents for countering indigenous medicine. To


Walima T. Kalusa

understand how and why auxiliaries subverted their employers’ intention to transform them into obedient servants we need to study their actions against the backdrop of postwar socio-economic policies, policies that worsened the district’s disease landscape and widened existing social inequalities and tensions in Mwinilunga. As noted in the introduction of this chapter, policies that led to the deterioration of the district’s disease ecology and deepened social inequalities in the postwar period were linked to Britain’s efforts to rebuild the economy after the war. Zambia’s role in resuscitating the British economy lay in expanding copper production. To this end, the British government enticed mining companies to increase their production of the base metal in the colony. The response of both British and other companies was overwhelming, leading to the opening of additional mines in the territory. This was especially so in the 1950s when soaring copper prices, induced by the Korean War, resulted in a boom in the copper industry. Ultimately, the colony emerged as one of the world’s major copper producers, with the African workforce on the Copperbelt growing from 200,000 in 1946 to 270,000 in 1953.44 Scholars operating within underdevelopment paradigms have observed that the expansion of the African mine workforce in colonial Zambia after the war increased the demand for beef and maize so significantly that European farmers, who had hitherto monopolized the food market in the colony, could no longer meet the demand.45 For most of the postwar period, therefore, the colonial state actively encouraged commercialized market production in rural areas to feed the miners. Besides urging people in Mwinilunga and other areas to abandon large villages in preference for small-scale settlements ideal for peasant commodity production,46 the state constructed roads in the district, provided free instruction in cash cropping, organized annual agricultural shows, and advanced loans in the form of cattle. The colonial state further established buying centers from which African and white traders purchased locally grown grain and cassava flour for export to the Copperbelt.47 Lastly, in the mid-1950s, colonial officials made marketing arrangements with mining companies in the nearby Belgian Congo to facilitate the export of surplus crops from Mwinilunga.48 By most archival and oral accounts, people in Mwinilunga responded to these initiatives enthusiastically. From the late 1940s on, district colonial administrators consistently reported that the Lunda were rapidly acquiring land for commodity production igniting endless, and often violent, struggles within and between chiefdoms.49 In place of consolidated villages of the interwar period now emerged small villages, along motor roads or near trade centers. Nuclear families established what locally came to be known as amafamu (the Lunda corruption of the English “farms”), where they engaged actively in market production, usually with family or hired labor. Mwinilunga thus became an exporter of food. In 1954 alone, local producers exported more than 670 tons of cassava meal and, a year later, the

Colonial Mwinilunga, Northern Rhodesia (Zambia), 1945–1964


district commissioner proudly informed his superiors in Lusaka, “The year has seen a record increase in the production of surplus foodstuffs”; this, he continued, enabled the district to export food worth £15,145, indicating an increase of more than £3,000 over the previous year’s earnings. 50 And this still excluded income earned from exporting beeswax and rubber to Europe, and rice, beans, and millet to other parts of the colony. It is clear, then, that by the mid-1950s Mwinilunga had emerged as a major food-growing area. With its deepening involvement in market production, the district not only replaced its barter economy with a moneybased one, it also escaped the economic depression into which the area had sunk after its incorporation into the colonial order at the beginning of the twentieth century. As a corollary, the pedicle chiefdoms in the northwestern section of the district saw the rise of wealthy men (mukwakuheta), in particular in the chiefdoms of Nyakaseya, Ikelenge, and Mwinimilamba. There, rich producers such as Thomas Kapita and Joseph Kanema accumulated sufficient wealth to enjoy a standard of living that some colonial officials said, perhaps exaggeratedly, to be “on the same plane as [that of] the middle class salaried man in England.”51 But this rising prosperity came at high epidemiological and social costs. The agricultural prosperity mostly took place in the pedicle area, which boasted fertile soil, a good road network, internal markets, and several African and European traders.52 Whereas agricultural prosperity in this area apparently insulated the nouveau riche from diseases of impoverishment, it did not extend to less successful producers within and outside the pedicle. Most adversely affected were the remote parts of the district devoid of fertile soils, roads, and markets, and from which the prosperous chiefdoms in the district increasingly recruited labor. It is no surprise then that although colonial authorities in Mwinilunga in the 1950s routinely recorded that “[t]he health of the people in [the pedicle region] is excellent,”53 they also noted that the lack of agricultural development and deepening poverty in peripheral parts of the district rendered people vulnerable to devastating diseases and epidemics.54 For instance, in 1948 district commissioner R.C. Dening reported a very high incidence of tuberculosis, hookworm, and malaria in the villages under the chiefs Kanyama and Kakoma. 55 His observations were echoed a few years later by several other administrative officials who reported seeing extremely thin and undernourished children in many villages. They attributed this situation to the high incidence of tuberculosis, influenza, hookworm, and dysentery, all of which contributed to the rising mortality rates in affected villages.56 Besides altering the pattern of the distribution of disease in the district, the expanding involvement of the Lunda people in commodity production exacerbated existing social inequalities and tensions. Victor and Elizabeth Turner, who carried out fieldwork in Mwinilunga in the 1950s, found that as the nascent la classe opulante relied more on the nuclear family or hired labor, they were less inclined to assist their kinsmen and women in keeping

164 Walima T. Kalusa their local matrilineal obligations. To the contrary, successful Lunda traders and peasants sought to disencumber themselves from such obligations by establishing their amafamu or businesses far away from their relations. They further hid their surplus income in boxes secretly buried in the ground or by investing it in such capital goods as sewing machines.57 Such practices, which inevitably led to deterioration in social relations and rising witchcraft accusations, were exacerbated by the ruthless exploitation of hired laborers, who sometimes reportedly included the mukwakuheta’s matrilineal kin. 58 Recent studies investigating shifting perceptions of witchcraft beliefs in modern Africa have noted that socio-economic forces acting upon kin dynamics tend to magnify social confl icts, thereby deepening existing societal tensions.59 This applies to postwar Mwinilunga, where the cumulative spirit of successful peasants and traders was fundamentally at odds with the Lunda matrilineal ideology that emphasized the importance of kinship ties and related obligations. The cumulative spirit that found expression in rising land disputes within families, establishing amafamu away from the prying eyes of kinsfolk, and hiding of money spawned tensions that fractured the social body.60 Such social tensions manifested themselves in increasing witchcraft accusations in the decades following World War II. These accusations were leveled against young successful entrepreneurs by their less successful kinsfolk, who saw those who prospered as acquiring their wealth through witchcraft. As Martin Chanock has eloquently argued, such accusations may have served as a strategy by which lineage elders sought to gain access to younger entrepreneurs’ goods and income essentially to bolster their own social, economic, and political power that had been severely eroded by colonial rule.61 However, to safeguard their own wealth, the new economic elites were quick to counter, and accused their elders of witchcraft. Thus, in 1955 a colonial administrator in the district lamented that witchcraft disputes now “tainted every aspect of the lives of the people.”62 This situation engendered growing anxiety among colonial officials and CMML missionaries, for they regarded witchcraft accusations as antithetical to the spirit of rural capitalist accumulation and to the spread of Christianity.63 In a society that perceived the root cause of disease and suffering as the outcome of broken social relationships, it is little wonder that most patients presented medical auxiliaries trained at Kalene Hospital with both the social challenges of their lives and their physical afflictions.64 It is against this background that one may perhaps discern how the role of auxiliaries diverged from the expectations of CMML evangelists. Shem Sanikosa, an auxiliary who manned the mission dispensary at Salujinga between 1955 and 1968, recalled that he spent less time treating patients than discharging pastoral duties, including settling land and family disputes. When kinsmen fought over land, a situation that often sparked witchcraft accusations, or when they “had other personal problems,” Sanikosa recalled, “they [came] to me

Colonial Mwinilunga, Northern Rhodesia (Zambia), 1945–1964


for arbitration”; and, according to the former medical orderly, the concerned parties were assured of an impartial hearing because he was a Christian.65 But it is more likely that people took their social problems to him because they saw missionary medicine as a variation of local medicine, whose practitioners operated beyond the medical frontier and resolved social conflicts as often as they confronted physical afflictions.66 That Sanikosa did not confine his work to treating diseases alone, but willingly attended to his patients’ social problem certainly reinforced this perception.67 Auxiliaries’ duties transcended the settlement of disputes, as exemplified by Samuel Majaji’s career. The only standard VI graduate trained by Wadsworth, Malaji opened the CMML dispensary at Mwilombi in the late 1950s. There, he and other auxiliaries often engaged in healing activities that were anything but “scientific.”68 For example, the auxiliaries routinely administered mission therapies to the gravely sick in the patients’ homes through rituals they crafted themselves. They often engaged the sick, together with their therapy management groups, in healing prayers that invoked the Holy Spirit. Such rituals attracted large crowds, including the sick and their relations, the rich, and the poor. At overnight prayers, auxiliaries kept vigil for the dying, dealt with suspected cases of witchcraft, and enjoined relatives of the sick to overcome their differences. These practices invariably drew the wrath of their European employers who dismissed them as little more than rank heathenism. In the hands of African medical auxiliaries, therefore, missionary medicine became more than an instrument for restoring good health to the afflicted. It was, more significantly, a vehicle through which auxiliary employees helped their patients to rework their rapidly breaking social relationships, contain expanding inequalities, and come to terms with other conflicts spawned by the Lunda’s growing involvement in the commercialized market economy post-1945. Through their healing ordeals auxiliaries focused on resolving social confl icts regarded by patients as the locus of human disease and suffering. Despite their rigorous training in scientific medicine, African medical auxiliaries in postwar Mwinilunga seldom “thought in terms of biomedical paradigms.”69 This last observation is not intended to imply that Wadsworth’s students did not appreciate microbial explanations of disease and healing. Numerous interviews with many former medical auxiliaries show that they did. But this did not stop them from reading disease in terms of existing social relationships.70 Far from being concerned with treating disease per se, auxiliaries, like their patients, sought to harmonize wider social relationships that gave form and meaning to disease and its treatment. Through healing prayers and other rituals, which colonial officials and European missionaries dismissed as “pagan” practices, medical auxiliaries placed “a [social] network of concern beneath” the sick and the dying, inexorably linking missionary medicine to socio-economic and epidemiological concerns in a rapidly transforming society. As Paul Landau argues for Christian converts in

166 Walima T. Kalusa Botswana, African auxiliaries reinvented Christian medicine “by working on the boundaries and connections between the patient and [the patient’s] changeful milieu”; and by treating disease as a matter of the patient’s situation in a wider social environment and not merely as the “interplay of confl icting elements within her [or his] body.”71 Seen from this perspective, it is not surprising that auxiliaries rejected the particularizing tendencies of missionary medicine, and the notion that the human body is the only possible site of healing.72 Their village-based healing rituals, in which patients and their kinsfolk participated, decompartmentalized evangelical medicine from its narrow confi nes in mission enclaves. Consequently, auxiliary workers, intentionally or unintentionally, bolstered interpersonal comprehension of disease. Willingly or unwillingly, they confounded their employers’ efforts to undermine social healing. Through African auxiliaries’ agency, and their position as subordinate medical workers, CMML mission medicine was refashioned into a system capable of confronting new social confl icts and equipped to heal an increasingly fragmented social body.

CONCLUSION When missionaries at Kalene Hill reorganized their medical training for African auxiliaries with the support of the colonial state after World War II, they hoped to train a new breed of auxiliaries who would work on the front line against social healing. But auxiliaries trained in the aftermath of the war were no simple lackeys of colonial or missionary doctors. Confronted with rising social inequalities and allied tensions spawned by colonialism, they refused to restrict their medical practice to mission enclaves alone. They invented their own healing rituals and practiced Christian medicine in ways that enhanced social relationships in which their patients understood and managed disease. Ultimately, auxiliary employees bolstered interpersonal comprehension of disease and played a significant role in managing social confl icts and tensions sparked by postwar economic policies. Notwithstanding the fact that African auxiliaries trained at Kalene Hospital occupied a subordinate status relative to their missionary employers—a status that helped determine how they were able to impact colonial medical policy—they were never pliant agents subservient to their every demand, but consistently frustrated the CMML and colonial state’s agenda to destroy Lunda medical culture and knowledge.

NOTES 1. Interview with Hilda Wadsworth, retired nurse matron, Kalene Hill, January 7, 2001. See also Evelyn Nightingale, “Medical Missionary Work in Northern Rhodesia,” Echoes of Quarterly Review 1, no. 2 (1959): 16–21.

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2. 3. 4. 5. 6. 7. 8.


10. 11. 12. 13. 14. 15. 16. 17.



This chapter draws on my doctoral work, “Disease and the Remaking of Missionary Medicine in Colonial North-Western Zambia: A Case of Mwinilunga District, 1902–1964,” (PhD diss., Johns Hopkins University, 2003). National Archives of Zambia (hereinafter NAZ)/KSE 6/1/4, Annual Report for the Year ending March 1922 (Luaka: Government Printer, 1922). Nightingale, “Medical Missionary.” William S. Fisher and Julian Hoyte, Ndotolo: The Life Histories of Walter and Anna Fisher of Central Africa (Ikelenge: Lunda-Ndembu Publications, 1992). Interview with Wadsworth. Fisher and Hoyte, Ndotolo. Ibid. This point is informed by Megan Vaughan, “Healing and Curing: Issues in the Social History and Anthropology of Medicine in Africa,” Social History of Medicine 7, no. 2 (1994): 283–295; Paul Stuart Landau, “Explaining Surgical Evangelism in Colonial Southern Africa,” Journal of African History 37, no. 2 (1996): 261–281; Paul Stuart Landau, The Realm of the Word: Language, Gender, and Christianity in a Southern African Kingdom (Portsmouth, NH: Heinemann, 1995); Paul Stuart Landau, “When Rain Falls: Rainmaking and Community in a Tswana Village, c. 1870 to Recent Times,” Journal of Southern African Studies 26, no. 1 (1993): 1–30. NAZ/ ZA7/6/7, H.S. de Boer, Report on [Medical] Conditions in Northern Rhodesia, 1933; H.S. de Boer, Medical Report Following Tour through North-Eastern and North-Western Rhodesia (Lusaka: Government Printer, 1934), 11; Northern Rhodesia, Medical Report on Health and Sanitary Conditions for the Year 1931 (London: Crown Agent, 1931), 61; Medical Report on Health and Sanitary Conditions for the Year 1936 (London: Government Printer, 1937), 1–2; Medical Report on Health and Sanitary Conditions for the Year 1939 (Lusaka: Government Printer, 1940), 8; P.C.G. Adams, “Disease Concepts among Africans in the Protectorate of Northern Rhodesia,” Rhodes-Livingstone Journal 10 (1950), 15. NAZ/ZA7/6/7, H.S. de Boer, Report on Conditions in Northern Rhodesia (Medical), 1933. Ibid. See Adams, 14–50. Ten-Year Development Plan for Northern Rhodesia as Approved by the Legislative Council on 11th February 1947 (Lusaka: Government Printer, 1947), 9. Interview with Wadsworth. See also Nightingale, “Medical Missionary.” Fisher and Hoyte, Ndotolo. See Walima T. Kalusa, “Language, Medical Auxiliaries, and the Re-Interpretation of Missionary Medicine in Colonial Mwinilunga, Zambia, 1922–51,” Journal of Eastern African Studies 1, no. 1 (2007): 57–78. For a recent study that challenges these assumptions, see Walima T. Kalusa, “Advertising, Consuming Manufactured Goods and Contesting Colonial Hegemony on the Zambian Copperbelt, 1945–1964” (paper presented at Frigilla Lodge, Chisamba, Zambia, August 27–29, 2010). See Maryinez Lyons, “The Power to Heal: African Medical Auxiliaries in Colonial Congo and Uganda,” in Contesting Colonial Hegemony in Africa and Asia, ed. Dagmar Engels and Shula Marks, 202 (London: British Academic Press, 1994). In the same volume, see Megan Vaughan, “Health and Hegemony Representation of Disease and the Creation of the Colonial Subject in Nyasaland”; and David Arnold, “Public Health and Public Power: Medicine and Hegemony in Colonial India,” 131–151. Also see Geraldine



20. 21. 22. 23.

24. 25.

26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

36. 37. 38.

39. 40. 41.

Walima T. Kalusa Forbes, “Managing Midwifery in India,” and Andrew Cunningham and Bridie Andrews, “Introduction: Western Medicine as Contested Knowledge,” in Western Medicine as Contested Knowledge, ed. Andrew Cunningham and Bridie Andrews, 1–23 (Manchester: Manchester University Press, 1997). For works that distance themselves from this view, see Harriet Bell, “Midwifery Training and Female Circumcision in Inter-War Anglo-Egyptian Sudan,” Journal of African History 39 (1998): 296–312; and Nancy Rose Hunt, A Colonial Lexicon of Birth Ritual, Medicalization and Mobility in the Congo (Durham, NC: Duke University Press, 1999). For studies that question this view, see John Illife, East African Doctors: The History of the Modern Profession (Cambridge: Cambridge University Press, 1998); Shula Marks, Divided Sisterhood: Race, Class and Gender in the South African Nursing Profession (London: St. Martin’s Press, 1994). Osaak a. Ollumwullah, Dis-ease in the Colonial State: Medicine, Society and Social Change among the Abanyole of Western Kenya (Westport, CT: Greenwood Press, 2000), 8. Kalusa, “Disease and the Remaking of Missionary Medicine.” Ibid. See Zeleza Tiyambe, “The Political Economy of British Colonial Development and Welfare in British Africa,” TransAfrican Journal of History 15 (1985): 139–161; Frederick Cooper, Decolonization and African Society: The Labor Question in French and British Africa (Cambridge: Cambridge University Press, 1996), chap. 5. Ten-Year Development Plan for Northern Rhodesia as Approved by the Legislative Council on 11th February 1947, 9. The figures derive from Annual Report on Northern Rhodesia for the Year 1950, 43; Health Department Annual Report for the Year 1952; Health Department Annual Report for the Year 1953, 3; Annual Report on Northern Rhodesia for the Year 1954, 14. See NAZ/MH 1/2/95, Tour Report No. 1/1952; NAZ/SEC2/960, Evelyn Nightingale to Director Medical Services, November 12, 1953; Nightingale, “Medical Missionary.” Nightingale, “Medical Missionary.” Ibid. Ibid. Interview with Wadsworth. Ibid. Ibid. Ibid. L.H. Holroyd, Provincial Medical Officer to Director of Medical Services, July 9, 1959. See NAZ/MH1/2/119. Interview with Wadsworth. Interviews with Maggie Thomas Sameta and Dorothy Chipisha, retired nurses, Kalene Hill, January 7, 2001; Chkeza Idah, retired nursing assistant, Kalene Hill, February 18, 2001, and Yuda Kapepala, retired nurse, Kapepala Village, February 23, 2001. NAZ/SEC2/962, Tour Report No. 8 of 1954. Ibid. Interviews with Shem Sanikosa, former medical orderly, February 23, 2001; Gibbison Chipisha, former medical orderly, January 7, 2001; Chilongo Chinyama, former medical orderly; Dorothy Chipisha, auxiliary nurse, January 7, 2001; Yuda Kapepela, former male nurse, February 23, 2001. Ibid. See, for example, Bell, “Midwifery Training,” 206. Interview with Wadsworth.

Colonial Mwinilunga, Northern Rhodesia (Zambia), 1945–1964


42. Bell, “Midwifery Training.” 43. Karen E. Fields, “Political Contingencies of Witchcraft in Colonial Central Africa: Culture and the State in Marxist Theory,” Canadian Journal of African Studies 16, no. 3 (1982): 568; see also Sean Redding, “Government Witchcraft: Taxation, the Supernatural, and the Mpondo Revolt in the Transkei, South Africa, 1955–1963,” African Affairs 95 (1996): 555–597. 44. James Anthony Pritchett, “Change and Continuity in an African Society: The Kanongesha Lunda of Mwinilunga” (PhD diss., Harvard University, 1989). 45. See Kenneth P. Vickery, “Saving Settlers: Maize Control in Northern Rhodesia,” Journal of Southern African Studies 11, no. 2 (1985): 212–234; Kenneth P. Vickery, Black and White in Southern Zambia: The Tonga Plateau Economy and British Imperialism, 1890–1939 (New York: Greenwood Press, 1986); Samuel N. Chipungu, The State, Technology and Peasant Differentiation in Zambia: The Case of Southern Province (Lusaka: Historical Association of Zambia, 1988); and Maud S. Muntemba, “Thwarted Development: A Case Study of Economic Change in the Kabwe Rural District, 1920–1970,” in The Roots of Rural Poverty in Central and Southern Africa, ed. Robin Palmer and Neil Parsons, 345–364 (London: Heinemann, 1977). 46. NAZ/SEC/962, Mwinilunga District Notebook, 1964; NAZ/KSE 4/1, Comments by the Provincial Commissioner on Tour Report No. 5 of 1952. 47. NAZ/SEC2/155, Annual Report on Native Affairs for the Year 1948; NAZ/ SEC2/960, Tour Report No. 3/1952; NAZ/SEC2/958, O.S. Wallace to the Director of Trade, Transport and Industry, May 31, 1951; NAZ/SEC2/962, Tour Report No. 9 of 1954. 48. NAZ/SEC2/962, Tour Report No. 8 of 1954. 49. NAZ/SEC2/962, Tour Report No. 4 of 1954; NAZ/KSE 4/1, Mwinilunga District Notebook. 50. NAZ/SEC2/137, Northwestern Province Annual Report for the Year 1955. 51. NAZ/SEC2/962, Tour Report No. 8 of 1954; NAZ/SEC2/963, Tour Report No. 6/1955. 52. Ibid. See also E.L.B. Turner and V.W. Turner, “The Money Economy among the Mwinilunga Ndembu: A Study of Individual Budget,” Rhodes-Livingstone Journal 181 (1955). 53. NAZ/SEC2/960, Tour Report No. 3/1952. 54. NAZ/SEC2/963, Tour Report No. 10 of 1955. 55. NAZE/SEC2/956, Tour Reports Nos. 1, 2, and 7 of 1948. 56. NAZ/SEC2/961, Tour Report No. 1 of 1953. 57. Turner and Turner, “Money Economy,” 28. See also V.W. Turner, Schism and Continuity in an African Society: A Study of Ndembu Village Life (Manchester: Manchester University Press, 1996), 135. 58. NAZ/SEC2/960, Tour Report No. 3/1952. Interview with Wilson Ilunga, peasant farmer, January 7, 2001. 59. The literature on this topic is legion. See, for example, Elizabeth Colson, “The Father and Witch,” Africa 70, no. 3 (2000): 333; Mary Douglas, “Sorcery Accusation Unleashed: The Lele Revisited, 1987,” Africa 69, no. 2 (1999): 177–193; Peter Geschiere, “Sorcery and the State: Popular Modes of Action among the Maka of Southeast Cameroon,” Critique of Anthropology 8, no. 1 (1988): 35–63. 60. Turner and Turner, “Money Economy,” 36. See also Boris Wastiau, “Mahamba: The Transforming Arts of Spirit Possession among the Luvale-Speaking People of the Upper Zambezi” (PhD diss., University of East Anglia, 1997), 252–260. 61. Martin Chanock, Law, Custom and Social Order: The Colonial Experience in Malawi and Zambia (Cambridge: Cambridge University Press, 1985).

170 Walima T. Kalusa 62. 63. 64. 65. 66. 67. 68.

69. 70. 71. 72.

NAZ/SEC2/963, Tour Report No. 7 of 1955. Ibid. Interview with Shem Sanikosa, former medical orderly, February 22, 2001. Ibid. See Kalusa, “Disease and the Remaking of Missionary Medicine.” Interview with Sanikosa. NAZ/MH1 2/119, Dr. Evelyn A. Nightingale and Dr. J.A. Lees, Kalene Mission Hospital African [medical] assistants, 1959; Interviews with Samuel Majaji, former medical orderly, February 23, 2001, with Crushwell Buluwaya, church elder, February 23, 2001, with Costa Kapula, pastor, February 25, 2001, and Sanikosa. Landau, Realm of the Word, chap. 5. This point is informed by John L. Comaroff and Jean Comaroff, Of Revelation and Revolution: The Dialects of Modernity on the South African Frontier, vol. 2 (Chicago: University of Chicago Press, 1997), 343. Landau, Realm of the Word, 124. Kalusa, “Disease and the Remaking of Missionary Medicine.”


The Mid-Level Health Worker in South Africa The In-Between Condition of the “Middle” Anne Digby

In his classic African survey of 1938 Lord Hailey wrote, “The medical service . . . can be envisaged as a pyramid, the base of which is formed by a large body of African subordinate staff, the apex by the fully qualified Medical Officers, and the central part by the African ‘auxiliary’ doctors or ‘medical aids.’”1 This chapter concerns itself (briefly) with the lower layer, and (more discursively) with the central, staffing layer of this pyramid in South Africa. A British colonial survey of 1944 revealed such health care assistants in Africa in “pretty well every colonial territory but under different names—‘hospital assistant, special grade dresser, dispenser etc.’”2 They were seen as “indispensable” because they enabled the colonial medical officer to use his skills to the best advantage. Wearing rose-tinted spectacles the report went on to describe indigenous personnel who were trained to nurse, dispense, diagnose, give intravenous and extramuscular injections, as well as to have an intuitive sense of whom to refer to the medical officer.3 In southern Africa such African medical assistants were found in British High Commission Territories such as Basutoland (now Lesotho) where, as early as 1931, there were many African personnel working in hospital wards and outpatient dispensaries under European supervision. This arrangement was put forward as a model that might advantageously be implemented in South Africa.4 South African reformers were interested in the use of such health care “middles” within more distant parts of Africa, and in 1927 the government’s Report into Hospital Provision had commended the French West Africa system of “native” medical auxiliaries, where Africans worked under European supervision doing minor surgical and medical work. They thus “cannot interfere with the practices of fully qualified medical men.”5 This overwhelming concern that the interests of a white-dominated medical profession should not be harmed contributed to making “middles” in South Africa both contested and contingent. Shula Marks has suggested that “ambiguity has been the price of survival in a contradictory [colonial] world,”6 and this is an apposite insight to apply to South African middles in their in-between world. In her study of the Congo Nancy Hunt developed this perception further in depicting “new colonial middle figures” such as nursing men and midwives who “negotiated

172 Anne Digby colonialism” and who were “central to processes of translation in a colonial therapeutic economy.”7 Maryinez Lyons gave a concrete example of this in northern Zaire by analyzing the African infirmier or aide infirmier (a medical auxiliary or assistant), who was used extensively by the Belgian colonial administration in their early twentieth-century campaign against sleeping sickness. With the aid of his microscope he might screen travelers under European medical supervision where possible, or alternatively could act as a medical orderly in a team of doctors and agents sanitaires helping examine, inject, or record cases.8 Lyons also compared medical auxiliaries/assistants—whom she aptly termed colonial “hybrids”—in the Belgian Congo with those in the British Protectorate of Uganda. In both territories there was a paternalistic concern to screen candidates carefully as well as to keep the assistant under close supervision within a controlling colonial hierarchy. Whereas demeaning inequalities of pay and working conditions and a perceived second-class status characterized medical auxiliaries in both schemes, their trajectories differed in that the British aimed to produce a specialist technician, as opposed to the Belgian objective of producing an assistant capable of a range of duties.9 And in colonial Nyasaland (now Malawi), Markku Hokkanen has researched the emergence of medical “middles” within a missionary world—the African medical assistants, dispensary “boys” and hospital “boys”—who worked under white doctors, and whose qualifications were as much religious as medical in nature.10 In-betweens are neither one thing nor the other, so that this is an appropriate description for these protean auxiliaries. “Middles” were strongly context specific, with individual agency shaped by social structures. Both colonialism (within an established racial hierarchy) and professionalism (with defi ned conditions of training and practice) delimited the space in which such intermediaries emerged. “Middles” are elusive subjects to research, however, and Marks has noted that South African ward attendants, nursing assistants, and orderlies were “virtually invisible in the written record.”11 Both Karin Shapiro and Vanessa Noble have written about “middles” in South Africa: Shapiro focused on the debate over the merits of fully trained black doctors versus medical aids/assistants,12 whereas Noble concentrated on health assistants in Natal, more particularly those at the Polela Health Center, where she highlighted their ambiguous status as both insider and outsider.13 In this chapter I shall focus on mid-level health care workers including hospital orderlies and medical aids in colonial and postcolonial South Africa. The emergence of these largely black health care intermediaries was stimulated both by an increasing demand for “Western” health care by Africans, Indians, and Coloreds (mixed race), and by the economic needs of a white settler population, which wanted to keep a black labor force healthy through expanded health care. Less overtly acknowledged was the need for these health care intermediaries to act as cultural brokers in interpreting indigenous languages, beliefs, and practices to their

The Mid-Level Health Worker in South Africa 173 white colleagues. Although required to underpin colonial health care, the intermediary’s status and designated functions were circumscribed by the requirement to slot into a subordinate position within established racial and professional hierarchies dominated by white personnel. For hospital orderlies, often untrained and working within the rigid hierarchies of hospital employment, this position involved nurses and/or medical officers supervising largely unskilled work. The continued survival of the post depended on flexible duties, which evolved in alignment with a changing institutional context. In contrast, medical aids and health assistants worked within a less defi ned health care context, where the fluidity of their job specifications often contributed to their short-lived existence because the ambitious professionalism of trained but subordinate African and Colored workers tended to impinge on the established preserves of higher level white professionals. Here key areas of contestation included rival views of professional independence versus supervision and whether posts involved what was perceived as higher status curative work, rather than lower status preventive and promotive medicine.

HOSPITAL ORDERLIES Before working in South Africa, the medical missionary Neil Macvicar pioneered the training of black medical assistants for employment in hospital wards, and in outlying dispensaries in Blantyre, Nyasaland.14 He also prepared a handbook for his local assistants to use in an eighteen-month training course, and on his departure was presented with a testimonial from the Free Church of Scotland’s missionary headquarters for work that included “the training of the Africans to medical work.”15 In 1902 he went as hospital superintendent to the recently established Victoria Hospital, Lovedale in the Eastern Cape of South Africa, where mission headquarters again thanked Macvicar for the “splendid work you are doing for the Kaffir people, alike in healing and teaching them nursing, dispensing and hospital service.”16 It perceived optimistically that “dawn is breaking all over South Africa and you will supply the great need of trained Kaffi r practitioners and nurses.”17 Victoria Hospital’s aim was thus not only in treatment, but also the pioneer training of Africans as nurses and orderlies.18 By 1907 three young men had qualified there as hospital assistants.19 They worked in male wards alongside African nurse probationers, as well as in the laboratory and the dispensary. Until the end of World War I there were references in the annual hospital reports to a handful of young men in training or apprenticeship who, after completing their training, generally went to work in Johannesburg, often to posts at the Compound Hospital for miners. 20 It appears that a total of twenty orderlies were trained, but that this ceased because there was insufficient work in the wards of a small hospital to train both female African nurses (seen as the priority) and male


Anne Digby

orderlies. 21 In addition there was a problem in getting the trained orderlies appropriate employment; an issue that was to recur later with medical aides and hygiene assistants.22 One of the best opportunities for the use of male orderlies was the mine hospital because mining companies traditionally had an aversion to employing female nurses. After public criticism of mine standards of health care mine medical officers debated the role and training of Africans employed as mine hospital attendants, orderlies, aides, or assistants. Implicit in this discussion of 1914–1915 was the assumption that only a training course inferior to that of a (white) female nurse should be given, lest inappropriate competition be introduced.23 Whether this discussion had a practical impact is uncertain, but an inquiry into the West Rand Consolidated Mines in 1928 found underqualified hospital staff at all levels, including two undertrained black nurse orderlies. 24 In her study of nursing in South Africa, Shula Marks referred variously to the African orderlies and assistants in black hospital wards as being both trained and untrained, who nevertheless offered skilled attendance as well as an ability to interpret. 25 Within a racially segregated South Africa there was reluctance to employ female white nurses in male African wards during the fi rst half of the twentieth century. A generalized racial anxiety by whites about the “uncivilized” or “unclean” black male informed a more specific fear of the inappropriateness of white female nurses looking after sick Africans. 26 Other reasons for the perpetuation of the role of male hospital orderlies were men’s disinclination to come forward to undertake nurse training in what was perceived to be a stereotypically female occupation and an institutional reluctance to provide such training. 27 Orderlies or assistants were used in a number of South African hospitals. In the Transvaal different salary rates were paid to black hospital assistants than to European assistants.28 Such assistants were plentiful in this province, and at the Jane Furse Mission Hospital, for example, there were as many as twenty-one (1944), seventeen (1945), and fourteen (1946), 29 although it is possible that these were inflated numbers because of nursing shortages during World War II. In the Cape Province hospital orderlies were widely found; in 1972 there were 226 male orderlies of whom twothirds were black.30 At the large provincial institution of Groote Schuur Hospital in Cape Town, there were orderlies from its inception in 1938. During the 1940s there were about two dozen African orderlies who were at fi rst encouraged to take Red Cross certificates in fi rst aid before a more formal training scheme was begun in 1944 when medical staff gave lectures and a hospital certificate was awarded. Once the hospital became a training school for a small cohort of male nurses in 1947, they took over more skilled duties while orderlies became responsible for tasks such as dealing with the obstreperous, lifting heavy patients, shaving male patients, or cleaning the ward.31 It is likely that a much more restricted ward “apprenticeship” or training on the job was then in use. That orderlies made themselves useful is indicated by a continued use of black orderlies in wards for Colored

The Mid-Level Health Worker in South Africa 175 (mixed race) and African males as well as in clinics and theaters. 32 That orderlies were at the base of the employment hierarchy was made clear by a grateful patient, who wrote to the local newspaper about his caring and compassionate treatment at the hospital in describing a progression from “the lowest orderly” up to the head of department.33 The male hospital orderly could play a vital part as a cultural broker, more especially in a hospital with black patients but a largely white medical staff such as Baragwaneth Hospital in Soweto during its mid-twentiethcentury years. Here an African orderly was described by the hospital chaplain as educating a young white doctor in cross-cultural issues: You see, doctor, it’s like this. When a patient goes to an African doctor [i.e., an indigenous healer] the doctor doesn’t ask him a lot of funny questions about “How do you feel? What is wrong with you? Where is the pain?” And so on. The doctor should know all about that. He can smell the sickness at once. What does take a long time is not the questions at the beginning but the treatment at the end—the mixtures and charms, the many things the patient is told to do or not to do. Very long instructions. But when the patient comes to the white doctor, the doctor asks him many, many questions about what he should know already. Then when it comes to the prescription the doctor only writes something very fast on a piece of paper, something you can’t read even if you understand English. The [African] patient is not impressed with such things.34 The newly qualified doctor apparently modified his approach in the light of this friendly advice, using information about the illness gained before he saw the patient—perhaps on the basis of the orderly’s information. Armed with prior knowledge, the doctor was enabled to ask the patient relevant question about his illness, and his prescriptions for medicine also became “more elaborate and ceremonious.” 35 In 1942 Paul Ngoyi put forward a reforming plan to utilize the scarce resource of trained African male health care workers in Johannesburg. This was a city then experiencing reform in the progressive provision of clinics for black people, with associated training of male health assistants to work in occupational therapy, as well as TB and VD facilities. Ngoyi was probably an experienced orderly or nurse, and his proposal, “A scheme for immediate action,” was unusual in focusing on trained African men and the use to which they could be put in a restructured health system. Here he envisaged them working under white public health officers in township clinics, but themselves supervising untrained African women. Catherine Burns has detected in Ngoyi’s letter a “new confidence and sense of entitlement,” reflecting the enhanced professional status of these health care workers and the better pay and subsidized housing they had received.36 But Ngoyi’s blueprint, like that of medical aides (discussed later), challenged

176 Anne Digby the current status quo to an unacceptable extent, not least in envisaging African auxiliaries doing not only preventive but curative work as well, thereby infringing the closely guarded preserve of a white-dominated medical profession. Predictably, Ngoyi’s scheme was not implemented. Within defined health care hierarchies the orderly’s borderline status— located somewhere between unskilled cleaner and skilled nursing assistant but with valuable additional skills in interpreting—suggests a lowly, ambiguous job category whose flexible but non-threatening character ensured its survival. Further up the employment pyramid, the post of medical aide had a much shorter life despite a comparable elasticity in job description, because in this case the fluidity of the post’s specifications fostered African professional ambitions that appeared to threaten vested white professional interests.

MEDICAL AIDES Trained medical assistants or aides had been deployed under white supervisors in other parts of Africa for some time, before South Africa took a comparable initiative.37 However, in the mid-twentieth century there was widespread concern in racially segregated South Africa about the lack of health care facilities for the African population, as well as about recent pressure on hospital facilities from them. In 1939 the Botha Committee on medical training highlighted the economic rationale behind any reform of health care provision for the African. It was based: not only on humanitarian grounds, but also for economic reasons. The non-Europeans, and especially the Natives, provide the cheap labour which makes it possible to run the gold mines and other industries of lesser importance, and they do the European’s work on his farm, and in his home. A healthy non-European population is therefore of vital importance to the Europeans themselves. 38 Instead of contemplating a necessarily slow expansion of qualified black doctors the committee envisaged a swifter growth of nurses, health visitors, and male assistants (medical aides). It therefore backed an expansion of the recently established medical aide scheme at Fort Hare.39 This support was reinforced two years later by the Native Affairs Commission’s preference for a medical aide service rather than an expansion of hospitals for Africans.40 This ill-fated medical aide scheme throws interesting light on the pressures and predicaments of health care intermediaries. The scheme to train African medical assistants had been discussed amongst missionaries for half a century.41 Indeed, at McCord Hospital in Durban in 1923 physicians James McCord and Alan Taylor had started a preliminary training course for male medical aides, with the intention that later training would take place at the South African Native College at Fort Hare but, because only

The Mid-Level Health Worker in South Africa 177 one student met the required educational standard, the experiment was abandoned.42 Finally, a training scheme was agreed upon with the government’s Department of Public Health (DPH) in 1934, and started in 1937.43 This four-year course at the South African Native College, Fort Hare had facilities to train up to fifteen men per year, and it was envisaged that a fi fth clinical year would be spent at a Durban hospital.44 The Minister of Health, Jan Hofmeyr, gave his backing for the Fort Hare scheme in order to provide a steady output of medical aids, rather than a mere trickle of fully trained African doctors.45 The scheme was fi nanced by a donation from the Johannesburg Chamber of Mines and as many as two hundred male aides were envisaged ultimately.46 Entry qualification was not the Junior Certificate normally appropriate for a medical subordinate’s training but full matriculation. But because the course was not shortened to take account of the higher entry qualification this meant that after one year’s pre-medical science, the course was not dissimilar to a full medical one. Clinical work involved classes under Macvicar at Victoria Hospital as well as assisting at district clinics where health education and nutritional supplements were supplied to African mothers and children. The academic syllabus included introductory anatomy, physiology, pathology, bacteriology, medicine, and surgery.47 However, the qualification after five years’ study was only a Diploma in Public Health and not a medical qualification. As a result, recruitment fell short of expectations because the few Africans who had matriculated at school wanted a better career than was offered by a medical aide post. Only eighteen students enrolled instead of the planned thirty during the fi rst three years of the course, and a meager total of thirtyfive medical aides were actually trained.48 Amongst them was Aaron Lebona, who enrolled in 1939 and qualified as a medical aide in 1942. Like many other Africans Lebona wanted to help his own people,49 and in a short article he recalled: Although this long course of five years training did not promise me a doctor’s degree, I decided on it because it was in line with my mission in life. Those years of study introduced me for the fi rst time to the human body, its structure, function and sufferings it experiences when seized with disease processes. I was keenly interested in the work, and always looked forward to demonstrations, lectures and ward rounds. I shall remember with gratitude those doctors . . . whose personality and sincerity of purpose influenced my medical outlook. As I was thus taken up in preparation for my future work among my people, and fully aware of the importance of efficiency, I began the policy of working in hospitals during the winter and summer vacations as an orderly. 50 Lebona worked in paid and unpaid employment at two mine hospitals on the Reef, as well as acting as a smallpox vaccinator, typhus or bilharzias assistant in the Transvaal, the Transkei, the Eastern Cape, and in Durban. This

178 Anne Digby was to earn the money required to carry him through his training and also to extend his clinical experience. He went on to say, “I knew I was accumulating something which money cannot buy, i.e. knowledge, and what is more, I was giving a hand where I was needed. These two facts have become the basis of my future work. Such experiences have transformed my whole being and I thank God for that.”51 Lebona’s work ethic and positive motivation resulted in him going on from his five-year medical aide training to a further six-year training as a medical student at the University of the Witwatersrand, the only known instance of this extended career progression.52 Contemporary verdicts on the plight of medical aides were critical about the scheme. One graduate of the course, E.D. Rwairwai, was dissatisfied with his uncertain status and role that meant he spent too much time merely dressing wounds. And another graduate, B.B. Nodada, had wanted to work in a rural area but found himself in a hospital, concluding that he had wasted five years of his life in training as a medical aide. 53 L.P. Msomi (who represented Africans on the indirectly elected, national Native Representative Council), perceived the uncertain status of the medical aide as having caused a recruitment problem. He reported that “many of them said that they would not train for it, because they felt that their chance of making a living would be very much circumscribed and they realise that one never gets two chances in life.”54 He stated that he was very much against offering inferior training and qualifications to Africans in order to supply personnel quickly.55 These views echoed those of a formidable critic of the principles of the medical aide scheme, A.B. Xuma, a leading early black doctor. He rejected arguments of urgency, together with those of quantity versus quality in supplying black medical personnel in the form of medical aides rather than of medical doctors. Xuma also attempted to address the fears of the white medical profession by stating that “the medical profession needs no ‘protective tariff ’ wall to shelter them from competition with other practitioners.”56 In addition, he argued that “unless and until there are members of the African people themselves trained for the highest and best qualifications in nursing, medicine, surgery and public health . . . nothing can be achieved. The medical aid idea is the most distasteful thing to all fair-minded people black and white.”57 Influential white players revealed fundamental ambivalence towards the creation of a corps of medical aides. D.L. Smit of the Native Affairs Department referred to the complaint of the Medical Association of South Africa that medical aides were becoming “half-baked doctors,” because their training was in curative rather than in the preventive medicine perceived to be useful in a health care service for local areas.58 By straying into curative medicine, the training of medical aides was perceived as a potential threat to the rural district surgeon’s fi nancially precarious private practice. Physician George Gale was another critic, although earlier he had been a supporter in acting as the fi rst medical lecturer for the original intake of

The Mid-Level Health Worker in South Africa 179 recruits in 1936–1937. He referred sympathetically to the few who had graduated. “They are dissatisfied and I must say that my sympathies are with them. They have certainly had a raw deal.”59 Gale recalled that when he went to Fort Hare “suspicion and resentment were already in full bloom among the students, who were the more bitter in that they felt they had been sold down the river” and were only too aware of the limitations of the scheme.60 And he suggested that “the term ‘Medical Aid’ had not been popular because it conveyed a subtle suggestion of inferiority.”61 In 1938 he published an extensive critique of the policy, rationale, and character of aides’ training as an unsatisfactory compromise between a full medical training and a lower level health assistant’s training.62 Later on, as assistant secretary to the DPH, Gale suggested that the medical aide plan was “a rather ambitious scheme . . . the original conceptions was perfectly sound; the thing, however, went wrong.”63 In his view this was because: It was intended originally to produce a very superior type of native health assistant . . . It was not intended that he should go further in the curative scheme than registered nurses were allowed to go . . . [but] you got a course of four or five years past matriculation, and the result was that these fellows . . . were half way on the road to becoming doctors, but they were not doctors. Well, the whole thing was a terrific muddle.64 That aides were “half way on the road to becoming doctors” was the fundamental reason why he thought that the course was terminated, in that they had been trained to do things that the Medical Dental and Pharmacy Act (1928) reserved for medical practitioners. “They have been carried too far, they should have been carried the whole length of the road or they should have been stopped much further back.”65 Hence medical aides had outgrown the intermediate status originally envisaged for them by white policy makers, insofar as they had been given the potential to leapfrog from medical subordinate to principal. In order to prevent this, the succeeding scheme—a three- to four-year BSc degree in hygiene—was solely devoted to preventive medicine. Despite half a century of intermittent discussion about the need for improved health care for the black population, and how to bring it about through training assistants or doctors, the scheme that fi nally came to fruition was vulnerable to opposition from organized interest groups.66 Professor C.P. Dent, principal of Fort Hare, reflected that “the medical aids who were trained under the old scheme were judged and condemned before they were started. That whole course was condemned before the men were tried out.”67 He also perceived recruitment difficulties as having undercut the scheme, in that because of adverse publicity candidates for the course were “not of the best academic character.”68 In addition, Fort Hare had jumped the gun in failing to run it formally past the South African Medical and Dental Council, which registered health professionals such as doctors,


Anne Digby

dentists, pharmacists, nurses, and dentists. The certificate gained from the course thus had no general professional currency. Yet the training given to medical aids included procedures—such as the use of the stethoscope, or the giving of intravenous injections—that the council viewed as the special prerogative of the doctor. Another factor was that the University of the Witwatersrand opened its hitherto white medical course to Africans in 1940, thus offering a more professionally attractive career. Able students at Fort Hare competed for bursaries for the course, and fifty-five holders of these had qualified as doctors by 1959 (when the apartheid government closed the course for non-Europeans). In 1950 a new Natal Medical School for Africans, Indians, and Colored students opened in Durban, offering a seven-year training course.69 Amongst the few medical aids that emerged from this contested arena was Edward Jali. A former health assistant of James McCord in Durban, Jali soon found employment in the Natal clinics of Tugela Ferry Mission Hospital (a sister hospital to Victoria Hospital, Lovedale where the medical aids had gained clinical experience). On graduating in January 1940 he had written to his sponsor McCord, “I have come to the end of my training. I am now fit to go out in the world . . . I will give myself for the service of my people.”70 In a follow-up letter to Margaret McCord written a few months later, he described how he stayed a week or a fortnight at each clinic, working independently. “My duty is not to examine the patients and prescribe some wonderful drug but to teach the people better ways to live . . . I tell them about the spread of disease. My best example is how TB is spread . . . People believe wherever I go that I am a doctor, but in thinking that they flatter me.”71 Apart from mission hospitals employment for the medical aide was found in a few pioneering health clinics, which progressives hoped would be the basic unit in an emerging national health service, but which got off the ground in only a few places.72 Dr. Kark employed medical aides at the groundbreaking Polela Health Unit that pioneered preventive and promotive-centered community health care in South Africa. Here a medical aide ran the Saturday morning nutrition clinic, and during the week medical aides visited homes to do routine vaccination and immunization against infectious diseases.73 By 1943 Jali had become the senior medical aide at Polela, giving promotive health education talks to local inhabitants on superstition and on African concepts of disease. Effectively he was acting as a cultural broker in ways that he had described earlier in his letters to the McCords about his work at Tugela Ferry. There he had explained in his teaching how he had replaced the mtakati [wizard]—as the originator of disease in African’s belief—with animals and fl ies as the carriers of disease.74 Jali and other medical aides worked side by side at Polela with more numerous health assistants employed to do detailed recording work in a program of family welfare.75 Simon Ngcobo was another mid-level health worker who was pivotal to the success of a health center. He was a respected intermediary at Botha’s

The Mid-Level Health Worker in South Africa 181 Hill Health Centre, having an in-between status between the white medical officer, physician Halley Stott, and the Zulu patients and, at the same time, becoming a strategic go-between with the wider Zulu community. He was principal health assistant at the Botha’s Hill Health Centre, Natal, from 1951 to 1963, and was married to the principal nursing sister. Together they made up “a splendid team which contributed in no small degree to the sound efficiency of the health centre service,” according to Stott.76 Furthermore: No decisions with regard to the planning and implementation of medical services in the community were made without prior consultation with Simon who, if in any doubt, would undertake a painstaking investigation of the situation, particularly public attitudes, before giving his carefully considered, and characteristically balanced opinions. Simon also aided pioneering work in nutrition undertaken by the neighboring NGO, the Valley Trust, through setting up a model vegetable garden by the entrance to the health center, thereby promoting the concept of holistic health, in that a nutritious diet contributed to the maintenance of health once medical treatment had begun the path back from sickness. A huge number of Africans traveled from Natal, Zululand, and the Transkei to be at Ngcobo’s funeral, thus showing the respect and admiration that his work had earned in the community.77 Medical aides fitted into the interstices of a fragmented South African health care system by working in institutions that included the specialist Bochen Institute in the Transvaal, as well as the Holy Cross Mission Hospital, the Umtata Rural Health Unit, and the Mkambati Leper Asylum in the Transkei.78 In the Umtata Unit four medical aides were employed to examine schoolchildren in recently established clinics and with follow-up work in their homes, as well as in investigating typhus outbreaks.79 Care was taken both to try to corral these aids into preventive health care duties and make them work under European supervision. One of these medical aides was Samuel Senokoanyane, who insisted on being proactive in envisaging what public health tasks needed doing. At Qokolweni Location in the rural Transkei, he developed “the fi rm conviction that the medical aid can and must be afforded the opportunity to fi ll up the gap in the education of the people” to enable them to live healthily and hygienically.80 He also did a valuable bilharzias survey.81 From the fi rst, medical aides had been trained to become subordinates.82 P.S. Mdala, who worked at Holy Cross Hospital, commented: I reached this popular country hospital at the end of January 1941 . . . [with] anxiety and ignorance of where I was to wedge in with my aid . . . It was with these mixed feelings that I reported for duty to the Medical Superintendent who soon calmed my mind by defi ning my


Anne Digby duties. I am now happy to say that I derive much satisfaction from my work of aiding the doctors, the sisters, and the nurses.83

As Mdala indicated, the medical aide fitted in as a medical auxiliary through assisting doctors and nurses, but the key issue was how much independence he possessed. According to the medical missionary F.S. Drewe, “their work is good and they are of tremendous help.”84 He stated of Mdala, “The man who is here in the hospital is intensely useful if he is under your supervision all the time.”85 But he had a tendency to branch out on his own, rather than appealing to Drewe for advice. Mdala worked mainly in the outpatient department of Holy Cross giving anti-syphilis treatments, injections, or in taking histories, thus effectively acting as a clerk or junior house surgeon under supervision.86 Drewe found the work of this “middle” sufficiently useful to try to obtain a health assistant as well.87 Peter Allan (secretary of the DPH), asserted of medical aides, “we cannot use them as they expect to be used” because of the European’s judgment that they could not work independently, but needed supervision.88 He went on to say, “The missionaries even, who are very keen on pushing natives into positions, and who are the greatest protagonists of the natives, say that they could not even trust them to run detached clinics; the only way they can be of use is absolutely under their eye.”89 This ruled out the model employed in other parts of Africa where substantially independent auxiliaries ran outlying clinics and dispensaries. Although we do not have the views of a medical aide on this issue, there is a comparable voice in that of an African nurse, Susan Sebeta, of the Bantu Trained Nurses Association. She argued that European supervision for black personnel in the fields of district health visiting and health education was in fact unnecessary: We feel that we are being held back. After we have fi nished our training, when we are out in the field, we feel that we should be given a greater measure of responsibility, that we should be able to do the work . . . As long as we feel that there is someone else who is ultimately responsible, we are not encouraged to act on our own initiative and to show our own sense of responsibility.90

HISTORICAL TRAJECTORIES Apart from hospital orderlies and medical aides there were other “middles” or health care intermediaries in colonial and postcolonial South Africa. Within a fragmented and overcomplex health system the grossly inadequate health services for the black population had precipitated discussion, rival schemes, and some practical initiatives from the early twentieth century onwards, although the medical council recognized none. By 1931 there were untrained African typhus inspectors in Natal,91 and the following

The Mid-Level Health Worker in South Africa 183 year malaria assistants began to be trained by physician Park Ross, and were said to have done exceptionally good work in this province.92 Some went to work as health assistants after the Polela Health Unit began in 1940. They received further training by Dr. Kark, who commented that “we can constantly go on experimenting with different methods until we reach something that is fairly suitable.”93 Also in Natal, Dr. Anning at Pietermaritzburg (and later on at Benoni in the Transvaal) persuaded the local authority to fi nance a course for Africans in public health work for black locations. Anning’s assistants went to work in places in other provinces including Cape Town, East London, King Williams Town, as well as Krugersdorp, Germiston, and Springs. Despite praise from the DPH, and the suggestion that this training should be placed on a formal footing, no official approval was forthcoming so that the assistants neither possessed a certificate, nor benefited from the kind of increased income and status that such certification would have conferred.94 Progressive figures giving evidence to the Gluckman Commission of 1942–1944 sketched out a blueprint for the use of black assistants within a future national health service. D.L. Smit of the Native Affairs Department supported “a large force of native health assistants specially trained in rural hygiene” to help staff the projected new rural health units proposed by the commission, where assistants would work with medical aids. He considered that the assistant’s training should be fi nanced by the DPH, as had been the case earlier with malaria assistants. Smit envisaged both Europeans and Africans taking basic hygiene degrees in rural areas where health units would serve the whole population. These assistants would be well equipped to cope with what he termed “the special problems of communities emerging from barbarism and still living in a purely rural environment.”95 It was also thought that a Native Health Service might benefit from staff recruited from the army, which had trained black recruits in hygiene and sanitation during World War II.96 Gale saw a need for African health assistants of more than one type, each with appropriate training, and considered them as “a most important pre-requisite to the effective development of a native health service.”97 He envisaged all these assistants working under the leadership of a doctor in a heath unit serving ten thousand to fi fteen thousand people.98 Later, Gale supported a three-year training for health assistants because, “There must be an intermediary between the doctor practising social medicine and the homes of his patients; and that intermediary must be a general purpose auxiliary speaking the vernacular and trained wholly for that particular job.”99 He was describing a cultural broker in all but name; an in-between auxiliary who, because he had had a foot in each of two worlds could bridge two different ways of life and explain Western ideas by reference to familiar forms of indigenous knowledge, so that African patients could understand their medical treatment. In 1948 the National Party won the general election in South Africa and soon put a brake on such progressive health proposals. When the medical


Anne Digby

aide course was terminated in 1943, it had been replaced by a three-year BSc (Hygiene) course in preventive medicine. Only sixty-nine had graduated before this program was ended in 1953 because of an alleged lack of job opportunities.100 From 1946 the progressive Institute of Family and Community Health at Durban (funded by the Union Health Department until the late 1950s), provided a training period for black health assistants that lengthened from six months to three years, and focused on health education, the maintenance of health center records, and on technical and laboratory procedures.101 The public health service was restricted largely to whites under the new apartheid regime instead of being geared to the whole population as the Gluckman Commission had earlier imagined. Progressives still hoped for a measure of reform, as in the South African Institute of Race Relations Report of 1965, which concluded, “The present and possible production of Bantu doctors is not rapid enough . . . so that attention has to be given to training Bantu medical assistants, in a short course for restricted purposes, to assist in bringing basic medical services to all sections of the community.”102 By 1965 the DPH had once again come around to the advisability of training intermediaries and initiated a two-year training course for African health educators.103 By the end of 1968, seventy-two health educators were trained and employed by the state. One of these was the Zulu P. Mgobozi, who had been trained as a health educator before attending an orientation course at the King George V Hospital in Durban. The course was to prepare him for work at the East Rand SANTA Center, where there were 750 beds for African patients with tuberculosis. Mgobozi’s professional dedication was evident in a short article describing his work in conducting group sessions and private interviews with patients. He not only had a middling status in the hospital, but was also effectively a cultural “middle” poised between black and white beliefs. He asserted, “An educated Bantu is not necessarily convinced of the truth of White beliefs. I myself, although previously qualified and working as a health educator, only really became convinced of the truth of what I now teach when I attended the orientation course.”104 And he had interesting observations on the clash of cultures in the hospital. “A health educator must be prepared to encounter some resentment. Certain patients (fortunately in the minority) despise him for ‘eating the white man’s saliva,’ in being over-influenced by European culture.”105 The health educators’ course was later truncated to twelve months, followed by six months practical in-service training, while at the same time their function was widened into that of “Bantu Health Assistants” with responsibilities not only for health education but for “sanitation, nutrition, and the combating of tuberculosis, malaria, bilharzias, and other infections and communicable diseases.”106 Courses were started at Edendale College, Maritzburg, and at Mmadikoti Technical College, Pietersburg.107 A more advanced course for medical technologists began, and a number of student bursaries were enrolled.

The Mid-Level Health Worker in South Africa 185 These initiatives suggest that there was growing acknowledgment by the state of the need for medical intermediaries to serve the black population, not least because of the very slow growth of black doctors. This recognition was also stimulated by the development of so-called “homelands” or Bantustans and these African intermediaries were increasingly directed to employment there.108 But professional interest groups viewed a growth in medical “middles” with caution. The Medical Association of South Africa made clear that such an assistant would only be trained to “perform certain simple, diagnostic and therapeutic acts” in order to “relieve the doctor of much work.”109 And Charlotte Searle, professor of Nursing at Pretoria, warned of “irreparable damage” to both the nursing and medical profession if a “second-grade of doctor or a physician’s assistant” were to be introduced.110 She argued against any revival of a scheme for medical assistants or “second-class doctors,” in referring to the earlier ill-fated Fort Hare scheme, stating that nurses could not take part in any “relay-station concept” whereby the doctor would give orders to an assistant who would then give orders to the nurse.111 South Africa is both a developed and a developing country, possessing different levels of economic development and of health provision. Those in the developed sector, where professionalization is at an advanced stage, have tended to be hostile to the introduction of intermediaries or “middles,” perceiving it as a form of professional dilution. Yet auxiliaries in health care have been found to be invaluable in developing countries, as Fendall’s classic handbook had made clear.112 And in many African countries, medical auxiliaries played a vital role, as Michael Gelfand’s African Medical Handbook elucidated, showing the importance of the nursing orderly’s varied hospital responsibilities.113 Some argued that dusting off Gelfand’s African Medical Handbook of 1947 would be a good starting point and that medical auxiliaries could be the appropriate response to South Africa’s continuing unmet health needs.114 But it was not until South Africa’s democratic transition of 1994 that there was a robust revival of the concept of a mid-level health care worker to serve the majority black population in a reformed health service that prioritized decentralized primary health clinics and aimed to redress imbalances in resources. At the beginning of the twenty-fi rst century mid-level workers existed in seven professional areas in South Africa, but with wide variation in their ratios to professionals, and with related problems such as professional protectionism, a lack of recognition, and an absence of clarity as to whether these workers were adjuncts to professionals or replacements in areas where recruitment was difficult. The Pick Report of 2001 took a bold line in recommending a broadening of the scope of mid-level workers’ tasks. Continuing problems in this area were indicated by the discontinuation of the generic Community Rehabilitation Worker program in 2003.115 However, the utility of the mid-level worker in a national health service has continued to attract policy makers, so that the government’s “strategic


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Priorities for the National Health System, 2004–9” announced, “A decision has been taken to implement a medical assistant program as a matter of urgency.”116 The then Minister of Health, M. Tshabalala-Msimang, launched this program in 2004 as a pilot in certain district hospitals. This was after a study group had looked to the best practice of Tanzania (with its four mid-level health workers) and to the U.S. (with its physician assistants), in planning a “mid-level” health worker. In doing so the South African Department of Health appeared ignorant of its own country’s earlier experience of such assistants. The proposed post would be part of the district hospital staff with a three-year training in a medical curriculum and a one-year internship.117 By 2008 the terminology had changed so that the new “middle” was labeled a clinical associate, and the minister formally launched the beginning of the fi rst such training program at the Walter Sisulu University.118 She celebrated this “new cadre of health care providers,” referred to the “long process of discussions, debate, preparation, and fi nally implementation” of their training that included consultation with the South African Medical Association, and the South African Nursing Council. The new clinical associate was to work “with and under” a qualified medical practitioner, and would be a “competent, professional” with “the necessary knowledge, skill, and attitudes to function effectively.”119 The minister attempted reassurance to professional bodies by emphasizing that such workers were meant to “bridge the gap between the urban and rural divide, the well-resourced and under-serviced parts of the country, it is by no means an attempt to replace any cadre of existing qualified health professional.”120 That such reassurance was needed in the face of anxiety from health care professionals had been suggested by an earlier editorial in the South African Medical Journal headed “Mid-Level Workers: HighLevel Bungling.” It argued that a new, educationally flawed health worker category was more likely to aggravate than solve health care problems.121 In a self-congratulatory endpoint, the minister stated that, “we have to be ever-creative and innovative in addressing challenges facing South Africa’s health care needs.”122 Creative perhaps, but this scheme was not innovatory. In South Africa the hybrid figure of the medical assistant had emerged in an earlier health care economy, but the ambiguities of the position had made it insecure and short-lived. The current need to reinvent the role indicates that there is a continued need for such an intermediate post to remedy gaps in health care provision. Indeed, an initiative to train pharmacy support personnel as pharmacy technicians has recently been scheduled to begin in 2011.123 Power relations within an earlier health care world had reflected racial assumptions and prejudices, because for many years the South African medical and nursing professions were white dominated whereas the “middle” was usually black. Almost by definition black “middles” straddled different worlds in linking Western and indigenous medicine through crossovers between their

The Mid-Level Health Worker in South Africa 187 training in the former and their assumed knowledge of the latter.124 This asymmetrical position—trained but not fully professional, assuming responsibilities yet under supervision—produced conflicting assessment of role and potential agency. An inbuilt tension existed because established professionals thought supervision essential within defined, controlled employment situations, whereas auxiliaries were keen to show their worth by enlarging the field of their duties. Borderline status, together with an inbuilt imprecision in function, resulted in recurrent difficulties in demarcating such posts appropriately within established hierarchies of training, status, and reward. Within the disjointed landscape of South African health care the ill-defined professional contours of the “middle” could be enabling in the short term (as posts were seen to fill important employment gaps), although it could be destructive in the longer term (as fellow professionals then perceived intermediaries as challenging their own position). Ideal blueprints but imperfect and evolving realities therefore characterized the ambiguous, in-between world of the colonial and postcolonial South African “middle.”

NOTES 1. Lord Hailey, An African Survey. A Study of the Problems Arising in Africa South of the Sahara (Oxford: Oxford University Press, 1938), 1182. 2. National Archives, London, CO 998/4–6, Committee on the Training of Nurses for the Colonies. Sub-Committee B on the Training Given in the Colonies to Indigenous Nurses, 1944. 3. National Archives, London, CO 998/4–6, Committee on the Training of Nurses for the Colonies. 4. N.M. Macfarlane, “Medical Services for Native Areas,” South African Medical Journal (hereafter SAMJ), February 28, 1931. 5. South African government papers, UG 35–1927, Hospital Survey Committee, 65. 6. Shula Marks, The Ambiguities of Dependence in South Africa; Class, Nationalism and the State in Twentieth-Century Natal (Baltimore, MD: The Johns Hopkins University Press, 1986), vii, 14. 7. Nancy Rose Hunt, A Colonial Lexicon of Birth Ritual, Medicalization, and Mobility in the Congo (Durham, NC: Duke University Press, 1999), 2, 10, 23. 8. Maryinez Lyons, The Colonial Disease. A Social History of Sleeping Sickness in Northern Zaire (Cambridge: Cambridge University Press, 1992), 129, 140, 142–145. 9. Maryinez Lyons, “The Power to Heal: African Medical Auxiliaries in Colonial Belgian Congo and Uganda,” in Contesting Colonial Hegemony: State and Society in Africa and India, ed. David Engels and Shula Marks, 202– 223 (London: British Academic Press, 1994) 10. Marku Hokkanen, Medicine and Scottish Missionaries in the Northern Malawi Region, 1875–1930 (Lampeter: Edwin Mellen Press, 2007), 412–420. 11. Shula Marks, Divided Sisterhood. Race, Class and Gender in the South African Nursing Profession (Johannesburg: University of Witwatersrand University Press, 1994), 62.


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12. Karen Shapiro, “Doctors or Medical Aids—The Debate over the Training of Black Medical Personnel in the Rural Black Population in South Africa in the 1920s and 1930s,” Journal of Southern African Studies 13 (1987): 234–255. 13. Vanessa Noble, “Health Is Much Too Important a Subject to Be Left to Doctors”: African Assistant Health Workers in Natal during the Early Twentieth Century,” Journal of Natal and Zulu History 25, no. 6 (2006–2007): 95–134. 14. Neil Macvicar (MD, DPH) was at Victoria Hospital from 1902 to his retirement in 1937. 15. National Library of Scotland (hereafter NLS): MS 7537, Letter 347 of June 8, 1899, from Archibald Scott to Neil Macvicar; NLS: MS 7538, Letter 805 of October 14, 1901, from A. Scott; N. Macvicar, Lectures to Hospital Assistants (Blantyre: Domasis Mission Press, 1898). 16. NLS: MS 7779, Letter 179 of May 13, 1904, from G. Smith. 17. NLS: MS7781, Letter 34 of March 26, 1909. 18. J. Wells, The Life of James Stewart (London: Hodder and Stoughton, 1909), 227. 19. Wells, James Stewart, 150, 227–228. 20. “Victoria Hospital Report, 1914” and “Victoria Hospital Report, 1916,” South African Outlook (hereafter SAO), February 1, 1915, and 1917. 21. R.H.W. Shepherd, Lovedale South Africa. The Story of a Century, 1841–1941 (Alice: Lovedale Press, 1941), 484–485. In contrast to this figure, Lunde states erroneously that only four were trained. M.J. Lunde, “North Meets South in Medical Missionary Work: Dr. Neil Macvicar, African Belief, and Western Reaction,” South African Historical Journal 61, no. 2 (2009): 348–349. 22. Marks, Divided Sisterhood, 87. 23. Catherine Burns, “A Man is a Clumsy Thing Who Does Not Know How to Handle a Sick Person: Aspects of the History of Masculinity and Race in the Shaping of Male Nursing in South Africa,” Journal of Southern African Studies 24 (1998): 704–706. 24. Burns, “A Man,” 708. 25. Marks, Divided Sisterhood, 61–62. 26. Burns, “A Man,” 701. 27. Anne Digby, Howard Phillips, with Harriet Deacon and K. Thomson, At the Heart of Healing: Groote Schuur Hospital, 1938–2008 (Johannesburg: Jacana, 2008), 170; Anne Digby, Diversity and Division in Medicine. Health Care in South Africa from the 1800s (Oxford: Peter Lang, 2006), 233. 28. University of Cape Town Library Government Publications, evidence to Gluckman Commission (hereafter GC), 329 (evidence by G. Pentz). 29. Rhodes House, University of Oxford, USPG M340, Jane Furse Hospital Reports. 30. Groote Schuur Hospital Archives, H-R. Saunders, “Focus on Nurses” (typescript, 1972). 31. Cape Archives, HN 21/1, October 1, 1958. 32. Digby et al., At the Heart of Healing, 170–171. 33. Cape Argus, July 24, 1998. 34. M. Jarrett-Kerr, African Pulse (London: Faith Press, 1960), 30. 35. Jarrett-Kerr, African Pulse, 30. 36. Burns, “A Man,” 711–714. 37. GC, 773–74 (evidence of James Collie). 38. South African government papers, UG 25–1939, Committee on Medical Training in South Africa, 37. 39. Committee on Medical Training, 37, 39–40.

The Mid-Level Health Worker in South Africa 189 40. South African government papers, UG 42–1941, Report of the Native Affairs Commission, appendix on “Native Health,” 59. 41. Digby, Diversity and Division, 192–193. 42. A. Kerr, “Fort Hare Historical Notes. The Health of the People, I,” SAO, October 2, 1961, 157. 43. Digby, Diversity and Division, 192–195; GC, 1760 (evidence of Dr. Gale). 44. “The Medical Training of Non-Europeans,” in Committee on Medical Training, 40. 45. SAO, May 1, 1940, 81. 46. British Medical Journal, July 21, 1934, 128. 47. SAO, March 1, 1940, 55; November 1, 1961, 170. 48. G. Gale, A Suggested Approach to the Health Needs of the Native Rural Areas of South Africa (Benoni: Record Printing Company, 1938), 19; SAO, November 1, 1962, 169. 49. See Lyons, “Power to Heal,” 218, and references in footnote 74; letter from Edward Jali quoted in J.B. McCord, My Patients Were Zulus (London: Muller, 1946), 238. 50. A.D. Lebona, “What I Hope to Do for My People,” SAMJ 18 (1944): 374. 51. Lebona, “What I Hope to Do for My People,” 374. 52. Lebona went on to be Minister of Health in Lesotho, and establish a flying doctor service (Obituary, Sunday Times, December 1, 2003). For a discussion of the ambiguity of “What I Hope to Do for My People,” see Anne Digby, “Early Black Doctors in South Africa,” Journal of African History 46 (2005): 427–454. 53. I.S. Monomadi, “Medical Doctors under Segregation and Apartheid: A Sociological Analysis of Professionalization among the Doctors in South Africa, 1900–1980” (PhD diss., Indiana University, 1996), 259. 54. GC, 9281. 55. Ibid. 56. University of Witwatersrand, SAIRR archive, ABX 360811, “The Training of Natives in Medicine: Notes on a Native Medical Service in Rural Areas,” SAMJ, January 24, 1931, 39–43; Letter of August 11, 1936, to the Secretary of the Committee of Enquiry on National Health Insurance. 57. Ibid. 58. GC, 2762. 59. GC, 1755. 60. George Gale, letter to Editor of SAO, December 2, 1963. 61. Gale, Suggested Approach, 27. 62. Ibid., 8–9, 16–19, 25–26. 63. GC, 1719. 64. GC, 1724. 65. GC, 1754. 66. See, for example, E. Holland, N. Haysom, A. Brodie, S. Javett and M. Abel, “National Health Insurance and Medical Services for Rural Areas,” SAMJ, April 11, 1936, 249–256, for opposition by district surgeons to medical aides. 67. GC, 7027. 68. GC, 7027. 69. Kerr, “Fort Hare,” SAO, November 1, 1961, 170–171. 70. McCord, Patients, 237–239. 71. Ibid. 72. See Anne Digby, “Vision and Vested Interests: National Health Service Reform in South Africa and Britain during the 1940s and Beyond,” Social History of Medicine 21, no. 3 (2008): 485–502.

190 Anne Digby 73. GC, 8648, 8655, 8657. 74. McCord, Patients, 237. 75. D.R., “An Experiment in Social Medicine. A Brief Description of the Work at the Polela Health Unit,” SAO, August 1, 1945, 120. 76. Obituary in Valley Trust Report, 1975, 7. 77. Ibid. 78. South African government papers, UG 8–1941, Report of Department of Public Health, 62. 79. R. Smit, “The Umtata Rural Health Unit,” SAMJ, April 22, 1944, 140; M. Macgregor, “Children of Umtata District,” SAMJ, April 22, 1942. 80. S.R. Senokoanyane, “Medical Aid in a Rural Location in the Transkei,” SAMJ, April 22, 1942, 129–130. 81. Senokoanyane, “Medical Aid in a Rural Location in the Transkei.” 82. A. Kerr. “Fort Hare Historical Notes. The Health of the People II,” SAO, November 1, 1961, 169. 83. Rhodes House, University of Oxford, USPG M386, Holy Cross Hospital Report, 1942. 84. GC, 8657. 85. Ibid. 86. Ibid. 87. Ibid. 88. GC, 511. 89. Ibid. 90. GC, 8035, 8038. 91. R.H. Welsh, “Medical Services to the Natives,” SAMJ, January 24, 1931. 92. GC, 1712. 93. GC, 8648, 8655, 8657. 94. GC, 1720–2. 95. GC, 2763–8. 96. GC, 2857 (evidence of Captain Kemp). 97. GC, 1713. 98. GC, 1729. 99. University of York, Borthwick Archives, Durban, Gale papers, file GA, undated, confidential annexure by Gale on Gear’s comments upon the training scheme for health personnel. 100. Kerr, “Fort Hare,” SAO, November 1, 1961, 170; SAIRR Report (1952– 1953), 71. 101. “The Institute of Family and Community Health,” SAMJ, November 24, 1951, 872. 102. Rhodes University, Cory MS 16,575, folder 3, Report on Secondary Education (Johannesburg: SAIRR, 1965). 103. South African government papers, RP 53–1969, Report of Department of Health 1965–7, 35. 104. “My Experience as a Health Educator in a Bantu Tuberculosis Hospital,” SAMJ 19 (July 1969): 909–910. 105. Ibid. 106. Ibid. 107. South African government papers, RP 87–1969, Report of Department of Health, 1968, 36. 108. Reports (SAIRR: Johannesburg, 1965), 288; (1966), 261, 265; (1967), 271, 291, 302. 109. “MASA information fi le,” SAMJ, October 7, 1972, 1499. 110. C. Searle, “No Need for Physicians’ Assistants in South Africa,” SA Verplegingstydskrif (March 1970): 24.

The Mid-Level Health Worker in South Africa 191 111. C. Searle, “The Second-Class Doctor and the Medical Assistant in South Africa,” SAMJ, March 31, 1973, 509–512. 112. N.R.E. Fendall, Auxiliaries in Health Care. Programs in Developing Countries (Baltimore, MD: The Johns Hopkins University Press, 1972), 174–196. 113. Michael Gelfand, African Medical Handbook: An Outline of Medicine and Hospital Practice for African Orderlies and Medical Assistants (Cape Town: African Bookman, 1947). 114. D. Whitaker, “South Africa’s Unmet Health Needs—Do We Need Medical Auxiliaries?” SAMJ 80 (September 1991): 216–217. 115. J. Hugo, “Mid-Level Health Workers in South Africa, Not an Easy Option,” in South African Health Review, 2005, ed. P. Ijumba and P. Barron, 149–157 (Durban: Health Systems Trust, 2005). 116. “Strategic Priorities for the National Health System, 2004–9,” 12, www. (accessed June 13, 2007). 117. “Launch of the Medical Assistant Program in South Africa,” March 29–30, 2004, speech of the Minister of Health, sp0329. 118. Twenty-three students are at Walter Susulu University, and another seventysix students will soon embark on training at Witwatersrand, Limpopo, and Pretoria Universities. Speech at the Official Launch of Clinical Associate Programme in South Africa, . ./08082012451006. htm. 119. Speech at the Official Launch of Clinical Associate Programme in South Africa, . ./08082012451006.htm. 120. Speech at the Official Launch of Clinical Associate Programme in South Africa, . ./08082012451006.htm. 121. SAMJ 96 (December 2006): 1209–1210. 122. Speech at the Official Launch of Clinical Associate Programme, 1–3. 123. “New Qualification to Help Pharmacists,” Business Report, October 5, 2009. 124. For a discussion of the nurse in this role, see Anne Digby and Helen Sweet, “The Nurse as Culture Broker in Twentieth-Century South Africa,” in Plural Medicine, Tradition and Modernity, ed. Waltraud Ernst, 113–129 (London: Routledge: 2002).


Juanita De Barros is Associate Professor in the Department of History at McMaster University, Hamilton, Canada. She works on urban history and the social history of health in the post-slavery Caribbean. Anne Digby is Research Professor in History at Oxford Brooks University and has published widely in the field of history of medicine. Her research interests include South African medicine; medical markets and health care systems; the history of British social policy and welfare; and the history of psychiatry. Ryan Johnson is Lecturer in History at the University of Strathclyde. He specializes in the history of British imperial tropical medicine and public health in British West Africa. Margaret Jones is Research Associate at the Wellcome Unit for the History of Medicine, University of Oxford. Her research interests include the history of public health in the British West Indies and Sri Lanka. Walima T. Kalusa earned his PhD from the Johns Hopkins University. Between 2007 and 2009 he was a Research Associate at Cambridge University on the “History of Death in Africa” project. His articles have been published in peer-reviewed journals, including the International Journal of African Historical Studies and, more recently, the Journal of Southern African Studies. Currently, Dr. Kalusa is teaching African history at the University of Swaziland. Amna Khalid is Assistant Professor in History at Carleton College. Her research interests lie at the intersection of South Asian history, the history of medicine, and British colonial history in the nineteenth century and early twentieth century. She is also interested in the study of sacred spaces as foci of epidemics as well as sites of worship, healing, and “queer” sexuality.



Seán Lang is Senior Lecturer in History at Anglia Ruskin University. He specializes in the history of the British Empire. His interests in imperial history range widely, including the social history of empire, imperialism in popular and children’s literature, and decolonization. James Mills is the founding Director of the Centre for the Social History of Health and Healthcare Glasgow and Senior Lecturer in History at the University of Strathclyde. He has published widely on psychiatry, drugs, and sport in British India. His next book, Cannabis Nation: Britain, Control and Consumption, 1928–2008 will be published by Oxford University Press in 2012. Atsuko Naono is Associate Fellow to the Centre for the History of Medicine at the University of Warwick and Research Associate with the Centre for Southeast Asian Studies at the School of Oriental and African Studies. She works on the history of colonial medicine, women and medicine, and medicine in Southeast Asia.


Note: Page numbers ending in “t” refer to tables.

A Ababio, Kojo, 136–137, 141, 144–149 Accra: hierarchy in, 139–141; plague in, 2, 135–149; politics in, 139–141; public health in, 135–139 African Medical Handbook, 185 Akwei, Anege, 141, 146 Alexander, Allen, 88 Ali, Mirza Hassam, 75, 78 Allan, Peter, 182 Almon, F. H., 90 Anderson, Benedict, 122 Anning, Dr., 183 anti-plague measures, 7–10, 19, 144. See also plague Antrobus, Reginald, 143 Arnold, David, 7–9, 118 asylum system: conditions in, 82, 88–96; cruelty in, 20, 76–79; in Egypt, 71–72, 77–79; experiences in, 71–77, 88–96; in India, 72–73, 77–79; intermediaries in, 78–79; in Jamaica, 20, 82–88, 92–96; personnel at, 18–20, 71–79; power over, 72, 77–78; practices in, 20, 74, 76–79; staffs of, 71–79; subordinates in, 72–79; violence in, 20, 74, 76–79, 82, 89 Aung, San Hla, 123, 124 Aung, Tun, 123 auxiliaries: in Mwinilunga, 161–166; as social healers, 161–166

B Baby’s Bath and Toilet, 123 Bannerman, James, 137 Baragwaneth Hospital, 175

Barbados: health system in, 100–117; infant mortality rates in, 100–107, 103t; infant welfare work in, 100–117; intermediaries in, 19, 100–117; low wages in, 102; politics of health in, 103–105; population of, 100–101, 102t; sugar production in, 101–102 Barnett, Mary, 93 Bashford, Alison, 8 Bayly, Christopher A., 13–14 Beilby, Elizabeth, 41 Belgian Congo auxiliaries, 18, 172 Bell, Heather, 161 Bell, Mary, 88 Bhattacharjee, Oparva Narain, 75 Bhattacharya, Sanjoy, 18, 21 Bigarries, 1–2 Birch, Surgeon Major, 76 Birth of the Clinic, The, 8 Bisset, E., 124 Blunt, E., 64 Boahen, A. Adu, 14 Bombay, 1, 20, 41, 43, 56 Bowerbank, Lewis, 85–89, 91–95 Boxill, Normal, 105–109 Boyce, Rubert, 143 British Empire: intermediaries in, 17–21; local participation in, 12–17, 20–21; medical institutions in, 5–12; medicine in, 5–12; public health in, 5–12, 17–21; subordinates in, 17–21. See also specifi c countries Brooks, George, 90–91 Bryan, Herbert, 135, 141–143, 145–148 Burke, Julian, 82



Burma: Department of Public Health in, 120–125, 128–131; health fi lms in, 120–131, 132n25; health officers in, 118–131; health trains in, 128–131; Health Week in, 125–128, 131; medical institutions in, 122, 130; milk products in, 126; public health in, 118–131; transformations in, 119–131 Burmanization of public health, 119–125, 131, 132n8 Burmese Red Cross: duties of, 119– 129; founders of, 121; goals of, 122; Health Week, 125–128 Burns, Catherine, 175 Burrowes, Nurse, 108–109

C Campbell, Alexander, 85 Campbell, Duncan, 91 Campbell, Samuel, 137 Cannon, Dr., 75 Carter, Sarah, 93 Catanach, Ian J., 10 Chamberlain, Joseph, 138 Chandler, W. K., 105 Chanock, Martin, 164 cholera: classifying, 9; epidemic of, 52, 55–57; fi lms about, 124; plague and, 7–8, 120, 127 Christian Missions in Many Lands (CMML), 154–161, 164–166 colonial hierarchy, 19–20, 156, 172–173. See also hierarchies colonial medical institutions: in British Empire, 5–12; in Burma, 122, 130; in Egypt, 71–72; in India, 71–72; surviving, 82–99 colonial medical interventions, 156, 159 colonial medical officers, 5, 11, 122, 130, 155–159, 171 colonial medicine, 3, 5–7, 149 colonial rule, 5–8, 13–15, 20, 79, 162–164 colonial state, 3–21, 34, 135–138, 148–149, 154–159 colonialism, 5–10, 13–17, 77, 138, 166, 171–172 Colonizing the Body, 9 Contagious Disease Acts, 9 Cooper, Frederick, 15 Cornish, William, 38–39

Crewe, Lord, 144 cultural intermediaries, 16–17. See also intermediaries Cunha, Mary, 91 Curing Their Ills, 8 customary rights of sweepers, 51–66. See also sweepers

D dais, 32–33, 36, 44–47 Darling, Governor, 82 Davies, William Broughton, 137 De Barros, Juanita, 19, 21, 100, 193 death rates: of infants, 100–107, 103t; at Kingston Hospital, 85–87, 86t; of mothers, 35, 38, 46–47 Dening, R. C., 163 Dent, C. P., 179 Department of Public Health (DPH): in Burma, 120–125, 128–131; in South Africa, 177–179, 182–186 Digby, Anne, 20, 171, 193 Discipline and Punish, 8 Disease, Medicine, and Empire and Imperial Medicine and Indigenous Societies, 6 Donaldson, Mary, 88 Drewe, F. S., 182 Dufferin Hospital, 45 Dullunda Hospital, 73 Dunn, C. L., 59, 62 dysentery, 107, 163

E Easmon, John Farrell, 138 educational fi lms, 120–131, 132n25 Egypt: asylum system in, 71–72, 77–79; language in, 71–72 Elgin, Earl of, 143, 145–146 epidemic diseases, 5–7, 9, 52, 61, 65, 139, 153n60. See also specifi c diseases Ernst, Waltraud, 9–10, 66 Evans, Arthur, 143

F Feierman, Steven, 5 Fendall, N. R. E., 185 fevers, classifying, 127 Fiddes, Alexander, 85 Fields, Karen, 161 fi lms, educational, 120–131, 132n25 Flint, Karen, 12 Ford, John, 5

Index Foucault, Michel, 7, 8, 156 Fyfe, Alexander, 83

G Ga mantse, 139–141, 145–148 Gale, George, 178–179, 183 Gallagher, John, 13 Garland, Patrick J., 139, 141 Ge, Shwe, 120–121 Gelfand, Michael, 185 Gibbs, James, 89, 93 Gold Coast, 135–138. See also Accra Gooptu, Nandini, 53 Graffe, Alexander de, 90 Groote Schuur Hospital, 174 Guha, Ranajit, 3, 15

H Haffkine, Waldermar, 143–145 Hailey, Lord, 171 Halalkhors, 1–2 Hall, Caleb, 93 Hamilton, Robert, 83 Hammond, Daniel Philip, 136 Hanshell, A. J., 105 “Harbour Blockyard Case,” 141, 146 Harran, J. H., 135, 143–144 Harrison, J. H., 60 Harrison, Mark, 6, 11, 18, 21, 66, 119 Hawkins, J. W., 105 Headrick, Daniel, 6 healing rituals, 154, 166 health assistants, 172–174, 176–184 health fi lms, 120–131, 132n25 health officers, 118–131 “health trains,” 128–131 Health Week, 125–128, 131 health workers: in government hospitals, 82–99; mid-level workers, 171–191; in South Africa, 171–191 hereditary sweepers, 51–65 hierarchies: in Accra, 139–141; administrative hierarchy, 4, 14–15, 34, 56, 79, 175–176, 187; colonial hierarchy, 19–20, 156, 172–173; political hierarchy, 136, 139–141; racial hierarchy, 172–176 higgling, 91 Hofmeyr, Jan, 177 Hokkanen, Markku, 172 Holy Cross Mission Hospital, 181–182 hookworm, 122–123, 163


Horton, James Beale, 137 hospital death rates, 85–87, 86t hospital midwives: as subordinates, 34–35, 44, 46–47; tracing, 32–50; training, 33–47. See also midwives hospital orderlies, 173–176 hospital staff salaries, 40–41, 40t Hunt, Nancy, 171 Hutson, John, 102–111 “hybrids,” 172

I India: asylum system in, 72–73, 77–79; language in, 71–72; medical institutions in, 71–79; public health in, 51–70; subordinates in, 51–66 Indian Medical Service, 34–35 Indian Red Cross Society, 120–121. See also Burmese Red Cross infant mortality rates, 100–107, 103t infant welfare work: infant mortality and, 100–107, 103t; midwifery and, 104–112 Innes, Charles Alexander, 127 inoculation programs, 18, 144–145, 148. See also vaccination practices insane asylums, 18–20, 71–79. See also asylum system intermediaries: in asylum system, 78–79; in Barbados, 19, 100– 117; in British Empire, 17–21; explanation of, 2–5, 12–21; in South Africa, 172–173, 176, 182–187 Intermediaries, Interpreters, and Clerks: African Employees in the Making of Colonial Africa, 15

J Jali, Edward, 180 Jamaica: hospital scandal in, 83–85, 94–96; investigation of hospitals, 85–96, 86t; lunatic asylum in, 20, 82–88, 92–96 Jane Furse Mission Hospital, 174 Johnson, Obadiah, 138 Johnson, Ryan, 1, 18, 19, 135, 193 Jones, Margaret, 11, 19–21, 66, 82, 193 Jordan, Edward, 93 Journal of Mental Science, 71 Jubilee Lying-In Hospital, 109



K Kalene Hospital, 18, 154, 159–166 Kalusa, Walima T., 18–19, 154, 193 Kanema, Joseph, 163 Kapita, Thomas, 163 Kark, Dr., 180, 183 Keech, Dr., 85, 91, 93 Ker, Alan, 83 Khalid, Amna, 1, 20, 51, 193 Kimble, David, 137 Kin, Ba, 129 King, Nathaniel, 138 King George V Hospital, 184 Kingston Public Hospital (KPH), 20, 83–86, 86t, 92, 94–96. See also Jamaica Klein, Ira, 5 Kojo, Wetse, 140–141 Kumbh mela, 56–57

L Lady Barkly’s Hospital, 84, 91 Landau, Paul, 165 Lang, Seán, 19, 21, 32, 194 “laudable experiment,” 19, 100–117 Lawrence, Benjamin, 15 Lebona, Aaron, 177–178 Lewis, Gordon K., 106 Lewis, Milton, 7 Lewis, Rosa, 82 “local participation,” 12–17, 20–21 Lucknow Hospital, 64, 74–75, 77 Lukes, Steven, 53, 65 Lunatic Asylum, 20, 82–88, 92–96 lunatic asylums: conditions in, 82, 88–96; cruelty in, 20, 76–79; in Egypt, 71–72, 77–79; experiences in, 71–77, 88–96; in India, 72–73, 77–79; inspection of, 95; intermediaries in, 78–79; investigation of, 85–96; in Jamaica, 20, 82–88, 92–96; personnel at, 18–20, 71–79; power over, 72, 77–78; practices in, 20, 74, 76–79; reports on, 95; sanitary efficiency in, 95; staffs of, 71–79, 95; subordinates in, 72–79; violence in, 20, 74, 76–79, 82, 89 Lying-In Hospital, 32–47 Lyons, Maryinez, 18, 172

M MacLeod, Roy, 7

Madness and Civilization, 7–8 Madras: maternal mortality rates, 35, 38, 46–47; midwives (1844–1881), 32–39; midwives (1881–1916), 39–46; subordinates, 34–35, 44, 46–47 Madras Lying-In Hospital, 32–47 Madras Maternity Hospital, 42, 46 Magrath, Dr., 87 Majaji, Samuel, 165 Making the Town: Ga State and Society in Early Colonial Accra, 139 Malaria, 123 malaria: assistants for, 183–184; epidemics, 5, 163; fevers, 129; mosquitoes and, 126–127 Mamdani, Mahmood, 14 Manson, Patrick, 135, 142–143 mantse, 139–141, 145–148 Mantsemei, 135–153 Marks, Shula, 14, 77, 171–172, 174 Mason, B. G., 101 Masselos, Jim, 56 maternal mortality rates, 35, 38, 46–47 maternity care, 46–47 Mayo, Lord, 58 McCord, James, 176, 180 McCord, Margaret, 180 McCord Hospital, 176 Mdala, P. S., 181–182 “medical aid,” 178–181 medical aides, 172–174, 176–184 medical auxiliaries: in Mwinilunga, 18, 161–166; as social healers, 161–166 Medical Dental and Pharmacy Act, 179 medical fi lms, 120–131, 132n25 medical intermediaries: in asylum system, 78–79; in Barbados, 19, 100–117; in British Empire, 17–21; explanation of, 2–5, 12–21; in South Africa, 172– 173, 176, 182–187 mental hospitals, 18–20, 71–79. See also asylum system Meston, Lord, 63 Mgobozi, Zulu P., 184 midwives: care by, 38–39, 46–47; categories of, 35–38, 43–44; expectations of, 44–47; in hospital (1844–1881), 32–39; in hospital (1881–1916), 39–46;



Naono, Atsuko, 18, 118, 194 Newbury, Colin, 14–15 Ngcobo, Simon, 180–181 Ngoyi, Paul, 175–176 night soil: disposing of, 51, 55, 59–62; selling, 54, 59–62; treating, 55, 59–62 Noble, Vanessa, 172 Nodada, B. B., 178 nursing staff salaries, 40–41, 40t

pavilion system, 39–40 Payne, Dr., 75 Pernick, Martin, 123 Pestonjee Cama Hospital, 41 plague: in Accra, 2, 135–149; antiplague measures, 7–10, 19, 144; in Bombay, 1; eradication of, 145–149; sanitary system and, 1–2, 9; smallpox and, 122, 127 Plural Medicine, 12 Polela Health Unit, 172, 180, 183 political hierarchy, 136, 139–141. See also hierarchies politics in Accra, 139–141 Poor Relief Act, 104 Prashad, Vijay, 56 Pratt, Ann, 82, 88 Probyn, Leslie, 105 propaganda fi lms, 123–124 Prout, William, 143 public health: in Accra, 137–139; in British Empire, 5–12, 17–21; in Burma, 118–131; Burmanization of, 119–125, 131, 132n8; in colonial societies, 2; in India, 51–70; medicine and, 5–12; overview of, 1–21 puerperal fever, 34, 38–39 pupil midwives: care by, 38–39, 46–47; categories of, 35–38, 43–44; expectations of, 44–47; in hospital (1844–1881), 32–39; in hospital (1881–1916), 39–46; midwifery kit, 44, 46–47; salaries of, 40–41, 40t; as subordinates, 46–47; tracing, 32–50; training, 33–47 Pyne, Charles, 90–91, 94



Obili, Taki, 136, 148 Okayama, Dr., 126 Onley, James, 14 orderlies, 173–176 Orientalism, 8 Osborn, Emily, 15

Quartey-Papafio, Arthur Boi, 141, 142 Quartey-Papafio, Benjamin William, 136–138, 142, 145, 148–149

infant welfare work and, 104–112; midwifery kit, 44, 46–47; salaries of, 40–41, 40t; as subordinates, 34–35, 44, 46–47; tracing, 32–50; training, 33–47, 110–111 Milford, Mr., 93 Mills, James, 8, 18–19, 71, 194 Mills, Thomas Hutton, 141 missionary medicine: expansion of, 158–159; in Mwinilunga, 154–166 Mkambati Leper Asylum, 181 Mommsen, Wolfgang, 13 mortality rates: of infants, 100–107, 103t; at Kingston Hospital, 85–87, 86t; of mothers, 35, 38, 46–47 mosquitoes, 123, 126–127 Msomi, L. P., 178 Municipal Act, 57, 62–63 municipal sweepers, 54–63, 66, 68n44. See also sweepers Mwinilunga: auxiliaries in, 161–166; medical training in, 154–166; social healing in, 161–166


P Panjab Act, 62 “pariah” women, 32, 38 Parker, John, 139 Parsons, Timothy, 13, 15, 17 Pati, Biswamoy, 10, 66 Patton, Adell, Jr., 138

R racial differences, 8, 11, 34, 37, 138, 186–187 racial hierarchy, 172–176 Ramanna, Mridula, 18 Rammasubban, Radhika, 6 Red Cross: duties of, 119–129; founders of, 121; members of, 121; training by, 174. See also Burmese Red Cross

200 Index Report into Hospital Provision, 171 “Resident’s rule,” 14 Rhodesia, 154–166 Richardson, Bonham C., 104, 105 Roberts, Richard, 15 Robertson, Alexander, 87 Robertson, Maria, 87, 92 Robinson, Ronald, 13 Rodger, John, 2, 144 Rosenberg, Charles, 5 Ross, Park, 183 Rouse, Richard, 85, 87, 90, 92 Russell, Richard, 78 Rwairwai, E. D., 178 Ryan, David, 92, 93 Ryan, Judith, 88, 92, 93

S Said, Edward, 8 Saing, U Tha, 121 salaries of midwifery staff, 40–41, 40t Sanikosa, Shem, 164–165 “sanitary principles,” 65–66 sanitary system: budgets for, 58–59; night soil and, 51, 54–55, 59–62; plague and, 9; sweepers and, 51–56; in United Provinces, 51–70 Sarkar, Sumit, 3 scavengers, 51–54, 63. See also sweepers Scharlieb, Mary, 35, 43 Scott, Eliza, 82 Scott, James, 85, 87, 93, 94 Scriven, Major, 75 Searle, Charlotte, 185 Sebeta, Susan, 182 Senokoanyane, Samuel, 181 Seven Months in the Kingston Lunatic Asylum, and What I Saw There, 82 Shapiro, Karin, 172 Sharkey, Heather, 13, 16 Shaw, James, 35 Sheridan, Richard, 7 Shircore, Surgeon Major, 74 Sibthorpe, Surgeon Major, 40, 42–43 Sim, G. G., 62 Simpson, William J. R., 135–137, 143–145, 148 Singh, Luchman, 75, 78 Sleeman, William, 54 sleeping sickness, 5, 172 smallpox, and plague, 122, 127

smallpox hospitals, 95 smallpox vaccination, 11, 18, 177–178 Smeaton, R., 61 Smit, D. L., 178, 183 Smith, Caroline, 89 Snow, P. C. H., 1 social healing: medical training and, 161–166; in Mwinilunga, 154–166 Solomon v. Noy, 140 South Africa: Department of Public Health in, 177–179, 182–186; health workers in, 171–191; historical trajectories in, 182–187; hospital orderlies in, 173–176; intermediaries, 172–173, 176, 182–187; medical aides in, 172–174, 176–184 South African Medical Journal, 186 Stein, Eric, 122 Steinhart, Edward, 14 Stott, Halley, 181 subaltern, 3–4, 10, 12 Subaltern Studies project, 3, 9, 15 subordinates: in asylum system, 72–79; in British Empire, 17–21; explanation of, 2–5, 12–21; in India, 51–66; Madras midwives as, 34–35, 44, 46–47; sweepers as, 51–66 Summers, Carol, 17 Swanson, M. W., 9 sweepers: in Bombay, 1–2, 20; categories of, 54–55; customary rights of, 51–66; duties of, 51–56; hereditary sweepers, 51–65; importance of, 51–66; in India, 51–70; municipal sweepers, 54–63, 66, 68n44; power of, 56–66; sanitary system and, 51–56; strikes by, 52–53, 56–57, 64–65, 68n26; as subordinates, 51–66; in United Provinces, 51–70

T Taylor, Alan, 176 Taylor, Henry, 82, 92, 93, 94 Tin, U, 129 Tiyambe, Zeleza, 158 Tools of Empire, 6 Trench, D. P., 90, 92–93 Trivedi, Lisa N., 122

Index Tshabalala-Msimang, M., 186 tuberculosis, 11, 163, 180, 184 Tugela Ferry Mission Hospital, 180 Turner, Elizabeth, 163 Turner, Victor, 163 typhoid fever, 127, 177, 181, 182

U Umtata Rural Health Unit, 181 Unhooking the Hookworm, 123 United Provinces: sanitary system in, 51–56; sweepers in, 51–70 University College Hospital, 84

V vaccination practices, 8, 10–11, 18, 144–145, 148, 180 Vaughan, Megan, 8 Victoria, Queen, 41 Victoria Hospital, 173, 177, 180 Village Well, The, 124


W Wadsworth, Hilda, 159–161, 165 War on Mosquitoes, The, 123 Warnock, John, 71–72, 78–79 Wesseling, Henk, 13 West Africa, 135–139, 143, 171. See also Accra West African Medical Staff (WAMS), 135, 138–139 West India, 100–107 witchcraft, 161, 164–165 Worboys, Michael, 11, 18, 21

X Xuma, A. B., 178

Z Zambia: medical training in, 154–166; missionary medicine in, 154– 161, 164–166; social healing in, 161–166