Following our initial call for review and our desire to offer both a clinical and academic perspective of ‘Medicine and Empire,’ Dr Caroline Mawer – a clinician based in London – offers her generous thoughts below.
Medicine & Empire aims to promote a deeper understanding of the problems plaguing global health. It narrates ‘the history of modern medicine itself’, by making analytic links with the history of European imperialism (p. vii). The book covers Asia, the Americas and Africa during the period 1600-1960. With this historical and geographical breadth, Medicine & Empire is specifically intended to be more comprehensive than other existing resources (such as MacLeod and Lewis 1988, and Arnold 1996 – as cited on p.vii).
Four broad historical periods are proposed: the Age of Commerce (1600-1800), the Age of Empire (1800-1880), the Age of New Imperialism (1880-1914), and the Era of New Imperialism and Decolonisation (1920-1960). The book’s introduction outlines the historiographical shift from the ‘triumph of European cultural superiority and military power’ (p. xvii); through originally-Marxist explanations of the importance of structure and economy; to include analyses of Orientalism, subaltern studies, ecological and environmental dislocations and losses, and resistance and agency.
After an initial chapter focusing on Medicine in the Age Of Commerce, there are then nine chapters focusing on either a topic – for example medicines and plants, the colonial armed forces, and bacteriology – or a geographical area – for example colonial India, or Africa. Although each chapter is approximately sequential, the thematic content also refers – more or less – to the four historical periods and the different historiographical approaches outlined in the introduction.
The book explores important historical shifts in medical thinking – for example from miasmatic theories (p. 45, p. 62) through moral and atmospheric hygiene (p. 49), to the germ theories epitomized by Pasteur and Koch (p. 166) and the linkage of environment and climate to germs in ‘contingent contagionalism’ (p. 145).
Cholera is discussed in some depth as an example of a disease the management of which evolved alongside the different theoretical approaches. Non-contagionist medical theorists believed that the disease was spread by ‘unhealthy vapours’ (p. 86). In 1850, therefore, in colonial Jamaica, the Board of Health ordered the firing of blank cartridges to destroy what was described as the ‘morbific power’ that lurked in the dark alleys of Kingston. In colonial India, infected troops were set to march ‘at right angles to the wind’. The airborne theory was challenged by John Snow’s famous 1854 linkage of cholera in London to the Broad Street pump (p. 87), and there were resultant improvements to water supplies in England. Poorer ex-colonial areas, for example in India, have still not yet been so lucky (Khurana and Sen, undated). In the nineteenth century, the enduring influence of non- and contingent contagionism – and especially the volumes of trade that might better be described as lucrative rather than free – contributed to the ‘obstinate’ stance by the British government against international quarantine regulations (pp. 86-91). A ‘general fear of the Orient’ meant that the ‘insanitary’ Haj pilgrims were an exception to this: they were forced into ‘brutal detentions’, most importantly in the Sinai peninsula (p. 88). Chakrabati repeats the generally held belief that it was Robert Koch who first discovered the cholera bacillus in 1882. In fact, it was Filippo Pacini, in 1854 (Frerichs, undated). Certainly, though, Koch’s work was the first that researchers and officials took any notice of – after Koch’s renowned 1884 lecture to the Imperial German Board of Health in Berlin (p. 90).
Medicine & Empire includes useful reminders of well-known historical incidents and basic concepts – including a detailed discussion of the hybrid and metropolitan origins of ‘tropical medicine’ (pp. 141-153) – as well as frequent repetitions of points that reinforce Chakrabati’s thesis.
The importance of finances is underlined throughout. For example, the death rates on the Middle Passage were highest when it was cheaper to abduct or buy ‘fresh slaves’ (p. 81) than it was to look after them. Colonial epidemics ‘attracted the attention’ of researchers ‘because they threatened … economic interests’(p. 155). Chakrabati makes it clear that malaria, TB and trypanosomiasis only became epidemic in the colonies after local people were impoverished (eg. p. 157) by an imperialism that might not be described by those it was forced upon as either ‘constructive’ (p. 152) or ‘civilising’ (p. 173).
As well as the broader themes, there are many fascinating nuggets throughout Medicine & Empire. For example, James Lind’s discovery of the anti-scurvy efficacy of lemons is well-known. Chakrabati describes much less reported details of how Lind saw lemons as what was then described as an ‘antiseptic’ – and then effectively set up a progenitor of modern randomised controlled trials (RCTs) (pp. 46-7).
The book does, however, have some shortfalls. Chakrabati notes that his historical periods overlap, and that they vary in different areas. There was, for example, a relatively later colonial entry into the African interior. However, if the proposed historical structure is to act as a useful frame, there could have been a clearer linkage back to it in each of the thematic chapters, if only to say that a particular theme was not relevant in a particular period.
No justification was given for starting the book in 1600. Chakrabati himself underlines that Western European commerce expanded globally from 1500 (p. 1). Although he suggests that historical writings on imperialism started in the nineteenth century (p. xvii), other researchers have found that earlier writings can give useful insights into the development of ideas about ‘the other’ (for example, relating to Persia in Mawer 2015).
More regional maps would have been useful, to allow a better understanding of the contemporary and also the modern geographical context. An illustration of the changing scale over time of the various empires would have provided evidence for the voracious nature of European imperialism.
There could have been more critical use of quantitative data – to further explore some of the specific points, as well as the underlying premises. For example, Chakrabati reports that ‘between 1615 and 1640, 40% of drugs on the English market came from the East Indies. By the second half of the seventeenth century, this had gone up to 60%’ (p. 13). This seems to imply the widespread use of drugs from the East Indies in English medical practice. However, the cited source is concerned with the importation of drugs rather than the totality of medication. It underlines the substantial use of ‘home-grown drugs and other substances’, and notes that much that was imported was subsequently re-exported (Wallis 2010). Further discussion of how drugs produced from resources in the East Indies were circulated within Britain, and traded externally, would have been welcome. In this example and more generally, some information about European changes in ideas about, and practice of, medicine would have given an idea of the comparative importance of physical imports and technical innovations from early travellers, military services and the colonies.
Perhaps most importantly, the book stops, at least in theory, at 1960. There is no stated reason for this: Chakrabati himself noted that World Health Organisation initiatives started from 1955 for malaria, and from 1967 for smallpox (p. 203). The artificial cut-off dilutes the undoubted relevance of much of Chakrabati’s material to a post-colonial, modern context.
For example, insanity in Africans is discussed as having been seen as a ‘collective norm’ (p. 135) and as though that was something confined to the past (pp. 134-7). Severe and forensic mental illness is, however, still now much more likely to be diagnosed in black people. Although it is recognized that this – at least in part – reflects individual responses to socio-economic marginalization and institutional racism, the societal response is still psychiatric diagnosis and treatment (for example, Mental Health Foundation, undated). Similarly, it’s not only in the past that malnutrition and poverty are the greatest killers in South Africa (p. xxi).
Chakrabati writes of how the global migrations consequent on imperialism form ‘the roots of modern multiracial societies’ (p. 73). His conclusion is titled ‘The colonial legacies of global health’ (pp. 200-205). But there’s no mention of epidemic non-communicable diseases: for example, the extraordinarily high rates of diabetes and associated heart disease in populations of South Asian origin now living in the UK (Diabetes UK 2014). Most recently, the Australian strict quarantine ‘war on foreign germs’ which ramped up with 1890s plague epidemics in China (p. 92, p.169), has now morphed into Asian ‘detainees’ being ‘exported’ to ‘living hell[s]’ (Riemer, 2015). The detentions are at least as brutal as those inflicted on nineteenth century Haj pilgrims. Australian doctors are currently threatened with imprisonment when they report that, for example, a 6 year old girl recently tried to strangle herself with a fence tie or that a defiant 15 year old boy sewed his lips together in silent protest (Isaac 2015).
Medicine & Empire is not only readable but does indeed spark reflection on both ‘succinct and [also] broader narratives’, just as Chakrabati desires (p. viii). I would like to wholeheartedly commend the book to a wide audience – including medical students, doctors and medical academics as well as undergraduate and postgraduate historians.
Reviewed by Dr Caroline Mawer, who is a GP and a Consultant in Public Health. Her overseas work has included working as Chief Medical Officer for Montserrat as well as in the TB prisons in Siberia. In the UK she used to commission sexual health services in South East London, and now works part-time in Urgent Care in North East London. She has also produced research on early seventeenth century Iran, and now writes about ideas regarding what makes a ‘good’ death.
Correspondence to Dr Caroline Mawer.
Twitter handles: @drcaromawer @caromawer
Arnold, David. 1996. Warm Climates and Western Medicine: The Emergence of Tropical Medicine 1500-1900. Rodopi.
Diabetes UK. 2014. Young South Asian people at higher risk of diabetes and associated heart disease.
Frerichs, Ralph R. Undated. Who first discovered Vibrio Cholerae? UCLA Department of Epidemiology. School of Public Health.
Isaacs, David. 2015. Doctors should boycott working in Australia’s immigration centres and must continue to speak out on mistreatment of detainees – despite the law. British Medical Journal.
Khurana, I and Sen, R. Undated. Drinking water quality in rural India: issues and approaches. WaterAid.
MacLeod, Roy and Milton Lewis. 1988. Disease, Medicine and Empire: Perspectives on Western Medicine and the Experience of European Expansion. Routledge.
Mawer, Caroline. 2015. By far the most amusing work on Persia that has ever been published. Personal Blog.
Mental Health Foundation. Undated. Black and Minority Ethnic Communities.
Riemer, Nick. 2015. Manus Island: The government uses the logic of terrorism in its treatment of asylum seekers. The Guardian.
Wallis, Patrick. 2010. Exotic Drugs and English Medicine: England’s Drug Trade, c.1550-c.1800. London School of Economics and Political Science: Working Papers No. 143/10