Leon Rocha and Kayleigh Wall
This chapter mobilises some of the primary sources (so-called ‘Grey Literature’) deposited at the Donald Mason Library, Liverpool School of Tropical Medicine (LSTM), to showcase the fruitful possibilities of researching the global histories of medicine, health, and disease from the late nineteenth to around the mid twentieth century. In the next section, we discuss the issue of provenance: how did these primary sources end up in the LSTM? To answer this question, we explore briefly the institutional history of the LSTM and its Donald Mason Library, as well as the general context of the development of ‘tropical medicine’ as a medical specialty in the late nineteenth century. In tandem, we discuss the historiography of global health and the issues that we need to bear in mind while approaching our primary sources.
For the purposes of this chapter, we have chosen two categories of primary sources from the LSTM’s ‘Grey Literature’ collection. First, we examine official publications from government agencies and colonial administrations, or from non-government organisations (NGOs) or philanthropic foundations. Second, we focus on annual reports from scientific research institutes or medical centres, some of which were established by colonial regimes or by postcolonial governments, and others were bankrolled by private individuals or charitable bodies. In the next section we comment on the selection and interpretation of sources for research essays or dissertation projects, before offering practical advice on the scholarship that we could craft through analysing ten historical items.
In the Victorian era, Liverpool emerged as a key port in global trade and commerce, and became the fabled ‘second city of the British Empire’. An enormous traffic of goods and passengers entered and departed Liverpool via land and sea on a daily basis. A large number of patients were admitted to hospitals and clinics across the city suffering from contagious diseases, or many unknown conditions. The patients included those who had visited distant, tropical regions of the world – sailors, labourers, soldiers, merchants, colonial officers – or who had some form of contact with these travellers. By the late nineteenth century, the sheer variety, ferocity and complexity of these conditions – combined with frequent outbreaks of epidemics – became a very pressing public health problem for the British government. The Secretary of State for the Colonies, Joseph Chamberlain (1836–1914), proposed in 1898 that the School of Medicine at Liverpool would establish a department dedicated to the investigation and treatment of tropical diseases. Funds were raised to support this endeavour – the shipping magnate and philanthropist Sir Alfred Lewis Jones (1863–1911) donated a significant sum of £350 – and the Liverpool School of Tropical Medicine was founded. At the outset, the School served two aims: first, to defend the British Isles and their population from the threat of foreign, ‘exotic’ diseases; second, to safeguard the economic interests of the British Empire by managing the health of colonial administrators and colonised peoples. It was a project of political power, in which medical knowledge and scientific expertise became instrumental to resolving issues of sovereignty and territorial integrity, surveillance and control, and the legitimacy of home and colonial rule (Power, 1999).
The pathologist and hygienist Sir Rubert William Boyce (1863–1911) acted as the LSTM’s inaugural dean, and Sir Ronald Ross (1857–1932), a former army doctor, was then recruited as the institution’s first lecturer. Ross became the most well-known faculty member in LSTM’s history when, in 1902, he became the first British recipient of the Nobel Prize in Physiology or Medicine for his discovery of the parasite that proved mosquitoes acted as vectors for malaria. The LSTM, along with the London School of Tropical Medicine (established in 1899 and later renamed the London School of Hygiene and Tropical Medicine, LSHTM), became internationally renowned centres for the study of infectious, debilitating and disabling diseases, as well as paediatric medicine and nutritional science. The Donald Mason Library at the LSTM emerged from Sir Ronald Ross’ personal books and papers, and over the last 100 years or so the Library continued to preserve ‘Grey Literature’ used by LSTM’s past members for their everyday research and training activities. The term ‘Grey Literature’ refers to documents ‘produced on all levels of government, academia, business and industry in print and electronic formats that are protected by intellectual property rights, of sufficient quality to be collected and preserved by library holdings or institutional repositories, but not controlled by commercial publishers, i.e., where publishing is not the primary activity of the producing body’ (Prague Definition of Grey Literature, Twelfth International Conference on Grey Literature, 2010). The ‘Grey Literature’ collection is distinct from the ‘normal’ LSTM Library holdings (books and journals from commercial publishers), and from the LSTM Archives (split between the LSTM and the University of Liverpool Library Special Collections) that incorporate historical documents and correspondences related to the School’s past members.
The oldest of the ‘Grey Literature’ date back to the 1860s – 35 bundles of Annual Reports from the Sanitary Commissioner with the Government of India (1865–1946; DMLHC #321) – and among the more recently added items include the Bernard Nocht Institute for Tropical Medicine Annual Reports (1982–2000, based in Hamburg; DMLHC #421) and the United Nations Development Programme Human Development Reports (1994–2004; DMLHC #285). Some of this ‘Grey Literature’ can also be found in other libraries and depositories, such as the British Library and the Wellcome Collection (both in London), the Library of Congress in Washington, DC, or the World Health Organisation Library in Geneva. However, some of the ‘Grey Literature’ at LSTM is extraordinarily difficult to locate in overseas collections. They rarely exist as a complete run in many archives and institutions, or materials might be badly damaged or lost altogether. Consulting with our colleagues at the Centre for Global Health Histories at University of York, we found that, for example, the Dar Es Salaam Medical Laboratory Annual Reports (DMLHC #211; dating back to the mid 1920s, from the former British Protectorate of Zanzibar and now a semi-autonomous region within the United Republic of Tanzania) or the Jamaica Yaws Commission Reports (DMLHC #211; dating back to 1930s) might be quite tricky to obtain in other places. Therefore the LSTM’s ‘Grey Literature’ collection is invaluable for undergraduate students writing their dissertations, when extensive, long-distance travel for research is usually difficult.
Before we ruminate upon the selection and interpretation of primary sources, we need some awareness of the historiography of health and medicine – in other words, the way that histories of health and medicine have been framed, which has transformed tremendously over the last few decades. Older histories of medicine were predominantly produced by medical practitioners; many of these medical practitioners might have retired from the profession and were reflecting on the history of their medical specialty. These histories could often be ‘Westernocentric’, focusing exclusively on European and American developments. Sometimes they were hagiographic, championing the careers of famous scientists and physicians or pronouncing the achievements of particular institutions or universities – the world-changing discoveries and ‘heroic’ cures of diseases. By the 1960s and 1970s, history of medicine came to be written by professional historians who might not have had any medical education. They tended to adopt a more sceptical approach towards notions of scientific progress and medical benevolence. Current historians have paid very careful attention to ordinary patients’ narratives of suffering and recuperation, to the beneficial as well as unintended (and sometimes deleterious) consequences that medical and public health interventions had on the everyday living of people around the world, and to the histories of healing traditions and cultures that were denigrated and displaced by Western biomedicine (Brieger, 1993; Cooter and Stein, 2013; Huisman and Harley Warner, 2006).
On the historiography of global health specifically, we should bear in mind two important points, which have been made in the new synthetic work by historian Randall M. Packard (2016). First, conventionally the history of colonial medicine and the history of global health were treated as separate topics. As Packard explains, this was largely the ‘result of a division of labour within the field of history’ (Packard, 2016: 347–48), as historians of colonial medicine had been trained as African, South Asian or Imperial historians, and histories of global health were considered under the jurisdiction of historians of public health, international organisation, and medicine and science who had relatively little interest in colonial history. However, colonial medicine and global health in fact ‘shared a long and complex history, stretching from the end of the nineteenth century up through the 1950s’ (Packard, 2016: 14). Colonial medical authorities and international health organisations frequently collaborated with each other on disease control in the same (colonial) regions around the world; the implementation of particular health interventions and policies fundamentally relied on the coercive power of colonial rule. Moreover, colonial personnel and health organisation officers regularly attended and fraternised at the same conferences, published in the same public health or medical journals, or moved back and forth between employment in the state/colonial system and the non-governmental sphere. Packard further argues that the interventions of international health organisations were ‘also shaped by colonial ideas about “the pathology of native populations” and the inability of colonial peoples to improve their own health’ (Packard, 2016: 14). All these political and practical entanglements mean that, to have a nuanced understanding of global health in all its configurations today, we must have a joined-up history between colonial medicine and global health. Therefore, the ‘Grey Literature’ collection at the LSTM, particularly the late-nineteenth to mid-twentieth century primary sources scrutinised in this chapter, could form the basis of invaluable new interventions in this area of historiography.
The second point to bear in mind, again following Randall Packard, is that we have to resist the temptation to see international health organisations past and present as straightforward ‘forces of good’. International health organisations – for instance, the Rockefeller Foundation or the World Health Organisation – had invested billions of dollars to combat diseases like smallpox, polio, malaria, tuberculosis, and AIDS, and in the process saved millions of lives in impoverished regions around the world. However, recent scholarship complicates this simplistic account of progress and benevolence. Randall Packard elegantly summarises six trends in global health in the past century or so:
1. Health interventions have been largely developed outside the countries where the health problems exist, with few attempts to seriously incorporate local perspectives or community participation in the planning process. During the first half of the twentieth century, this planning occurred primarily in the metropolitan capitols of European and American colonial powers. After World War II, new centres of international-health planning and governance emerged in Geneva, Atlanta, and New York City, and at conference centres in Bellagio, Italy; Talloires, France; and Alma-Ata, in the former Soviet Union.
2. Health planning has privileged approaches based on the application of biomedical technologies that prevent or eliminate health problems one at a time.
3. Little attention has been given to supporting the development of basic health services.
4. The planning of health interventions has often occurred in a crisis environment, in which there was an imperative to act fast. This mindset has privileged interventions that are simple, easy to implement, and have the potential to quickly make a significant impact. On the other hand, it has discouraged longer-term interventions aimed at building health infrastructure, training personnel, and addressing the underlying determinants of ill health.
5. Global-health interventions have been empowered by faith in the superiority of Western medical knowledge and technology and a devaluing of the knowledge and abilities of the local populations.
6. Health has been linked to social and economic development, but this connection has focused primarily on how improvements in health can stimulate economic development, while ignoring the impact that social and economic developments have on health. What we now call the social determinants of health have received little attention. (Packard, 2016: 8–9).
When we work with the LSTM’s ‘Grey Literature’, then, we need to acknowledge the fact that reports and publications produced by colonial administrations or international health organisations might well be the only available source on health and medicine in a particular region at a particular period. It can be extremely challenging – sometimes impossible – to go beyond the official narrative and to recover the agency and practices of local, non-elite, non-prominent folk who were often on the receiving end of medical care and health interventions. We have to heed historian of global medicine Sanjoy Bhattacharaya’s warning not to be ‘over-reliant on the voices of few individuals’, and not to take the privileged views of colonial administrators or international health officials as ‘being representatives of the thoughts and actions of the vast majority of participants’ (Bhattacharya, 2011: 145). We need to be cautious about the original producers and intended audience of the primary sources. For instance, many of the English-language reports on health and disease in India or East African regions, penned by colonial bureaucrats from Britain for the consumption of other government officials, promoted a triumphant or paternalistic view when discussing the successful implantation of Western medicine throughout dependencies of the British Empire, and adopted a hostile or condescending tone when attacking local practices or describing resistance to colonial interventions. A historian’s sensitivity to context, as well as the ability to sometimes ‘go against the grain’, are paramount so that we do not reproduce some of the primary sources’ rhetoric or ideology in our historical scholarship.
Selecting and interpreting sources
For the purposes of this chapter, we have chosen two categories of primary sources from the LSTM’s ‘Grey Literature’ collection: (i) official publications from government agencies and colonial administrations, or from NGOs or philanthropic foundations; (ii) annual reports from scientific research institutes or medical centres, some of which were established by colonial regimes or by postcolonial governments, while others were bankrolled by private individuals or charitable bodies.
The first kind of sources may be used to explore more large-scale questions. How did colonial governments in the late nineteenth to mid twentieth centuries in different parts of the world administer a population’s health? How did policies and provisions evolve in a particular colony over time, or how did regimes deal with epidemics, quarantining, vaccination, or general healthcare in the urban setting versus the rural environment? How were statistics gathered and what could they tell us about state priorities? How did colonisers seek to legitimise their rule, or ‘enlighten’ the colonised people, via modern, scientific knowledge? How did Western medicine and public health infrastructures become established, standardised, or imposed internationally? How did knowledge and texts, personnel and artefacts move between distant locations? And when Western medicine competed against or clashed with local beliefs, cultural tradition and ‘indigenous’ healing practices, what happened? Were they eliminated or accommodated? How did private foundations, transnational organisations and medical philanthropy work in the ‘Third World’, in the era of decolonisation? How successful were they in dealing with deadly illnesses, or in tackling social conditions like infant mortality and malnutrition?
The second kind of sources, namely, annual reports of scientific and medical institutions, could help us comprehend the multiple settings in which research was conducted and new knowledge about illnesses was constructed. How were scientific and medical sites (clinics, hospitals, laboratories, teaching centres) set up around the world? What kind of agenda did they have, and what kind of work was being done in the laboratories, in the hospital, or in the field? How did scientists recruit research subjects? What kind of scientific research was enabled and foregrounded (or inhibited and de-emphasised) because of these institutions’ geographical location and accessibility, and what was the relationship between the ‘centre’ (prestigious universities and establishments in Europe and America like the LSTM) and the ‘periphery’ (the colonies, the ‘Third World’)? What kind of resources and funding support did these research centres or hospitals secure, and how were they spent? Who were the members of staff, where did they come from, what training did they receive or offer, what was the division of labour, and what might be the dynamics between white and non-white workers in colonial scientific institutions? What were the power relations between these institutions and the (colonial or postcolonial) government?
With these potential questions in mind, how should we go about selecting a set of sources appropriate for a research project, and how should we then interpret these sources? Broadly speaking, we can select sources based on some very general criteria, such as geography (a particular nation or region of the world) or chronology (a decade or several decades). We could select sources in a ‘longitudinal’ fashion by, say, reading through a run of annual public health reports over a time period. For example, the Annual Colonial Reports of Basutoland (DMLHC #760) would give us a sense of how the British Empire and colonial administration, which until 1955 occupied the area now known as the Kingdom of Lesotho, administered the health of the population – the infrastructure, the resources, and the personnel put in place. We could read through a run of Basutoland reports from 1890 to 1910, to study how policies and provisions evolved in those 20 years. Alternatively, we could select a set of sources in a ‘lateral’ way, say, we could compare and contrast all the annual colonial reports around 1907 from Basutoland (DMLHC #760), Sierra Leone (DMLHC #761), the Seychelles (DMLHC #756), the Gold Coast (DMLHC #766), and others. This would paint a general picture of British colonial involvement in different parts of the African continent. We could even compare and contrast colonial interventions, and the work of postwar international agents across the African continent by, for instance, scrutinising the Annual Report of the Regional Director to the Regional Committee for Africa (1967–1980), published by the World Health Organisation Regional Office for Africa in Brazzaville, Republic of the Congo (DMLHC #256). This allows us to test the aforementioned arguments from historian Randall Packard regarding the continuities and discontinuities between medicine and public health in the colonies, and the work of global organisations in the postwar, decolonised era.
Methodologically speaking, we could also focus on a medical condition or health problem to track longer historical changes. Suppose we were interested in the problem of infant mortality, child malnutrition and maternal health in the British colony of Ceylon (now Sri Lanka) in the early twentieth century. We could take the Administrative Reports of the Director of Medical and Sanitary Services from Ceylon (DMLHC #348), say from 1920 to 1929, and a comparison of statistics on birth rates, reported diseases, and causes of death over that decade might indicate the scale of the problem as well as the Medical and Sanitary Services’ proposed solutions. These might involve training doctors, nurses and midwives, health education efforts to the public, and the popularisation of reproductive hygiene. From these administrative reports, the organisations and individuals that collaborated with or were employed by the Ceylon Medical and Sanitary Services could also be mapped, thus generating further clues about how the local, regional, and international agents constructed maternal and child health policy in Ceylon and beyond.
However, the role of serendipity in historical research, and the great value of selecting and browsing through sources with an open mind and without any rigid plan, must not be underestimated. By simply skimming through the LSTM’s ‘Grey Materials’, we could pick up case histories of unusual or untreatable conditions in the Pacific Islands, or perhaps a commemorative photograph album of a research institute in the ‘Third World’, or an architectural plan for a mental asylum in West Africa that was never built, or perhaps a transcript of a heated debate on public health policy and provisions between doctors at a medical conference in South America. This was precisely what happened in our case; we serendipitously encountered the primary sources under consideration in this chapter, selected particular excerpts, and then uncovered the tantalising links that could animate further research. Of course, it is vital to check existing secondary scholarship to see if a primary source (or set of primary sources) has already been analysed by other historians, so that we know if we are making new, original interventions in the field. In the next section, entitled ‘Practical Advice’, we aim to provide quick guidance through 10 sources under our two categories, so we can see the historical interpretation and contextualisation in action. It goes without saying that our suggestions are intended to be illustrative rather than authoritative!
Official governmental or non-governmental publications
In this section, we discuss official publications from government agencies and colonial administrations, or from NGOs or private, philanthropic foundations. Our first example is the Annual Report of the Department of Medical Services, Western Region of Nigeria, 1955 and 1957 [A]. Nigeria was formally the British Colony and Protectorate of Nigeria from 1914 until independence in 1960. This type of primary source is extremely useful for finding basic information relating to medical practice, infrastructure, personnel, and disease within the geographical area covered (in this case Western Nigeria under colonisation). For example, looking at the table of contents for the 1957 Report, we see that it was divided into 20 sections plus four appendices, detailing staff appointments and financial details of the Medical Services for the 1957 calendar year, the health of the European versus African population, preventive measures against epidemics and insect-borne diseases, as well as the conditions of water supply, sewage, refuse, and other public health provisions. There were also sections on school hygiene, labour conditions, food and nutrition, housing and town planning, health propaganda and education, maternity and child welfare, dentistry, leprosy, tuberculosis, laboratory services, prisons, and medical training.
One area of interest in the Annual Reports is the explanation of progression and evolution of medical institutions. This could be changes to resources and procedures, or the construction of new hospitals, dispensaries, maternity centres, and rural health clinics. Take, for instance, the section on mental health (section VIII in the 1955 Report, section X in the 1957 Report), which recorded the establishment of the Aro Hospital for Nervous and Mental Diseases in Abeokuta in Southwest Nigeria, a city that had approximately 100,000 inhabitants at that time. The planning for the construction of Aro Hospital began decades beforehand, with funds already set aside around the 1930s (Sadowsky, 1999: 40). Thomas Adeoye Lambo (1923–2004), often credited as the first Western-trained psychiatrist in Africa, worked at the Aro Hospital and in the 1970s would become a Deputy Director General in the World Health Organisation. The 1955 annual report summarised the intended use of the hospital, which would be the largest in the country, stating that inpatients would be those with acute mental health problems, who would be resident for around nine months to a year. While the Aro Hospital was still being finished (it would be in full operation by around 1958), it ran a temporary ‘Day Hospital’ and the existing asylums in the area would incarcerate the bulk of mental patients. The ‘Day Hospital’ at Aro dealt with patients who exhibited a wide range of illnesses including schizophrenia, psychoneurosis, and Parkinson’s disease. Treatments given to patients are also listed in the Report, such as electro-convulsion therapy, insulin therapy, and psychotropic medication.
However, there was a deep irony in the arrangement of the Aro Hospital. While the Report stated that the ‘Day Hospital’ would allow patients to stay within their community, thereby making recuperation swifter and rehabilitation easier, it also acknowledged the effectiveness of occupational therapies vis-à-vis more invasive interventions. So the ‘Day Hospital’ was only a temporary measure, and the Aro Hospital continued the trends of colonial psychiatry by subscribing to the idea that inpatient facilities were ultimately the means to improve mental health in the population. Historian Megan Vaughan argued that colonial psychiatry encouraged removal from society and culture as a form of treatment – she called this ‘deculturation’ (Vaughan, 1991: 108–09). The mental health patients in Abeokuta were essentially doubly ‘othered’ – first ‘othered’ as colonised subjects, then ‘othered’ again via incarceration and isolation from their social world. The Western Nigerian Medical Report, specifically the section on mental health, is therefore very useful as it opens up historical questions around patient treatment, medical infrastructure, colonial policies, and the assumptions that informed them.
Our second example takes us to Mandatory Palestine, a geopolitical entity under British administration from 1920 until 1948, and we are scrutinising the Palestine Department of Health Annual Report for the Year 1942 [B]. Very much like the Western Nigerian Medical Services Report, the Palestine Report covers legislation and finances, vital statistics of the Palestinian population, the establishment of hospitals and dispensaries, maternity and child welfare, nursing service, police and prisons, laboratory services, water supplies, quarantine, sewage and drainage, and many other areas. The report also carries subsections on communicable diseases such as plague, smallpox, malaria, tuberculosis, and venereal diseases. Here let us concentrate on the subsection on the rat plague in Tel Aviv and Jaffa from 1942 to 1943; records of these public health incidents offer historians a glimpse of how governmental administrators and medical officers discovered and resolved outbreaks of disease.
On 7 November 1942, a young girl from the Jaffa–Tel Aviv area died of an acute febrile condition that had seemingly been misdiagnosed. Suspicion of plague arose and post-mortem examination revealed the presence of Yersinia pestis, a bacterial species that transmitted from rodents to humans by Xenopsylla cheopis, also known as the Oriental rat flea. Health officials discovered pockets of rat infection in numerous areas around Tel Aviv, demonstrated on the map entitled ‘Spread of Rat Plague, 1942–1943 Jaffa–Tel Aviv’, as 15 human cases of plague accumulated (nine of which were fatal). Anti-plague measures consisted primarily of rat destruction using traps, poison bait, and toxic gases – with barium carbonate and motor car exhaust gas (presumably containing carbon monoxide) being particularly effective. Inoculations were carried out and by March 1943, 16,800 people had been given Haffkine’s vaccine (see later discussion on Haffkine [G]). The Department also demolished 230 inhabited dwellings and 8640 shacks, and had to provide temporary camps for approximately 150 families who were rendered homeless in the process. Even though the number of fatalities had been relatively small, they served to justify very heavy-handed medical and environmental interventions that involved the significant displacement of large numbers of people in Jaffa and Tel Aviv. As historians we could take an account like this and analyse it in a ‘lateral’ fashion by investigating how other health departments handled rat plague around the same time period, or we could place this in a ‘longitudinal’ context by going through the whole run of Palestine reports to see how the management of disease outbreaks evolved under British rule. Having a sense of what the interventions were (barium carbonate, arsenic, Haffkine’s vaccine, etc.), we could also attempt to trace the histories of the global production and movement of these chemicals.
We could also investigate how governments have tried to tackle epidemics using long-term, environmental solutions, particularly in places of enormous political and military significance. This takes us to our third quick case study, the Egyptian Government Preliminary Report of the Anti-Malarial Commission, 1919 [C]. British forces occupied Egypt from the end of the Anglo-Egyptian War in 1882, and in 1922 Britain abolished the Egyptian Protectorate by unilaterally declaring Egyptian independence and the establishment of the Kingdom of Egypt, and formally withdrew all British troops in the 1950s. In the mid 1910s, it became clear to the colonial administration that malaria, long existent in the oases in the Western desert and along the Suez Canal, was now threatening the entirety of Egypt due to a series of high floods at the River Nile. At the end of 1916 an Anti-Malarial Commission was formed to deal with this threat, in order to protect the large populations in Alexandria and Cairo, but also to safeguard British economic and commercial interests at the Suez Canal.
Many of the Commission’s projects were civic and environmental engineering: repairing and redesigning drainage, clearing up marshes and lakes, pouring concrete into ditches, reclaiming flooded lands and shoring up food defences, eliminating railway borrow-pits and pools of stagnant water, and so forth. The 1919 Report included textual description as well as architectural blueprints and illustrations. The application of advanced construction know-how and modern medical knowledge also served to legitimise colonial rule: the British occupiers showed that they could resolve a pressing public health concern affecting the white colonisers and the colonised population. The LSTM preserved the Anti-Malarial Commission Reports up to 1936, thus allowing us to evaluate the efficacy of these environmental measures. Comparative historians could use this source to assess how another site of key global strategic interest – the Panama Canal – was controlled by the American forces (Isthmian Canal Commission) using a similar set of engineering and epidemiological solutions, shortly before the Egyptian Anti-Malarial Commission was established. Of course, both Britain and the United States were confronting the problem of malaria, in Egypt and Panama, respectively, well before the spraying of insecticides became commonplace in the 1930s and 1940s. Using primary sources on these Commissions helped us reveal how the discovery, manufacture, and subsequent widespread dissemination of DDT impacted malariology in particular and epidemiological reasoning in general.
When Western medicine was introduced to a colony, it often clashed with or had to compete against a pre-existing, ‘indigenous’ healing tradition. Colonial regimes and the colonised people – European–American public health officials versus local medical practitioners – might negotiate for coexistence and accommodation. Colonial administrators might even turn a blind eye to ‘indigenous’ medical practices. But more often than not, colonial governments launched campaigns to denigrate and marginalise these local medical systems as mere quackery or superstition; sometimes they were aided in such educational efforts by a compliant local elite and/or colonised subjects who were trained in Western medicine and recruited by the colonial governments. The use of Western medicine was often strictly imposed in government-sponsored hospitals and clinics. A primary source from the ‘Grey Literature’ Collection that illustrated such dynamics was the Hong Kong Principal Civil Medical Officer’s Report, 1897 and 1902 [D], specifically the brief report from a Commission appointed in 1897 by Sir William Robinson (1836–1912), the eleventh governor of Hong Kong (1891–98). The Commission conducted an inquiry into the operation and management of Tung Wah Hospital in Sheung Wan, Hong Kong Island; a British physician and a Chinese physician (both trained in Western medicine) were hired to be the inspecting officers.
The Tung Wah Hospital had its origins in a small, local temple, built around the 1850s and used for ancestor worship. It was gradually taken over by the sick and destitute as a refuge, and became a public health concern. A group of Chinese community leaders decided to raise funds to build a hospital in the neighbourhood, and a piece of land was granted by the Hong Kong colonial government. The hospital was finally finished in 1872 and provided free medical treatment to the poor (Sinn, 2003). Dr John C. Thomson, the Commission’s inspecting medical officer, discovered that at Tung Wah ‘more than four-fifths of the inmates [were] treated by so-called Chinese methods’ and that this was ‘somewhat anomalous in a British colony’. The Commission argued that, while a statesman might have to ‘consider the desirability of humouring to some extent the prejudices of the Chinese population’, from a medical point of view, the Commission considered the Chinese medical methods (including acupuncture) as ‘really nothing but empiricism or quackery’. Dr Thomson observed that patients at Tung Wah were mostly ‘poor people of the artisan class’ who were fearful of Western medicine, particularly surgery. The Commission finally argued that, because the sick were not receiving ‘proper’ medical treatment, Tung Wah ultimately could not be recognised as a ‘hospital’, but that it corresponded ‘more to a workhouse’. It was advised that the Hong Kong Government had to establish another hospital, ‘similar to the Tan Tock Seng Hospital at Singapore’, where only European methods of treatment would be permitted. At Tan Tock Seng, the medical staff consisted of ‘both Europeans and Asiatics’, but the ‘Asiatics’ were only employed as ‘dressers’, under the direct supervision of the Colonial (European) Surgeon in charge.
There was no indication as to whether the Commission’s suggestions were carried out, or if the inspecting officers attempted to implement interventions at Tung Wah to halt the practice of Chinese medicine – for that we would need to dive deeper into archive materials deposited at the Reference Library of Tung Wah Museum in Hong Kong. What we do know is that, as often happened in colonial history, epidemics provided an opportunity for Western medicine to decisively displace local practices. From the 1902 report, we saw how successive epidemics in Hong Kong (rat plague, cholera, malaria) meant that, at Tung Wah Hospital, ‘all cases of infectious diseases [went] under European methods of treatment, and [were] hence more under the control of the Inspecting Medical Officer’. Moreover, ‘the violent jealousy that previously existed against the introduction of European methods, especially among the native doctors, [had] to a large extent subsided’.
Finally, let us turn our attention to an interesting and very short document, from a private, voluntary entity – an NGO in Georgetown, Guiana (British colony 1814–1966) active in the 1910s and 1920s. This was The Baby Saving League of British Guiana: The First Annual Report, 1914 [E]. Established in 1914 through private donations as well as some governmental support, with Lady Egerton (wife of the Governor of British Guiana) acting as patron, the Baby Saving League attempted to reduce infant mortality rates in the colony. Their projects included: installing qualified and registered midwives in various districts; establishing clinics such that the health of mothers and infants could be regularly monitored; intervening in cases of paternal neglect; supplying safe sources of milk; as well as ‘enlightening ignorance and dispelling superstition’ by displacing folk childbirth and childcare practices, particularly in the Guiana countryside. Through this primary source, we see how colonial administration could fail to address a widespread social problem, and a private charitable body responded swiftly to offer solutions. We also discern the process of bringing local, Afro-Caribbean population into the realm of (white) Western medicine (see De Barros, 2014).
Reports from scientific and medical research institutions
In this section, we discuss annual reports and documentation from scientific and medical institutions around the world, deposited as part of the LSTM’s ‘Grey Literature’. In simplest terms, the reports underlined the work that the institutions carried out within a certain time period (usually in the previous calendar year), and included information on staff expertise, training programmes, built facilities, acquired funding, international partnerships, future plans, as well as research results and impact. These scientific and medical centres were supported by the state (such as a ministry of health, a colonial administration, a national institute of research or state research council, a state university or higher education establishment), founded by a private foundation (for example, Rockefeller Foundation, Howard Hughes Medical Institution), or a combination of private and public funding.
Our first example is the East African Institute of Malaria and Vector-Borne Diseases Report [F]. The Institute was based in Amani in Tanzania, and began life as the East African Malarial Unit in 1949 that served British Somaliland, Kenya, Uganda, Tanganyika and Zanzibar in the control of malaria. The unit had been reorganised over several decades, and its most recent incarnation was the Amani Medical Research Centre of the National Institute for Medical Research of Tanzania, which investigated malaria as well as other parasitic diseases.
Take the 1951 and 1955 Annual Reports. Collaborative projects, as well as connections with local medical departments and affiliations with international agencies, were listed. In 1951, cooperation with the East African Medical Survey was praised with leading to less ‘wasteful overlapping’ of resources and more funding from the East African Community due to mutual interests. In 1954 the Institute was also assisted by the United Nations, which provided staff and resources (vehicles and materials for spraying insecticides) supported by the United Nations Children’s Fund. Therefore, these institutional reports could inform historians of the formation of networks and circulation of scientific expertise. With regard to the Institute’s activities, there were detailed write-ups of research projects undertaken and conclusions drawn from practical fieldwork. These reports offered a glimpse of how scientific research was undertaken – the process as well as the expenditure, the successes as well as the failures. For example, one study from April to May 1951 into the effectiveness of air-spraying DDT in Dar es Salaam generated inconclusive results due to extreme rainfall in the region. We could argue that, in tackling malaria in Tanzania, transplanting techniques that worked elsewhere (air-spraying insecticides in this case) had been a standard move. However, the source showed that scientific and medical interventions had to be modified to meet the challenging climate conditions and the diverse across Africa (Webb, 2014). Shifts in research topics and methodologies over a period of time could reveal the evolution of a scientific institute’s research priorities. In its early years, research at the East Africa Malaria Institute (EAMI) focused on understanding the lifecycles of mosquitoes; extensive resources were devoted in 1951 into the time differences between egg-laying and blood meals of marked mosquitoes. This kind of research would indicate an interest in preventing the spread of malaria by analysing ways of eliminating its vector, while in later years the EAMI was much more preoccupied with trialling anti-malarial medications (with elaborate statistics on duration and types of treatments, cure and fatality rates, and so forth).
Our second primary source is the Summarised Report of the Bombay Plague Research Laboratory for 1896–1902 [G]. Thanks to the voluminous scholarship – for instance, Mark Harrison’s Public Health in British India: Anglo-Indian Preventive Medicine 1859–1914 (1994) – historians have a good sense of the management of plague epidemics and the circulation of bacteriological knowledge in South Asia. In September 1896 the first case of bubonic plague was detected in Bombay (now Mumbai), which rapidly spread and the death toll was estimated at 1900 people per week. In October 1896 the Bombay government established a Plague Research Committee to investigate the disease and, if possible, to produce a vaccine. At Sir J.J. [Jamshedjee Jeejeebhoy] Hospital, the Bombay Plague Research Laboratory was set up and the Russian–Jewish bacteriologist Waldemar Mordechai Haffkine (1860–1930) was hired to be its director-in-chief –– as we can see from the front cover, Haffkine was the author of the 1896–1902 Report. According to Mark Harrison, by ‘December 1896 Haffkine announced that he had devised such a vaccine, raising European hopes of a truly effective method of prevention’ (Harrison, 1994: 144). After favourable tests in a local prison, Haffkine’s inoculation was introduced into communities in Bombay and then across West India.
The first section of the Summarised Report of the Bombay Plague Research Laboratory gives us a sense of the scale of Haffkine’s project. Up until 31 May 1901, around 2.3 million doses of the plague prophylactic (i.e. Haffkine’s vaccine) were manufactured in India, of which 1.9 million were distributed within India and around 440,000 exported (to places including Burma, Ceylon, China, Cyprus, Japan, Philippines, Turkey, United Kingdom, the Netherlands, Russia, Australia, as well as colonies across the African continent). Readers may recall that Haffkine’s vaccine was used by the British Palestine Department of Health during the Jaffa–Tel Aviv plague outbreak in 1942, as we have explored already [B]. In the Bombay Plague Research Laboratory Report, details on the Indian distribution of the vaccine were tabulated. The primary source also carried descriptions on vaccine preparation techniques and protocol, on trials on the immunising properties of the vaccine on local populations, and on some of the difficulties and resistances encountered given that, of course, Haffkine’s team was testing plague bacteria on human subjects. The published scientific papers associated with each trial were listed and could be followed up by historical researchers. All these leads from the Report give historians a sense of the networks that Haffkine and his team built and relied upon, and more generally how colonies like India functioned, following Ann Laura Stoler and Frederick Cooper’s provocative turn of phrase, ‘laboratories of modernity’ (Stoler and Cooper, 1997: 5; see also Tilley, 2011). Fundamentally, scientific progress and medical innovation depended on the colonies that supplied the illnesses and the possibilities of experimenting interventions – including potentially fatal interventions – on a subjugated population over long periods of time.
Our third case study involves the United Fruit Company Medical Department Annual Reports [H], and we have chosen reports from 1913 and 1931. Much historical work has already been produced on the United Fruit Company (UFC), which was an American corporation that, since the mid 1980s, has been known as Chiquita Brands International. The UFC traded in tropical fruits, especially bananas, grown in plantations in Latin American nations such as Honduras, Costa Rica, Guatemala, Ecuador, Panama, Colombia, and many others. The UFC was tremendously powerful in the early to mid twentieth century, and came to dominate the economy and politics of these Latin American nations to such an extent that critics had labelled them ‘banana republics’, or a ruling elite, often a corrupt military dictatorship, that exploited its agricultural labourers and working-class population, and that was subservient to a gigantic transnational corporation like the UFC for private enrichment. In other words, critics argued that UFC were engaging in a form of ‘neo-colonialism’ by operating a medical Department that began to build, from the early 1910s onwards, hospitals, clinics, and dispensaries that oversaw the health of company workers and their dependents, as well as some local non-employees.
We can see the overarching objective of the Medical Department in the ‘Letter of Transmittal’, dated 9 December 1913, from the General Superintendent Robert E. Swigart to the President of the UFC A.W. Preston: ‘The broad policy adopted by the Company in maintaining a sanitary and medical organisation to protect its business investments through the health of the 65,000 employees and dependents in Central and South America, Cuba, and the West Indies, has its reward in the total absence during the year of a single quarantinable disease in any tropical division or on any steamship of the Company’. Using the 1913 Annual Report, we could zoom into the situation in Guatemala, where the UFC owned 200,000 acres of land at that time, with 5000 employees and 8000 dependents which the Medical Department managed, particularly against the threat of malaria. There were illustrations and architectural drawings of the new hospital that they built in Quiriguá in south-eastern Guatemala, as well as statistics on hospital admittance, contracted diseases, performed surgeries, death reports, and laboratory investigations. The Medical Department also organised sanitation and hygiene within UFC property, such as the installation and repair of plumbing and sewage, water supply and drainage, garbage disposal, and inspection of houses and labour camps.
Historian David Aliano has pointed out that the UFC Medical Department ‘envisioned a much greater role for itself in the field of tropical medicine’ (Aliano, 2006: 44), beyond providing healthcare to United Fruit employees. In fact, the company doctors saw themselves as part of a ‘civilising mission’ – they thought ‘their modern facilities and innovative methods of sanitation and treatment of disease [would] serve as a model to members of the medical profession’ in Latin America (Aliano, 2006: 44). If we scrutinise the table of contents of the 1931 Report, we see that the UFC Medical Department’s priorities have shifted towards the dissemination of scientific research and promotion of healthcare interventions. Compared to the 1913 Report, there was far less detailed discussion on the establishment and operation of medical infrastructure; instead, the 1931 report was dominated by scientific papers. We will not analyse in detail these scientific papers; suffice it to say that they captured what was then cutting-edge scientific and medical research, and could give historians a sense of knowledge-making at the UFC Medical Department’s network of laboratories and clinics. We could use the scientific papers to identify the scientists’ agenda, where they agreed with or argued against one another, how they sought to answer their questions (methodologies, experimental designs, mathematical techniques, acquisition of research objects/subjects), what outcomes they proposed (solutions, interventions or public health policies), and how all that information was circulated and disseminated to governments or the wider public. Historical scientific papers carried enough details to allow historians to chart the careers of individual or groups of scientists and physicians employed by the UFC Medical Department. We could also interrogate how researchers working in different parts of the world communicated and collaborated with their peers, how they built consensus and resolved controversies, the possible ethical issues involved or the political interests served by these research projects.
The ‘Letter of Transmittal’, dated 1 May 1932, from the General Manager of the Medical Department Dr R.C. Connor to the UFC headquarters in Boston, showed that the Company was working closely with the United States Public Health Service and the Rockefeller Foundation in building international networks, recruiting and sponsoring educated scientific and medical elite in Latin America, and transforming the whole region. Studying the United Fruit Company Medical Department Annual Reports could therefore be illuminating in not just seeing how malaria, yellow fever and other epidemics were handled in Guatemala, Honduras, Colombia and other countries. We argue that medicine functioned as instruments of power – in this case not the direct imposition of policies by a colonial regime (e.g. British India government in Bombay as in source [G]), but instead a powerful transnational corporation worked to entrench its influences and further its interests across a vast geographical area.
Finally, let us turn our attention briefly to two sources –– [I], from the Report of the Medical Research Institute for the Year 1916 (Lagos, Nigeria), and [J] from the photograph album, Eijkman Instituut 1888–1938 (Jakarta, Indonesia). Reports and documentation from scientific and medical institutions are often accompanied by plenty of images. In [I], we see that the Medical Research Institute in Lagos, Nigeria experimented in 1916 with treating patients at the Yaba Leper Asylum suffering from leprosy. The Institute used a treatment involving the hypodermic use of a mixture of chaulmoogra (Hydnocarpus wightiana) seed oil, camphorated oil, and resorcin. The Report describes seven cases, with grotesque photographs demonstrating how leprosy nodules, ulcers, and maculae improved or even disappeared after several months of treatment. Source [J] is a photograph album commemorating the fiftieth anniversary of the Eijkman Institute in Jakarta, Indonesia. Established in 1888 as a Research Laboratory for Pathology and Bacteriology, its most famous faculty was the Dutch physician Christiaan Eijkman (1858–1930), who discovered the relationship between vitamin B1 (thiamine) deficiency and beriberi and was awarded the Nobel Prize in Physiology or Medicine in 1929 (shared with Frederick Gowland Hopkins). In 1938, when the photograph album was published, the Research Laboratory for Pathology and Bacteriology was renamed the Eijkman Institute and became a renowned centre for tropical medicine. It closed in the 1960s in the aftermath of Indonesian independence, and was reopened in the mid 1990s. While much of the album simply contained photographs of laboratories and training facilities, we were drawn to the section on the commercial production of vitamin B1 tablets from rice bran, which presumably was a source of income for the Eijkman Institute. Overall, these visual primary sources provide tantalising clues on how a research institution operated, or how visual evidence for illnesses (medical photography) was amassed and disseminated.
This chapter offers a mere glimpse into the ‘Grey Literature’ collection deposited at the LSTM. We have certainly not covered every kind of primary source from the collection. For example, we have only really considered English-language sources, and there is a significant portion of materials written in French or German on public health, sanitation, and medical provision in former French or German colonies. We have also excluded items such as technical specifications, instruction manuals for scientific instruments and medical equipment, ‘bluebooks’ or almanacs containing epidemiological data sets and population vital statistics, historical maps and atlases, old dictionaries and encyclopaedias, or old doctoral theses on tropical medicine and public health. We have also not studied the vast collection of historical scientific papers and conference proceedings produced or amassed by faculty members at the LSTM.
Readers will note that we have not explored every facet within each primary source – some official publications or annual reports run to hundreds or even thousands of pages and we cannot cover their entire contents very easily! We also have not addressed how the ‘Grey Literature’ had been used by past and current researchers at the LSTM. And it goes without saying that there are many other kinds of primary sources – sources that do not form part of the LSTM ‘Grey Literature’ – that could be marshalled to write all kinds of histories of medicine. Historians have used letters and diaries from practitioners and patients, interviews and oral histories, films and artwork, medical manuscripts and charts, case records from clinics and hospitals, textbooks and handbooks, newspapers and magazines, artefacts and material culture, and many others. We hope to have shown that, from the small slice of the ‘Grey Literature’ we have investigated, there is an enormous constellation of research questions on the history of colonial medicine and global health. Many of these questions might be fruitfully explored in research essays or in dissertations; some could effectively sustain an academic researcher’s entire career.
Aliano, D., 2006. Curing the ills of Central America: the United Fruit Company’s medical department and corporate America’s mission to civilise (1900–1940). Estudios Interdisciplinarios de América Latina y el Caribe (EIAL), 17, pp.35–59.
Arnold, D., 2000. The new Cambridge history of India, III.5: science, technology and medicine in Colonial India. Cambridge: Cambridge University Press.
Bhattacharya, S., 2011. Global and local histories of medicine: interpretive challenges and future possibilities, in Mark Jackson (ed.), The Oxford handbook of the history of medicine. Oxford: Oxford University Press, pp.135–49.
Brieger, G., 1993. Historiography of medicine, in W.F. Bynum and Roy Porter (eds.), Companion encyclopaedia of the history of medicine. London: Routledge, pp.24–44.
Cooter, R. with Stein, C., 2013. Writing history in the age of miomedicine. New Haven, CT: Yale University Press.
De Barros, J., 2014. Reproducing the British Caribbean: sex, gender, and population politics after slavery. Chapel Hill, NC: University of North Carolina Press.
Harrison, M., 1994. Public health in British India: Anglo-Indian preventive medicine 1859–1914. Cambridge: Cambridge University Press.
Huisman, F. and Harley Warner, J. (eds.), 2006. Locating medical history: the stories and their meanings. Baltimore, MD: Johns Hopkins University Press.
Packard, R. M., 2016. A history of global health: interventions into the lives of other peoples. Baltimore, MD: Johns Hopkins University Press.
Power, H. J., 1999. Tropical medicine in the twentieth century: a history of the Liverpool School of Tropical Medicine 1898–1990. London: Kegan Paul International.
Sadowsky, J., 1999. Imperial bedlam: institutions of madness in colonial southwest Nigeria. Berkeley, CA: University of California Press.
Sinn, E., 2003. Power and charity: a Chinese merchant elite in colonial Hong Kong. Hong Kong: Hong Kong University Press.
Stoler, A. L. and Cooper, F., 1997. Between metropole and colony: rethinking a research agenda, in Cooper, F. and Stoler, A. L. (eds.), Tensions of empire: colonial cultures in a bourgeois world. Berkeley, CA: University of California Press, pp.1–56.
Tilley, H., 2011. Africa as a living laboratory: empire, development, and the problem of scientific knowledge, 1870–1950. Chicago, IL: University of Chicago Press.
Vaughan, M., 1991. Curing their ills: colonial power and African illness. Cambridge: Polity.
Webb Jr, J. L. A., 2014. The long struggle against malaria in tropical Africa. Cambridge: Cambridge University Press.