African Therapeutic Practices in a Precolonial World

For many centuries prior to the advent of European colonialism, Africans had recourse to different groups of healers and their healing practices to control human disease (for animal diseases and veterinary medicine in colonial Africa, see, for instance, the article “The African Rinderpest Panzootic”). Therapeutic practices varied greatly across the continent, but many societies centered on redressing imbalances in persons, societies, and environments, thereby combining the use of materia medica from the natural world, spiritual divination, and community healing. This meant that the way in which they conceived of disease and the human body differed fundamentally from the individualized body that would lie at the core of European biomedicine from the late 19th century onwards (see the section “Disease Control and European Health in the Late 19th Century”). In many African settings, the diseased body was understood in its relationship to the society and environment in which people were living. Disruptions in the social body could cause individual illness, while the restoration of the social body was seen as essential to the healing of individuals (see article “African Religion and Healing in the African Diaspora”).¹

Many societies divided illnesses into two groups: “natural diseases” or “diseases of God,” which had a natural cause and were treated with herbs and other natural substances, and “diseases of man,” which were caused by other human beings through sorcery or by offended ancestral spirits. Ideal-typically, the former were addressed by so-called “herbalists” and the latter by so-called “diviners,” who were also responsible for diagnosing the causes of disease and misfortune. In practice, however, many healers combined these functions, just like diseases could have multiple and/or shifting causes that were addressed by different therapeutic practices. African healers were also polyvalent in another way: many of them used medicines and witchcraft not only to heal individuals and societies, but also to harm enemies and competitors.²

Healing power and political power were often closely connected and even mutually constitutive. Political leaders were responsible for the health and prosperity of their people and hence depended on healers’ and their own ability to protect society and environment against misfortunes such as diseases, wars, and droughts. Access to the most powerful and successful medicines symbolized political power and legitimized rule. Conversely, the political legitimacy of rulers suffered when they proved unable to secure population health and well-being. Consequently, epidemics and famines often generated widespread turmoil and political crisis.³

African therapeutic practices not only varied across space. In contrast to colonial representations of unchanging “healing traditions,” they were open to change over time. They incorporated new and abandoned or reordered ancient elements as societies expanded, interacted, or were confronted with new political, economic, religious, or environmental challenges.⁴ Such hybridization processes can be observed long before the colonial conquest of the continent in the late 19th century. The spread of Islam, for instance, brought new medical concepts and actors to societies in eastern and western Africa. Islamized Mandé healers, for instance, introduced talismans covered with religious symbols or containing Koranic verses as charms with important healing power to coastal societies in the Senegambia and Guinea Bissau region from the 13th century onwards.⁵ Or, to give another example, Hausa kings and commoners began in the 15th century to incorporate Islamic practices of prophetic healing, magic, and divination into their medical panoply.⁶

Another major precolonial moment of change through exogenous contact was the establishment of European trade settlements in coastal Africa and the onset of the transatlantic slave trade. Between 1500 and 1870, about 12.5 million Africans, two thirds of them men, were forcibly shipped as slaves across the Atlantic.⁷ Moreover, the ensuing “Columbian Exchange” between Africa, Eurasia, and the New World altered disease environments and nutritional conditions in sub-Saharan Africa through the introduction of new diseases like syphilis and new high-nutrition crops like cassava, maize, and sweet potatoes.⁸ While historians and historical demographers still controversially debate the precise (and regionally varying) demographic consequences of these processes, it is clear that they strongly influenced the political, social, and cultural life of many societies in West and West Central Africa.⁹

The slave trade and early Afro-European contacts also had tangible effects on therapeutic practices in the African societies involved. John Janzen, for example, has shown that the political and socioeconomic disruptures wrought by the slave trade changed the hierarchy of ritual techniques and healing associations on the Loango coast in West Central Africa, with Lemba gaining ascendancy over other medicines between the 17th and 19th centuries.¹⁰ Furthermore, many of the Afro-Atlantic contact zones in West and West Central Africa became sites of cross-cultural exchanges of materia medica, healing symbols, and cosmologies. These exchanges went in both directions. Doubting the efficacy of their own healing methods against tropical fevers and other illnesses unknown in their home countries, European merchants, sailors, and missionaries sought treatment from local healers or adopted the use of local plants, shrines, and talismans. Conversely, West (Central) Africans incorporated European remedies as well as medicinal flora from tropical regions in America and Asia into their arsenal of healing practices.¹¹

The slave trade not only affected disease control on the African coast. It also caused African (including Islamic) healers, healing practices, and drugs to cross the Atlantic. In the Americas, African healers, most of them slaves, not only reproduced the spiritual healing rituals and herbal treatments from their regions of origin; they often also incorporated Amerindian knowledge of local plants, European medical and religious elements, and therapeutic practices from other African regions into their healing practices. In some cases, cross-cultural borrowings gave rise to new syncretized forms of healing such as Vodun in Haiti and Candomblé in Brazil. Although many of them were enslaved, African healers often received considerable freedom of movement to treat other slaves or free persons of African descent on the plantations and in the cities. Despite the growing resistance of colonial governments, priests, and trained physicians, who increasingly tended to see them as competitors and charlatans, African healers often enjoyed great popularity among white Europeans as well, since they were believed to be more capable of curing (tropical) illnesses than the few European physicians (see the article “African Religion and Healing”).¹² Within the Atlantic World, African healers, healing practices, and materia medica also made their way to some parts of Europe, most notably Portugal, where they became entangled with local traditions of folk healing.¹³

Such cross-cultural borrowings were possible partly because African and European medical beliefs revealed important similarities. From the 16th to the early 19th century, European “professional” medicine, in the metropoles and colonies alike, was basically humoral medicine. Developed by Hippocrates and fellow doctors in ancient Greece from the 5th century bce onwards, humoral medicine posited that illness was caused by a misbalance between the four humors or key bodily fluids: blood, phlegm, black bile, and yellow bile or choler. Disbalances, meaning the excess or lack of one or more humors, resulted from faulty diets, wrong dosages of physical exercise, or changes in environments, climates, and seasons. Accordingly, measures to maintain or restore health focused on maintaining or restoring the equilibrium of humors, through lifestyle changes and medical interventions such as bloodletting and purging that were to let out the “bad” humors. Physicians thereby used leaves, roots, and barks to purge the blood and restore balance. Such materia medica were also widely employed by “popular” healers who practiced outside—but were often in mutual exchange with—academic orthodoxy.¹⁴ In not so dissimilar ways, many African healing systems were equally concerned with balance and included practices to liberate the body from toxic substances. They employed bleedings or used plants and other natural products as laxatives and vomitives. Another conceptual bridge was that the “African” idea that illnesses were caused (and could be cured) by spiritual forces was still strong in European medical practices as well. While early modern Catholic ecclesiastical medicine relied on saints and their miracle cures, sometimes also on licensed church exorcists, “magical healers,” often wise women, were an integral part of folk medicine.¹⁵

Nevertheless, hybridization and transculturation tendencies in early Euro-African(-American) contact zones were not boundless. In their quest for healing, European and African “laymen” borrowed medical substances and practices from each other’s healing systems, thereby benefiting from a pluralistic “medical market.” Sometimes, however, they risked public condemnation or even persecution by the Inquisition.¹⁶ Moreover, while patients moved between spheres and systems to cure their ills, professional medical practitioners on both sides were less prone to (openly) borrow from one another. European physicians and surgeons as well as African healers often remained convinced of the superiority and incommensurability of their respective healing systems.¹⁷ This tendency would become particularly virulent on the European side from the late 19th century onwards.

Disease Control and European Health in the Late 19th Century

When, in the last third of the 19th century, European colonial powers gradually explored, conquered, and occupied the vast interior of the African continent, the conditions of the medical encounter between Africans and Europeans were changing. While violent colonial conquest and rule were causing much more asymmetrical power relations, major shifts within Western medicine were turning it into something quite different from African therapeutic practices and, among its proponents, prompting a growing belief in its therapeutic superiority.¹⁸ This would increasingly limit cross-cultural borrowings and hybridizations, although they still occurred.¹⁹

Since the early 19th century, a new “rational” and empirically based “scientific” medicine had gained ascendancy over humoral beliefs. Rather than collecting and analyzing the (subjective) symptoms of disease through bedside observation, it searched for (objective) pathological signs through the physical examination of the living and the dissection of the dead in order to identify the disease and devise appropriate remedies.²⁰ This new “scientific” medicine had its origins in the large hospitals of revolutionary Paris, but also in the late 18th-century medical culture in the colonies.²¹ In the middle decades of the 19th century, microscopy, laboratory research, and physiological experimentations were also producing new insights in physiology and pathology. They paved the way for the advent of germ theory in the 1870s that attributed the cause of disease to the “invasion of the body by microscopic living organisms.”²²

While these developments revolutionized European and Western academic medicine and made it increasingly distinct from African medical beliefs and practices, European practices of disease control in colonial sub-Saharan Africa would, throughout the 19th century, largely be governed by another development. Already in the 18th century, naval and civil colonial doctors had come to conceive of diseases in tropical regions as “tropical diseases,” as (a body of) diseases that were ontologically distinct from diseases of temperate climates, since they were caused, primarily, by the tropical climate itself: either because the abundance of heat and moisture in the tropics accelerated the putrefaction of organic matter and caused the ubiquitous ill-making miasmas or because the oppressive and enervating climate exhausted human bodies and attacked their nervous systems. By the 19th century, the idea that tropical climate was the prime cause of a distinct body of fevers and other—often deadly—diseases was firmly entrenched in European medical thought. It was based on a spatial understanding of disease, which postulated a strong causal link between place (including environment and climate) and disease—and which was in part due to the rediscovery of Hippocrates’ text Airs, Waters and Places.²³

This spatial understanding implied that newcomers to a particular place in the tropics were deemed particularly vulnerable to the pernicious influence of its climate, while those who had been living there for generations were not. This also contributed to a racialized understanding of disease. The observed differences in disease susceptibility would, from the late 18th century onwards, increasingly be seen as innate characteristics of human “races.” Crucial in this context was the idea that “races” or other population groups had over the course of many generations adapted to their environment and acquired some kind of immunity to diseases to which they were constantly exposed. On this basis, doctors explained why Europeans were so likely to succumb to malarial and other fevers in the tropics, whereas Africans seemed to be almost immune against them, but particularly vulnerable to imported diseases like tuberculosis.²⁴ In this context, tropical Africa would gain a particularly bad reputation. Supported by statistics that indicated excessively high mortality rates among European soldiers, travelers, settlers, and missionaries, tropical Africa became widely viewed as the most dangerous place on earth for Europeans, the “white man’s grave.”²⁵

These new understandings of disease also had a bearing on the so-called acclimatization debate, that is, about whether and how Europeans were able to adapt to tropical climates. During the 18th and early 19th centuries, most European doctors and scientists believed that human bodies, like plants and animals, could be transferred to and thrive in other climes if certain hygienic precautions were taken.²⁶ This belief in the flexibility of human constitutions did not entirely disappear, but over the course of the 19th century opinions about the adaptability of Europeans to tropical climates grew more pessimistic. This was, in part, due to the aforementioned idea of “racial immunities” to tropical diseases that could only be acquired after many generations, if at all. But new theories of heredity and more rigid concepts of race in the second half of the 19th century also played their part. They induced powerful and vociferous anthropologists like Rudolf Virchow to deny the possibility of both individual and “racial” acclimatization, and hence white settlement, in the tropics. While they still considered individuals as malleable, they no longer viewed the physiological and mental hybridizations Europeans would experience in the tropics as steps toward successful acclimatization, but as pathological and degenerative. They would inevitably lead to the demise of the European “race.”²⁷

Such pessimist views about the dangers of tropical climates, Europeans’ predisposition to tropical diseases, and the difficulties of acclimatization would guide early European conquest and colonization of Africa in many intertwined ways. Perhaps the main consequence was that, until the early 20th century, the primary focus of colonial health services, which only received limited budgets and staff, would be to preserve the health of Europeans. Besides the curative services offered by state hospitals and private doctors, early colonial healthcare was based largely on preventive measures.

Colonial hygienists thus issued a series of recommendations that were to counterbalance the pernicious influence of tropical climate on unadapted European constitutions. Published in the form of medical treatises or settler manuals, they focused much on adequate food, clothing, and housing, and prescribed the avoidance of excesses of all kind alongside the adoption of a moderate lifestyle. In order to stay healthy, Europeans in the tropics (in Africa as well as elsewhere) were to avoid direct exposure to the sun, adopt a moderate diet with regular meals and without much alcohol, wear comfortable clothes and always cover their heads, live in spacious and well-aired houses far away from swamps and, if possible, in higher altitudes, and make sure that they got enough sleep. Many manuals also advised avoiding heavy manual labor.²⁸ These recommendations were very similar to those in medical treatises and manuals in the late 18th century, with the exception that they no longer referred to humoral medicine.²⁹ Moreover, many of them would stay en vogue long after the acceptance of the germ theory of disease (see the section “Tropical Medicine and Sleeping Sickness Control in Colonial Africa”).

Another key measure was the preventive use of quinine against malaria—a term used before the 1890s to designate a broad range of “tropical fevers” that were not yet understood as a disease caused by plasmodium parasites and transmitted by anopheles mosquitoes. In this context, scholars like Philip D. Curtin and Daniel Headrick have argued that preventive quinine was—alongside gun technology and steamships—a quintessential “tool of empire.” By substantially lowering mortality rates among soldiers and civil servants during conquest and early occupation, it was key in enabling the colonization of sub-Saharan Africa.³⁰ Others, however, have claimed that, while this might have been true for British Africa, it was not a universal experience. French colonial conquest in Africa, William Cohen has thus argued, did not depend on a lower death rate among French soldiers, who did not systematically take preventive quinine before the end of the 19th century. Mortality rates among the French only fell after conquest, when living conditions improved and the colonies could rely more on indigenous soldiers.³¹ In a similar vein, Bouda Etemad has argued that preventive quinine was only used on a large scale among Europeans in Africa in the 20th century.³²

As most Europeans lived in cities, urban health, and particularly the avoidance of epidemic diseases in urban settings, also became a prime focus of early colonial medicine in Africa. In the late 19th and early 20th centuries, disease control measures in colonial cities oscillated between sanitation and separation/segregation, policies that resulted from two distinct, but partially overlapping etiological convictions that had been around for many decades.³³ Sanitation involved draining swamps near cities, cleaning the cities, and removing “insalubrious” indigenous housing infrastructures. It was based on “localist” (and deeply Hippocratic) beliefs attributing (epidemic) disease to local environmental conditions. They held that “bad air” (hence mal’aria) or miasmas emanating from swamps, decaying organic waste, or overcrowded cities were responsible for the wide range of fevers affecting Europeans in sub-Saharan Africa and other parts of the tropical world. The other policy was the physical separation between the sick and the well. It was based on the “contagionist” belief that at least some epidemic diseases, most notably plague, cholera, and smallpox, spread from one person to another and hence demanded anti-contagionist measures like quarantine, isolation, and disinfection. In practice, anti-contagionist measures often included separation between European and African neighborhoods. Enforced during epidemic urgencies through so-called cordons sanitaires, these measures were also taken preventively. In some places, they turned into permanent segregation.³⁴

The discovery of the parasite-vector explanation for much-dreaded diseases like malaria, yellow fever, or bubonic plague at the turn of the century (see the section “Tropical Medicine and Sleeping Sickness Control in Colonial Africa”) would not diminish the popularity of spatial separation/segregation policies in urban Africa. In part, this showed the persistence of old beliefs and practices among colonial public health officers, as Myron Echenberg has argued.³⁵ But it was also because the parasite-vector explanation, while dismissing direct contagion between humans, still suggested that Europeans could be infected due to the proximity of diseased Africans. Viewing African neighborhoods as permanent reservoirs of germs and illnesses, many a colonial doctor promoted residential segregation and a broad cordon sanitaire as the best means to protect Europeans from being bitten by infected anopheles mosquitoes or plague-causing lice.³⁶ Moreover, segregation was not only based on medical rationales—the planned expulsion of Africans from European quarters or the (re)location of European residential quarters onto plateaux and hill stations also aimed at gaining economic advantages, showcasing political superiority, and implementing ideas of racial difference. Medical and other rationales often mutually reinforced each other, as during the expulsion of Africans from Cape Town during the epidemic of bubonic plague or the attempted expulsion of the African merchants from Duala’s prosperous harbor area by the Germans.³⁷ In practice, urban segregation was applied unevenly across the continent due to the diverging opinions of local European doctors and administrators about the adequacy of such measures and the different power positions of local African elites.³⁸

Tropical Medicine and Sleeping Sickness Control in Colonial Africa

Around the turn of the century, European beliefs in racial immunities and the innate biological advantages of Africans on the continent still persisted, but they slowly began to crumble. Colonial regimes grew convinced that Africans also suffered from a wide range of tropical diseases and that the general morbidity and mortality level among them was very high. This shift was in part due to the progressing occupation of the continent, which generated new information about the actual incidence of disease among Africans, but also to the changing value of the African population for European colonialism. With the acclimatization problem unsolved, a healthy and growing population was considered to be crucial for both the economic development and the legitimacy of colonial rule.³⁹ Another cause for this shift was the rise of a new form of tropical medicine based on the germ theory of disease. Microbiological explanations for the etiology of tropical diseases did not immediately supplant theories of racial immunity, but they would contribute to limiting their explanatory power and, most importantly, become a game-changer for disease control on the continent.⁴⁰ Another game-changer was the sleeping sickness epidemic that was wreaking havoc among the “native” populations in large parts of tropical Africa since the 1890s and that would serve as the first major testing ground for tropical medicine on the continent.

Advanced by the likes of Louis Pasteur and Robert Koch from the 1870s onwards, the germ theory of disease posited that disease was caused by “microbes” or microscopic living organisms entering the body. As the often-used term “bacteriological revolution” suggests, germ theory was initially based on the discovery of bacteria as causal agents of infectious diseases.⁴¹ Yet, starting in the 1890s, the application of the same innovative microbiological research design—that is, the isolation and observation of pathogenic microorganisms in bodily fluids through microscopes in laboratories—to diseases in the tropics eventually led to the discovery of parasites as the causal agents of many diseases that were, if not unique to, prevalent in the tropics, such as malaria, yellow fever, or sleeping sickness. As a consequence, “tropical diseases” were no longer defined only by their geographical origins but also by their shared etiology as vector-borne parasitic diseases. They gave rise to specific disease-coping strategies, which integrated knowledge and practices from various disciplines such as parasitology, entomology, ecology, and human and veterinary medicine—and as such diverged greatly from contemporary public health measures in Europe.⁴²

This new kind of tropical medicine was not a merely European “invention.” European doctors surely played a pivotal role, conducting research in Southern Europe and tropical regions across the world, but important early contributions also came from doctors in the Americas or their Indian colleagues.⁴³ Nevertheless, it is hardly a coincidence that the rise of tropical medicine occurred during the heyday of European colonial expansion in sub-Saharan Africa. The rapid institutionalization of this new specialty through journals, conferences, and particularly state-financed schools and research institutes in Europe’s colonial metropoles around the turn of the 20th century reflected its instrumental value for colonial governments—and the ability of the new epistemic community of tropical medicine experts to capitalize on this.⁴⁴ In practice, tropical medicine not only established new disease etiologies, it also brought new experts, research designs, and ways of dealing with tropical diseases to sub-Saharan Africa.

To be sure, tropical medicine based on germ theory did not immediately transform European medical practices in colonial Africa. For some years, quite a few colonial doctors were not inclined to subordinate their long-standing and experience-based medical beliefs and practices, in which sanitation, social improvement, and behavioral change were the keys to health, to the new and much more narrow parasite-vector model of understanding and fighting disease promoted by—often younger—experts in tropical medicine.⁴⁵ This conflict bore large similarities with how many medical practitioners in 19th-century Europe had previously resisted the new “scientific truth” proposed by bacteriologists.⁴⁶ The rise of germ theory in general did not let climate entirely off the hook as a medical problem either. In European medical circles, fears about the climatic toxicity of the tropics for Europeans persisted until well into the 20th century. Certainly, climate was no longer seen as the direct cause of disease, but it was still believed to weaken European constitutions and strengthen Europeans’ predisposition to tropical disease. Even in the 1920s and 1930s, doctors discouraged European women and children in particular from going to the tropics since they were considered to be particularly vulnerable to the deleterious effects of the tropical climate—and prone to experience physical and mental breakdowns.⁴⁷ Moreover, some of the practices that would become key to tropical disease management in the 20th century, such as isolation and sanitation, were already en vogue among colonial doctors before the emergence of germ theory-based tropical medicine.⁴⁸ Finally, with few but notable exceptions, colonial health services in tropical Africa remained geared toward European health prior to 1914. In the long run, however, tropical medicine did have a strong impact on disease control in colonial Africa.

Early colonial campaigns against sleeping sickness constitute perhaps the best example to illustrate the transformative impact of tropical medicine on medical views and practices in Africa. Sleeping sickness or Human African Trypanosomiasis (HAT) is a vector-borne parasitic disease exclusive to sub-Saharan Africa that attacks the central nervous system, causing confusion, changes of behavior, and, as it was reported from early on, an “irresistible urge to sleep.”⁴⁹ Untreated, it is usually fatal. It is caused by the Trypanosoma brucei gambiense or rhodesiense, a parasite that enters the body through the bite of an infected tsetse fly or Glossina.⁵⁰ Sleeping sickness had probably existed on the continent for centuries, but it began to receive more attention from European doctors from the 1870s onwards and particularly after epidemic outbreaks in West Central Africa in the 1890s and the Great Lakes region in East Africa in the early 1900s.⁵¹ These events shocked the public and colonial governments alike; they triggered the Portuguese, British, Belgians, French, Germans, and Spanish into sending almost twenty research commissions to the field prior to World War I in order to unveil the etiology of the disease and investigate its epidemiology.⁵² This “scientific scramble for sleeping sickness”⁵³ was not only a constitutive moment for (the institutionalization of) tropical medicine in Europe, as various historians have argued; this much-dreaded disease also inspired colonial health services to launch their first massive campaigns focusing on the health of rural Africans.⁵⁴ These campaigns, which continued with varying intensity and results throughout the colonial and postcolonial era until the early 21st century, were typical for tropical medicine’s response to vector-borne parasitic diseases, insofar as they tried to control either the vector, the parasite, or the transmission of the disease—or a combination of these elements.⁵⁵

The first, entomological or ecological, approach of vector control aimed to eradicate tsetse flies in certain areas by destroying their habitat or by directly capturing and killing flies. Particularly in the vicinity of larger cities, colonial health services used African workers, in regimes of either wage or forced labor, to clear the vegetation where tsetse flies used to breed.⁵⁶ In some places, they also proceeded to the direct capturing of flies: on the Portuguese-controlled island of Príncipe, plantation owners and health officials from 1906 onwards used African indentured laborers dressed in black bird-lime-coated cloths to catch tsetse flies. Compared to bush clearing and other measures, however, direct fly capturing probably contributed only little (if at all) to the successful vector eradication campaign on Príncipe.⁵⁷ Nevertheless, similar experiments with human fly catchers were subsequently conducted elsewhere as well.⁵⁸ After World War I, these catchers would be replaced by mechanical fly traps that were also and primarily used to monitor fly density.⁵⁹ Particularly in East and Southern Africa, but also on Príncipe, governments also debated and sometimes implemented controversial schemes of game killing, since wild animals were suspected to be alternative hosts for both flies and parasites.⁶⁰ After World War II, governments also utilized DDT and other insecticides to extirpate tsetse flies, primarily by spraying their breeding sites.⁶¹

The second, medical or microbiological, approach entailed the killing of the parasites in the human bodies, through the use of powerful trypanocidal drugs. While drugs were developed by pharmaceutical researchers and laboratories in Europe, their efficiency as well as the most adequate dosages and administration methods were usually tested on African patients in the colonies, before they were either abandoned or applied on a wider scale.⁶² Yet even the drugs of choice, first atoxyl, later tryparsamide, and, after 1945, pentamidine and Mel B, were not very effective in curing the disease, especially in its advanced stages. Moreover, all drugs had severe side effects, ranging from pain to blindness and death. Consequently, many African patients did not believe in their therapeutic value; some of them even blamed their illness on the injections.⁶³ However, drug treatment for all “suspects” was compulsory, just like the diagnostic screening which increasingly relied on the (again) painful extraction and microscopical examination of blood as well as lumbar and cerebrospinal fluid. Such extractions, together with postmortem examinations, gave rise to widespread rumors accusing colonial health workers of vampirism and cannibalism.⁶⁴

The third, spatial or epidemiological, approach consisted of avoiding disease transmission. This was done by removing people from tsetse-infested areas, controlling the internal and cross-border movement of people through the introduction of mandatory medical passports, and confining those who were suspected to be ill in so-called segregation or concentration camps, where they received compulsory treatment.⁶⁵ These camps, which were often far away from Africans’ villages, met with such resistance from African patients that this isolation measure was gradually abandoned in the 1910s and 1920s and replaced by mobile teams of doctors, nurses, and microscopists, who regularly visited infected areas to detect and treat patients.⁶⁶

Colonial campaigns against sleeping sickness not only showcase how tropical medicine redesigned the techniques of disease control in colonial Africa, but also reveal the rationales, challenges, and blind spots of tropical medicine. First of all, they show how little experts in tropical medicine were prepared to learn from African disease understandings, therapeutic practices, and environmental approaches of disease control. Certainly, Africans actively participated in anti-sleeping sickness campaigns in various ways, as bush-clearers and fly-catchers, gland-feelers and drug-injectors, camp-wards and nurses, thus influencing the local acceptance and success of these campaigns.⁶⁷ But with the exception of a few early medical cross-overs, experts in tropical medicine and colonial doctors did not integrate African views of disease causation and healing practices in their campaigns.⁶⁸ They were also not aware that the (temporal) popularity of some biomedical interventions, such as Africans’ initial enthusiasm for the sleeping sickness camps around Lake Victoria and the drugs they received there, was not because of their inherent scientific rationality, but because local societies could relate them to their own cosmologies and previous experiences with epidemic diseases.⁶⁹ Moreover, until very late, medical experts ignored the possibility that African precolonial societies might have learnt to control sleeping sickness by shaping their contact with flies, trypanosomes, and mammals, and that it was colonialism that triggered epidemic sleeping sickness by disrupting these ecological balances.⁷⁰

Second, the campaigns demonstrate at what lengths colonial states were prepared to go to preserve the health of their African populations. On the one hand, campaigns were very costly in terms of budget and personnel. These massive investments reflected European fears that the disease would depopulate entire regions—and hence deplete the African labor force needed to “develop” the tropical colonies. On the other hand, European campaigns involved a host of disruptive measures and the massive use of force, as they infringed upon Africans’ body sovereignty, restrained their freedom of movement, and disrupted the ecosystems in which they lived. For many Africans, anti-sleeping sickness measures provoked much human suffering and high socioeconomic costs.⁷¹

Third, the campaigns show how difficult the control, let alone eradication, of vector-borne diseases was. Although a host of researchers would study the behavior of the tsetse fly and its relationship to the environment, the existence of different subspecies and their complex and varying bionomics made vector eradication almost impossible, with the exception of isolated areas such as the island of Príncipe.⁷² Over the 20th century, malaria-control programs pursuing species sanitation would face similar problems.⁷³ The quest for an efficient and safe drug to prevent and cure sleeping sickness would be disappointing as well—despite recurrent beliefs in new wonder drugs, the quest continues even today.⁷⁴ Biological complexities were not the only problem. Anti-sleeping sickness campaigns encountered many forms of resistance on the part of Africans. They eluded passport controls, avoided medical screening, escaped from or revolted against sleeping sickness camps, refused painful and ineffective injections, and resisted resettlement measures, thus undermining the “technical” solutions advanced by tropical medicine.⁷⁵

Fourth, early sleeping sickness campaigns neatly reveal the “vertical” approach of tropical medicine, also visible, for instance, in anti-malaria campaigns, as they focused on the treatment, prevention, and sometimes eradication of a single disease, without addressing the broader social and economic conditions of disease.⁷⁶ Anti-sleeping sickness campaigns were the first major disease-control campaigns among rural populations in colonial Africa; the methods employed and difficulties encountered foreshadowed those of many other “vertical” campaigns on the continent.

Fifth, the campaigns also highlight the racial dynamics underwriting both colonial and tropical medicine. Certainly, in the early 1900s, the discovery of the disease’s etiology and the acknowledgment of cases in white Europeans had done away with the long-standing idea that sleeping sickness was a “racial disease” that only targeted black Africans. However, Europeans would not be subjected to compulsory screening campaigns, treatments, and resettlements in the same random way as Africans. Although based on biology, tropical medicine’s methods differed according to class and race.⁷⁷

Finally, anti-sleeping sickness campaigns are illustrative of the transimperial character of both tropical and colonial medicine. Although, at times, colonial powers or local governments might have preferred different approaches, as Michael Worboys has argued for pre-1914 East Africa, these approaches were never purely national. Due to transnational networks of researchers, international conferences and journals, as well as bilateral exchanges, methods, drugs, and schemes, circulated across imperial boundaries and were constantly re-adopted and adapted. The long-term British predilection for ecological interventions and the French, Belgian, and Portuguese focus on medication might in part have resulted from different national expertise and path dependencies, but it was also due to environmental and epidemiological specificities that distinguished East and Southern from West and Central Africa.⁷⁸ Inter- and transimperial comparisons and exchanges, though sometimes criticized and/or hidden, would shape colonial policies of disease control and public health throughout the colonial era.⁷⁹

Public Health and Social Medicine in the Interwar Period

Beyond the State? Missionary and Company Medicine

Beyond the state actors on which this article has thus far concentrated, missionary societies and large private companies were also key players in disease control in colonial Africa. Particularly in the early decades of colonial rule, many Africans were even in closer contact with these actors than with government doctors. The rationales, methods, and focus of missionary and company doctors at times diverged from those of the colonial state’s health services, but there was often also convergence and collaboration.

Throughout much of the early colonial period, Christian—and in particular Protestant—missionary societies were the main providers of Western biomedicine to Africans in rural areas.¹²⁸ As long as European healing methods and drugs had no clear therapeutic superiority over African healing practices, missionary medicine on the colonial frontier had relied much on spiritual healing and the creation of clean and civilized European-like individuals.¹²⁹ Yet in the last quarter of the 19th century, Protestant missionary societies readily embraced Western biomedicine as a tool of evangelization. They professionalized their medical services by employing fully trained physicians and nurses as “medical missionaries.” These in turn also educated and employed African nurses and midwives in their missionary hospitals.¹³⁰ Catholic missions, by contrast, lagged behind. Most of them only professionalized their medical services somewhere between the 1920s and 1940s. Until then they could merely offer rudimentary healthcare to their Christians.¹³¹ When colonial health services began to “occupy” the vast interior of the colonies in the interwar years, missionary medicine often turned to new “niches.” It increasingly focused on particular diseases such as leprosy or on popular services such as birth and infant welfare clinics and individual surgery.¹³²

The rationales of missionary medicine diverged from state colonial medicine. Medical assistance was not intended to increase the colonial labor reservoir and the legitimacy of colonial rule, but to increase the number of Christians and the legitimacy of missionary work, both vis-à-vis African societies and the colonial state. Besides humanitarian concerns, medical work was meant to make Africans more receptive to the word of God and facilitate their conversion. For that reason, missionary medicine was also particularly keen on destroying “pagan” indigenous healing “traditions,” since these were believed to play a pivotal role in the indigenous belief systems they wanted to replace.¹³³ In many cases, missionary societies also invested in medicine to increase the legitimacy of missionary work vis-à-vis the colonial state. This was particularly true when missionary societies were of different denomination to the colonial state and, hence, perceived as a threat.¹³⁴

Given its preoccupation with winning African souls, missionary medicine was—and has often been described as—rather curative and individual than preventive: wonder cures or complicated surgery in moments of affliction were believed to have a greater impact on the African soul.¹³⁵ This rationale of (re)producing converts also explains missionary medicine’s strong focus on maternal and child healthcare. Fertility treatments, hospital childbirths, and postnatal consultations brought African women in crisis situations into prolonged contact with missionary health workers and hence constituted promising evangelical opportunities.¹³⁶ Due to its tendency to provide particular curative services much sought after by Africans, missionary medicine was generally also less coercive than state medicine and its compulsory public health campaigns.¹³⁷ This division of labor did not exclude, however, that missionary doctors were sometimes incorporated in state campaigns against epidemic and endemic diseases.¹³⁸ Just like state medicine, missionary healing practices interacted with and sometimes integrated elements from local African therapeutic practices. Particularly, mission-educated African nurses served as cultural brokers.¹³⁹

The key interest of colonial companies’ health departments was to preserve—and sometimes even improve—the health of their workers. This was, of course, paradoxical: the harsh working and living conditions in and around colonial mines, plantations, or railway construction sites were themselves responsible for appalling mortality rates among the mostly male African workers. In the gold mines on the South African Witwatersrand, for instance, official mortality rates still oscillated between 5 and 10 percent yearly in the early 1910s.¹⁴⁰ And many companies initially invested little in healthcare, most notably when they could rely on cheap and local recruitment or when the state provided them with workers. The case of the Congo–Océan Railway in the AEF, where in the 1920s almost 20,000 African construction workers died due to extremely demanding labor conditions, grossly misdirected food policies, and a lack of medical assistance, illustrates the grave shortcomings of company medicine, even if the Congo–Océan Railway was technically speaking a state enterprise.¹⁴¹

Yet particularly where and when the cost of recruitment was high, companies invested in medical infrastructure (mainly hospitals and health staff) and disease-control programs, which in quality sometimes equaled or even surpassed those of the state health services. After World War I, the large mining companies in South and Central Africa, for instance, managed to decrease the appalling mortality rates among their workers by tackling particular diseases such as labor-related TB and pneumonia or endemic malaria and sleeping sickness, but also by improving some of the social conditions of health, in particular diets and housing, and by improving both working conditions and recruitment schemes. Companies often took great pride in this. However, falling mortality rates were also the consequence of a more thorough previous selection of mine workers, changing migration regimes, and broader economic shifts.¹⁴²

Initially, long-distance recruitment had been a major killer, since workers often arrived in bad condition and had difficulties adapting to new climatic conditions, disease environments, and diets. Therefore, mining companies in the Belgian Congo or Angola, for instance, introduced acclimatization periods for newly arrived workers in the 1920s or, later on, offered truck transport to reduce the stresses and strains of the journeys.¹⁴³ These companies also began to select their workers with greater care, by using, for instance, the anthropological Pignet index to determine the physical robustness of potential workers or by screening them for particular diseases.¹⁴⁴ In the copper and diamond mines of Katanga, Northern Rhodesia, and Angola, falling mortality rates might also have been the result of the gradual reduction of long-distance (and mostly single-male) labor migration. Starting in the 1920s, Central African mines began to “stabilize” the workforce on or near the mining sites in order to locally “reproduce” the labor force. These “stabilization” schemes gained pace after the world economic crisis of the early 1930s. They not only reduced the human and economic costs of migration, but also entailed better housing conditions, more food security through agricultural improvement schemes, and the provision of infant and maternal welfare services.¹⁴⁵

The gold and diamond mines on the South African Witwatersrand, by contrast, did not abandon migrant labor. But, as Randall Packard has shown, changing migration patterns and a more careful selection of workers also contributed to declining mortality rates. On the one hand, the mines benefited from the government’s ban on the recruitment of so-called “tropical” workers from Central Africa, who had proven particularly susceptible to pneumonia and TB, between 1913 and the mid-1930s. On the other hand, the labor surplus generated by the Depression in the early 1930s allowed them to be more selective in their hiring. This led to the paradoxical situation that “whereas the general health of rural Africans may have declined during the depression years, the overall fitness of the mine labor force increased.”¹⁴⁶ Moreover, the gold mines’ tendency to externalize their health costs and to repatriate diseased workers rather than to treat them contributed to the spread of TB throughout rural Southern Africa.¹⁴⁷

Toward “Global Health”? Late Colonial Developments

World War II worsened health conditions in colonial Africa. On the one hand, the mobilization of many African men for military service contributed to the recrudescence of communicable epidemic diseases such as smallpox and syphilis.¹⁴⁸ On the other hand, the economic and financial sides of the war effort, with the reintroduction or expansion of forced labor across the continent and strained colonial health budgets, led to a general deterioration of health conditions.¹⁴⁹

After World War II, all colonial powers on the continent expanded their health services as part of a broader effort to relegitimize colonialism in the face of mounting critique of empire, at home, in the colonies, and on the international stage.¹⁵⁰ Even more than before, colonial healthcare was to emphasize the benign side of colonialism, as part of a broader thrust toward social, economic, and human welfare. Social development was at the core of the British Colonial Development and Welfare Act (CDWA) of 1940, the French Fonds d’Investissement pour le Développement Économique et Social (FIDES) established in 1946, or the Portuguese and Belgian five- or ten-year development plans starting a few years later.¹⁵¹ Increasing health budgets and staff allowed for the establishment of more specialist services and research facilities, more primary healthcare, but also more vertical campaigns. Indeed, it was after 1945 that many of the developments that had started before the war came to fuller fruition.

Postwar policies of disease control were marked by a two-pronged strategy. On the one hand, governments fostered basic healthcare services by expanding the number of rural dispensaries and the services they offered. A good example are also the infant and maternal welfare services, including birth clinics, which became much more common in rural areas, with the Belgian Congo probably leading the dance. According to Belgian sources, more than 40 percent of Congolese babies were, by 1958, delivered under biomedical supervision.¹⁵²

On the other hand, many colonial health services invested in new large-scale vertical campaigns aimed at controlling or even eradicating endemic diseases such as smallpox, malaria, yaws, or leprosy. From a practical/technical point of view, these campaigns usually continued in the molds that had been shaped in the 1920s and 1930s: they were executed by specialized and largely autonomous mobile services, such as the Service Général d’Hygiène Mobile et de Prophylaxie in French Africa, and relied heavily on new “wonder drugs” such as pentamidine, penicillin, and chloroquine or new insecticides such as DDT.¹⁵³ Often, however, these campaigns received more funding and technical assistance from governments and research entities in the metropolis than before the war. A good example are the permanent commissions for the study and control of endemic diseases in Portugal’s African colonies, which were funded and controlled by the Lisbon Institute of Tropical Medicine.¹⁵⁴

The major difference, however, was the increasing role of international organizations in disease control and eradication campaigns after 1945. Historians have framed this development as an important step toward “global health.” “Global health” is a somewhat fuzzy term, en vogue since the 1990s, that is used to refer to health initiatives designed and/or sponsored by foreign non-state actors such as international organizations, philanthropies, and non-governmental organizations (NGOs) in what is now often called the Global South. While many historians locate the antecedents of “global health” in colonial and tropical medicine, it is mostly employed for non-state actors.¹⁵⁵ Prior to 1945, non-state medical involvement—abstraction being made of missionary societies and private companies—was extremely limited in colonial Africa. The International Health Board (IHB) of the Rockefeller Foundation, the most powerful international health organization during the first half of the 20th century, focused its hugely influential disease control and eradication efforts (most notably against hookworm and yellow fever) on Latin America and Southeast Asia, spending only 3 percent of its grants in Africa.¹⁵⁶ The activities of the LNHO, the other major international health player in the interwar years, were also confined to a few initiatives: it coordinated anti-sleeping sickness efforts between colonial powers through its Sleeping Sickness Committee and two major conferences in Europe in the 1920s, it organized a study tour for colonial health officers through West Africa, and it helped organize two “pan-African” health conferences in South Africa in the 1930s.¹⁵⁷ As colonial powers were wary of LNHO interference or pursued conflicting agendas, the influence of the LNHO in Africa remained much more limited than in East and Southeast Asia.¹⁵⁸ Only after 1945 did health activities of international organizations in Africa gain pace with the game-changing foundation of the United Nations (UN) and its agencies, most notably the World Health Organization (WHO), which absorbed the LNHO and Office International d’Hygiène Publique (OIHP), the Food and Agriculture Organization (FAO) and the United Nations Children’s Fund (UNICEF).¹⁵⁹

Founded in 1951 as one of six regional WHO offices, the WHO African Regional Office (AFRO), which would move its headquarters to Brazzaville in 1953, developed and funded various health programs during the 1950s, most notably in the fight against endemic diseases. AFRO thus sponsored a vast and successful campaign against yaws, which greatly diminished disease incidence through penicillin injections. It also supported localized pilot programs for malaria eradication at a moment when Africa as a whole was excluded from the WHO “global” malaria eradication program.¹⁶⁰ UNICEF and FAO, for their part, contributed to tackling widespread malnutrition. Together with the WHO, they supported supplementary nutrition programs that distributed protein-rich foods (most notably skimmed milk) and collaborated with colonial governments on nutritional research and agricultural reform schemes.¹⁶¹

These initiatives had the same “vertical approach” as many colonial health campaigns, meaning that they focused on the control and/or eradication of a particular disease or health condition and did not or only sparsely acknowledge African opinions.¹⁶² This affinity is not surprising: international health interventions in late colonial Africa were usually not autonomous but grafted onto colonial programs, to which they provided additional expertise, manpower, and money.

They also stood in competition with colonial programs, however. Colonial governments accepted UN support because of budgetary constraints, but simultaneously they were very wary of the health activities of the WHO and other UN agencies in their colonies. They feared that these would showcase colonial states’ inability to solve health problems on their own and further the UN anticolonial agenda.¹⁶³ Consequently, colonial governments often tried to avoid UN “interference,” by clinging to their own national schemes or by promoting inter-colonial cooperation through the Commission for Technical Cooperation in Africa South of the Sahara (CCTA), an interstate agency founded in 1950 between France, the United Kingdom, Belgium, Portugal, Rhodesia, and South Africa.¹⁶⁴ Among other things, the CCTA organized conferences on health matters like nutrition, housing, and medical cooperation, promoted the education and inter-colonial exchange of health staff, and entertained the Bureau Permanent Interafricain pour la Tsé-tsé et la Trypanosomiase (BPITT), in Leopoldville.¹⁶⁵ The CCTA’s impact on disease-control policies and health conditions in late colonial and postcolonial Africa has not yet been thoroughly analyzed, yet one of its primary aims clearly was to compete with UN agencies in the same domains.

Beyond Dichotomies: Hybridized Medicine and Medical Pluralism

Despite—or perhaps because of—the fact that it was promoted by colonial states and other “foreign” actors, Western biomedicine never gained hegemony in colonial Africa. On the one hand, biomedical interventions to control disease and foster public health provoked manifold resistances among Africans, as many studies, including this article, have emphasized. On the other hand, colonial regimes did not manage to eliminate the influence and the practices of “traditional” African healers. Certainly, this was an integral part of the civilizing mission promoted by colonial administrations, medical departments, and missionary societies alike in the late 19th and 20th centuries, who mostly viewed “traditional” healers, often decried as “witchdoctors,” as the main obstacle to the diffusion of Western biomedicine, Christianity, and sociocultural progress at large.¹⁶⁶ Many colonial states also issued legislation to regulate or prohibit their activities. They particularly acted against divining and witchcraft practices, which were often outlawed in the beginning of the 20th century, whereas other forms of healing were less affected.¹⁶⁷ But the firmness of such actions varied considerably between territories, as the example of Southern Africa shows: in South Africa, legislation in the 1920s banned all African healers except inyanga (herbalists), but most other British territories in the region refrained from such bans and mainly tried to ignore their existence. The Angolan medical department even explicitly allowed African healers to practice, as long as they did not treat white Europeans or assimilated Africans.¹⁶⁸ Most importantly, colonial states were often not powerful enough to enforce interdictions. This was especially true for rural areas, but even where control was tighter, such as in urban areas, healers continued to practice clandestinely, as patients still sought their medicines.¹⁶⁹

Another major reason for their survival was their ability to adapt to the new situation of colonialism. Healers tried to improve their position in the “medical market” by showcasing the failures and limitations of Western biomedicine or by selectively appropriating certain elements of it that were much prized by colonial governments and/or African patients. Such borrowings could be the incorporation of biomedical diagnostic instruments (such as the stethoscope) or forms of treatment (such as pills or glass bottles to store them) in their healing repertoire, but also the adoption of biomedical language. Often, healers also specialized in those healing activities that were not explicitly forbidden.¹⁷⁰

The “medical encounter” also produced hybridization tendencies in the other direction. Especially for missionary medicine, scholars have shown that European medical staff willfully adopted elements of local healing traditions in order to popularize their medicine. Walima Kalusa, for instance, has shown how doctors at a missionary hospital in Zambia, after initial resistance, began to accept and even promote the presence of patients’ relatives and their participation in the healing process as was common in local medical culture. Medical staff also adopted local language medical terms to gloss biomedical concepts such as “medicine,” “disease,” or “patient” in order to make them more comprehensible or accommodated patients’ apparently futile preferences for, particularly, colored or shaped pills. Adapting Western biomedicine to existing cultural practices was necessary to make it both comprehensible and attractive. In this translation and adaptation process, African nurses often played a crucial role as medical brokers.¹⁷¹

While hybridizations in both directions helped to bridge the ontological gaps between both medical systems and make them mutually understandable, they did not necessarily blur their boundaries. On the contrary, hybridizations might have facilitated the coexistence of distinct medical systems and allowed patients to utilize both of them.¹⁷² Indeed, patient-centered histories of medicine in Africa have highlighted the condition of medical pluralism that often marked the (post)colonial situation: supported by therapy management groups, patients consulted Western-educated doctors as well as (different kinds of) African healers for one and the same illness.¹⁷³ The term “medical pluralism,” hence, not only refers to the coexistence of European and African systems, but also to the internal plurality of the latter and, as Digby has argued, the ingrained eclecticism of African patients, which partly explains their willingness to test certain new biomedical practices.¹⁷⁴ In some regions, Africans could also “cherry-pick” from other external, for instance, Indian healing systems.¹⁷⁵

Conclusion: Colonial Disease Control and its Impact

The control of human diseases in colonial sub-Saharan Africa involved a wide variety of actors and diverging medical systems. The span of health workers ranged from local African diviners, herbalists, and other healers, and European (or North American) doctors, experts in tropical medicine, scientists, and nurses to biomedically trained African doctors, nurses, and midwives. They worked for local communities, colonial states, missionary societies, big companies, or international organizations. Their methods varied due to diverging sets of medical beliefs, but were not applied in total isolation from each other, as different forms of contact between them led to adaptation and hybridization processes. The views and actions of patients were also part of the equation. From a patient-centered perspective, the colonial situation often involved the more or less violent imposition of biomedical interventions upon them and their bodies. It also led to situations of medical pluralism, in which patients could selectively make use of elements from various systems in order to tackle their ills.

Disease control in colonial Africa was partial, uneven, and changing. Disease-control measures targeted people in different ways and intensities depending on “race,” class, gender, age, and location. While Western biomedicine initially focused on European and urban populations, controlling diseases affecting the vast majority of Africans living in rural areas gained greater urgency for colonial powers as the 20th century progressed, due to the changing ideologies and economic rationales of colonial rule. Even then, disease control remained very uneven across space. Although expertise and “best practices” traveled across imperial and colonial boundaries, disease control “on the ground” varied between empires and colonies, due to different political, economic, and financial conditions.¹⁷⁶ Also within colonies there were marked differences between regions and populations, as some were deemed more important for the colonial project than others.¹⁷⁷ Gender and age were discriminating factors as well. While the health of male adults was initially more visible and important for colonial states and companies as they constituted the lion’s share of the “productive” labor force, the (reproductive) health of women and children turned into a major focus as demographic concerns rose after World War I.

Some diseases also received more attention than others. From early on, colonial governments focused on “tropical diseases” such as malaria and sleeping sickness or other infectious diseases such as syphilis or smallpox, because of the high mortality they provoked among Europeans and Africans, particularly during epidemic upsurges. The fact that these diseases had microbiological origins that could be explained and tackled by bacteriologists and the emerging community of experts in tropical medicine adds another explanation to the priority that was given to them. Conversely, many other diseases prevalent in colonial Africa were virtually ignored, because their effects were less immediate and visible and because they could not be explained with contemporary scientific models. Non-infectious diseases like primary liver cancer or nutritional diseases like kwashiorkor thus stayed under the colonial radar for a long time.¹⁷⁸ Throughout the colonial era, tropical medicine probably remained the most influential medical specialty in disease control in Africa. Vertical campaigns, that is, medical campaigns aimed at controlling and eradicating a particular tropical disease, were at the heart of both colonial and international health efforts. From the 1920s onwards, however, they began to be challenged by more comprehensive “horizontal” approaches of basic healthcare and by broader understandings of disease and ill-health that paid more attention to nutrition, housing, and other social determinants of health. Colonial health services also started to address low fertility and high infant mortality rates in novel ways. The history of disease control in colonial Africa is marked by shifting rationales, medical paradigms, and interest groups.

In sum, the short- and long-term effects of colonial disease-control measures on disease incidence, mortality, and demographic growth are as diverse as controversial. There is little doubt that disease-control measures did lower the incidence and mortality of certain diseases at certain moments in time. The continuous efforts against sleeping sickness, for instance, had nearly eradicated the disease by the time of decolonization.¹⁷⁹ And although smallpox infection rates, to give another example, remained remarkably constant in the last decades, mass vaccination campaigns that took place in virtually all colonies were usually effective in containing and ending epidemic outbreaks.¹⁸⁰ But there is also little doubt that, over and again, colonialism itself had aggravated the burden of disease. Particularly in the early decades of colonial rule, military conquest, oppressive economic policies, and increased (labor) mobility facilitated the spread of infectious diseases such as smallpox, sleeping sickness, or TB: these factors worsened the social determinants of health and hence increased Africans’ general susceptibility to disease.¹⁸¹ Deteriorating health conditions during World War II illustrate the extent to which improvements were precarious, as they depended on the political, economic, and financial vicissitudes of colonial regimes.

Moreover, colonial health campaigns sometimes contributed themselves to the emergence or intensification of (other) diseases. It has thus often been argued that colonial programs against yaws increased the incidence of venereal syphilis by removing cross-immunity and increasing susceptibility to other—and more virulent—treponemal infections.¹⁸² Various studies have also advanced the idea that between the 1920s and 1950s mass campaigns against endemic diseases such as HAT, syphilis, and yaws, through the repeated use of unsterile needles for drug injections, as well as early blood transfusions, contributed to the iatrogenic spread of HIV in West and Central Africa.¹⁸³ And others have drawn attention to large-scale medical accidents during anti-sleeping sickness campaigns or to the adverse effects that the distribution of skimmed milk to tackle kwashiorkor could have on infants’ health.¹⁸⁴

In the long run, colonial disease control very probably contributed to demographic growth, even if the causal relationship between both processes is not always straightforward, nor accepted by all scholars. Indeed, the debate over 20th-century African demography is marked by contrasting interpretations of the effects of colonial health programs. On the one hand, most scholars agree that, in many parts of the continent, with the notable exception of the Central African Infertility Belt, demographic growth set off in the 1920s and 1930s, before accelerating and becoming more visible after World War II and peaking after decolonization. Historical demographers estimate that the population of sub-Saharan Africa almost doubled from about 140 to 150 million in 1900 to some 280 million in 1960, and subsequently increased almost threefold to attain some 800 million by the end of the century.¹⁸⁵ On the other hand, however, scholars disagree on the main causes of early colonial population growth, in part due the lack of reliable and dynamic demographic data. Some historians and historical demographers have pointed at a range of medical interventions as key drivers of mortality decline and hence population growth between 1920 and 1960: from early epidemic disease and famine control measures to investments in preventive medicine, the introduction of new powerful drugs, the expansion of maternal and infant welfare measures, and improved health education. Others, however, have remained more skeptical about the effects of colonial health measures on mortality levels, particularly for the period before 1945. In their opinion, early population growth was not due to mortality decline but to fertility increase, promoted mainly by socioeconomic changes and incentives.¹⁸⁶

Discussion of the Literature

During the colonial and early postcolonial era, European historiography on disease control in colonial Africa was largely dominated by a heroic narrative of medical progress, which focused on the conquest of particular (tropical) diseases and the achievements of “great European men.”¹⁸⁷ Tales of progress and heroism did not disappear overnight, but starting in the 1970s, they were challenged by more critical views that paid greater attention to the social, political, cultural, and economic contexts of health, disease and medicine. Such critical views emerged from within the discipline of the history of medicine, but were also promoted by Africanist historians and anthropologists as well as by scholars of European colonialism.¹⁸⁸ Although it is true that, initially, historians of medicine rather focused on the history of Western biomedicine in Africa (and other colonial spaces) and Africanists on a broad spectrum of African healing practices, as Lyn Schumaker has repeated, one should be cautious to categorize scholars along these lines, since there has been much cross-fertilization of perspectives and approaches and since the intellectual trajectories of scholars often do not fit such clear dichotomies.¹⁸⁹

Re-examining the connection between disease control and imperialism, many scholars have questioned the disinterested, humanitarian, and benevolent character of colonial medicine. Some reframed it as a “tool of empire,” needed by colonial powers to penetrate, control, and exploit the territories under their rule.¹⁹⁰ Others, particularly those working on urban sanitation measures or large-scale “vertical” disease campaigns, stressed the violence, racism, and disruptive effects of colonial medicine in practice.¹⁹¹ Looking at the nexus between disease control and imperialism from a political economy of health perspective, others have analyzed how colonialism affected the health of Africans by changing their working and living conditions and their access to (bio)medical care.¹⁹²

Since the 1990s, many scholars have deconstructed the “leviathan” of colonial medicine. In parallel with a broader trend in the historiography of colonialism stressing the weakness and internal contradictions of the colonial state, they have shown how Africans resisted and avoided biomedical interventions, stressed that these interventions were limited in scope and efficiency, and pointed at conflicting actors and paradigms within Western biomedicine.¹⁹³ Going beyond the paradigm of resistance, an increasing body of scholarship has stressed the continued coexistence of Western biomedicine and African healing practices and mutual hybridization tendencies. Following Janzen’s pathbreaking study, some scholars have adopted a patient-centered perspective to show how, under the conditions of medical pluralism, African patients and their therapy management groups navigated between medical systems. Others have looked deeper into the cultural negotiations that took place between (European) doctors and (African) patients in Africa and the role of African intermediaries, such as nurses and midwives, as cultural brokers.¹⁹⁴

Since the mid-2000s, the transnational and global turns in history (of medicine) have begun to “denationalize” colonial medicine and its disease-control programs. These are now increasingly being analyzed from transnational and global perspectives that emphasize the circulation of medical knowledge, practices, and actors across colonial, imperial, and continental borders.¹⁹⁵ In this context, historians are also re-examining the role of international organizations in colonial disease-control programs, as they are looking for the (colonial) antecedents of global health.¹⁹⁶