Disease Control and Public Health in Colonial Africa
Disease Control and Public Health in Colonial Africa
- Samuël CogheSamuël CogheDepartment of History, Freie Universität Berlin
Disease control and public health have been key aspects of social and political life in sub-Saharan Africa since time immemorial. With variations across space and time, many societies viewed disease as the result of imbalances in persons and societies and combined the use of materia medica from the natural world, spiritual divination, and community healing to redress these imbalances. While early encounters between African and European healing systems were still marked by mutual exchanges and adaptations, the emergence of European germ theory-based biomedicine and the establishment of racialized colonial states in the 19th century increasingly challenged the value of African therapeutic practices for disease control on the continent.
Initially, colonial states focused on preserving the health of European soldiers, administrators, and settlers, who were deemed particularly vulnerable to tropical climate and its diseases. Around 1900, however, they started paying more attention to diseases among Africans, whose health and population growth were now deemed crucial for economic development and the legitimacy of colonial rule. Fueled by new insights and techniques provided by tropical medicine, antisleeping sickness campaigns would be among the first major interventions. After World War I, colonial health services expanded their campaigns against epidemic diseases, but also engaged with broader public health approaches that addressed reproductive problems and the social determinants of both disease and health.
Colonial states were not the only providers of biomedical healthcare in colonial Africa. Missionary societies and private companies had their own health services, with particular logics, methods, and focuses. And after 1945, international organizations such as the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) increasingly invested in health campaigns in Africa as well. Moreover, Africans actively participated in colonial disease control, most notably as nurses, midwives, and doctors. Nevertheless, Western biomedicine never gained hegemony in colonial Africa. Many Africans tried to avoid or minimize participation in certain campaigns or continued to utilize the services of local healers and diviners, often in combination with particular biomedical approaches. To what extent colonial disease control impacted on disease incidence and demography is still controversially debated.
- Colonial Conquest and Rule
- Image of Africa
- Medical History
- Religious History
- Social History
- Women’s History
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
After World War I, the focus of colonial medicine further shifted from urban European to rural African (or “native”) populations. This shift has usually been explained with the falling mortality rates among Europeans in Africa and the growing consensus among Europeans that the continent was not only underpopulated, but actually depopulating due to the many health problems from which Africans were suffering. This in turn endangered both the economic “mise en valeur” of the colonies, for which the “native” labor force was indispensable, and the civilizing mission, which, being renegotiated as trusteeship, dual mandate, or human “mise en valeur,” promised to take care of Africans’ well-being.80
This turn to African healthcare did not invalidate the tropical medicine approach: the interwar years would witness more and larger “vertical” campaigns against particular epidemic and endemic diseases, such as yaws, smallpox, or sleeping sickness.81 However, these campaigns would be executed by highly mobile units and, particularly in French, Portuguese, and Belgian Central Africa, be integrated in more comprehensive schemes of so-called Assistance Médicale aux Indigènes. Simultaneously, new ways of conceptualizing and tackling disease emerged. They were part and parcel of a broader public health approach that focused more and more on the social causes of both disease and health and that advocated preventive measures to protect the health of the individual and social body. This approach has often been labelled as social medicine.82
Expanding Budgets and Medical Staff
These developments went hand in hand with expanding budgets and medical staff: in French Equatorial Africa (AEF), to give an example, healthcare expenditures increased more than twentyfold (and still about tenfold if one subtracts inflation) between 1919 and 1930, while the number of European doctors more than doubled from twenty-six (1919) to sixty-one (1932). The health services in the AEF also hired additional health staff, such as non-Western doctors serving as hygiénistes and hundreds of African nurses.83 Parallel developments can be observed elsewhere: in the same period, the number of doctors in the British colonies in Africa, in the Belgian Congo, or Portuguese Angola almost tripled.84
The most paradigmatic change was the systematic inclusion and education of Africans as nurses and midwives. This Africanization strategy responded to distinct rationales. On the one hand, filling the subordinate ranks of the health services with lower-paid Africans was meant to limit expenses and to circumvent the difficulties colonial health services encountered in finding enough European doctors, nurses, and midwives. Or, as the head of the health services in the Belgian Congo put it: “In a tropical colony, we can in fact not seriously consider an endless augmentation of European civil servant doctors, which are expensive and often very hard to recruit. We must assist the natives with natives.”85 On the other hand, many European doctors believed that African auxiliaries, due to their linguistic, cultural, and “racial” background, would encounter less distrust and resistance from African patients and hence be valuable assets in brokering biomedical knowledge and practices.86
Formal training of African nurses, midwives, and doctors varied greatly between colonies. While the French and the British started training African doctors in medical schools in Dakar (1918), Makerere (Uganda) (1923/24), Khartoum (1924), or Yaba (Nigeria) (1930), the Belgians and Portuguese only trained nurses and medical assistants before the late 1950s.87 Differences were also noticeable within empires: the medical school in Dakar had trained almost 150 “native” doctors and more than 200 midwives for French West Africa (AOF) by 1935, whereas in AEF the education of nurses was by then still minimal and mostly done on the job, and midwife training programs met with very little success.88
Africans were not employed on an equal basis. Due to racial prejudice, they worked in subordinate and precarious positions and were paid less than their European counterparts. Many medical reports warned that African intermediaries, particularly poorly skilled nurses, could not be fully trusted: without strict control, they would turn to extortion or other forms of power abuse or return to their ancient practices of fetishism and charlatanism.89 Despite these reservations, however, African nurses would often be left in command of rural health stations or in charge of itinerant mass injection campaigns.90 They also played an important role in mission hospitals. In these and other positions, they would often carve out spaces of agency for themselves—and sometimes be key in making biomedicine and local African healing traditions mutually understandable.91
Given the geographical extension of African colonies, staff were, of course, still largely insufficient to provide comprehensive healthcare. Yet, increasing budgets and a growing number of European and African employees allowed the colonial health services to tackle a wider array of health issues and to test new methods.
Mobile Teams and Sector-Based Health Schemes
A first major innovation was the use of mobile medical teams to tackle epidemic and endemic diseases. Composed of a European doctor and both European and African nurses, these teams canvassed rural areas where they forcibly and regularly assembled, examined, and treated African villagers. To do so, the territory to be controlled was usually divided in individual sectors that were covered each by a different mobile team. First implemented by Eugène Jamot in AEF against sleeping sickness from 1917 onwards, this innovative scheme was soon adopted and adapted by other colonies and empires. While Jamot himself exported his “model” to Cameroon (1926) and AOF (1931), the Portuguese in Angola and the Belgians in Congo introduced similar schemes in the 1920s.92 Characteristic of these schemes is that they ran parallel to the regular health services, thus constituting separate health bodies with much autonomy and their own staff. Another salient feature is that they relied heavily on quick (first clinical, then laboratorial) diagnostic methods and the injection of new potent drugs, both for curative and preventive aims. These mobile teams and their shifting focus from disease control to disease eradication would become the model of most “vertical” health campaigns in rural Africa during the late colonial and early postcolonial era.93
Some of these health schemes, however, starting with the AMI (Assistência Médica aos Indígenas) in Angola and the (FORÉ)AMI (Fonds Reine Élisabeth pour l’Assistance Médicale aux Indigènes) in Belgian Congo, became enmeshed with a broader public health approach. Though firmly rooted in the fight against sleeping sickness, they gradually enlarged their focus. They targeted a broad range of endemic diseases, invested in maternal and infant welfare, entertained rural dispensaries and maternities in their sectors, and called for a broad approach toward rural health based on the collaboration between all colonial services. In such cases, the sector system was seen as facilitating the shift from individual curative to mass preventive medicine advocated by leading French, Portuguese, and Belgian colonial health officers in the interwar years.94
Statistics on Diseases and Populations
A second key development in the interwar years was the increased importance of statistical information in disease management. Prior to World War I, statistics on the incidence of particular diseases at best covered the sparse towns and semi-urban areas endowed with hospitals or health stations. These figures included most Europeans as well as those Africans living in or near towns, but they only provided a very incomplete image of disease incidence among the vast majority of rural Africans. The lack of reliable morbidity, but also mortality and fertility, statistics is one of the reasons why historians and historical demographers have struggled so much to quantify the medical and demographic impact of colonial conquest and occupation on Africa’s population, resorting either to educated guesses, extrapolations of available data, or retro-projections from late colonial censuses.95 The underreporting of diseases persisted throughout much of the colonial period, since Africans were not always willing or able to make use of European healthcare. It was not the only statistical issue, however. Due to the lack (of precision) of diagnostic methods and/or doctors’ eagerness to receive more recognition and money for their work, early colonial epidemics were sometimes vastly exaggerated as well. A case in point is the syphilis epidemic in early 20th-century Uganda, as Megan Vaughan and Shane Doyle have shown.96
More accurate medical statistics on African populations did not become available overnight. The lack of reliable statistical data on the devastating influenza epidemic between 1918 and 1920, for instance, is symptomatic.97 But after World War I the expansion of both health and administrative services allowed for gradually more encompassing and more accurate morbidity statistics, particularly for major infectious diseases. Having such statistics also became a hallmark of modern scientific colonialism and an international imperative. Certainly, the continent was all but excluded from the International Sanitary Convention of 1926, in which over fifty sovereign states promised to notify each other of the outbreak of epidemics of cholera, plague, yellow fever, smallpox, and typhus.98 And only coastal eastern Africa from Cairo to the Cape would be included in the globally circulating weekly epidemiological bulletins compiled and transmitted by the League of Nations Health Organization’s (LNHO) Far Eastern Bureau in Singapore from the mid-1920s onwards.99 This was also because plans to establish a similar bureau with pan-African vocation in West Africa failed.100 Yet many colonies in Africa sent epidemiological data to the LNHO in Geneva, or concluded bilateral treaties in which they promised to notify their neighbors about epidemic outbreaks or about the incidence of particular diseases in border regions.101
Colonial doctors also increasingly used demographic data to track down health problems and to monitor the impact of ongoing health campaigns. In the absence of functioning civil registries or reliable population censuses, colonial health workers started producing more detailed and dynamic data on the mortality, natality, and migration movements of rural African populations through medical registries and interview-based sample studies. While the continuous registration of populations was only possible in areas of intense medical control, such as those covered by the powerful (FORÉ)AMI services against sleeping sickness and other endemic diseases in Portuguese, Belgian, and French Africa, the sample studies were conducted to an extent everywhere, as they were less demanding in terms of medical infrastructure. They consisted in questioning women in and beyond childbearing age about their reproductive behavior—that is, mainly the number of children, stillbirths, and sometimes also abortions they had had and the number of children that had died during childhood—in order to reconstruct (age-specific and total) fertility rates as well as infant mortality rates. These studies, which would be continued in specific areas or on specific ethnic groups throughout (and beyond) the colonial era, reflected mounting anxieties surrounding the reproductive behavior and success of African populations.102 While such efforts brought forth some of the best dynamic demographic data and disease statistics for rural Africa, these were, however, still flawed and limited to a few regions. At the end of the day, they did not produce anything close to a comprehensive picture of patterns of sickness and health among African populations.
Interventions in Reproductive Health
Colonial interventions into the reproductive health of Africans constitute a third key development that took root in the 1920s. Against the background of mounting depopulation anxieties, colonial health services and administrations devised policies aimed at increasing the birth rates and lowering infant mortality rates. Many of these pronatalist policies, which have been designated by Lynn Thomas as the “politics of the womb,” specifically targeted women and their bodies.103 But increasing fertility also implied a host of administrative measures and medical campaigns against sexually transmitted diseases (STDs) that included men as well.
Nancy Rose Hunt, for instance, has explored the panoply of measures that the colonial government in the Belgian Congo conceived to increase African women’s birth rates. It promoted early weaning and the rapid resumption of marital sex after childbirth in order to reduce birth spacing, granted tax benefits to large families while increasing the tax burden for polygamous men and “single” women, and campaigned against illegal abortions.104 In East Africa, mission-led campaigns against “female circumcision” or “genital cutting” were not only grappling with moral and gender issues, but partially guided by reproductive concerns as well.105 And across the continent, colonial states started or stepped up their fight against STDs, most notably syphilis and gonorrhea. These were deemed responsible for high rates of stillbirths, infant mortality, and infertility, and hence insufficient population growth, particularly in what later became known as the Central African Infertility Belt.106
Colonial policies against STDs in Africa reveal a tension between moral and technical approaches to disease. At the heart of the “moral” (and in this case also preventive) approach was the desire to curb and regulate Africans’ presumed “untamed” sexuality, by instilling a Christian sense of morality and shame, by discouraging polygyny, or by surveilling female sex workers. This moral take was particularly advocated by missionary doctors. The “technical” approach, which was more en vogue among state doctors, involved the medical treatment of patients with new synthetic drugs such as bismuth and (neo)salvarsan.107 Effects of early drug therapy were often limited, however, since many sufferers did not seek or discontinued a drug treatment that was painful, riddled with side effects, and very prolonged.108 When more effective drugs, most notably penicillin, became available after 1945, this greatly facilitated medical campaigns, yet some doctors now came to blame the “needle mentality” of Africans: they would rather go for treatment than restrain their excessive sexual behavior which, for most observers, was the prime cause of the high incidence of STDs.109
This “civilizing” dimension is also salient in colonial policies against high infant mortality. Most colonial doctors blamed the very high infant mortality rates found during demographic inquiries on the backwardness of African mothers. They assumed that African women ignored the most basic notions of infant hygiene and nutrition and were hence responsible for the premature death of their children. Accordingly, early maternal and infant welfare programs in the 1920s and 1930s were not only (and often not even primarily) geared toward facilitating confinements and treating ill children, that is, curative medicine. Underwritten by the idea of prevention, they also offered educational courses or ad hoc advice aimed at instilling African mothers with modern notions of motherhood and infant hygiene.110 The midwife training courses established in AOF, Nigeria, or the Belgian Congo followed the same preventive rationale—apart from practicing new biomedical techniques of childbirth, “native” midwives were supposed to eradicate harmful practices and beliefs often embodied by “traditional” midwives.111 However, as Jean Allman and others have noted, African mothers often used the available services as they saw fit, rejecting some of them and accepting others. In some cases, their preference for curative interventions for themselves and their children over lectures in the science of mothercraft and infant hygiene changed the kinds of services that were offered in a particular place.112
Cultural explanations for both STDs and high infant mortality among Africans prevailed throughout the interwar years. European doctors blamed Africans, especially women, for their archaic behavior and their slowness to become “modern.” Some health workers, however, also began to address the social determinants of these health conditions, particularly during and after the Depression of the 1930s. They pointed at how (mainly male) migrant labor and urbanization had modified gender balances and sexual behavior, and hence paved the way for the rapid spread of STDs. Some also identified poverty and under- and malnutrition as main causes of high infant mortality rates and discussed the extent to which these conditions had worsened due to the disruptive effects of colonial rule.113
Nutrition and the Social Determinants of Health
Discussions about poverty, nutrition, and other social determinants of health were illustrative of a broader (and in this article the fourth major) shift in disease control that began in the interwar years. Following discussions that resurged in Europe during the world economic crisis, hygienists increasingly stressed the impact of diets, housing conditions, rural hygiene, and education on morbidity and mortality levels in colonial Africa. This social medicine view was also pushed by the LNHO, which organized major conferences on rural hygiene in Europe (1931) and Asia (1937) and also put this issue on the agenda of the two “pan-African” conferences in South Africa in the 1930s.114
Colonial governments in Africa started to intervene in all of these areas.115 Nutrition was probably the field that received most attention, bringing together nutritional scientists and doctors, agricultural experts and administrators. Colonial powers had long been aware of periodic famines on the continent, but it was only in the 1920s that they began to acknowledge that many Africans were suffering from chronic under- and/or malnutrition—undernutrition being the insufficient intake of calories and malnutrition referring to unbalanced diets lacking certain constituents—and that these conditions severely affected their health, labor potential, and reproductive success.116
As Michael Worboys has argued, historians and social scientists have disagreed on whether under- and malnutrition were long-standing conditions in sub-Saharan Africa that were merely “discovered,” medicalized, and put on the political agenda after World War I or whether these conditions increased under colonial rule due to impoverishment, oppressive labor regimes, and disrupted gender balances.117 Contemporaries disagreed as well. Some colonial observers already blamed colonialism for creating or at least aggravating conditions of under- and malnutrition. Most, however, preferred to blame Africans’ cultural and behavioral backwardness, most notably their “traditional” agricultural methods and foodways and their lack of education.118
Either way, the growing colonial awareness for nutritional problems was premised on changing views on nutrition and agriculture. First of all, there was the growing field of nutritional science. New studies stressed the importance of vitamins, minerals, and animal proteins for human diet and (re)framed “old” diseases such as beriberi and newly discovered ones such as kwashiorkor as nutritional deficiency diseases.119 Against this backdrop, health workers and administrators grew aware of the excess of carbohydrates and the lack of (animal) proteins, fats, and certain vitamins and minerals in the daily diets of many Africans and defined this as a medical problem. The first nutritional field studies in the mid-1920s suggested that “traditional” African diets were not only unbalanced, but sometimes also grossly insufficient in terms of calories.120 Second, colonial enterprises’ growing demand for healthy African laborers was key to recognizing the amplitude of the problem. Their “rationalized” anthropometric selection procedures, by which, in an attempt to lower labor mortality, workers’ bodies were measured to evaluate their physical robustness and suitability for heavy labor, revealed how widespread undernutrition probably was.121 Third, undernutrition became conceivable because of changing views on the fertility of tropical soils. European observers had long perceived tropical Africa as a “land of plenty” where a luxurious nature produced an abundant amount of food for “indolent” natives. Pedological and agricultural studies between the two world wars reversed this image, however. They pointed at thin layers of humus, the frequent lack of certain essential elements for plant growth, and the problem of soil erosion.122
Colonial governments devised various policies to remedy under- and malnutrition. One kind of policy consisted in providing improved diets to some Africans. Particularly plantation and mine workers as well as colonial soldiers benefited from scientifically calculated improved rations adapted to the heavy labor they were supposed to perform.123 Children sometimes benefited from supplementary nutrition as well. In the 1920s, infant welfare centers in larger cities began to distribute baby milk.124 In the 1950s, children in rural areas became the target of colonial and international campaigns against kwashiorkor, a protein deficiency disease: they received skimmed milk and sometimes other high-protein supplements.125 Another set of measures targeted agriculture: they aimed at improving agricultural yields and making Africans cultivate more—and preferably also more nutritious—food crops. Agricultural education measures and model farms often met with little success, however. In many places, calls to produce more food and less cash crops ran counter to the rationales and practical implications of colonial cash crop production and colonial labor regimes in general. As many men became migrant laborers for mines and other colonial enterprises, women in the villages had to shoulder both cash and food crop production, which, moreover, often had conflicting timetables. The priority given to cash crops or to easy-growing food crops like cassava or maize led to impoverished diets.126 Other policies, finally, were geared toward facilitating the distribution of agricultural produce through roads and marketplaces. And in some cases, as Robins has shown for colonial Ghana after World War II, governments tried to improve diets by changing foodways and women’s cooking methods.127
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
I would like to thank Sarah Bellows-Blakely and the two anonymous reviewers for their insightful remarks on earlier drafts of this article.
Most histories of disease control in colonial Africa use both archival and published written sources. Africanist historians often include oral sources as well, in order to integrate the voices of African patients, healers, or observers that are absent, hidden, or distorted in most written sources, whether archival or published.
Key archival sources are the official reports and correspondence produced and received by the (imperial) health departments in the colonial ministries and the health services in the individual colonies. The former—or what is left of it—can usually be found in the national or specialized colonial archives of Europe’s former colonial powers: the National Archives in London, the Bundesarchiv-Lichterfelde in Berlin, the Arquivo Histórico Ultramarino in Lisbon, the Archives Nationales d’Outre-Mer in Aix-en-Provence, or the Archives Africaines of the Ministry of Foreign Affairs in Brussels—soon to be transferred to the Belgian National Archives. The latter, that is, the documents produced by doctors and health services in the colonies, are often more difficult to locate. Many medical reports were sent in copies to the respective colonial ministry and can hence be found in the aforementioned archives in Europe, alongside with those medical archives that were, as, for instance, the French and Belgians partially did, “repatriated” from the colonies at independence. However, many more documents that were produced in the colonies and that often provide very local perspectives should be sought for in the national, regional, municipal, and hospital archives in Africa. While municipal archives can shed detailed light on urban sanitation measures,197 the patient records still available in some (state or mission) hospital archives can be used to scrutinize the very local impact of Western biomedicine by quantifying admissions or analyzing diagnoses and treatment trajectories of (African) patients.198
Other important archives include those of Europe’s schools of tropical medicine and other research institutes such as the Institut Pasteur in Paris. Besides their own institutional archives, these institutions sometimes harbor important collections of state-produced sources as well as personal files of doctors and researchers. This is, for instance, the case of the archives of the Institut Pasteur in Paris or the Institut de médecine tropicale du service de santé des armées (IMTSSA) in Toulon. Looking beyond the state, the archives of missionary societies engaged in medical work; of large companies in colonial sub-Saharan Africa; and of international organizations such as the LNHO, the WHO, or UNICEF are also of prime importance.
Essential printed sources are the journals of tropical medicine published by national schools, associations, and sometimes independent publishers in the colonial metropoles, such as the Bulletin de la Société de Pathologie Exotique in France, the Anais do Instituto de Medicina Tropical in Portugal, or the Journal of Tropical Medicine in the United Kingdom, and the medical bulletins or yearbooks compiled by the health departments of colonial ministries such as the Annales de médecine et d’hygiène coloniales in France or the Medizinal-Berichte über die deutschen Schutzgebiete in Germany. While articles in the former are more (though not exclusively) geared to research on particular diseases and drugs, the colonial health bulletins mostly contain longer reports by colonial doctors on their activities in a particular year or on a particular issue, thus offering more information on medical (inter)action “in the field.” Both kind of journals, however, usually lack African perspectives. Most medical journals were published in the metropoles, but in some colonies doctors also published local journals, such as the Revista Médica de Angola or the (Kenya and) East African Medical Journal, which both emerged in the 1920s.199 Research and practices of disease control in colonial Africa were also discussed in a broad range of other—medical, scientific, colonial, missionary, and so on—journals and in the publications of international organizations such as the LNHO, OIHP, or WHO. Monographs and memoirs by colonial medical staff, local newspapers, as well as colonial law bulletins are further key written sources.
Africanist historians sometimes use oral interviews with healers, patients, or people who lived or worked in particular disease environments or companies to get hold of their views, experiences, and practices.200 Given the dearth of such information in written (European) documents, oral sources are key to writing the history of the “medical encounter” from an African(ist) perspective. Conversely, interviews with former European health staff can also shed more light on their experiences. Due to the often considerable time gap between the interviews and the colonial era, however, scholars should be aware of the changing politics of remembrance of interviewees.201
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1. For this paragraph and the next, see generally Steven Feierman, “Change in African Therapeutic Systems,” Social Science and Medicine 13B, no. 4 (1979): 277–284; Gloria Waite, “Public Health in Precolonial East-Central Africa,” in The Social Basis of Health and Healing in Africa, ed. Steven Feierman and John Janzen (Berkeley: University of California Press, 1992), 212–233; John Janzen, “Ideologies and Institutions in Precolonial Western Equatorial African Therapeutics,” in Social Basis, ed. Feierman and Janzen, 195–211; and Lyn Schumaker, “History of Medicine in sub-Saharan Africa,” in A Global History of Medicine, ed. Mark Jackson (Oxford: Oxford University Press, 2018), 197–200.
2. For the close link between healing and harming therapeutic practices, see Nancy Rose Hunt, “Health and Healing,” in The Oxford Handbook of Modern African History, ed. John Parker and Richard Reid (Oxford: Oxford University Press, 2013), 384–386.
3. See, for instance, Steven Feierman, The Shambaa Kingdom: A History (Madison: University of Wisconsin Press, 1974); Markku Hokkanen, “Contestation, Redefinition and Healers’ Tactics in Colonial Southern Africa,” in Healers and Empires in Global History: Healing as Hybrid and Contested Knowledge, ed. Markku Hokkanen and Kalle Kananoja (Basingstoke, UK: Palgrave Macmillan, 2019), 121–123; and Mari K. Webel, The Politics of Disease Control: Sleeping Sickness in Eastern Africa, 1890–1920 (Athens, OH: Ohio University Press, 2019), 14–15, 118–138.
4. See Janzen, “Ideologies and Institutions”; Waite, “Public Health”; Schumaker, “History of Medicine,” 197–200.
5. Philip J. Havik, “Hybridising Medicine: Illness, Healing and the Dynamics of Reciprocal Exchange on the Upper Guinea Coast (West Africa),” Medical History 60, no. 2 (2016): 181–205.
6. Ismail H. Abdalla, “Diffusion of Islamic Medicine into Hausaland,” in Social Basis, ed. Feierman and Janzen, 177–194.
8. Nathan Nunn and Nancy Qian, “The Columbian Exchange: A History of Disease, Food, and Ideas,” Journal of Economic Perspectives 24 (2010): 163–188. On the spread of epidemics between Asia and Africa before the late 19th century, see David Arnold, “The Indian Ocean as a Disease Zone,” South Asia 14, no. 2 (1991): 1–21.
9. Compare John C. Caldwell and Thomas Schindlmayr, “Historical Population Estimates: Unravelling the Consensus,” Population and Development Review 28, no. 2 (2002): 183–204 with Patrick Manning, “African Population, 1650–2000: Comparisons and Implications of New Estimates,” in Africa’s Development in Historical Perspective, ed. Emmanuel Akyeampong et al. (New York: Cambridge University Press, 2014), 131–152; and See, for instance, the classic John Thornton, Africa and Africans in the Making of the Atlantic World, 1400–1800, 2nd ed. (Cambridge, UK: Cambridge University Press, 1998).
10. Janzen, “Ideologies and Institutions.”
11. Havik, “Hybridising Medicine”; Kalle Kananoja, “Bioprospecting and European Uses of African Natural Medicine in Early Modern Angola,” Portuguese Studies Review 23, no. 2 (2015): 45–69.
12. See Karol K. Weaver, Medical Revolutionaries: The Enslaved Healers of Eighteenth-Century Saint Domingue (Urbana: University of Illinois Press, 2006); Kalle Kananoja, “Infected by the Devil, Cured by Calundu: African Healers in Eighteenth-Century Minas Gerais, Brazil,” Social History of Medicine 29, no. 3 (2016): 490–511; and Londa Schiebinger, Secret Cures of Slaves: People, Plants, and Medicine in the Eighteenth-Century Atlantic World (Stanford, CA: Stanford University Press, 2017).
13. See, for instance, Timothy Walker, “Sorcerers and Folkhealers: Africans and the Inquisition in Portugal (1680–1800),” Revista Lusófona de Ciência das Religiões 3 (2004): 83–98; and Kananoja, “Bioprospecting and European Uses,” 58–61.
14. Roy Porter, Blood and Guts: A Short History of Medicine (London: Penguin, 2003), 25–32 and 99–100. On the connections and overlaps between “popular”/“folk” and “university”/“learned” medicine, see David Gentilcore, “Was There a ‘Popular Medicine’ in Early Modern Europe?” Folklore 115 (2004): 151–166; and Michael Stolberg, “Learning from the Common Folks: Academic Physicians and Medical Lay Culture in the Sixteenth Century,” Social History of Medicine 27, no. 4 (2014): 649–667.
15. David Gentilcore, Healers and Healing in Early Modern Italy (Manchester: Manchester University Press, 1998); Timothy Walker, Doctors, Folk Medicine and the Inquisition: The Repression of Magical Healing in Portugal during the Enlightenment (Leiden, The Netherlands: Brill, 2005). For the similarities between African and European early modern medicine, see also explicitly Kananoja, “Bioprospecting and European Uses,” 47–48.
16. Havik, “Hybridising Medicine”; and Kananoja, “Infected by the Devil.”
17. Jonathan Roberts, “Medical Exchange on the Gold Coast during the Seventeenth and Eighteenth Centuries,” Canadian Journal of African Studies 45, no. 3 (2011): 480–523. See also Kananoja, “Bioprospecting and European Uses,” 64–68.
18. For this shift, see Jean Comaroff, “The Diseased Heart of Africa: Medicine, Colonialism, and the Black Body,” in Knowledge, Power, and Practice: The Anthropology of Medicine and Everyday Life, ed. Shirley Lindenbaum and Margaret Lock (Berkeley: University of California Press, 1993), 305–329.
19. See, for instance, Cristiana Bastos, “Medical Hybridisms and Social Boundaries: Aspects of Portuguese Colonialism in Africa and India in the Nineteenth Century,” Journal of Southern African Studies 33, no. 4 (2007): 767–782.
20. Porter, Blood and Guts, 75–79.
21. Mark Harrison, Medicine in an Age of Commerce and Empire: Britain and its Tropical Colonies, 1660–1830 (Oxford: Oxford University Press, 2010).
22. For a quick overview, see Porter, Blood and Guts, 79–90, quote at: 86.
23. David Arnold, “Introduction: Tropical Medicine before Manson,” in Warm Climates and Western Medicine: The Emergence of Tropical Medicine, 1500–1900, ed. David Arnold (Amsterdam: Rodopi, 1996), 1–19; and Harrison, Medicine in an Age of Commerce and Empire.
24. Harrison, Medicine in an Age of Commerce and Empire, 89–120; Suman Seth, Difference and Disease: Medicine, Race, and the Eighteenth-Century British Empire (Cambridge, UK: Cambridge University Press, 2018); Warwick Anderson, “Immunities of Empire: Race, Disease, and the New Tropical Medicine, 1900–1920,” Bulletin of the History of Medicine 70, no. 1 (1996): 94–118.
25. See Philip D. Curtin, Disease and Empire: The Health of European Troops in the Conquest of Africa (Cambridge, UK: Cambridge University Press, 1998), xviii; and Philip D. Curtin, “‘The White Man’s Grave’: Image and Reality, 1780–1850,” Journal of British Studies 1 (1961): 94–110.
26. See Mark Harrison, Climates and Constitutions: Health, Race, Environment and British Imperialism in India, 1600–1850 (New York: Oxford University Press, 1999); Michael A. Osborne, “Acclimatizing the World: A History of the Paradigmatic Colonial Science,” in Nature and Empire: Science and the Colonial Enterprise, ed. Roy MacLeod (Chicago: University of Chicago Press, 2000), 135–151.
27. From the extensive literature on the question of European acclimatization in the tropics, see especially David N. Livingstone, “Tropical Climate and Moral Hygiene: The Anatomy of a Victorian Debate,” British Journal for the History of Science 32, no. 1 (1999): 93–110; Pascal Grosse, Kolonialismus, Eugenik und bürgerliche Gesellschaft in Deutschland, 1850–1918 (Frankfurt: Campus-Verlag, 2000), 54–96; Eric T. Jennings, Curing the Colonizers: Hydrotherapy, Climatology, and French Colonial Spas (Durham, NC: Duke University Press, 2006), 8–39; and Cristiana Bastos, “Migrants, Settlers and Colonists: The Biopolitics of Displaced Bodies,” International Migration 46, no. 5 (2008): 27–54.
28. See, for instance, Manuel Ferreira Ribeiro, Principios elementares de hygiene colonial (Lisbon: Minerva Avenida, 1890); and Georges Treille, Principes d’hygiène coloniale (Paris: Carré & Naud, 1899).
29. Compare with the 18th-century manuals described in Kananoja, “Bioprospecting and European Uses,” 64–65.
30. Philip D. Curtin, The Image of Africa: British Ideas and Action, 1780–1850 (Madison: University of Wisconsin Press, 1964), 355–362; and Daniel R. Headrick, The Tools of Empire: Technology and European Imperialism in the 19th Century (New York: Oxford University Press, 1981), 58–79.
31. William B. Cohen, “Malaria and French Imperialism,” Journal of African History 24, no. 1 (1983): 23–36.
32. Bouda Etemad, Possessing the World: Taking the Measurements of Colonisation from the 18th to the 20th Century (New York: Berghahn Books, 2007), 31–36.
33. For these different etiologies, see, for instance, Kalala J. Ngalamulume, “Keeping the City Clean: Yellow Fever and the Politics of Prevention in Colonial Saint-Louis-du-Sénégal, 1850–1914,” Journal of African History 45 (2004): 183–202; and Peter Baldwin, Contagion and the State in Europe, 1830–1930 (Cambridge, UK: Cambridge University Press, 1999), 2–9.
34. For early examples from Senegal, see Ngalamulume, “Keeping the City Clean”; and Myron J. Echenberg, Black Death, White Medicine: Bubonic Plague and the Politics of Public Health in Colonial Senegal, 1914–1945 (Portsmouth, NH: Heinemann, 2002), 27–31.
35. Echenberg, Black Death, 92.
36. See, for example, Philip D. Curtin, “Medical Knowledge and Urban Planning in Tropical Africa,” American Historical Review 90, no. 3 (1985): 594–613; and Wolfgang U. Eckart, “Malariaprävention und Rassentrennung: Die ärztliche Vorbereitung und Rechtfertigung der Duala-Enteignung 1912–1914,” History and Philosophy of the Life Sciences 10, no. 2 (1988): 363–378; and Echenberg, Black Death, 92–93.
37. Maynard W. Swanson, “The Sanitation Syndrome: Bubonic Plague and Urban Native Policy in the Cape Colony, 1900–1909,” Journal of African History 18, no. 3 (1977): 387–410; and Bill Freund, “Contrasts in Urban Segregation: A Tale of Two Cities, Durban (South Africa) and Abidjan (Côte d’Ivoire),” Journal of Southern African Studies 27, no. 3 (2001): 527–546; Eckart, “Malariaprävention und Rassentrennung.”
38. Curtin, “Medical Knowledge”; Odile Goerg, “From Hill Station (Free Town) to Downtown Conakry (First Ward): Comparing French and British Approaches to Segregation in Colonial Cities at the Beginning of the Twentieth Century,” Canadian Journal of African Studies 32, no. 1 (1998): 1–31.
39. See Georges Treille, “Mesures propres à assurer la conservation de la race, à prévenir sa dégénérescence physique, à améliorer ses conditions d’existence,” in Congrès International de Sociologie Coloniale tenu a Paris du 6 au 11 août 1900, ed. Exposition Universelle Internationale de 1900, 2 vols. (Paris: Arthur Rousseau, 1901), 108–115; Francisco Xavier da Silva Telles, “These Assistência os Indígenas,” in I Congresso Colonial Nacional: Actas das Sessões, ed. Sociedade de Geografia de Lisboa (Lisbon: A Liberal, 1902), 26.
40. See Anderson, “Immunities of Empire.”
41. For a critical appraisal of the underlying processes and the term itself, see Michael Worboys, “Was there a Bacteriological Revolution in Late Nineteenth-Century Medicine?,” Studies in History and Philosophy of Biological & Biomedical Sciences 38, no. 1 (2007): 20–42.
42. Michael Worboys, “Germs, Malaria and the Invention of Mansonian Tropical Medicine: From ‘Diseases in the Tropics’ to ‘Tropical Diseases,’” in Warm Climates and Western Medicine, ed. Arnold, 181–207.
43. See, for instance, Jaime Larry Benchimol, Dos micróbios aos mosquitos: Febre amarela e a revolução pasteuriana no Brasil (Rio de Janeiro: Editora Fiocruz/Editora da UFRJ, 1999); Flávio Coelho Edler, A medicina no Brasil Imperial: Clima, parasitas e patologia tropical (Rio de Janeiro: Editora Fiocruz, 2011); Warwick Anderson, Colonial Pathologies: American Tropical Medicine, Race, and Hygiene in the Philippines (Durham, NC: Duke University Press, 2006); and Mark Harrison, “Tropical Medicine in Nineteenth-Century India,” British Journal for the History of Science 25, no. 3 (1992): 299–318.
45. See Worboys, “Germs,” 191–192; and Echenberg, Black Death, 92; Randall M. Packard, The Making of a Tropical Disease: A Short History of Malaria (Baltimore: Johns Hopkins University Press, 2007), 115–117.
46. Compare with Bruno Latour, The Pasteurization of France (Cambridge, MA: Harvard University Press, 1988).
47. Jennings, Curing the Colonizers; Anna Crozier, “What Was Tropical about Tropical Neurasthenia? The Utility of the Diagnosis in the Management of British East Africa,” Journal of the History of Medicine and the Allied Sciences 64, no. 4 (2009): 518–548.
48. See, for instance, Ngalamulume, “Keeping the City Clean.”
49. Quote from Sociedade das Sciências Medicas, “Relatório da commissão encarregada de dar um parecer sobre a communicação do sr. Ribeiro acerca da doença do somno,” Jornal da Sociedade das Sciências Médicas de Lisboa 36 (1871): 251–253, 264–272, quote at: 251.
51. For West and West Central Africa, see Samuël Coghe, Population Politics in the Tropics: Demography, Health and Colonial Rule in Portuguese Angola, 1890s–1940s, PhD thesis, European University Institute, Florence, 2014, 41–130; Sebastião Nuno de Araújo Barros e Silva, The Land of Flies, Children and Devils: The Sleeping Sickness Epidemic in the Island of Príncipe (1870s–1914), PhD thesis, University of Oxford, 2013; for Central and East Africa, see Maryinez Lyons, The Colonial Disease: A Social History of Sleeping Sickness in Northern Zaire, 1900–1940 (Cambridge, UK: Cambridge University Press, 1992); Kirk Arden Hoppe, Lords of the Fly: Sleeping Sickness Control in British East Africa, 1900–1960 (Westport, CT: Praeger, 2003); and Webel, Politics of Disease Control.
52. For an overview, see Hoppe, Lords of the Fly, 11–15, and Helen Tilley, Africa as a Living Laboratory: Empire, Development, and the Problem of Scientific Knowledge, 1870–1950 (Chicago: Chicago University Press, 2011), 174–176.
53. Hoppe, Lords of the Fly, 28.
54. Lyons, Colonial Disease; Neill, Networks.
55. See Worboys, “Germs”; Michael Worboys, “The Comparative History of Sleeping Sickness in East and Central Africa, 1900–1914,” History of Science 32, no. 1 (1994): 89–102. For these three approaches in malaria control, see Curtin, “Medical Knowledge,” 597–599.
56. See, for instance, Jeff D. Grischow, “K. R. S. Morris and Tsetse Eradication in the Gold Coast, 1928–51,” Africa. The Journal of the International African Institute 76, no. 3 (2006): 381–401; and John Jay McKelvey, Man against Tsetse: Struggle for Africa (Ithaca, NY: Cornell University Press, 1973), 107–120.
57. Bernardo Francisco Bruto da Costa et al., Sleeping Sickness: A Record of Four Years’ War against it in Principe, Portuguese West Africa (London: Baillière, Tindall & Cox, 1916), 56–138, esp. 103–108, 137–138.
58. Émile Hegh, Notice sur les glossines ou tsétsés (London: Hutchinson, 1915), 111–115; and Mari K. Webel, “Mapping the Infected Landscape: Sleeping Sickness Prevention and the African Production of Colonial Knowledge in the Early Twentieth Century,” Environmental History 20, no. 4 (2015): 730.
59. William Beinart and Lotte Hughes, Environment and Empire (New York: Oxford University Press, 2007), 197–198; McKelvey, Man against Tsetse, 123; and Karen Brown, “From Ubombo to Mkhuzi: Disease, Colonial Science, and the Control of Nagana (Livestock Trypanosomosis) in Zululand, South Africa, c. 1894–1953,” Journal of the History of Medicine and the Allied Sciences 63, no. 3 (2008): 285–322.
60. See Luise White, “Tsetse Visions: Narratives of Blood and Bugs in Colonial Northern Rhodesia, 1931–9,” Journal of African History 36, no. 2 (1995): 219–245; and Brown, “From Ubombo to Mkhuzi.”
61. See, for instance, Brown, “From Ubombo to Mkhuzi” and João Fraga de Azevedo, M. da Costa Mourão, and J. M. de Castro Salazar, A erradicação da Glossina palpalis palpalis da ilha do Príncipe (1956–1958)/The Eradication of Glossina Palpalis Palpalis from Príncipe Island (1956–1958) (Lisbon: Junta de Investigações do Ultramar, 1962).
62. Neill, Networks; Wolfgang U. Eckart, “The Colony as Laboratory: German Sleeping Sickness Campaigns in German East Africa and in Togo, 1900–1914,” History and Philosophy of the Life Sciences 24, no. 1 (2002): 69–89; Rita Headrick, Colonialism, Health and Illness in French Equatorial Africa, 1885–1935 (Atlanta: African Studies Association Press, 1994), 318–334; Myriam Mertens and Guillaume Lachenal, “The History of ‘Belgian’ Tropical Medicine from a Cross-Border Perspective,” Belgisch Tijdschrift voor Filologie en Geschiedenis 90, no. 4 (2013), 1249–1272; and Guillaume Lachenal, Le médicament qui devait sauver l’Afrique: Un scandale pharmaceutique aux colonies (Paris: La Découverte, 2014), 19–73.
63. Lyons, Colonial Disease, 188–190.
64. Lyons, Colonial Disease, 188–190; Luise White, Speaking with Vampires: Rumor and History in Colonial Africa (Berkeley: University of California Press, 2000); and Sokhieng Au, “Cutting the Flesh: Surgery, Autopsy and Cannibalism in the Belgian Congo,” Medical History 61, no. 2 (2017): 295–312.
65. See Lyons, Colonial Disease, 102–136, 214–219; Hoppe, Lords of the Fly, 55–80; and, specifically on the concentration camps, Hiroyuki Isobe, Medizin und Kolonialgesellschaft: Die Bekämpfung der Schlafkrankheit in den deutschen “Schutzgebieten” vor dem Ersten Weltkrieg (Münster, Germany: LIT, 2009), 71–117, 178–185, 238–265.
67. On their role as intermediaries, see Mari K. Webel, “Medical Auxiliaries and the Negotiation of Public Health in Colonial North-Western Tanzania,” Journal of African History 54, no. 3 (2013): 393–416. More specifically on their role as drug injectors, see Lachenal, Médicament.
68. For a few early cross-overs, see Neill, Networks, 108–109; Coghe, Population Politics, 89–90.
69. For this argument, see Webel, Politics of Disease Control.
70. For such an interpretation, see John Ford, The Role of the Trypanosomiases in African Ecology (Oxford: Clarendon Press, 1971); and James Giblin, “Trypanosomiasis Control in African History: An Evaded Issue?” Journal of African History 31, no. 1 (1990): 59–80.
71. On the rationales of sleeping sickness campaigns, see Coghe, Population Politics, 47–64. On the socioeconomic effects, see M. C. Musambachime, “The Social and Economic Effects of Sleeping Sickness in Mweru-Luapula, 1906–1922,” African Economic History 10 (1981): 151–173.
72. Helen Tilley, “Ecologies of Complexity: Tropical Environments, African Trypanosomiasis, and the Science of Disease Control in British Colonial Africa, 1900–1940,” Osiris 19 (2004): 21–38.
73. See Lyn Schumaker, “The Mosquito Taken at the Beerhall: Malaria Research and Control on Zambia’s Copperbelt,” in Evidence, Ethos and Experiment: The Anthropology and History of Medical Research in Africa, ed. Wenzel Geissler and Catherine Molyneux (Oxford: Berghahn Books, 2011), 403–427.
74. See, for instance, Serap Aksoy et al., “Human African Trypanosomiasis Control: Achievements and challenges”, PLoS Neglected Tropical Diseases 11 (2017).
75. For an overview, Lyons, Colonial Disease, 181–222.
76. See Packard, Making of a Tropical Disease, 117–118 and 126; and Worboys, “Germs,” 198–199.
77. See, for instance, Sarah Ehlers, “Medical Missions—Racial Visions: Fighting Sleeping Sickness in Colonial Africa in the Early Twentieth Century,” in Health and Difference: Rendering Human Variation in Colonial Engagements, ed. Alexandra Widmer and Veronika Lipphardt (New York and Oxford: Berghahn Books, 2016), 91–110.
78. Compare Worboys, “Comparative History” with Hoppe, Lords of the Fly, 11–15; and Neill, Networks; Lachenal, Médicament; and Samuël Coghe, “Sleeping Sickness Control and the Transnational Politics of Mass Chemoprophylaxis in Portuguese Colonial Africa,” Portuguese Studies Review 25, no. 1 (2017): 57–89.
79. See Samuël Coghe, “Inter-Imperial Learning and African Health Care in Portuguese Angola in the Interwar Period,” Social History of Medicine 28, no. 1 (2015): 134–154.
80. See Joseph Morgan Hodge, Triumph of the Expert: Agrarian Doctrines of Development and the Legacies of British Colonialism (Athens, OH: Ohio University Press, 2007), 118–125.
81. See William H. Schneider, “Smallpox in Africa during Colonial Rule,” Medical History 53, no. 2 (2009): 193–227.
82. On the “volatile” concept of social medicine, see Dorothy Porter and Roy Porter, “What was Social Medicine? An Historiographical Essay,” Journal of Historical Sociology 1, no. 1 (1988): 90–106; and Iris Borowy, “International Social Medicine between the Wars: Positioning a Volatile Concept,” Hygeia Internationalis 6, no. 2 (2007): 13–35.
83. Headrick, Colonialism, Health and Illness, 220–230.
84. See Tilley, Africa as a Living Laboratory, 333–352; Coghe, Population Politics, 92–93; and Giovanni Trolli, Colonie du Congo Belge: Rapport sur l’Hygiène Publique pendant l’année 1930 (typescript, Library of the Institute of Tropical Medicine in Antwerp), 1.
85. Jerôme Rodhain, “Rapport sur l’organisation générale du service médicale au Congo Belge,” Revista Médica de Angola 4, no. 1 (1923): 185–191, quote at: 190 (my translation). Similarly, F. Heckenroth, “L’Oeuvre d’Assistance Médicale Indigène en Afrique Occidentale Française,” Revista Médica de Angola 4, no. 1 (1923): 207–219, esp. 213; and António Damas Mora, “Assistência Médica ao Indígena em África,” A Medicina Contemporânea 43 (1926): 353–357, 393–396, esp. 393.
86. See, for instance, Anne Digby and Helen Sweet, “Nurses as Culture Brokers in Twentieth-Century South Africa,” in Plural Medicine, Tradition and Modernity, 1800–2000, ed. Waltraud Ernst (London and New York: Routledge, 2002), 113–129.
87. For the British and French, see Maurice Blanchard, “La formation des auxiliaires médicaux dans les colonies françaises: L’école de médecine de l’AOF à Dakar,” Bulletin de l’Office International d’Hygiène Publique 27, no. 8 (1935): 1575–1592; John Iliffe, East African Doctors: A History of the Modern Profession (Cambridge, UK: Cambridge University Press, 1998), 60–91; and Adell Patton, Physicians, Colonial Racism, and Diaspora in West Africa (Gainesville: University Press of Florida, 1996), 33. For the Belgians and Portuguese, see Maryinez Lyons, “The Power to Heal: African Auxiliaries in Colonial Belgian Congo and Uganda,” in Contesting Colonial Hegemony: State and Society in Africa and India, ed. Dagmar Engels and Shula Marks (London: I.B. Tauris, 1994); and Paulo de Carvalho, Víctor Kajibanga, and Franz-Wilhelm Heimer, “Angola,” in African Higher Education: An International Reference Handbook, ed. Damtew Teferra and Philip G. Altbach (Bloomington and Indianapolis: Indiana University Press, 2003), 162–175.
88. Compare Blanchard, “Formation” and Pascale Barthélémy, Africaines et diplômées à l´époque colonial (1918–1957) (Rennes, France: Presses Universitaires de Rennes, 2010) with Headrick, Colonialism, Health and Illness, 244–252.
89. See, for instance, Lyons, “Power to Heal,” 210–213 and José Firmino Sant’Anna, “O problema da assistência médico-sanitária ao indígena em Africa,” Revista Médica de Angola 4 (1923): 73–178, esp. 164–165.
90. See Headrick, Colonialism, Health and Illness, 251–253.
91. Walima T. Kalusa, “Language, Medical Auxiliaries, and the Re-Interpretation of Missionary Medicine in Colonial Mwinilunga, Zambia, 1922–51,” Journal of Eastern African Studies 1, no. 1 (2007): 57–78. On the agency of African nurses, see also Lyons, “Power to Heal,” 212, 219–222.
92. On the French, see Headrick, Colonialism, Health and Illness, 345–384; Josiane Tantchou, Épidémie et Politique en Afrique: Maladie du Sommeil et Tuberculose au Cameroun (Paris: L’Harmattan, 2007); Jean-Paul Bado, Médecine coloniale et grandes endémies en Afrique 1900–1960: Lèpre, trypanosomiase humaine et onchocercose (Paris: Karthala, 1996), 291–310; and Noémi Tousignant, “Trypanosomes, Toxicity and Resistance: The Politics of Mass Therapy in French Colonial Africa,” Social History of Medicine 25, no. 3 (2012): 625–643. On the Portuguese and Belgians, see Coghe, “Inter-Imperial Learning”; and Myriam Mertens, Chemical Compounds in the Congo: Pharmaceuticals and the ‘Crossed History’ of Public Health in Belgian Africa (ca. 1905–1939), PhD thesis, Universiteit Gent, 2014.
93. Lachenal, Médicament; Philip J. Havik, “Public Health and Tropical Modernity: The Combat against Sleeping Sickness in Portuguese Guinea, 1945–1974,” Manguinhos. História Ciências Saúde 21, no. 2 (2014): 641–666; and Coghe, “Sleeping Sickness Control”; and Sarah Cook Runcie, Mobile Health Teams, Decolonization, and the Eradication Era in Cameroon, 1945–1970, PhD thesis, Columbia University, 2017.
94. For more details, see Coghe, “Inter-Imperial Learning”; Samuël Coghe, “Reordering Colonial Society: Model Villages and Social Planning in Rural Angola, 1920–1945,” Journal of Contemporary History 52, no. 1 (2017): 16–44. See also Giovanni Trolli, L’assistance médicale aux indigènes du Congo Belge et notre dynastie: Historique et nouvelle méthode adoptée par (FORÉ)AMI (Antwerp, Belgium: Editions de l’Avenir Belge, 1935).
95. Compare, for instance, Jan Vansina, Being Colonized: The Kuba Experience in Rural Congo, 1880–1960 (Madison: University of Wisconsin Press, 2010), 127–149 with Ewout Frankema and Morten Jerven, “Writing History Backwards or Sideways: Towards a Consensus on African Population, 1850–2010,” Economic History Review 67, no. 4 (2014): 907–931.
96. Megan Vaughan, “Syphilis in Colonial East and Central Africa: The Social Construction of an Epidemic,” in Epidemics and Ideas: Essays on the Historical Perception of Pestilence, ed. Terence Ranger (Cambridge, UK: Cambridge University Press, 1992), 269–302; and Shane Doyle, Crisis and Decline in Bunyoro: Population and Environment in Western Uganda, 1860–1955 (Oxford: Currey, 2006), 155–156, 221–223.
97. See Headrick, Colonialism, Health and Illness, 170–180; and K. David Patterson and Gerald Pyle, “The Diffusion of Influenza in sub-Saharan Africa during the 1918–1919 Pandemic,” Social Science and Medicine 17, no. 17 (1983): 1299–1307.
98. Anne Sealey, “Globalizing the 1926 International Sanitary Convention,” Journal of Global History 6, no. 3 (2011): 431–455.
99. Heidi J. S. Tworek, “Communicable Disease: Information, Health, and Globalization in the Interwar Period,” American Historical Review 124, no. 3 (2019): 813–842; and Sealey, “Globalizing,” 450–454.
100. Coghe, “Inter-Imperial Learning,” 144–145.
101. See, for instance, Schneider, “Smallpox,” 195ff; and See the documentation on treaties and data exchange between the Belgian Congo and its neighboring colonies in Ministère des Affaires Etrangères, Archives Africaines, Brussels, Hygiène, Boxes 4465–4468.
102. For more details, see Samuël Coghe, “Medical Demography in Interwar Angola: Measuring and Negotiating Health, Reproduction and Difference,” in Health and Difference, ed. Widmer and Lipphardt, 178–204. An excellent overview of such studies is also given in Robert René Kuczynski, The Cameroons and Togoland: A Demographic Study (London: Oxford University Press, 1939).
103. Lyn Thomas, Politics of the Womb: Women, Reproduction and the State in Kenya (Berkeley: University of California Press, 2003).
104. Nancy Rose Hunt, “‘Le Bébé en Brousse’: European Women, African Birth Spacing and Colonial Intervention in Breast Feeding in the Belgian Congo,” International Journal of African Historical Studies 21, no. 3 (1988): 401–432; Nancy Rose Hunt, “Noise over Camouflaged Polygamy, Colonial Morality Taxation, and a Woman-Naming Crisis in Belgian Africa,” Journal of African History 32, no. 3 (1991): 471–494; and Nancy Rose Hunt, “Colonial Medical Anthropology and the Making of the Central African Infertility Belt,” in Ordering Africa: Anthropology, European Imperialism and the Politics of Knowledge, ed. Helen Tilley and Robert J. Gordon (Manchester: Manchester University Press, 2007), 252–281.
105. Thomas, Politics of the Womb; Heather Bell, Frontiers of Medicine in the Anglo-Egyptian Sudan, 1899–1940 (Oxford: Clarendon Press, 1999), 198–228.
106. Hunt, “Colonial Medical Anthropology.”
107. Megan Vaughan, Curing their Ills: Colonial Power and African Illness (Cambridge, UK: Polity Press, 1991), 129–154; and Carol Summers, “Intimate Colonialism: The Imperial Production of Reproduction in Uganda, 1907–1925,” Signs 16 (1991): 787–807.
108. Doyle, Crisis and Decline, 221–225; and Philip J. Havik, “Public Health, Social Medicine and Disease Control: Medical Services, Maternal Care and Sexually Transmitted Diseases in Former Portuguese West Africa (1920–63),” Medical History 62, no. 4 (2018): 485–506, esp. 494.
109. Vaughan, Curing their Ills, 146–152.
110. See Jane Turrittin, “Colonial Midwives and Modernizing Childbirth in French West Africa,” in Women in African Colonial Histories, ed. Jean M. Allman, Susan Geiger, and Nakanyike Musisi (Bloomington: Indiana University Press, 2002), 176; and Anne Hugon, “La redéfinition de la maternité en Gold Coast, des années 1920 aux années 1950: Projet colonial et réalités locales,” in Histoire des femmes en situation coloniale: Afrique et Asie, XXe siècle, ed. Anne Hugon (Paris: Karthala, 2004), 119–144.
111. Summers, “Intimate Colonialism”; Deanne van Tol, “Mothers, Babies and the Colonial State: The Introduction of Maternal and Infant Welfare Services in Nigeria, 1925–1945,” Spontaneous Generations 1 (2007): 110–131; Turrittin, “Colonial Midwives”; Pascale Barthélémy, “Sages-femmes africaines diplômées en AOF des années 1920 aux années 1960: Une redéfinition des rapports sociaux de sexe en contexte colonial,” in Histoire des femmes, ed. Hugon, 119–144; and Nancy Rose Hunt, A Colonial Lexicon of Birth Ritual, Medicalization, and Mobility in the Congo (Durham, NC: Duke University Press, 1999).
112. Jean Allman, “Making Mothers: Missionaries, Medical Officers and Women’s Work in Colonial Asante, 1924–1945,” History Workshop 38, no. 1 (1994): 23–47, esp. 30–34. See also van Tol, “Mothers,” 119–123.
113. See Randall Packard, “The History of the Social Determinants of Health in Africa,” in History of the Social Determinants of Health: Global Histories, Contemporary Debates, ed. Harold John Cook, Sanjoy Bhattacharya, and Anne Hardy (Hyderabad, India: Orient BlackSwan, 2009), 46–52; and António Damas Mora, “A mortalidade infantil de brancos e indígenas nas Colónias de Angola e Moçambique, suas causas principais e remédios possíveis: Métodos para a organização de estatística da mortalidade infantil,” in Memórias e comunicações apresentadas ao Congresso Colonial (IX Congresso), ed. Comissão Executiva dos Centenários (Lisbon: Publicações do Congresso do Mundo Português, 1940), 605–608.
114. Iris Borowy, Coming to Terms with World Health: The League of Nations Health Organisation, 1921–1946 (Frankfurt: Lang, 2009), 301–420; Annick Guénel, “The 1937 Bandung Conference on Rural Hygiene: Towards a New Vision of Healthcare,” in Global Movements, Local Concerns: Medicine and Health in Southeast Asia, ed. Laurence Monnais-Rousselot and Harold John Cook (Singapore: NUS Press, 2012), 62–80; Paul Weindling, “Social Medicine at the League of Nations Health Organisation and the International Labour Office Compared,” in International Health Organisations and Movements, 1918–1939, ed. Paul Weindling (Cambridge, UK: Cambridge University Press, 1995), 134–153. For the importance of rural hygiene during the pan-African conferences, see Randall M. Packard, A History of Global Health: Interventions into the Lives of Other Peoples (Baltimore: John Hopkins University Press, 2016), 47–49.
115. For an overview, see Coghe, “Reordering Colonial Society.”
116. Michael Worboys, “The Discovery of Colonial Malnutrition between the Wars,” in Imperial Medicine and Indigenous Societies, ed. David Arnold (Oxford: Oxford University Press, 1988), 208–225; Vincent Bonnecase, “When Numbers Represented Poverty: The Changing Meaning of the Food Ration in French Colonial Africa,” Journal of African History 59, no. 3 (2018): 463–481; and Jonathan E. Robins, “‘Food Comes First’: The Development of Colonial Nutritional Policy in Ghana, 1900–1950,” Global Food History 4, no. 2 (2018): 168–188.
117. See Worboys, “Discovery,” 208–209.
118. Robins, “Food Comes First.” On these debates, see also Henrietta L. Moore and Megan Vaughan, Cutting Down Trees: Gender, Nutrition, and Agricultural Change in the Northern Province of Zambia, 1890–1990 (Portsmouth, NH: Heinemann, 1994) and Tilley, Africa as a Living Laboratory, 115–168.
119. On the “discovery” of kwashiorkor in the 1930s, see Jennifer Stanton, “Listening to the Ga: Cicely Williams’ Discovery of Kwashiorkor on the Gold Coast,” in Women and Modern Medicine, ed. Lawrence Conrad (Amsterdam: Rodopi, 2001), 149–172.
120. For interwar studies and surveys in French and British colonies, see Bonnecase, “Numbers,” 466–473; Cynthia Brantley, “Kikuyu-Maasai Nutrition and Colonial Science: The Orr and Gilks Study in Late 1920s Kenya Revisited,” International Journal of African Historical Studies 30 (1997): 49–86; and Moore and Vaughan, Cutting Down Trees.
121. See Jorge Varanda, “A Bem da Nação”: Medical Science in a Diamond Company in Portuguese Angola, PhD thesis, University College London, 2006, 191–244; and Jorge Varanda and Todd Cleveland, “(Un)healthy Relationships: African Labourers, Profits and Health Services in Angola’s Colonial-Era Diamond Mines, 1917–75,” Medical History 58 (2014): 87–105, esp. 94–96.
122. Tilley, Africa as a Living Laboratory, 115–168.
123. Bonnecase, “Numbers,” 466–469.
124. Hunt, “Bébé en Brousse.”
125. Jessica Lynn Pearson, The Colonial Politics of Global Health: France and the United Nations in Postwar Africa (Cambridge, MA: Harvard University Press, 2018), 154–162; and Jennifer Tappan, “The True Fiasco: The Treatment and Prevention of Severe Acute Malnutrition in Uganda, 1950–1974,” in Global Health in Africa: Historical Perspectives on Disease Control, ed. Tamara Giles-Vernick and James L. A. Webb Jr. (Athens, OH: Ohio University Press, 2013), 92–113.
126. On these contradictions, see Doyle, Crisis and Decline, 228–232; Robins, “Food Comes First”; Allen F. Isaacman, Cotton is the Mother of Poverty: Peasants, Work, and Rural Struggle in Colonial Mozambique, 1938–1961 (Portsmouth, NH: Heinemann, 1996), 150–170; and Osumaka Likaka, Rural Society and Cotton in Colonial Zaire (Madison: University of Wisconsin Press, 1997).
127. Robins, “Food Comes First,” 10–12.
128. Michael Jennings, “‘Healing of Bodies, Salvation of Souls’: Missionary Medicine in Colonial Tanganyika, 1870s–1939,” Journal of Religion in Africa 38 (2008): 27–56, esp. 28.
129. Comaroff, “Diseased Heart,” 313–319.
131. Hardiman, “Introduction,” 22–25. See also Barbra Mann Wall, Into Africa: A Transnational History of Catholic Medical Missions and Social Change (New Brunswick, NJ: Rutgers University Press, 2015).
132. See Vaughan, Curing their Ills, 55–99; Hunt, Colonial Lexicon; Michael Jennings, “‘A Matter of Vital Importance’: The Place of the Medical Mission in Maternal and Child Healthcare in Tanganyika, 1919–1939,” in Healing Bodies, ed. Hardiman, 227–250.
133. See Robert Fletcher Moorshead, The Appeal of Medical Missions (New York: Revell, 1913), esp. 49–115.
134. See the case of Portuguese Angola: Coghe, Population Politics, 120–122, 301–305.
135. Jennings, “Healing of Bodies,” 35.
136. Hunt, Colonial Lexicon, 227–230; Coghe, Population Politics, 302–305; Jelmer Vos, Kongo in the Age of Empire, 1860–1913 (Madison: University of Wisconsin Press, 2015), 66.
137. Comaroff, “Diseased Heart,” 306.
138. See, for instance, Jennings, “Healing of Bodies” and Lyons, Colonial Disease, 129.
139. See Kalusa, “Language”; Walima T. Kalusa, “Missionaries, African Patients, and Negotiating Missionary Medicine at Kalene Hospital, Zambia, 1906–1935,” Journal of Southern African Studies 40, no. 2 (2014): 283–294.
140. Randall M. Packard, White Plague, Black Labor: Tuberculosis and the Political Economy of Health and Disease in South Africa (Berkeley: University of California Press, 1989), 89; and Raymond Dumett, “Disease and Mortality among Gold Miners of Ghana: Colonial Government and Mining Company Attitudes and Policies, 1900–1938,” Social Science and Medicine 37, no. 2 (1993): 213–232.
141. Headrick, Colonialism, Health and Illness, 273–310.
142. See Packard, White Plague, Black Labor, 159–193; Bruce Fetter, “Changing Determinants of African Mineworker Mortality: Witwatersrand and the Copperbelt, 1911–1940,” Civilisations. Revue Internationale d’Anthropologie et de Sciences Humaines 41 (1993): 347–359; and Schumaker, “Mosquito”; Jorge Varanda, “Cuidados biomédicos de saúde em Angola e na Companhia de Diamantes de Angola, c. 1910–1970,” História, Ciências, Saúde—Manguinhos 21, no. 2 (2014): 587–608. For West African Ghana, see Dumett, “Disease and Mortality.”
143. See Todd Cleveland, Diamonds in the Rough: Corporate Paternalism and African Professionalism on the Mines of Colonial Angola, 1917–1975 (Athens, OH: Ohio University Press, 2015), 42–79; and Emile van Campenhout, “Considérations sur l’utilisation de la main-d’oeuvre au Congo Belge,” Bulletin de l’Office International d’Hygiène Publique 23, no. 9 (1931): 1627–1651.
144. See note 144.
145. See Charles Perrings, Black Mineworkers in Central Africa (New York: Africana, 1979), 77–130; Bruce Fetter, “Relocating Central Africa’s Biological Reproduction, 1923–1963,” International Journal of African Historical Studies 19, no. 3 (1986): 463–475; Cleveland, Diamonds in the Rough, 48–56, 153–158; Varanda, “A Bem da Nação,” 125–126, 176–181; Hunt, “Bébé en Brousse,” 412–420.
146. Packard, White Plague, Black Labor, 184–193, quote at: 187. Also Randall Packard, “The Invention of the ‘Tropical Worker’: Medical Research and the Quest for Central African Labor on the South African Gold Mines, 1903–36,” Journal of African History 34, no. 2 (1993): 271–292.
147. Packard, White Plague, Black Labor, 92–125.
148. Schneider, “Smallpox,” 194–198; Vaughan, Curing their Ills, 144–145.
149. Judith A. Byfield et al., eds., Africa and World War II (New York: Cambridge University Press, 2015).
150. See Philip J. Havik, “Public Health and Disease Control in Former Portuguese Africa: Negotiating Health System Management and Strategies, 1945–1965,” in Learning from Empire: Medicine, Knowledge and Transfers under Portuguese Rule, ed. Poonam Bala (Cambridge, UK: Cambridge Scholars, 2018), 141–173; Pearson, Colonial Politics.
151. For an overview, see Joseph Morgan Hodge, Gerald Hodl, and Martina Kopf, eds., Developing Africa: Concepts and Practices in Twentieth-Century Colonialism (Manchester: Manchester University Press, 2014), 14–22.
152. Hunt, Colonial Lexicon, 3–4.
153. See, for instance, Runcie, Mobile Health Teams.
154. Havik, “Public Health and Disease Control.”
155. For definitions, see Theodore M. Brown, Marcos Cueto, and Elizabeth Fee, “The World Health Organization and the Transition from ‘International’ to ‘Global Public Health,’” American Journal of Public Health 96, no. 1 (2006): 62–72; and James L. A. Webb Jr. and Tamara Giles-Vernick, “Introduction,” in Global Health in Africa, ed. Giles-Vernick and Webb Jr., 2–3; Anne-Emanuelle Birn, Yogan Pillay, and Timothy H. Holtz, eds., Textbook of Global Health, 4th ed. (Oxford: Oxford University Press, 2017), 76–79.
156. John Farley, To Cast Out Disease: A History of the International Health Division of the Rockefeller Foundation (1913–1951) (Oxford: Oxford University Press, 2004), 294. On the role of IHB in the history of global health, see also Steven Paul Palmer, Launching Global Health: The Caribbean Odyssey of the Rockefeller Foundation (Ann Arbor: University of Michigan Press, 2010) and Packard, History of Global Health, 32–46.
157. See Borowy, Coming to Terms, 225–235 and 255–261 and Coghe, “Inter-Imperial Learning,” 144–145.
158. See also Marcos Cueto, Theodore M. Brown, and Elizabeth Fee, The World Health Organization: A History (Cambridge, UK: Cambridge University Press, 2019), 26–28.
159. On the history of the WHO, see Cueto, Brown, and Fee, World Health Organization. For the history of global health initiatives, see Packard, History of Global Health, and, for Africa in particular, Giles-Vernick and Webb Jr., eds., Global Health in Africa.
160. Cueto, Brown, and Fee, World Health Organization, 77–85 and 92–95. See also Birn, Pillay, and Holtz, eds., Textbook of Global Health, 56–59.
161. See note 148.
162. Cueto, Brown, and Fee, World Health Organization, 92–95; Birn, Pillay, and Holtz, eds., Textbook of Global Health, 56–59.
163. Pearson, Colonial Politics, 141–163.
164. Jessica Pearson-Patel, “Promoting Health, Protecting Empire: Inter-Colonial Medical Cooperation in Postwar Africa,” Monde(s) 7, no. 1 (2015): 213–230; Pearson, Colonial Politics, 67–88. On the CCTA, see also John Kent, The Internationalization of Colonialism: Britain, France, and Black Africa, 1939–1956 (Oxford: Clarendon Press, 1992), 263–285; and Frederico Ágoas and Cláudia Castelo, “Ciências sociais, diplomacia e colonialismo tardio: A participação portuguesa na Comissão de Cooperação Técnica na África ao Sul do Saara (CCTA),” Estudos Históricos (Rio de Janeiro) 32 (2019): 409–428.
165. See Daniel Vigier, “La Commission de coopération technique en Afrique au Sud du Sahara,” Politique Etrangère 19, no. 3 (1954): 335–349.
166. See Digby and Sweet, “Nurses,” 114–115; Karen Flint, “Competition, Race and Professionalisation: African Healers and White Medical Practitioners in Natal, South Africa in the Early Twentieth Century,” Social History of Medicine 14, no. 2 (2001): 199–221, esp. 199–200; and Alberto Carlos Germano da Silva Correia, “Os processos práticos de hospitalização dos indígenas e a sua assistência médica em Angola,” Revista Médica de Angola 4, no. 2 (1923): 179–200, esp. 191–194.
167. Hunt, “Health and Healing,” 384–386; Hokkanen, “Contestation,” 124–127.
168. Hokkanen, “Contestation,” 126–129; Flint, “Competition”; Gôverno Geral de Angola, “Regulamento do exercício da arte de curar em Angola,” Boletim Oficial da Colónia de Angola, Série II, no. 18 (1931), 2nd supplement, 1–22, art. 6.
169. Steven Feierman and John Janzen, “Introduction,” in Social Basis, ed. Feierman and Janzen, 16–18; Hokkanen, “Contestation,” 132–133.
170. Hokkanen, “Contestation,” 130–138.
172. For this argument, see Julie Livingston, “Productive Misunderstandings and the Dynamism of Plural Medicine in Mid-Century Bechuanaland,” Journal of Southern African Studies 33, no. 4 (2007): 801–810 and Kalusa, “Missionaries.”
174. Digby and Sweet, “Nurses”; Walter Bruchhausen, “Medical Pluralism as a Historical Phenomenon: A Regional and Multi-Level Approach to Health Care in German, British and Independent East Africa,” in Crossing Colonial Historiographies: Histories of Colonial and Indigenous Medicines in Transnational Perspective, ed. Anne Digby, Waltraud Ernst, and Projit B. Muhkarji (Newcastle, UK: Cambridge Scholars, 2010), esp. 106–107.
175. Hokkanen, “Contestation,” 119.
176. See Headrick, Colonialism, Health and Illness on the Cinderella position of AEF within the French Empire or Barbara Cooper on the marginality of Niger within AOF: Barbara Cooper, “The Gender of Nutrition in the AOF: Military Medicine, Intra-Colonial Marginality, and Ethnos Theory in the Making of Malnutrition in Niger,” in Health and Difference, ed. Widmer and Lipphardt, 149–177.
177. See the diverging levels of biomedical interventionism within Uganda and within the Great Lakes region addressed by Shane Doyle in Crisis and Decline and Before HIV: Sexuality, Fertility and Mortality in East Africa, 1900–1980 (Oxford: Oxford University Press, 2013), 1–7.
178. Jean-Paul Bado, “Colonial Histories of Cancers: Primary Liver Cancer in Africa, 1900s–1960s,” in Health and Difference, ed. Widmer and Lipphardt, 111–128 and, for kwashiorkor, Stanton, “Listening to the Ga”; Tappan, “True Fiasco.”
179. See, for instance, David Molyneux, Joseph Ndung’u, and Ian Maudlin, “Controlling Sleeping Sickness: ‘When Will They Ever Learn?’”, PLoS Neglected Tropical Diseases 4 (2010): e609.
180. Schneider, “Smallpox.”
181. On the impact of colonial conquest on morbidity and mortality, see Vansina, Being Colonized, 127–149.
182. Doyle, Crisis and Decline, 221–222.
183. Jacques Pepin, The Origins of AIDS (Cambridge, UK: Cambridge University Press, 2011); Tamara Giles-Vernick et al., “Social History, Biology, and the Emergence of HIV in Colonial Africa,” Journal of African History 54, no. 1 (2013): 11–30.
184. Lachenal, Médicament; Tappan, “True Fiasco.”
185. See Frankema and Jerven, “Writing History Backwards”; Manning, “African Population.”
186. For this debate, see Shane Doyle, “Demography and Disease,” in Oxford Handbook of Modern African History, ed. Parker and Reid, 41–45.
187. See Michael Gelfand, Tropical Victory: An Account of the Influence of Medicine on the History of Southern Rhodesia, 1900–1923 (Cape Town: Juta, 1953).
188. See the pathbreaking volumes by Roy MacLeod, ed., Disease, Medicine, and Empire: Perspectives on Western Medicine and the Experience of European Expansion (London: Routledge, 1988); Arnold, ed., Imperial Medicine; and Feierman and Janzen, eds., Social Basis.
189. Schumaker, “History of Medicine,” 196.
190. Headrick, Tools of Empire, esp. 3–14 and 58–79. See also Curtin, Disease and Empire.
191. See Swanson, “Sanitation Syndrome”; Lyons, Colonial Disease; or Lachenal, Médicament.
192. See Packard, White Plague, Black Labor and many contributions in Feierman and Janzen, eds., Social Basis.
193. See Andrew Cunningham and Bridie Andrews, eds., Western Medicine as Contested Knowledge (Manchester: Manchester University Press, 1997).
194. Janzen, Quest for Therapy; Karen Flint, Healing Traditions: African Medicine, Cultural Exchange, and Competition in South Africa, 1820–1948 (Athens, OH: Ohio University Press, 2008); Ernst, ed., Plural Medicine; Kalusa, “Missionaries”; and many of the contributions in Digby, Ernst, and Muhkarji, eds., Crossing Colonial Historiographies and Hokkanen and Kananoja, eds., Healers and Empires.
195. See Neill, Networks; Mertens and Lachenal, “History”; and many contributions in Digby, Ernst, and Muhkarji, eds., Crossing Colonial Historiographies.
196. Giles-Vernick and Webb Jr., eds., Global Health; Packard, History of Global Health; Birn, Pillay, and Holtz, eds., Textbook of Global Health, 1–88.
197. See Kalala J. Ngalamulume, Colonial Pathologies, Environment, and Western Medicine in Saint-Louis-du-Senegal, 1867–1920 (New York: Peter Lang, 2012).
198. See Shane Doyle, Felix Meir zu Selhausen, and Jacob Weisdorf, “The Blessings of Medicine? Patient Characteristics and Health Outcomes in a Ugandan Mission Hospital, 1908–1970”, Social History of Medicine 33, no. 3 (2020): 946–980.
199. See K. S. Ombongi et al., “The East African Medical Journal: Its History and Contribution to Regional Malaria Research during the Last 75 Years,” East African Medical Journal 75, no. 6 (1998): 10–19.
200. See, for instance, Terence Ranger, “Godly Medicine: The Ambiguities of Medical Mission in Southeast Tanzania,” Social Science and Medicine 15B, no. 3 (1981): 261–277 and Hunt, Colonial Lexicon.
201. On the challenges of oral history in general, see Barbara M. Cooper, “Oral Sources and the Challenge of African History,” in Writing African History, ed. John Edward Philips (Rochester, NY: University of Rochester Press, 2005), 191–215.