Curing Their Ills

Colonial Power and African Illness

Megan Vaughan

• Publisher: Polity
• Year: 2013
• ISBN:
  9780745668949
• Edition: 1
• Topic: Histoire
• Subtopic: Histoire du 19ème siècle

Curing their Ills traces the history of encounters between European medicine and African societies in the nineteenth and twentieth centuries. Vaughan's detailed examination of medical discourse of the period reveals its shifting and fragmented nature, highlights its use in the creation of the colonial subject in Africa, and explores the conflict between its pretensions to scientific neutrality and its political and cultural motivations.

The book includes chapters on the history of psychiatry in Africa, on the treatment of venereal diseases, on the memoirs of European 'Jungle Doctors', and on mission medicine. In exploring the representations of disease as well as medical practice, Curing their Ills makes a fascinating and original contribution to both medical history and the social history of Africa.

1 Introduction: Discourse, Subjectivity and Differences

Alone I walk the quiet ward
Where shaded lamps long shadows cast,
No noonday bustle – noonday sun,
No noise of speech from anyone.
Outside, the Stars of Africa
Twinkle around the Southern Cross.
The wards beyond may suffer loss –
But mine is gain, as when I tend the cord
And welcome into the night
A dark-skinned babe whose palms are white.

(P. G. Adams, ‘Night Duty: African Hospital’)¹

Alone at night in the hushed wards of a colonial African hospital, the young white doctor contemplates questions of life and death. Dark shadows are cast over the death-filled wards, but from the window he catches a glimpse of a brilliant star-filled African night sky. The birth of a baby interrupts a night of death, and as he ‘tends the cord’, his eyes fall on the unexpectedly white palms of the black baby’s hands.

In the late twentieth century, as in the late nineteenth, the European imagination is easily captured by the image of the white doctor in a dark Africa. In the nineteenth century this encounter would probably have been framed in a jungle-like setting, as in many pictorial representations of David Livingstone. The white doctor stands confronting both the ‘nature’ and the ‘culture’ of the dark continent, the boundaries between which are disturbingly ill-defined. Armed only with his faith and his medicine, he is stalked both by the animals of the bush and by men in animal skins. By the mid twentieth century the scene of the encounter has moved indoors to the hospital ward. Here the constant play of light and dark, lamplight and shadows, hope and fear, is used to inscribe the encounter. The wild Africa is still there, to be glimpsed through the window as something both beautiful and deadly, whilst inside the hospital the encounter with the other Africa goes on in struggles with disease and death. But, we are reminded, there is also hope – not so much in the birth of a black baby but in the miracle of its white palms.

The western medical discourse on Africa, as this example indicates, is not always marked by its subtlety. In the post-Enlightenment European mind Africa, it seems, has been created as a unique space, as a repository of death, disease, and degeneration, inscribed through a set of recurring and simple dualisms – black and white, good and evil, light and dark.²

In his book on Difference and Pathology (1985), Sander Gilman has described western discourses on sexuality, race and madness from the eighteenth century onwards.³ His book is about objectification, and his framework a psychoanalytic one. All human beings, he argues, create stereotypes, and none of us can function in the world without them. The creation of stereotypes begins in childhood. The child can grow into an individual only through articulating a sense of difference between her or himself and the rest of the world. The development of a ‘normal’ personality, Gilman argues, involves the objectification and distancing of that part of the self which individuals are unable to control and through which they are exposed to anxiety. This part of the self, the ‘bad’ self, is distanced by being identified with some external, ‘bad’ object. Herein, he argues, lie the ontological origins of the development of stereotypes.

Stereotypes are necessarily ‘crude representations of the world’, for their function is to perpetuate an artificial sense of difference between ‘self’ and ‘Other’, and to preserve the illusion of control over the self and the world.⁴ The need for stereotyping, however, takes place at the level of the ‘group’, as well as at the level of the individual, and functions in much the same way. The need for control, and the constant threat of loss of that control, necessitates the projection of difference on to some ‘Other’, and all images of the ‘Other’, he argues, derive from the ‘same deep structure’. Central to this ‘deep structure’ is an anxiety over sexuality, and the relationship which develops between sexuality, pathology and ‘difference’ in the form of skin colour: ‘sexual anatomy is so important a part of self-image that “sexually different” is tantamount to “pathological” – the Other is “impaired”, “sick”, “diseased”. Similarly, physiognomy or skin colour that is perceived as different is immediately associated with “pathology” and “sexuality”.’⁵

The relationships between these different categories and signs of ‘otherness’ are the focus of Gilman’s work. In his chapter on ‘The Hottentot and the Prostitute’, for instance, he describes the development of a nineteenth-century discourse on black female sexuality, and its realization in the figure of the ‘Hottentot Venus’. In this, as in other chapters, Gilman demonstrates the inter-dependence of many nineteenth-century scientific discourses. Discourses on ‘blackness’, for example, rely heavily on images of sexual difference, whilst discourses on white female sexuality draw on images of ‘blackness’.⁶

Gilman traces the same kinds of connections in the nineteenth-century discourses on madness and on degeneration, and in the twentieth-century specialisms of sexology and psychoanalysis. It was Freud who, as Gilman points out, referred to contemporary ignorance of the nature of female sexuality as the ‘dark continent’ of psychology. In the use of this English phrase, writes Gilman, ‘he tied female sexuality to the image of contemporary colonialism and thus to the exoticism of and the pathology of the Other’.⁷

My purpose in this book is, I think, rather different from that of Gilman, though our concerns clearly overlap at many points. Gilman takes a broad sweep over European and North American culture from the eighteenth to twentieth centuries, and draws on a wide array of cultural forms and texts for his evidence. These range from the iconography of prostitution in the texts of an emerging science of sexuality in the nineteenth century, through fin-de-siècle dramas and mid-nineteenth-century art works to close analyses of the texts of psychology. All systems of representation, he argues, can be analysed as ‘texts’ for the purpose of the study of stereotypes, and he quotes the following passage from Terry Eagleton’s book Literary Theory to support this position: ‘Discourses, sign systems and signifying practices of all kinds, from film and television to fiction and the languages of natural science, produce effects, shape forms of consciousness and unconsciousness, which are closely related to the maintenance or transformation of our existing systems of power. They are thus closely related to what it means to be a person.’⁸

Of course cultures as systems of representation are constituted by a very wide range of ‘signifying practices’, and Gilman traces the resonances of these as they apply to race, sexuality and madness in modern European culture. But by painting his picture on such a broad canvas, and by relying heavily on a ‘deep’ structural psychological analysis, he leaves us with a sense both of the coherence of this culture and of the inevitability of its form. There are few cracks or dissonances in the picture he paints. Images of race, sexuality and madness feed off each other to form a whole and, furthermore, they are all the product of a universal psychological mechanism of distancing and objectification, the function of which is to create ‘normal’ human beings.

Convincing as Gilman’s account is in many ways, it neglects, in its broad cultural sweep, two central elements in the analysis of discourses mentioned by Eagleton. The first is the fact that they are ‘closely related to the maintenance or transformation of our existing systems of power’; the second, that ‘they are thus closely related to what it means to be a person’.

Gilman’s work is primarily concerned with the process of objectification. As such, it does indeed deal with ‘what it means to be a person’, but it does so only in terms of the function performed by objectification in the development of the ‘normal’ individual and of group consciousness. Gilman does not discuss, as Fanon and other writers on colonialism have, and as a body of feminist work has, the question of the effects of this process on those who are so objectified. Neither can the process of objectification, within the chosen framework of analysis (the role of the ‘stereotype’), raise the possibility that some discourses might operate less through a one-way process of objectification than through a more complex process of the creation of subjectivities.

In the chapters which follow, I attempt to analyse, within the specific historical context of British colonialism in Africa, the processes both of objectification and of the creation of subjectivities, through a delineation and discussion of biomedical discourses on ‘the African’. I am less concerned with the psychology of these processes than I am with what Gilman calls their ‘realization’ in a specific social context. As such, my discussion is closely tied to the question of the nature of colonial power. By taking as my object of study a much more limited area of the production of knowledge (biomedical knowledge of ‘the African’) and a more closely defined social and political context, I hope to create a picture, not so much of the inevitability of insistent objectification and the endurance of images, but a more complex, and sometimes more blurred one, which can incorporate resistances and fractures. Though the sometimes crude simplicity of the biomedical discourse on Africa is much in evidence in the chapters which follow, I hope also to show that the production of that discourse was far from simple.

Social constructionism and the history of biomedicine in Africa

A number of overlapping literatures have informed my approach in this book. Firstly, and perhaps most evidently, I have been informed by a social constructionist approach to the history of biomedicine.⁹ One of my main concerns has been to analyse the ways in which medical knowledge was produced in colonial Africa. This exercise is of course premised on the assumption that all forms of scientific and medical knowledge are to some extent socially constructed. In the chapters which follow on the history of madness, on the construction of leprosy and on missionary medicine, I have viewed medical texts and medical theories rather as narratives which draw on a wide range of cultural signs and symbols for their effect.

The social constructionist part of my argument has both been informed by, and has developed in response to, recent literature on the history of biomedicine and of ‘medical pluralism’ in Africa.

In recent years a number of critiques of the role of biomedicine in the ‘Third World’, and particularly in colonialism, have emerged. These critiques take various forms, the most influential having been those which emerge from a materialist perspective and which provide a ‘political economy’ of health and disease in colonial and post-colonial Africa.¹⁰ But there is another strand in these critiques which draws less on political economy than on a late-twentieth-century scepticism about ‘science’, and disillusionment with ‘modern medicine’. The ‘problem’ with biomedicine as it emerged at the end of the nineteenth century is seen to be its reliance on a process of objectification of the body, and a resulting sense of alienation on the part of the person whose body it is, and who is constructed as the ‘patient’. This scientific method, it is argued, has the effect of removing health and illness from the social context in which they are produced, and in which they belong, to another level, which is both internal to the individual but also outside her or his control. Not only does this cause those who are ill to feel powerless and alienated but, it is also argued, this way of viewing the production of disease is also inefficient. By focusing exclusively on the ‘natural history’ of disease, and on the interaction between ‘hosts’ and pathogens, epidemiology as a theory and medicine as a practice cannot understand the true origins of disease. These lie, according to this view, not just in ‘nature’, but, crucially, in the organization of society, and its constructions and manipulations of ‘nature’. They lie in systems of production and of social reproduction and in exploitation; they lie in poverty and in the exercise of political power. Epidemiologists, with their biological blinkers, will never be able to account for patterns of disease and their changes over time, if they continue to focus on individual pathology, rather than on society and on politics.¹¹

Many aspects of this critique have informed my own analysis in this book. I have little disagreement with the central idea that biomedicine neglects to address the fundamental social, economic and political causes of ill-health, and I agree that there can be no ‘natural history’ of disease. What I am less certain about, however, are the assumptions made about the nature of biomedical knowledge here. It is certainly true that many biomedical theories and interventions have failed in Africa because no account was taken of the social and political context, and there are many examples of such instances in this book. At the same time, what is striking about so much of the medical knowledge produced in and about colonial Africa is its explicit concern with finding social and cultural ‘origins’ for disease patterns. Biomedicine drew for its authority both on science and on social science. Biomedical knowledge on Africa was thus both itself socially constructed (in the sense that its concerns and its ways of viewing its object of study were born of a particular historical circumstance and particular social forces) and at the same time ‘social constructionist’, in that it often sought social explanations for ‘natural’ phenomena. Furthermore, and perhaps even more importantly, biomedical knowledge played an important role in the wider creation of knowledge of ‘the African’.

The paradoxes and contradictions in a biomedical ‘world view’ have been noted by many writers. Amongst others, Jean Comaroff has discussed the nature of biomedical knowledge, arguing that, whilst it is ostensibly based on ‘empirical objectivity’, in practice its underlying epistemology remains a ‘cultural construct’, existing in ‘dialectical relationship with its wider social context’.¹² Central to biomedicine’s ‘cultural construction’, argues Comaroff, is ‘rational individualism’, a view of ‘man’ as a ‘self-determining, biologically contrived individual’ existing in a context of ‘palpable facts and material things’.¹³ Following Foucault and others, Comaroff links this ideology of self-determination with a capitalist mode of production and with modernity which, while it bestowed on its subjects a sense of self-determination, simultaneously removed them from direct control over the means of production. In times of sickness and affliction, Comaroff argues, the contradiction between our supposed self-determination and the reality of our lack of control over our own bodies comes to be starkly obvious, leading us to feel conflicted and alienated.

I will return to Comaroff’s arguments, and to the ‘rational individualism’ of biomedicine later in this chapter. Unlike some critiques of biomedicine, and other comparisons between biomedicine and African healing systems, Comaroff’s analysis demonstrates that biomedicine is itself a very complex phenomenon. A reliance on scientific rationalism in biomedical theory does not, as Comaroff shows, mean that there is no cultural construction going on in biomedical theory. It is not its scientific method so much as the particular forms of social construction used within this method which makes biomedicine different from other healing systems.

Social constructionist analyses of biomedicine take many forms.¹⁴ Most...