Public Health in the British Empire

Intermediaries, Subordinates, and the Practice of Public Health, 1850-1960

Ryan Johnson, Amna Khalid, Ryan Johnson, Amna Khalid

• Publisher: Taylor & Francis
• Year: 2012
• Print ISBN: 9780415890410
• eBook ISBN: 9781136596452
• Edition: 1
• Topic: History
• Subtopic: 19th Century History
• Index: History

Over the last several decades, historians of public health in Britain's colonies have been primarily concerned with the process of policy making in the upper echelons of the medical and sanitary administrations. Yet it was the lower level staff that formed the backbone of public health systems in the colonies. Although they constituted the bases of many colonies' public health machinery, there is no consolidated study of these individuals to date. Public Health in the British Empire addresses this gap by bringing together historians studying intermediary and subordinate staff across the British Empire.

Along with investigating the duties and responsibilities of medical and non-medical intermediary and subordinate personnel, the contributors to this volume show how the subjectivity of these agents influenced the manner in which they discharged their duties and how this in turn shaped policy. Even those working as low level assistants and aids were able to affect policy design. In this way, Public Health in the British Empire brings into sharp relief the disaggregated nature of the empire, thereby challenging the understanding of the imperial project as an enterprise conceived of and driven from the center.

1 The Control of Birth

Pupil Midwives in Nineteenth-Century Madras

Seán Lang

The annual report of the dispensary at the Madras Government Lying-In Hospital for 1870 contains a small but intriguing detail. A “pariah” woman called Ponee, probably a pauper dalit (“untouchable”), is recorded as having explained why she had chosen to go to the hospital for treatment of what turned out to be an ovarian cyst. She said that someone had pointed out to her in the street another woman, coincidentally bearing the same name, who had gone to the hospital with the same condition and there undergone an ovariotomy under anesthetic. Ponee, the hospital report noted, had “come to the Hospital with the full determination of submitting to the operation, even if it should cost her life”; both women recovered and the two cases were recorded on the same page of the report.¹ To the British medical authorities such a tale was extremely encouraging, because it appeared to suggest that Indian women were beginning to recognize the superiority of Western medical care in what was termed “diseases of women and children” over traditional practice, at least in emergencies or cases of severe abdominal pain. If this proved a sign of a general trend, it might suggest that the hospital’s main aim, to establish Western medicine, especially in midwifery, as the norm for all women in south India, was on its way to being achieved.

The Madras Lying-In Hospital had been founded in 1840 by a group of British medical officers concerned about the high maternal death rates resulting from the management of labor by dais, India’s traditional birth attendants.² The dai fulfilled a hereditary role of central importance in the religious ritual that surrounded Indian birthing practice. Because childbirth in India was traditionally considered a time of unusually strong ritual pollution, the management of birth was confined to low caste women: most dais came from the “barber” caste. Although it was generally agreed even by the most critical European commentators that the dai could provide the mother with good support in natural labor, her complete lack of any sort of formal medical education meant that she was forced to improvise whenever complications set in, often with disastrous results. European accounts of dai practice are full of tales of babies’ limbs or heads being ripped off, mothers’ vaginas being torn open, and of dais binding women’s abdomens tightly or jumping on their stomachs. With only a few exceptions, the consensus among European observers was that the dai was a menace whose influence should be rooted out completely.³

How to achieve this aim was more problematic. Even with government backing, a single lying-in hospital could hardly make a difference to Indian birthing practice, even within the city of Madras. However, it might have an impact as a midwifery training school, sending properly qualified midwives out into the city and the surrounding area (known in India as the mofussil) where they could operate either independently or attached to one of the numerous civil dispensaries dispersed throughout the presidency. The Madras Lying-In Hospital therefore placed the training of midwives at the heart of its work, which was soon attracting lavish praise and generous support from the Madras government. By the 1870s the Madras Lying-In Hospital was being described in official correspondence as a first-class medical institution that was earning the presidency a worldwide reputation for excellence in the field of female medicine.⁴ A heavy responsibility for maintaining Madras’s reputation therefore lay on the shoulders of the hospital staff, and especially its pupil midwives, who made up the entirety of its nursing establishment.

Tracing pupil midwives in the records is not easy. The surviving records are overwhelmingly from the hospital superintendent, who corresponded with government and oversaw the administration and the surgical work of the hospital but had relatively limited contact with the midwifery pupils. The hospital’s annual reports give overall figures for the midwifery class and categorize the pupils by ethnic group, but give no further information. We have no firm evidence of their ages, for example, although we may surmise that most would have been in their twenties or thirties. It was not uncommon for European or Eurasian pupils to be married; indeed, in the hospital’s early days it was expected that most European midwives would be. How they managed to combine the long hours and heavy commitment the hospital demanded of them with any sort of married or family life we cannot tell from the sources. Much of the picture given in this chapter has had to be gleaned or surmised from passing or indirect evidence. Nevertheless, there is enough to enable us to construct a picture, however incomplete, of the life and work of the pupil midwives upon whom devolved the responsibility for carrying out the Madras presidency’s policy on maternity and midwifery.

The Pupil Midwife Within the Hospital, 1844–1881

The Madras Lying-In Hospital was something of an exception to the general rule of nineteenth-century maternity provision. Lying-in hospitals in Britain were usually pauper institutions, sometimes attached to medical schools so that students could gain some practice in midwifery. Until late in the century they had a poor reputation, both because of the uncaring attitude of medical students, who seldom took much interest in midwifery, and because of their notoriously high death rate from puerperal, or “childbed” fever.⁵ Unlike the lying-in hospital in Calcutta, which was attached to the Calcutta Medical School, the Madras hospital was separate from its local medical college. Indeed, in its first years medical students were discouraged from attending it.⁶ Instead, the hospital’s priority was the training of midwives. So keen was the Madras government on producing a class of trained midwives who would supplant the dai that it attempted to set up training schemes at local dispensaries. However, only one, at the small town of Mannargudi, actually came to anything.⁷ The main center of midwifery training remained the Madras hospital.

It is tempting to see colonial hospitals through Foucauldian eyes as maledominated hierarchical institutions subjecting patients not only to the clinical gaze, but also to the racially driven gaze of the colonial state. Certainly individual labor cases, suitably categorized and analyzed, were presented in the reports submitted by the hospital superintendent to the Madras government. On arrival at the hospital, women were categorized, and in effect defined, by race, caste, and religion. Male military medical officers in the service of the Madras government ran the hospital; and the Indian Medical Service existed principally to cater to the medical needs of the Indian Army and medical officers. Even in civil positions, the Indian Medical Service remained subject to military discipline and the demands of military exigency. Subordinate medical staff was expected to obey superiors without question and defiance of orders was regarded as a serious breach of discipline. Even the hospital superintendent was subject to this hierarchical discipline: he was expected to obey the decisions of the governor in council, whatever his personal feelings, and any attempt to get round an unwelcome decision could earn him a severe reprimand.⁸

However, it would be wrong to overdo the image of the hospital as a symbol of male European dominance. It was an unimpressive building, low, rambling, and badly lit, on a riverside site that was subject to frequent flooding.⁹ The compound was crowded, not only with women coming in to give birth, but with in- and outpatients attending the hospital dispensary, which opened in 1853, for whom beds in the “native” wards were set aside. It was common for a woman’s family to move into the hospital with her and to cook her meals, for which the hospital paid a daily grant. The hospital was so crowded that Indian women often had to be put into the European wards and extra beds put up on the verandas.¹⁰ The impression received by anyone visiting the hospital, therefore, was not of an alien European institution imposing itself on Indian sensitivities but of a building teeming with life that had, in effect, itself been colonized and absorbed by the local community.

The day-to-day running of the hospital lay much more in the hands of the subordinate medical staffthan it did with the hospital superintendent or the European apothecaries. The latter dealt mainly with complicated labors and combined their work at the hospital in any case with their other duties as officers of the Indian Medical Service. Women coming into the hospital had far more contact with the matron and the pupil midwives, who were the key figures in determining the hospital’s local reputation. On arrival, a woman saw the matron, who assessed her age and state of pregnancy, categorized her by race or caste, and decided whether or not to allocate her a bed.¹¹ Because it was far from uncommon for women to turn up well before term, hoping to enjoy bed and board at the hospital’s expense, the matron had to be prepared to deny a woman admittance and to tell her to come back at a later date.¹² The matron generally oversaw the management of natural labors; matron-conducted deliveries tended to have a much lower mortality rate than those conducted by doctors or surgeons, who dealt mainly with life-threatening cases.

Confidence in the matron’s ability to deliver babies safely, without risk to mother or child, helped forge a bond of trust between the matron and the women of the community, which could to some extent replicate that between mother and dai.¹³ Some matrons clearly had a reputation for being caring and supportive. A “Mrs. O’Flaherty,” matron in the hospital’s early years, was so popular and respected that the hospital superintendent petitioned government for a pay rise for her (though, sadly, she was not popular enough for the government to grant it); Mary Scharlieb describes a later matron, a “Mrs. Secluna,” in similarly affectionate and respectful terms.¹⁴ It seems plausible that the woman cited earlier, who recommended the hospital to her friend because of the kind treatment she had received, was referring to the hospital matron.

Whereas the matron’s role was tied up with the operation of the hospital itself, more important for the hospital’s mission to transform Indian birthing were the hospital’s pupil midwives. Pupil midwives in Madras fell into two categories: in-pupils, who received a small government monthly stipend of Rs 7, and out-pupils, who were either privately financed or supported by a local municipal board.¹⁵ The terms of the hospital’s original foundation had stipulated that the intake of pupil midwives should be spread equally between Europeans and Indians, but in practice in the hospital’s early years they were overwhelmingly European or Eurasian; the midwifery school had to be relaunched in 1872 in order to attract a wider range of applicants.¹⁶ The government had originally wanted a training course of twelve months but the hospital superintendent, James Shaw, thought this unnecessarily long and successfully lobbied for a reduction of the course to six months.¹⁷

The training course on offer at Madras was rather less well organized and structured than the term suggests. The government had originally intended pupil midwives only to be in the hospital to work and to attend lectures during the day. Shaw, however, insisted on their attending day and night, as their certificate was made dependent upon their residence within the hospital.¹⁸ The reason is not difficult to see given the pupil midwives made up the hospital’s entire nursing staff. However, this was a heavy requirement for women who often had children of their own. Moreover, the government, not having expected the pupil midwives to be resident, had made no provision for their accommodation: they had to bed down where they could, usually on a spare bed in the European wards.¹⁹ There does not seem to have been a structured teaching course as such. Apart from occasional lectures from the hospital superintendent, who also conducted their (oral) examinations, the pupil midwives were taught by the hospital matron, who had to fit teaching sessions into her busy working schedule. It seems probable that the training was largely practical with some formal instruction. We know that later in the century, when the midwifery school was better organized, much of the learning was done by rote from a set midwifery handbook, and it seems likely that the same would have been true for the earlier period as well. Teaching by rote requires minimal preparation on the part of the teacher and fits well into an already heavy w...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Content
• List of Tables
• Acknowledgments
• Introduction
• 1. The Control of Birth: Pupil Midwives in Nineteenth-Century Madras
• 2. “Unscientific and Insanitary”: Hereditary Sweepers and Customary Rights in the United Provinces
• 3. “Left in the Hands of Subordinates”: Medicine, Language, and Power in the Colonial Medical Institutions of Egypt and India
• 4. Surviving the Colonial Institution: Workers and Patients in the Government Hospitals of Mid-Nineteenth-Century Jamaica
• 5. “A Laudable Experiment”: Infant Welfare Work and Medical Intermediaries in Early Twentieth-Century Barbados
• 6. Burmese Health Officers in the Transformation of Public Health in Colonial Burma in the 1920s and 1930s
• 7. Mantsemei, Interpreters, and the Successful Eradication of Plague: The 1908 Plague Epidemic in Colonial Accra
• 8. Medical Training, African Auxiliaries, and Social Healing in Colonial Mwinilunga, Northern Rhodesia (Zambia), 1945–1964
• 9. The Mid-Level Health Worker in South Africa: The In-Between Condition of the “Middle”
• List of Contributors
• Index