Colonial Medicine

Colonial Conceptions of Health
form the amazing NGO Unite for Sight

European colonization had enormous effects on the health of both indigenous populations and colonists through the transfer of new diseases, mechanisms of oppression, and the process of urbanization. Today’s “global health” is the child of international health, itself rooted in colonial enterprises. Colonialism’s negative impact on public health is threefold; first, through the introduction of non-native diseases; second, through facilitation of the rapid spread of disease; and third, by the extraction of wealth that prevented indigenous people from “growing out” of the cycle of poverty and disease.

As human populations developed over the centuries, two main transformations led to the development of epidemic diseases: the growth of cities and the proximity of human living space with that of animals.(1) Because these developments did not occur uniformly throughout human civilizations, the prevalence of disease did not either. Thus, when civilizations encountered one-another, diseases were exchanged between populations that had no previous exposure or immunity. The smallpox epidemic in the Americas is a perfect example of a public health disaster directly caused by the arrival of colonists.(2) Malaria’s introduction to South America is another example of the introduction of non-native diseases.(3)

Beyond simply introducing new diseases, colonialism changed population densities in a way that made indigenous people vulnerable to the epidemics brought by Europeans.(4) The creation of crowded urban centers throughout Africa, India, and the Americas provided a breeding ground for infectious diseases such as cholera, tuberculosis, and smallpox, and laid a foundation for today’s AIDS epidemic. The social transformation caused by colonialism – urbanization – was a clear catalyst for the emergence of epidemic diseases.

Lastly, on a larger scale, colonialism played a large role in the initiation of today’s poverty-begets-illness, illness-begets-poverty cycle. During the colonial era, the subjugation of individuals for profit was the impetus for health interventions. In other words, ‘public health’ served the interests of colonial powers, with improvements in local health a negligible and secondary side-effect.(5) This is because colonialism was based, first and foremost, on the extraction of wealth to benefit colonizing nations. During the height of European colonialism in the nineteenth century this wealth took a variety of forms including ivory, slaves, sugar and eventually cotton, rubber, gold, coffee, and tea. This extraction left developing nations without many of the exportable goods they may have otherwise benefited from. Today, the structures of power left by colonialism continue to exacerbate the already top-heavy distribution of wealth in nations that were once European colonies.
Case Study: Panama Canal

The ways in which colonialism informed global health can be witnessed in the construction of Panama Canal in the early 20th century. The Panama Canal was primarily an effort to increase trade. Unfortunately, this effort was at the expense of 21,000 laborers who died in the project before its failure. The failure of the French to build the Panama Canal was due to an epidemic of yellow fever and malaria among workers. Two physicians and leaders in public health, Walter Reed and Carlos Finlay, tried to solve this problem by examining potential causes of the outbreak, such as an increase in mosquito populations and swamps. While this effort seemed to be a humanitarian endeavor, it was by no means motivated by charity or social justice ideals. Instead, public health interventions were motivated by economic incentives as the poor health of workers was a detriment to commerce and colonial power:

“I feel sure that as a few months or years pass by the diseases which have stood in the way of the completion of the Panama Canal, which we might term the ideal of the President of the United States to accomplish, will be removed and that the great good to this country which is expected in health, wealth, and prosperity will flow from it…”(6)
Case Study: Haiti

The Columbian Exchange had a devastating impact on the health of subjugated populations. To use the French colony of Saint-Domingue as a case study, it is estimated that there were 400,000 indigenous people living on the island of Hispaniola before the Spanish arrived in 1492. By the 17th century, not a single one had survived. They died from mistreatment at the hands of Europeans, but also in droves from measles, smallpox, and tuberculosis—a pattern that emerged all over the New World in the following centuries. (7) This widespread appearance of epidemic disease was the backdrop of 19th century endeavors, and fear of disease was inextricably tied to commerce and military occupation.

Yet Saint-Domingue was the most productive slave colony in the world. Haiti, as it is now called, became the leading port for slavers in the 19th century, with up to 29,000 slaves brought in each year shortly before the French Revolution in 1789.(8) Haiti is an example of how colonial subjects came to be regarded as investments. This is the centrality of colonial medicine: international medicine and public health were advanced because of commercial interests.
Legacies of Colonial Medicine

While roughly two-thirds of Latin America had achieved independence by 1900, there was only one free state in Africa at the turn of the century. Thus, the legacy of colonialism lies heavy on the African continent. In her book, Curing their Ills, Megan Vaughn explores colonial power and African illness in British colonies between the 1890s and 1950s. (9) Vaughn investigates how colonial power operated, and how far it relied upon the kind of ‘repressive’ mechanisms characteristic of pre-modern regimes. She argues that missionary medicine focused on the control of populations for physical as well as moral health. “Healing, for medical missionaries, was part of a program of social and moral engineering through which ‘Africa’ would be saved.”(10)

Furthermore, the legacy of colonialism left its mark on the western world, as public health conceived of and practiced in the United States and Western Europe during the past century has primarily been a state activity and has been closely connected to the protection of the state’s interests. With concerns of an increasingly globalized world, many of the health issues that policy-makers face today remain “international” health issues. One of the key principles of this international conception of global health has been to protect citizens against threats perceived as having an external origin, particularly infectious diseases carried across national borders. “During the 1990s, American scientists, public health officials and defense experts argued that ‘emerging diseases’ presented a threat to American national security, international development and global health. In doing so, they recapitulated the previous century’s dominant logics of international health policy”.(11) Public health has thus been ‘international’, and closely allied with ideologies of national security and commerce.

Furthermore, Western medical research has addressed the needs of the developing world in beneficial ways—by developing quinine as a malarial prophylactic, prevention for yellow fever, etc.—but it has done so with a “West first” attitude consistent with the ethos of colonialism. The advances made in vaccinations, preventions, and treatments were researched almost exclusively because Western nations had military or commercial interest in areas where tropical diseases were prevalent. Through prevention and treatment, the international spread of disease was curbed and the extraction of wealth was preserved.
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Footnotes
(1) Armegalos, George, Peter Brown and Bethany Turner. “Evolutionary, historical and political economic perspectives on health and disease.” Social Science and Medicine. 2005;61:755-765.

(2) Turshen, Meredith. The Politics of Public Health. New Brunswick: Rutgers University Press, 1989.

(3)4 Packard, Randall. The Making of a Tropical Disease: A Short History of Malaria. Johns Hopkins University Press; 2007.

(4) Charles Van Onselen, “The World the Mine Owners Created,” in Van Onselen, Studies in the Social and Economic History of the Witwatersrand, 1886-1914. Vol. 1. New Babylon (Essex, 1982), 1-43.

(5) Arnold (1988a)David Arnold, ‘Introduction: Disease, Medicine, and Empire’, in Arnold (1988b): 1–26.

(6) Transactions of the Second General International Sanitary Convention of the American Republics, Held in Washington, D.C., October 9, 10, 12, 13, and 14, 1905, Under the Auspices of the Governing Board of the International Union of the American Republics. Washington D.C.: Government Printing Office, 1906, p. 94.

(7) Cueto, Marcos. Missionaries of Science: the Rockefeller Foundation and Latin America. Bloomington, Indiana University Press, 1994, p. 12.

(8) Farmer, Paul. The Uses of Haiti. Monroe, ME: Common Courage Press, 1994.

(9) Vaughn, Megan. Curing Their Ills: Colonial Power and African Illness. Stanford: Stanford University press, 1991. p. 202.

(10) Ibid.

(11) King NB. 2002. Security, disease, commerce: ideologies of postcolonial global health. Social Studies of Science 32:763–89.

EUROPE! HANDS OFF OUR MEDICINE

Millions of people in developing countries rely on affordable generic medicines to stay alive. More than 80% of the medicines used by MSF to treat AIDS across the developing world are produced in India. But the European Commission is now shutting off the tap of affordable medicines by attacking the production, registration, transportation and exportation of generic medicines. People who need these will be left without a lifeline.

Help Médecins Sans Frontières send a message to the European Commission to keep their HANDS OFF OUR MEDICINE!

Stemming the Brain Drain of Health-Care Workers From Developing Countries

Published on Saturday, May 29, 2010
The Seattle Times


by Amy Hagopian, Eric B. Williams and Emily DeRiel

Last week, international health leaders meeting at the annual World Health Assembly in Geneva made history by endorsing new guidelines to prevent health-worker brain drain from developing countries.

Nations unanimously adopted a voluntary global code that sets ethical principles around the movement of health workers. It was only the second time in the assembly's history that nations agreed to an ethical code.

The Global Code of Practice on the International Recruitment of Health Personnel acknowledges the right of health workers to migrate, while also acknowledging the right to the highest attainable standard of health. It calls on rich nations to meet their own internal demands without taking health workers away from countries that can least afford to lose them.

The critical shortage of health workers in developing countries is staggering. For example, Washington state has 11,000 doctors for its 6.6 million residents; Ethiopia by comparison has 2,000 doctors for its 80 million people. This would be equal to 165 doctors for the entire state of Washington.

Low-income countries invest significant resources to train health workers. Active recruitment of their doctors and nurses systematically deprives communities and entire populations of their right to health.

The loss of these investments equates to a form of reverse foreign aid. Not only is that ethically unacceptable, but speaking strictly parochially, it undermines the efforts of the many Seattle-based organizations working to improve global health. Discovering vaccines does no good if there is no one to administer them.

While the code is welcome news for those of us who work to advance health and human rights, we must admit the final version of the code was weakened in closed-door negotiations. After U.S. lobbying, rich nations reduced their responsibility for tracking the movement of health workers or for providing technical or financial assistance to developing countries.

Nonetheless, important elements of the document were retained and governments must now take steps to implement it.

Some countries have already moved to curb their active-recruitment practices. The United Kingdom and Norway have adopted policies to refrain from recruiting health workers from severe-shortage countries. Canada, too, has ramped up training programs so as to create less demand for foreign-trained health workers. The United States should follow suit.

As an initial step, we have to do a better job of tracking health-worker migration to inform policy decisions on increasing our domestic training programs to better meet demand. While we know approximately one in four U.S. physicians and about 220,000 nurses were trained abroad (largely in lower-income countries), those data are hard to come by.

Current information systems are fragmented and privatized. The only national data source on physicians is proprietary and only available for purchase from the American Medical Association. Nurse licensure data are available only on a state-by-state basis.

With 32 million uninsured Americans soon to be eligible for care, it's time to get serious about the fact that the U.S. health work force is too small and unevenly distributed across urban and rural areas. The Council on Graduate Medical Education has predicted the U.S. will be short approximately 85,000 physicians by 2020.

Thirty years ago, the U.S. was the only nation to oppose the World Health Organization's first ethical code, which limited the marketing of infant formula in poor countries because it undermined breast-feeding. This time, the U.S. stood with 192 nations in a show of global solidarity for the health of people in poor countries.

The Code of Practice offers real opportunity. We (and all nations) must now follow through as if we really meant it — because countless lives depend on it.