Heather Bell. Frontiers of Medicine in the Anglo-Egyptian Sudan, 1899-1940. Oxford: Clarendon Press, 1999. viii + 261 pp. $78.00 (cloth), ISBN 978-0-19-820749-8.

Reviewed by Robert O. Collins (Department of History, University of California, Santa Barbara)
Published on H-Africa (July, 2001)

During the decades after the Second World War historians of imperial medicine made little distinction between the empire and individual colonies. They emphasized the similar characteristics of medical practice throughout the British tropical empire resulting from common class and institutional education in Britain. The author of Frontiers of Medicine in the Anglo-Egyptian Sudan, 1899-1940 argues that this interpretation can no longer be sustained. Health care in the empire was not monolithic. It was determined by the differences from one colony to another that were controlled more by local conditions and parochial institutions than any centralized authority inspired by imperial ideology. This observation is hardly a revelation, rather a perceptive commentary on the structural interpretations of empire. Lord Hailey revealed these differences after the Second World War in African Survey (London: Oxford University Press, 1957). The Sudan was not included. It could conveniently be ignored. It has always been neither African nor Arab.

Having discovered there is no "binary division between colonizer and colonized" (p.1), the author arrives at her principal and revisionist conclusion "that colonial medicine was concerned with boundaries and frontiers of all kinds, physical and psychological, natural and imposed, real and imagined" (p. 3). The doctors of the Sudan Medical (Department) Service became surveyors who established boundaries in the Southern Sudan and the border patrol who administered them. They were also the vanguard of colonialism whose pursuit of colonial medicine was crucial in establishing the territory of the colonial state, but their more formidable boundaries were personal. These were the borders they carried within the inner sanctum of their own emotional and intellectual baggage when they became the pawns and the predators of the colonial state.

There is confusion here. Borders are not frontiers whether on the ground or in the mind. Boundaries are distinct lines drawn on a map or in the mind to demarcate territory, turf. Frontiers are wide swaths of land that attract the expansive proclivities of the mind defined by imprecise geographical features through which individuals and ideas have historically passed irrespective of governments--North America, South Africa, Australia, Central Asia, and certainly the Sudan. The author believes that the most formidable frontiers are personal not physical boundaries. Few, and certainly not this reviewer, would quarrel with this assumption, but only the arrogant or the ignorant define the frontiers of the human experience as boundaries. There is the expectation, implied and explicit, that the doctors of colonial medicine in the Sudan should have constructed new frontiers of medicine that were beyond the boundaries demanded of them by their ethnicity, education, training, and profession. The British, Syrian, and Sudanese doctors had their own personal agenda that delimited their careers and financial security in the Sudan service. Everyone does that in every culture and every society. Clint Eastwood succinctly expressed this conundrum in a well-known spaghetti western: "A man has to know his own limitations."

Some members of the Sudan Medical Service did, others did not. Frontiers are the central theme of this book. Frontiers are the opportunity to expand the mind across the land. Borders are for containment. No one enjoys a snappy title better than this reviewer, but in the chapters that follow, the author's frontiers are boundaries, the borders that demarcate the official mind of the authoritarian colonial state. The subsequent chapters are case studies (bilharzia, sleeping sickness, yellow fever, and female circumcision) to confirm the pervasive role of the practitioners of colonial medicine in support of the colonial state in the Sudan. They were not on the frontiers of the land or the mind. They were there to build the borders of an authoritarian, imperial administration. The author has mobilized with perceptive skill the massive documentation accumulated by the Anglo-Egyptian rulers of the Sudan and their Sudanese subjects to support her thesis. This is very solid stuff whose composition is a conglomerate from which the architect can select the most suitable materials to build a sturdy edifice.

The foundations are laid in chapter 2, "Medical Policy and Practice after the conquest in 1899". There was little revenue to support the expansion of medical facilities beyond those necessary to keep the occupying Anglo-Egyptian forces healthy. Many of the early doctors were military from the Egyptian army, but the author makes clear the division between civil and military in the Sudan Medical Department was not an issue considering the magnitude of the problems of public health in the Sudan. Like doctors since Hippocrates they believed in the universality of medical science and its demonstrative role in the advancement of civilization that could only be accomplished by those sufficiently skilled and trained to do it. The medical education of an elite has always produced professional hierarchies in which class, gender, and race have never been disassociated from the more aseptic criteria of science. They were not in the Sudan Medical Service. Nothing new in this observation except when medical science was applied in the Sudan, as the author argues, to impose and sustain the imperative colonial administration.

The more divisive and beguiling issue in the Sudan Medical Service, fundamental in all science, was the confrontation between basic and applied research. This remains a consummate theme for the author. The question was as irreconcilable to British doctors in the Sudan at the beginning of the twentieth century as it is today for those in the medical profession at the end of the millennium. There were differences of personality among the doctors in the Sudan Medical Service as there will be in any organization. The magnitude of disease and the problems of public and private health in the Sudan could not be resolved by the limited resources available. The doctors were concerned about disease and not the empire. The author argues in chapter 3, "The Organization of Research", that the poverty of the Sudan determined British doctors to become applied professionals despite differences in class, race, and skill. This identity with the practical could only be forged by a belief in the efficacy of basic science promoted by the Wellcome Tropical Research Laboratory (WTRL).

The laboratories were opened in Khartoum in 1903. Henry Wellcome was an American who had made his fortune with Silas Burroughs selling "tabloid" medicine that enabled him to carry out his belief that the advance of civilization could only be carried out by the conquest of disease under the aegis of the British Empire. He understood, as few did at the time, that this required basic research into its causes. Today billions are spent on this quest. His laboratory in Khartoum was not dependent on a government subvention. It was financially independent to pursue commerce and civilization to support the colonial administration. The author argues that its demise on 1 April 1935 was the result "that something broader was going on" (p. 88). Undoubtedly there was, but in the Sudan in the depths of the Depression the broader had been reduced to the particular, dominated by personalities concerned to provide for their scientific satrapies and pensions from the only sustainable source of revenue--the Gezira Irrigation Scheme. Basic research disappeared before the need for applied research to sustain the Gezira and the colonial state in depression. The Gezira is the expansive cotton-growing scheme south of Khartoum that has provided throughout this century sixty percent of the government's revenues. Inaugurated by the British in the 1920s, its vast irrigation complex was warm water for schistosomiasis (bilharzia) and malaria.

The author believes in chapter 4, "Disease, Quarantine, and Racial Categories in the Gezira Irrigation Scheme", that the scheme brought considerable health costs that were the result of the failure of British doctors in the Sudan to understand the epidemiology of the diseases. This dilemma produced tensions in medical policy for the Gezira between those concerned about disease control and those concerned about efficient operations. She is correct on all counts. The development of the Gezira produced disease in canals that had hitherto never existed. It produced stagnant water in new channels that spawned malaria. It produced prosperity for the colonial state and the cultivators who could now send their sons to the Gordon Memorial College. It mobilized the Sudan Medical Service to prevent rather than cure disease in the Gezira. It was mission impossible, and they failed. The few doctors and technicians could not contain the spread of bilharzia and malaria in the labyrinth of quiet waters meandering through the canals of progress. This was the Sudan in the 1920s and 1930s. The author criticizes the colonial administration for its failure to provide more health care during the years of economic depression in the Sudan when it would be another twenty years before the installation of the National Health Service in Britain. Only in the green hills of the Congo-Nile watershed did the doctors become the imperial authorities of the colonial state in chapter 5, "Sleeping Sickness and the Ordering of the South".

Sleeping sickness in the Sudan did not have the destruction of human life experienced in Uganda and Tanganyika because of its late arrival in 1910, and the determination of the colonial state to prohibit its advance beyond the boundaries of the Congo-Nile watershed. "Sleeping sickness shows colonial medical power at its most forceful" (p. 161). To stem the spread of the epidemic, the medical authorities as administrators of the colonial state forcefully relocated villages away from streams infected by the tsetse fly. They had no miracle drugs, only the support of the indigenous authorities who knew about the devastation of sleeping sickness south of the Congo-Nile watershed. With few resources they contained the spread of sleeping sickness by enforcing restrictions to the streams free from the fly. They sent patrols along the border, but the Azande, Kuku, and Kakwa continued to pass through the gallery forests to see kin and deal in the market. The doctors played "a significant role in the creation of the spatial, territorial conception of sleeping sickness that dominated medical thinking in the Sudan throughout this period" (p. 162) in a region then and today of little interest to the central government in Khartoum. Once having contained sleeping sickness the doctors, the Azande, and most certainly the central administration in Khartoum lost interest in expensive measures of resettlement that by 1937 were unpopular with the Africans and not cost effective for the colonial state. Sleeping sickness control had become a marginal problem in a remote region that could now be ignored by the payment of a few paltry subsidies. Today sleeping sickness has returned to the Congo-Nile watershed infecting an estimated 20 percent of the population.[1] Unfortunately, there is no spatial colonial medicine to contain or control the disease.

Yellow fever is not bilharzia or sleeping sickness. It is a New World disease exported to the Sudan across international borders by the airplane. New international health organizations were formed after the First World War with the assistance of the Rockefeller Foundation. Yellow fever was first confirmed in the Sudan in 1933 but remained no threat to public health until its epidemic in the Nuba Mountains in 1940. The new imperialists from the foundation descended upon Africa "pursuing its international agenda [that] depend on collaborative relationships with many of its colonial administrations." The Sudan was no exception. "International medicine in this context served as a reinforcement, rather than a negation of the colonial system" (p. 195). The author acknowledges the accustomed independence of the Political Service, the "Sudan showed a determination to go its own way," but fails to explain how the "self-confident medical researchers" could have pursued the yellow fever virus without the cooperation of those who controlled Khartoum. They, like their successors seeking the cause of Ebola fever fifty years later, may be accused of "overpowering imperialism" for "their lack of engagement with, and concern about Sudanese people" (p. 195). They were in the Sudan to unravel and explain the appearance of yellow fever. Their success in the Nuba Mountains that "marked a substantial breakthrough" (p. 193) had little to do with their failure to socialize with the Nuba or to become anthropologists.

The final chapter [7] is not about disease but the contentious controversy over female circumcision, midwifery, and the relationship between traditional and western medicine. It "relies heavily" if not exclusively on the papers of the Wolff sisters. In 1921 they established the Midwifery Training School (MTS) to teach traditional midwives, dayas, western gynecological practices of childbirth in which female circumcision was "deeply embedded in the cultures of the northern Sudanese ethnic groups" (p. 201). Despite the usual dearth of funds they were remarkably successful in training Sudanese midwives to improve the conditions and complications in childbirth from circumcision. Their very success, the author argues, "incorporated the Wolff sisters and Sudanese midwives into the work of the colonial state," on the one hand, while being "marginalized within that state" on the other (p. 200). It is true that the sisters had few resources and little remuneration, but no one in the Sudan during the Great Depression had either. As for their status and authority, they had a great deal of the former and little of the latter. Throughout the Sudan service they were affectionately known as the "Wolves," and the wives of British officials and their more reluctant husbands provided tea,sympathy and personal support when there was no cash in the treasury.

There is no question that female circumcision is a political issue. It has always been in history and will undoubtedly be in the future. It was a dilemma that the male British officials of the Sudan sought to avoid. It was "a rigid boundary drawn between medicine and politics in the Sudan" (p. 201). Nothing has changed. It remains even more "rigid" at the end than the middle of the twentieth century, and this boundary is most certainly not a frontier. The author is quite right to conclude that senior British officials of the Sudan government (all male) were terrified to confront the question of female circumcision. At least the "Wolves" sufficiently intimidated them to make it a public issue with as low visibility as the Islamic establishment could muster. The male Sudanese successors of the Anglo-Egyptian Sudan, much to their relief, have become more concerned with the same "high politics, domestic and international" that motivated the British rulers of the Sudan than female circumcision.

The author has been convincing in her thesis that colonial medicine can only be understood by examining its unique development in each colony rather than by an imperial mandate from London. The Sudan, of course, was never in the colonial empire, and the particular history of its medical service is demonstrable evidence of this fact which is confirmed by the author's diligent research. Her second argument that the British and Sudanese medical practitioners were the agents of the colonial state "preoccupied with creating a country, protecting a profession, and controlling disease by erecting and reinforcing boundaries" (p. 233) is less persuasive. Boundaries are fortunately no longer frontiers, but they appear more an extrapolation of the official mind than the realities of practicing medicine during the first half of the twentieth century in the "Vast Sudan." I have known British and Sudanese doctors of the Sudan Medical Service who practiced before and after the Second World War (mostly in the South). They would be surprised (or more correctly, rolling in their graves) to learn that their primary responsibility was to the colonial state and not themselves, their profession, and the need to combat disease in the Sudan and to cure the Sudanese sick.

Notes

[1]. "Sleeping Sickness in Western Equatoria", Sudan Information Centre. 4 November 1999.

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Citation: Robert O. Collins. Review of Bell, Heather, Frontiers of Medicine in the Anglo-Egyptian Sudan, 1899-1940. H-Africa, H-Net Reviews. July, 2001.
URL: http://www.h-net.org/reviews/showrev.php?id=5316

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