Modernity, the State, and New Medical Histories in Non-European Contexts

Histories of medicine and science in the colonies have, conceptually and theoretically, travelled some distance in the last three decades. While public health and epidemics in certain Asian contexts,¹ and mental health and medical stereotypes in the African case,² appear to have preoccupied historians during the early years, there has been an increasing willingness to charter new paths and explore new possibilities. This has made the sub-discipline more exciting and inter-disciplinary – for example, the move away from the state and its discourses has led to an increased attention to other forms of medical treatments and their interactions with regional publics. The interdisciplinarity, too, is evident in seemingly innocuous changes. For instance, medical historians have begun to make more frequent use of the term ‘health’, which, until the noughties at least, was a concept mostly employed by sociologists and anthropologists. It is heartening to see that all four books under review, to a greater or lesser extent, bridge these divides in obvious and not-so-obvious ways.

In another notable development, while historians in the past found it difficult to free themselves of the looming presence of post-colonial theory – which led to a fascination with deconstructing colonial stereotypes³ – they are now much more interested in ‘indigenous’ reactions and developments. This has led to the idea of modernity making increasing appearances in recent works. There is also a growing willingness to question the supposedly unreflexive rejection, by indigenous peoples, of modern or ‘Western’ medical ideas and practices. Indeed, the consensus now appears to be that biomedicine was likely to be widely accepted if the state used persuasive strategies and persisted with its policies for a reasonable length of time.⁴ In those cases where policies were ultimately rejected, this could simply be attributed to the fact that biomedicine in the nineteenth century was highly ineffective – often killing more people than it cured – and people across the globe were aware of this reality.⁵

Such critical approaches towards medicine have been possible because we have been partly successful in fulfilling Roy Porter's call to ‘“defamiliarize” ourselves with the assumptions of modern physician-focused history and sociology of medicine, and hack our way into the empirical forests of the past in all their strangeness and diversity’.⁶ This call, made in 1985, is far from fulfilled, but we certainly appear to be moving in the right direction. The books under review bear this out. Laurence Monnais shows, for example, that there was such an exponential growth in the demand for biomedicine (from below) that it could hardly be fulfilled through extant channels of distribution. Mary Augusta Brazelton's Mass vaccination: citizen's bodies and state power in modern China, though discussing a very different scenario, shows that people eventually became amenable to receiving vaccination from state agencies, mostly through the use of a number of persuasive strategies on the latter's part. These strategies were so effective that it became possible to vaccinate nearly the entire country against smallpox within the space of a single decade (the 1950s).

Another conceptual category, briefly mentioned above, which all four authors engage with, is the idea of modernity – with all its multiplicities, regional differences, and hybridities.⁷ While many historical works in the colonial context theoretically accept the idea of multiple modernities, there have been few that have convincingly demonstrated, with detailed case-studies, how this played out in practical terms. In a refreshing development, some of the books under review do this quite persuasively. To an extent, this is enabled by the fact that medicine had, on the one hand, an inseparable connection with the idea of modernity (in both the state's and the public's imagination), while, on the other hand, it also had deep roots in people's intimate/inner lives – making it easier to find useful case-studies. However, these linkages have only begun to be made in the last decade or so, which has been possible due to the impressive intellectual ambition displayed by medical historians.

Before we go deeper into a discussion of the books themselves, I wish to elaborate further on the point regarding inter-disciplinarity. Apart from the somewhat insubstantial example cited above – regarding ‘health’ and ‘medicine’ – it is clear that some of the works under review have engaged with new theoretical concepts such as the idea of the ‘anthropology of the state’,⁸ and how the state interacted with its citizens – or, indeed, created citizens – in its day-to-day interactions with them (e.g. Mary Augusta Brazelton). In another excellent example of inter-disciplinarity, Shinjini Das's work contains a strong element of the history and sociology of the book and the book-publishing industry, very often bridging the divide between the past and the present. All four works also engage with the question of agency, showing how people made their choices based on their worldviews, conveniences, and well-founded beliefs, and that they invariably found ways of negotiating with even the most coercive, restrictive, and complex circumstances. And, finally, some authors like Hans Pols venture into fields such as micro-histories – not a new field by any means, but one that has returned with a new flavour due to its cross-hatching with sub-fields such as history of emotions.

One of the more impressive books under review, which does many of the things mentioned above, is Laurence Monnais's The colonial life of pharmaceuticals. Though relying primarily on French sources (while occasionally dabbling in vernacular ones), it presents a complex picture of interactions between biomedicine and indigenous forms of medicine, and the reception of the former by various sections of the Vietnamese population. It focuses on the period after the 1880s – a time when both imperialism and the pharmaceutical industry were coming into their own – and explores the entangled histories of the two. The author succeeds in showing that indigenous attitudes towards biomedicine, and what she calls Sino-Vietnamese medicine, were constantly mutating from the 1850s onwards. For instance, while biomedicine was seen as ‘medicine of the last resort’ for most of the nineteenth century, by the 1930s, the demand had grown to such an extent that a veritable industry dealing in counterfeit biomedicine had begun to develop – another great example of our earlier point regarding indigenous willingness to try all forms of medicine. In fact, she notes that ‘in some regions quinine was sold so quickly it was hard to maintain stocks’ (p. 116), or that the consumption of this form of medicine became a status symbol at least amongst the middle classes (p. 209).

At the same time as highlighting this picture from below, Monnais also delves into the nature of colonial stereotypes regarding Sino-Vietnamese medicine. However, in a notable shift from the static picture of stereotypes often presented by scholars, she underlines the various shifts and changes over time: for example, while early colonial officials were mostly concerned with the toxicity of popular medical substances, this was later replaced with a discourse around their inefficacy. What also distinguishes her work is the link she draws between stereotypes on the one hand, and the strengthening ties between pharmaceutical companies (like Bayer), research laboratories, and the state on the other – a foreshadowing of connections that were going to become extremely powerful by the mid-twentieth century. This is significant, as even though many post-colonial authors (including Edward Said) acknowledge the links between territoriality, realpolitik, and knowledge-formation, they ultimately pay little attention to more ‘practical/empirical’ aspects. This book does this in finely grained detail, partly because despite its broad theme, it is also contained or restricted enough to make finer details admissible.

Complementing Monnais's work on the links between biomedicine and modernity in the colonial context is Das's monograph on homeopathy in India, which tells the intricate and fascinating story of the indigenization of a form of medicine that became so popular by the early twentieth century as to rival the popularity of biomedicine. In a work full of interesting insights, one of the most fascinating discussions is regarding the contradictory claims made by homeopathic firms and practitioners while marketing their products. For instance, advertisements often played up the European (or German) origins of this form of medicine, while simultaneously claiming that it was more suitable for the Indian body and was, in a sense, ‘Ayurveda made modern’. At another point, Das notes that ‘homeopathy was projected not only as a form of medicine, but also as an ethical and moral regimen of Hindu life’ (p. 15).⁹ ‘Typical texts’ like Susrut O Hahneman presented a detailed picture of the supposedly conjoined trajectories of Ayurveda and homeopathy, with this particular work claiming that ‘[Ayurvedic doctrines] travelled west primarily with the spread of Buddhism. On reaching Greece, some of the ayurvedic tenets were translated to Latin by the Romans that influenced Hippocrates…These ‘historical truths’ explain why homeopathy truly [had] deep roots in India’ (p. 163). While this indigenization often led to homeopathic pills becoming more palatable, the idea of Western/modern roots (often seen interchangeably during these times) continued to be seen as a desirable quality, especially amongst the middle classes. This is clear from the exponentially growing demand for ‘Western’ biomedicine that Monnais highlights in her work. Das takes the story further by focusing on how even advertisements for pills emphasized the fact that they were not only directly imported from Europe, but that the sellers themselves had been trained abroad (pp. 46–51). The portrayal of Friedrich Hahnemann, seen as the ‘inventor’ of homeopathy, also reflects this contradictory conceptualization: while he was often depicted as a European individual, he was also, simultaneously, indigenized as an avatar of Hindu gods (pp. 139, 249). This contradictory strategy proved effective and helped shore up homeopathy's popularity.

Another advantage that homeopathy had over other forms of medicine was its accessibility. At a time when biomedicine was becoming increasingly dominant and impersonal, here was a form of medicine – born (according to some) in the same mythical space called Europe where biomedicine was supposedly ‘invented’ – which gave people a sense of control over their bodies. Das produces several proofs in support of this: for instance, homeopathic firms began to sell chests of pills for a range of ailments; or advice manuals meant for young wives, such as Grihinir Hitopdesh (Advice for the wife), began to devote considerable space towards teaching the housewife some of the basic tenets of homeopathy. In fact, the author of this particular manual noted that it was ‘essential for every woman to possess some medical knowledge to run the family. Respectable women should know [a bit of] homeopathy’ (p. 174). This line of argument also reinforces our earlier point that people were making choices regarding health based on a number of factors, including the idea of a sense of ownership over one's body.

As a result of these factors, homeopathy became incredibly popular both in the cities and in the mofussils (small towns).¹⁰ Though Das does not make this argument extensively, it seems that its massive popularity might have led – by the mid-twentieth century– to an amnesia regarding its European links. In this sense, there is a parallel between homeopathy and other European imports, such as cricket, which were thoroughly indigenized in the process of being integrated into the fabric of everyday life in the colonies.¹¹ Indeed, while going through Das‘s book, I was reminded of Ashis Nandy’s famous sentence on cricket: that it is ‘an Indian game accidentally invented [in Britain]’.¹² Even if Nandy‘s formulation might not fully apply in this case, homeopathy, at the very least, appears to have occupied, and continues to occupy, a liminal space between the spiritual/traditional and the ‘hypermodern’,¹³ enabling it to make strategic claims on both categories.

Another book that attempts to break new ground is Brazelton‘s Mass vaccination: citizen’s bodies and state power in modern China. While its focus is on state-sponsored vaccination programmes, just like the two other books it does not limit itself to the state, but is more interested in exploring the response of subaltern sections to state policies. Once again, like Monnais, it shows that the state‘s persistence with its policies, and its willingness to use a wide range of strategies of persuasion, led to vaccination becoming increasingly popular amongst ordinary people. Apart from this, Brazelton also delves into a discussion of the strategies of persuasion employed by the state, including the use of posters, songs, and radio jingles. These campaigns portrayed the idea of vaccination as the patriotic duty of every citizen, and, at least in one particular case, as a precaution against the ‘germ warfare of American Imperialism’ (cover image; also reproduced on p. 130). Interestingly, apart from being portrayed as a patriotic duty, vaccination also began to be seen as an explicitly ‘political’ act (in the old-fashioned sense of the word). The message repeatedly stressed was that one needed to get vaccinated ‘for the sake of the masses’. In an article in a public health journal, even medical men were instructed that ‘before giving vaccinations, [they] must go through the ideological mobilization, and make sure that the parents of children receiving the vaccine underst[ood] the idea of immunization’ (p. 146).

Besides such methods of propaganda, various other practical strategies were employed to achieve acceptance or ‘indigenization’, which is a running theme throughout the other works under review too, as we have seen above. For instance, local people were trained in immunization, and subsequently recruited to carry out vaccinations; besides this, ‘barefoot doctors’ were also sent out to every part of the country on vaccination drives. Despite all this, however, popular uptake of vaccination was slow, with a contemporary health worker noting that ‘in the first years of the existence of the medical post, these vaccinations did not have great success; but for the past two years, they have followed a constant and very marked progression’ (p. 44).

In the process of discussing all this, Brazelton shatters at least one important myth regarding the People's Republic of China – the assumption that it must have relied purely on coercion in order to eliminate any signs of reluctance amongst the public. The figures and statistics mentioned in the book speak for themselves. Brazelton notes, for example, that nearly 500 hundred million people were vaccinated against smallpox during a single decade (the 1950s). Such massive success could not have been achieved without a growing public acceptance that the measure was effective. This insight applies to the colonial contexts too, where the state was constantly making adjustments to its medical measures and institutions to ensure greater acceptability for them. In the particular context of vaccination, they often adopted strikingly similar measures – training ‘natives’ into vaccination, or using ‘acceptable’ vaccinators in order to make the measure appear less alien.

One of the other interesting aspects of the work is the link that it draws between wars and medical research. For example, during the Sino-Japanese War (1937–45), the province of Yunan began to attract a constant stream of scientists and researchers from regions that were easier targets for Japanese air raids. It was assumed that this forced displacement would slow down research; on the contrary, though, the concentration of scientists in Yunan led to an efflorescence of scientific work, which had consequences for the discovery and production of vaccines too. In recent years, medical historians have increasingly made links between medical innovation and warfare, but this is certainly a new and interesting example of such a connection.¹⁴

The final book under review is Hans Pols's Nurturing Indonesia: medicine and decolonisation in the Dutch East Indies which, like some of the other works, traverses the gap between the colonial and the post-colonial, but does so in a much more extensive manner. Similar to some of the other works, though, the colonial period – and the stereotypes that were pervasive during it – are not visualized as monoliths but as ever-changing entities. Pols notes that, during the early phase of colonialism, the state was in tacit alliance with the plantocracy, but this changed in 1901 when the ‘Ethical Policy’ was adopted. There were other substantial changes during the First World War, when the colonial government began to act independently of metropolitan dictates, and the final transformative moment arrived, of course, in 1949, when independence from colonial rule was achieved.

Pols looks at these periods of change through the lens of indigenous doctors’ lives. This might appear to be a top-down approach, and therefore contrary to the approach of the other works under review, but Pols reveals – with great sensitivity – the various facets of the subordination of ‘indigenous’ doctors to the official Dutch establishment. He also attempts to go beyond the polarities between the colonizer and the colonized, and is one of the authors on colonial medical history to look at the ideas of ‘medical middlemen’ in great detail.¹⁵ In doing this, he describes the emergence of ‘political doctors’, who became the leading group of professionals in the anti-colonial movement and in the movement to ‘reform backward natives’ and their ways of life.¹⁶

The discussion of the life of Dr Abdul Rivai – to which Pols devotes a substantial amount of space – is instructive in highlighting many of these issues. Rivai was a man from a relatively modest background, who, through sheer force of will and perseverance, was able to achieve the same professional qualifications as his European contemporaries. Amongst his numerous struggles was the fact that he had to obtain two medical degrees – one in Indonesia and one in the Netherlands – and was forced to wait several years in the Netherlands before becoming eligible for a Dutch degree. In the meantime, he decided to publish a bi-weekly illustrated magazine called Bintang Hindia (Star of the Indies), which ‘informed readers about everyday life in the Netherlands, the importance of education, and the benefits of modern [or Western] civilization’ (p. 16).

While the magazine soon became very popular, reaching a circulation of 27,000 within just two years, it also show-cased Rivai‘s contempt for Indonesian ways of life. In one of his essays, he noted that Indonesians were ’primitive and mired in superstition‘ (p. 30); at another place, he argued that they were lacking in mental development (p. 27) and that only a thorough education in Western science and technology could rescue them. This pedagogical/civilizational aspect of medicine was a strong article of faith amongst physicians in other non-European contexts too, and has had a long afterlife, refusing to simply die away with a change in political circumstances. The new wave of pathbreaking works on decolonization studies discuss the stickiness of such stereotypes in abundant detail, and Pols’s work fits within this trend.¹⁷

Coming back to Rivai, like a number of other medical men of the time, he was very Westernized both in his professional beliefs and personal life. He got married thrice, each time to a Dutch woman, and a major portion of his life was dedicated to acquiring the ‘Dutch qualities’ that he admired so much – including a mastery over the Dutch language, a degree from a Dutch medical college, and a number of personal traits (including clothing) that he saw as being particularly Dutch. What was tragic about the lives of people like him, though, was that, despite all their struggles, self-fashioning, and tortuous personal transformations, they were never seen as part of the Dutch ruling elite.¹⁸ Towards the end of his life, Rivai made the moving confession that

At school you think life is rosy. Only later you are disillusioned. You see how you are a physician and also not a physician, how you are closer to the Dutch because of your science but because of that same science you are repelled by them as well. You are not allowed to speak their language but are thrown back on the great pile of uncivilized natives. (p. 36)

This is a sentiment that not just colonized peoples could identify with, but also those belonging to ‘Other’ classes, communities, and genders. The struggle of the outsider to become an insider is always a fascinating story, and invariably reveals new issues. Pols's work also shows this in an extremely interesting way.

Looking at all the books together, it seems that the idea of modernity, the commodification of health, and the related notion of economic impulses – which were common to sellers of homeopathy and Western pharmaceuticals alike – often provided the guiding force for both sellers and practitioners. Out of these, the economic idea is still a bit underdeveloped, and one hopes that the increasing return to economic history in recent times will lead to filling some of these gaps. There is certainly greater attention being paid to the concept of ‘medical markets’ even within the sub-field of the history of medicine.¹⁹ That said, these books are a welcome sign of new directions in medical history in non-European contexts. Apart from the broad trends outlined in the introduction, a detailed survey of them shows an affinity towards certain themes. One of these is the idea of indigenization and/or hybridity; another is the distinct ways in which medical discourses, stereotypes, and substances were consumed. These are dealt with differently by different authors, with some inevitably showing more interest in certain aspects than others. Of all the books under review, the present reviewer found Das's and Monnais's works the most compelling and theoretically sophisticated, though it did occasionally feel that Das was trying to pack in too many threads into her narrative. As a result, she could not sustain all facets of her interesting narrative until the very end (e.g. the thread on homeopathic publishing houses). Pols, too, uses novel sources – including a student magazine published in the STOVIA medical school for ‘native’ physicians – but does not carry out a nuanced theoretical discussion of them. For example, while analysing the magazine (and other texts), he appears to equate the idea of modernity with the rather vague idea of ‘Westernization’ noting, rather sweepingly, that ‘advocates of modernity worldwide questioned tradition, religion, and hierarchies…they renounced the past and embraced the future’ (p. 10). This is a rather formulaic definition, which denies the possibility of ‘multiple modernities’, that other books acknowledge.²⁰ In a similar vein, the idea of medical modernity also does not feature very explicitly in Brazelton's account, though it is present throughout as a subtext. Das and Monnais, on the other hand, see it as a much more pervasive concept, and, without imposing their own definitions on it, attempt to decipher what contemporaries felt about it.

Having said that, all four books attempt to do something new, explore hitherto unexplored territories, and are testimony to the vitality of medical histories of the non-European world. All of them show that indigenous people were not condemned to be perpetual consumers of biomedicine (or of modernity, for that matter);²¹ that they were engaging with it actively, while also simultaneously engaging with a host of other alternatives. The fact that all this was taking place against the background of intense social and political developments makes these narratives all the more compelling. There is no doubt that these works are wonderful additions to the growing corpus of medical histories in non-European contexts, and will be hugely useful for researchers and students alike.