H-Net Book Review
Published by H-List@h-net.msu.edu (July, 2001)

Heather Bell. _Frontiers of Medicine in the Anglo-Egyptian
Sudan, 1899-1940_. Oxford: Clarendon Press, 1999. viii + 261 pp.
Tables, maps, notes, bibliography, and index. $78.00 (cloth), ISBN
0-19-820749-2.

Reviewed for H-List by Robert O. Collins
<rcollins@humanitas.ucsb.edu.>, Department of History,
University of California, Santa Barbara

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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