Effects of Ill Health on the Service of Scottish Presbyterian Missionaries 1867-1929 Jonathan H

Effects of Ill Health on the Service of Scottish Presbyterian Missionaries 1867-1929 Jonathan H. Cossar and Derek A. Dow

Background: The experience of Scottish Presbyterian missionaries serving overseas between 1867 and 1929 was analyzed. Method: Data were compiled during a 4-year postgraduate research program from such sources as the General Assembly Re- ports of the Foreign Mission Committees of the Church of Scotland, numerous missionary magazines, school records, medical directories, and newspaper and medical journal obituaries. Results: Data show that the year of appointment, the mission station and continent location, and medical knowledge were all influencing factors on the length of missionary service, early retirement on account of ill health, death in service, and age at death. Conclusions: This method of comparative, historical study may have further useful applications in looking at the health experi- Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 ence of other groups who lived and worked abroad at the turn of the century, such as civil servants, the military, or other comparable missionary groups. (J Travel Med 1:16-29, 1994)

In 1612 Francis Bacon observed “Travel in the However, recognition of the importation of in- younger sort, is a part of education; in the older, a fection by travelers is not new. In response to out- part of experience.”’ breaks of plague during the Middle Ages, following He would have needed remarkable foresight to the arrival of ships from the East, measures were taken anticipate that the opportunity afforded by travel for to protect communities from these epidemics; Venice education and widening of experience would give rise and Rhodes introducing the first regulations in the to 341 million international tourists by 1986.2It was twelfth century.24 Ships arriving at these European then impossible to predict the medical problems asso- ports were kept at a distance and travelers detained in ciated with contemporary travel abroad, problems isolation for 40 days (quaranta giorni) before they were which are compounded by the widespread destina- allowed to proceed to their final de~tination.~~First tions, and the speed and frequency of this travel. In imposed in 1377 by the Venetian Republic, this was the last decade alone over 20 different infections have the origin of the concept of quarantine. Other cities been imported into the United Kingdom (typh~id,~ and countries followed this example until some form he pa ti ti^,^ p~liomyelitis,~leptospirosis,6 schistoso- of sanitary regulation became general in many coun- miasis,’ amoebiasis,* ~holera,~rabies,’O giardiasis,” tries during the next five centuries. salmonellosis,12 shigell~sis,~~dysentery,I4 leishma- Scotland’s difficult terrain (75% uninhabitable niasis,” lassa fever,I6 trypanosomiasis,” legionnaires’ hilVmountainous country),26inhospitable climate, im- disease,18 di~htheria,’~cytomegalovirus infection,20 poverished domestic economy, agricultural insuffi- malaria:’ acquired immunodeficiency syndrome,22and ciency, and political oppression all combined to en- sexually transmitted diseases23). courage the Scots to travel abroad. Allied to natural enterprise in the fields of exploration, commerce, and the acquisition and dissemination of knowledge, many examples of this Scottish translocation can be found during different episodes of colonization, in military Jonathan H. Cossar, MD, Ch B: General Practitioner and records, and in educated Scottish pioneers whose glo- Research Associate Communicable Diseases (Scotland) Unit, bal exploits earned them international recognition. It Ruchill Hospital, Glasgow, Scotland. Derek A. Dow, MA, Dip has been stated that in the three decades from 1871 to Ed, PhD: Formerly, Archivist to Greater Glasgow Health 1901,483,000 Scots emigrated, perhaps the nation’s Board, University of Glasgow, Glasgow, Scotland. Currently, Honorary Research Fellow, Department of General Practice, greatest world export.27 School of Medicine, University of Auckland, Auckland, New In sharp contrast to the current problem of im- Zealand. ported infections associated with rapid air transit, pre- Reprint requests: Jonathan H. Cossar, MD, CbB, Research vious generations of travelers were exposed to a wide Associate, Communicable Diseases (Scotland) Unit, Ruchill range of health hazards while abroad. The best known Hospital, Glasgow, G20 9NB United Kingdom of these episodes occurred during the ill-fated Darien Cossar and Dow, Ill Health and Scottish Missionaries 17

Expedition of the 1690s, when some 2000 Scots died coded information was punched in at the University as a result of appalling local conditions in which ma- of Glasgow Department of Computing Science and laria and yellow fever were rife.28a. By the nineteenth thereafter analyzed using the SPSSx statistical program. century the continent of Africa posed the greatest There was sufficient information on 141 6 individuals threat. Mungo Park, David Livingstone, and Mary to permit a meaningful analysis. Slessor, who succumbed respectively to trauma From studying the information on the original (&owned while under attack by hostile natives), dys- cards there were obvious limitations on the impartial- entery with internal hemorrhage, and “exhaustion,” ity of the final analyses. For example, the missionar- were three of the most heroically tragic figures in Scot- ies were preselected by religious faith (Protestant)and tish history. country of origin (predominantly Scotland). The study Livingstone and Slessor both journeyed to the period was limited to 1867-1929, and the quality of Dark Continent as Protestant missionaries, a form of data was dependent upon the availability and com- Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 service in which Scotland played a disproportionate pleteness of the original missionary records. Statisti- part considering the size of its population, supplying cally the missionaries are an extremely nonrandom more recruits in absolute terms than any other Euro- sample of all Britons working abroad at the specified pean It was therefore deemed appropri- time due to vocational motivation, the selection pro- ate to use this group to provide a historical compari- cedures which they underwent, and the selectivity of son with the health hazards experienced by contem- the data collected on them. However, this was com- porary Scottish mon to the group as a whole, and therefore compari- sons within this population are valid. Where relevant, statistical analyses have been carried out using the chi- squared (x2)test of independence in a two-way table. The raw data used in this exercise were compiled Occasionally when dealing with tests for trend or during a 4-year postgraduate research program lead- three-way tables, it was necessary to use more com- ing to the completion of a PhD thesis in 1977.41The plicated methods, namely log-linear and logistic mod- sources included General Assembly Reports of the els. Foreign Mission Committees of the Church of Scot- Due to the nature of retrospective collection of land, the Free Church of Scotland and the United Free information from historical records, the details for Church of Scotland, Synod Reports of the United Pres- some individuals were incomplete thereby precluding byterian Church, Life and Work, Free Church Monthly identical totals in all the analyses for the different Record, Home and Foreign Missionary Record, and groups. other similar missionary magazines, university ma- triculation and graduation records, Medical Directo- Results ries, and newspaper and medical journal obituaries. A summary card index was completed for each mis- The mission fields of 1409 Presbyterian mission- sionary identified in the course of this work. These aries serving abroad between 1867 and 1929, divided data were subsequently recompiled with a view to into subgroups and subtotals, were identified (Table conducting a comparative analysis of different mis- 1). Similar numbers served in India and Africa (594 sionary subgroups, by assessing such factors as (1) and 612 respectively) accounting for the major pro- retiral from missionary service due to personal or fam- portion (85Y0)of the total. One hundred and forty- ily ill health; (2) death while in service; (3)the cause two (10%)served in China, and the remaining 61 (4%) and age at death; (4)the length of service at different were equally divided between Jamaica and other ar- mission stations, and (5) areas, countries, and conti- eas (Arabia, New Hebrides, Japan). nents during different periods of appointment. Male missionaries (739: 52%) and female mis- Information coding was carried out for gender sionaries (639:45%)were the largest subtotals; 3% and occupational grouping, mission fields, year of could not be classified by gender (where only an ini- birth, age at death, year of appointment, years of serv- tial or a nongender-specific first name was available). ice, reason for retirement, and specified cause of death. Females who were neither trained in health care nor The missionaries were subdivided into groups-or- ordained comprised the largest subgroup (441: 31 YO), dained males, nonordained males, male doctors, or- followed by ordained males (384: 27%), and those dained male doctors, female nurses, female doctors, trained in health care (343; 24%).The remaining five other females, and into subtotals-males, females, and subgroups (3, 5, 7, 9, and 15% of the total) range those with training in health care (all doctors and from 47 ordained male doctors to 210 nonordained nmses)-for the purposes of comparative analysis. The males. 18 Journal of Travel Medicine, Volume 1, Number 1

Table 1 Mission Field Distribution of Subgroups Mission Fields Missionary India Africa Iarnaica China Other Totals Overall

Su bgrou pings % % YO % % (%)

Ordained male 44 39 7 8 3 384 (27) Nonordained male 19 75 1 5 1 210 (15) Male doctor 33 43 0 19 5 98 (7) Ordained male doctor 26 4.5 <1 15 13 47 (3)

Subtotal males 34 so 4 9 3 739 (52)

Female 54 38 <1 7 <1 44 1 (31) Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 Female nurse 34 43 0 17 6 125 (9) Female doctor 67 11 0 22 0 73 (5)

Subtotal females 51 36 <1 11 1 639 (45)

Subtotal health care trained 40 36 <1 18 5 343 (24)

Totals 594 (42%) 612 (43%) 30 (2%) 142 (loo/,) 31 (2%) 1409 (100)

Ranges (19-67%) (11-75%) (0-7%) (5-22%) (0-13%) (3-52%)

Taking the distribution within subtotals and sub- portions (38%) of their groups represented-81 and groups by area served, 5 1YO of all female missionaries 48, respectively. Only 4 (9%)of ordained male doc- served in India, thereby accounting for 55% of all the tors served less than 5 years, but this group had the missionaries who served there. The largest proportion highest proportion of their numbers (7: 15%) serve of female doctors (67%) and also of those trained in over 40 years compared with the other subgroups. health care (40%) served in India.42 Of those serving between 20 and 39 years the Fifty percent of all male missionaries served in range was from 13% (17)female nurses to 36% (17) Africa, accounting for 60% of all who served there. ordained male doctors, with ordained males account- Seventy-five percent of the nonordained males com- ing for the largest proportion of the total (128:35%) prised 26% of all missionaries to Africa. The largest followed by females (114: 31%). proportion of ordained male doctors, male doctors, There is a difference of 7% or less between the and nurses all served in Africa (45,43, and 43%, re- proportions of the subtotals for male missionaries, spectively). female missionaries, and missionaries with training in Seventy (51%) of those who served in China were health care who served for less than 5 years (23,27, female, 16 of whom were doctors (22% of all female and 29%, respectively), 5 to 19 years (35, 38, and medical missionaries). In the remaining mission fields, 42%), 20 to 39 years (27,23, and 21%) and over 40 19 had training in health care (including seven or- years (8,2, and 2%). The difference between the pro- dained male doctors-15% of this subgroup), and the portion of females serving for more than 40 years com- majority, 51, were male missionaries (31 and 84'70, pared with males (2 and 8%, respectively) is statisti- respectively, of the total for these fields). cally significant (p c .001). The length of service among the missionary sub- The mean number of years served ranged from groups is shown in Table 2. The mean number of years 25.1 for ordained male doctors, 24.9 for ordained served by the 1427missionaries studied was 21.1 with males, and 24 for females to 13.8 for nonordained the largest group (522: 37%) serving between 5 and males. 19 years and equal proportions (25%) serving either Table 3 details the length of service by selected less than 5 years or from 20 to 39 years. Seventy-four mission stations, all mission stations, and continents. (5%) served more than 40 years, and the length of Those serving less than 5 years ranged from 7% of service was not determined for 108 (8%) of the mis- those in Jamaica to 36% of those in West Africa. The sionaries. range for those serving 5 to 19 years was from 27% Among those serving less than 5 years, nonor- (China) to 43% (Livingstonia). Among the subtotals dained males and female nurses had equally high pro- and subgroups serving between 20 and 39 years, there Cossar and Dow, Ill Health and Scottish Missionaries 19

Table 2 Length of Service within Missionary Subgroups Service (yr) Not Missionary <5 5-1 9 20-39 > 40 Stated Mean Totals Overall

Su bgroupings % YO YO % YO (Y r) (%)

Ordained male 13 32 33 13 9 24.9 388 Nonordained male 38 37 19 1 4 13.8 213 Male doctor 35 43 19 0 3 15.9 100 Ordained male doctor 9 38 36 15 2 25.1 47

Subtotal males 23 35 27 8 6 20.5 748

25 36 26 3 10 24.0 446 Female Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 Female nurse 38 42 13 0 6 18.1 126 Female doctor 20 42 27 1 9 14.6 74

Subtotal females 27 38 23 2 9 21.8 646 (45)

Subtotal health care trained 29 42 21 2 5 17.7 347

Totals 360 (25%) 522 (37%) 363 (25%) 74 (S?'o) 108 (8%) 21.1 1427

Ranges (9-38%) (32-43%) (13-36%) (O-ISYo) (2-1 0 Yo ) ( 13.8-25.1 )

Table 3 Length of Service by Mission Location Service (yr) Not Mission <5 5-2 9 20-39 > 40 Stated Mean Totals Overall

Location % % % % YO (Yr) (Yo)

Calcutta 33 38 24 0 5 16.6 82 N.E. India 27 37 25 2 8 21.5 209 N.W. India 19 37 31 7 6 23.9 270 S. India 25 38 27 2 7 22.4 99

India subtotal 23 38 28 5 7 22.8 594

Livingstonia 29 43 19 4 6 22.9 122 Blantyre 32 29 24 4 10 18.5 96 Central Africa 29 39 20 4 8 21.0 283 Calabar 34 36 17 2 11 15.4 174 West Africa 36 36 17 1 10 15.1 203 S. Africa 16 37 23 17 7 28.2 126

Africa subtotal 29 37 20 6 9 21.1 612

China 21 27 42 4 6 23.5 142

Jamaica 7 33 30 23 7 30.4 30

Other areas 32 42 19 0 6 20.9 31

Totals 360 (25%) 522 (37%) 363(25 %) 74 (5%) 108 (8%) 21.1 1427

Ranges (7-3 6 % ) (27- 43 Yo) ( 17- 42 yo) (0-23 % ) (5-11%) (15.1-30.4) (2-47%) 20 Journal of Travel Medicine, Volume 1, Number 1 was a low of 17% for missionaries to West Africa and pointed pre-1900 (284: 20% between 1890-1899) and Calabar, and a high of 42% for missionaries to China. 856 (60%)were appointed post-1900 (324: 23% be- The distribution of those serving more than 40 years tween 1920-1929). Those serving less than 5 years varied enormously; there were none in other areas prior to 1900 range from 16% during 1880 and 1889 (Arabia, New Hebrides, Japan), 1% in West Africa, to 30% between 1890 and 1899. After 1900 ;here is a and a peak figure of 23% in Jamaica. The different greater similarity between decades-25,25, and 28% proportions of missionaries, those serving less than 5 respectively. In missionaries serving from 5 to 19 years, years, 5 to 19 years, 20 to 39 years, and over 40 years the smallest proportion (28%) was among those ap- in India, Central Africa, West Africa, and South Af- pointed between 1890 and 1899 and the highest pro- rica compared with the rest are statistically signifi- portion (42%)among those appointed between 1920 cant (p < .0001). and 1929. Comparing the experience of missionaries to the Missionaries serving between 20 and 39 years Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 Indian subcontinent (594)with those to Africa (612), ranged from 18'70 appointed between 1867 and 1879 fewer served less than 5 years in India (23% com- to 29% appointed between 1900 and 1909. The compared with 29%), similar proportions served 5 to 19 parative proportions for those serving over 40 years years (38 and 37%), disparate proportions remained are 2% (1910-1929) and 13% (1867-1879). in their posts for 20 to 39 years (28 and 20%), and Comparing the length of service pre-1900 with similar proportions for more than 40 years (5and 6%, post-1 900 the proportions serving less than 5 years respectively). A similar contrast exists within Africa and between 20 to 39 years are similar (24 and 26%, between missionaries serving in South Africa compared and 25 and 26%), whereas the proportions serving with those in Central and West Africa. The respective between 5 and 19 years and over 40 years are differ- figures are less than 5 years-16, 29, and 3670, re- ent (32 and 40%, and 10 and 2%). spectively; 5 to 19 years-37,39, and 36%; 20 to 39 Table 5 shows the number of missionaries retir- years-23, 20, and 17%; and over 40 years-17, 4, ing early on account of personal ill health, ill health in and 1%. the family, marriage, or premature death, and also The mean number of years served ranged from among the subtotals and subgroups of the missionar- 15.1 for missionaries to West Africa to 30.4 for mis- ies. Overall 287 (20%) returned prematurely due to sionaries to Jamaica. ill health, 70 (so/) due to family ill health, 76 (5%) The length of missionary service was also exam- on marriage, and 151 (11 %) died in service. The ma- ined in relation to the date of appointment-the first jority 837 (59'%0)completed their appointed period of 12-year period (1867-1879), then the five ensuing dec- service. ades (1880-1889, 1890-1899, 1900-1990, 1910- Within the subtotals, comparing male missionar- 1919,1920-1929). The results are shown in Table 4. ies, female missionaries, and missionaries trained in Of 1416 missionaries studied, 560 (40%) were ap- health care, similar proportions returned due to per-

Table 4 Length of Service by Year of Appointment Service (yr) Not ~~40 Stated Totals Overall~~

~~Year YO % YO YO % I"/.)~~

~~1867-1879 25 37 18 13 7 103 (7) 1880-1889 16 35 27 12 10 173 (12) 1890-1899 30 28 25 8 9 284 (20)~~

~~Subtotal pre-1900 24 32 25 10 9 560 (40)~~

~~1900-1909 25 36 29 3 7 273 (19) 1910-1 919 25 41 27 2 6 259 (18) 1920-1 929 28 42 23 2 5 324 (23)~~

~~Subtotal post-1900 26 40 26 2 6 856 (60)~~

~~Totals 360 (25%) 522 (37%) 363 (25%) 74 (5%) 108 (8%) 1416 ( 100)~~

~~Ranges (16-30%) (28-42%) (18-29%) (2-13%) (5-10%) (7-60%) Cossar and Dow, Ill Health and Scottish Missionaries 21~~

~~Table 5 Reason for Leaving Service within Missionary Subgroups Due to Diedin Family To Be Missionary 111 Health Service Ill Health Married Other Totals Overall Su bgrou pings % % % % % (%)~~

~~Ordained male 21 13 6 <1 60 388 (27) Nonordained male 16 14 4 0 66 213 (15) Male doctor 15 12 10 <1 62 100 (7) Ordained male doctor 24 15 9 0 53 47 (3)~~

~~Subtotal males 19 12 6 <1 61 748 (52)~~

~~Female 21 9 4 11 56 446 (31) Female nurse 22 11 2 11 54 126 (9) Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 Female doctor 19 8 4 12 57 74 (5)~~

~~Subtotal females 21 9 4 11 56 646 (45)~~

~~Subtotal health care trained 20 11 5 7 57 347 (24)~~

~~Totals 287 (20%) 151 (llyo) 70 (So/,) 76 (5%) 837 (590/,) 1427 (100)~~

~~Ranges ( 15-24% ) (8-1 So/,) (2-1 0 Yo) (0-12%) (53-66%) (3-52%)~~

sonal ill health (19, 21, and 20%, respectively) and those who died in service, the range is from 7 (Cal- due to family ill health (6, 4, and 5%); there was cutta) to 20% (Jamaica),with missionaries to Africa greater disparity in the proportions who died in serv- contributing the largest number within this total-73 ice (12, 9, and 11%) and in the proportions retiring (48%); the mission fields of Livingstonia (20: 16%) to marry (less than 1, 11, and 7%). and Calabar (26: 25%) account for 63% of this Among those who died in service, ordained males number. had the highest number (50; 33% of this total); pro- Among those leaving to marry, the percentage portionately the range was from 6 (So/) female doc- ranged from nil in Jamaica to 11YO in South India. tors to 7 (150/,)ordained male doctors. Among those Table 7 shows the reason for leaving service dur- retiring on account of personal ill health, the propor- ing the six appointment periods studied (the initial tions ranged between 15% (15 male doctors) and 24% 12-year period and five ensuing decades). Comparing (11 ordained male doctors). Those returning due to those retiring due to ill health pre-1900 and post-1900, illness in the family ranged from three female nurses the proportions are 24 and 18%, respectively, with a (2%)to 10 male doctors (10%).Taking the same range range of from 15 (1920-1929) to 25% (1890-1899). extremes among those leaving to be married, there Using a logistic regression model, the decreasing trend were no nonordained males or ordained male doctors in the percentages leaving due to ill health over all six compared with nine female doctors (12%). appointment periods is statistically significant (p < The reason for leaving missionary service accord- .0001). ing to the missionary location by continent, subconti- Making a similar comparison among those who nent, smaller areas, and some mission stations is shown died in service, the proportions are 17% and 7% (pre- in Table 6. The proportions retiring due to ill health 1900 and post-1900) and 4 to 19% (1920-1929 and within continental and subcontinental divisions range 1890-1 899); these two decades (in parenthesis) ac- from 14 (China)to 27% (Jamaica),the other propor- count for the highest numbers of missionaries (324: tions within this subdivision being 21, 21, and 19% 23% and 284: 20%, respectively). (India, Africa, and other areas, respectively). Subdi- Among the 70 missionaries who returned prema- viding further within these areas the proportions range turely on account of family ill health, there was little from 17 (South India) to 27% (Calcutta). Within the difference during the appointment periods studied number affected by ill health in the family, the lowest (range, 4-6%), and of the 76 who left to be married, Proportion affected of any of the subdivisions was 2% the percentages were lower pre-1900 compared with (Blantyre, South India, South Africa) and the highest post-1900 (range, 2% from 1880-1889 to 7% from 10% (other areas). Making a similar comparison for 1910-1929). 22 Journal of Travel Medicine, Volume 1, Number 1

~~Table 6 Reason for Leaving Service by Mission Location Dueto Diedin Family To Be Mission Ill Health Service 111 Health Married Other Totals Overall Location % YO YO % YO (“w~~

~~Calcutta 27 7 6 4 57 82 N.E. India 26 8 5 5 56 209 N.W. India 19 9 8 6 59 270 S. India 17 8 2 11 62 99~~

~~India subtotal 21 8 6 7 58 594~~

~~Livingstonia 19 16 5 4 57 122~~

Blantyre 18 14 2 2 65 96 Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 Central Africa 18 13 4 4 61 283 Calabar 24 15 6 5 50 174 West Africa 25 14 5 4 52 203 S. Africa 21 9 2 2 66 126

~~Africa subtotal 21 12 4 4 59 612~~

~~China 14 15 4 6 61 142~~

~~Jamaica 27 20 3 0 50 30~~

~~Other areas 19 13 10 3 55 31~~

~~Totals 287 (20%) 151 (11Yo) 70 (5%) 76 (so/) 837 (59%) 1427~~

~~Ranges (14-27%) (7-2OYo) (2-1 0 Yo) (0-1 lY0) (5O-66YO)~~

~~Table 7 Reason for Leaving Service by Year of Appointment Dueto Died in Family To Be Year 111 Health Service Ill Health Married Other Totals Overall~~

~~YO % % YO YO (YO)~~

~~1867-1879 23 14 4 3 56 103 1880-1889 24 17 4 2 52 173 1890-1899 25 19 5 4 48 284~~

~~Subtotal pre-1900 24 17 4 3 51 560~~

~~1900-1909 21 8 5 6 59 273 1910-191 9 16 9 6 7 62 259 1920-1929 15 4 4 7 69 324~~

~~Subtotal post-1900 18 7 5 7 63 856~~

~~Totals 287 (59%) 151 (11%) 70 (So/,) 76 (5%) 832 (59%) 1416~~

~~Ranges (4-6 Yo ) (2-7%) (48-69%) (7-60%)~~

The comparison between pre-1900 and post-1900 Among those retiring prematurely due to ill health, missionary appointments in India, Africa, all other the lowest proportion (11 YO) was in missionaries to areas, three mission stations in Africa, and one in In- Livingstonia between 1900-1929 and the highest dia and the reason for leaving service is shown in Ta- (32%)was in missionaries to Calabar between 1867- ble 8. 1899. The proportion range of those who died in serv- Cossar and Dow. Ill Health and Scottish Missionaries 23

~~Table 8 Reason for Leaving Service by Year of Appointment and Mission Location Due to Died in Family To Be Mission 111 Health Service 111 Health Married Other Totals Overall Locution % % % % % (%)~~

1867-1 899 Calcutta 29 12 6 6 47 34 (2) India 28 13 6 5 48 218 (15) Livingstonia 22 29 2 0 47 55 (4) Blantyre 19 19 2 0 58 43 (3) Calabar 32 22 4 4 38 76 (5) Africa 24 19 2 2 52 259 (18) Other areas 18 20 5 0 56 79 (6) Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 Subtotal pre-1900 24 17 4 3 51 560 (40)

1900-1929 Calcutta 23 4 6 2 65 34 (2) India 17 5 6 8 64 374 (26) Livingstonia 11 4 7 7 64 67 (5) Blantyre 18 8 2 4 69 51 (4) Calabar 19 8 8 5 59 97 ( 7) Africa 18 7 6 5 63 348 (25) Other areas 17 13 5 8 59 120 (8)

~~Subtotal post-1900 18 7 5 7 63 856 (60)~~

~~Totals 287 (20%) 151 (11%) 70 (5%) 76 (S~O)832 (59%) 1416 (100)~~

~~Ranges (11-32) (4-29%) (2-8%) (0-8%) (38-69%) (2-60 Yo)~~

~~Table 9 Age at Death within Missionary Subgroups (range 23-105 yr) Age (Yr) Total % of Missionary 20-29 30-39 40-49 50-59 >60 Mean Known Overali Subgroup~~

~~Subgroupings % % % % % % (YO)~~

~~Ordained male 1 8 6 8 76 69.2 295 (55) 76 Nonordained male 21 5 29 5 40 52.1 42 (8) 20 Male doctor 3 25 3 8 63 61.1 40 (7) 40 Ordained male doctor 0 10 0 10 79 60.5 39 (7) 83~~

~~Subtotal males 3 10 7 8 72 66.6 416 (77) 56~~

~~Female 1 12 1 6 79 72.7 78 (15) 17 Female nurse 0 21 14 0 64 64.3 14 (3) 11 Female doctor 0 11 0 4 85 71.5 27 (5) 36~~

~~Subtotal females 1 13 5 5 79 71.4 119 (22) 18~~

~~Subtotal health care trained 1 17 3 7 73 66.2 120 (22) 35~~

~~Totals 14 (3%) 55 (10%) 34 (6%) 42 (8%) 392 (73%) 67.4 537 (100) 38~~

Ranges (0-21%) (5-25%) (0-29%) (0-10%) (40-85%) (52.1-72.7) (3-77%) (11-83%) 24 Journal of Travel Medicine, Volume 1, Number 1 ice is from 4% (Livingstonia, 1900-1929) to 29% lowest proportion of deaths over 60 years (40%),and (Livingstonia, 1867-1 899). Adding the proportions the lowest mean age at death (52.1 years). for those retiring due to ill health to the proportions There were 40 male doctors in whom the age at of those who died in service, the comparable figures death was determined (40% of subgroup), and they are 15% (Livingstonia 1900-1929) and 54% (Calabar, had the highest proportion (25YO) of deaths between 1867-1899). 30 and 39 years; female doctors (27 total, 36% of There is a proportion range from 2% (Living- subgroup) had the highest proportion (85%)over the stonia, Blantyre, and Africa pre-1900; Blantyre post- age of 60 years. The highest mean age at death (72.7 1900) to 8% (Calabar post-1900) among those re- years) was recorded in the 17% (total 78) of the fe- turning due to family ill health, and from nil to 8 % in male subgroup. Within the subtotals, male missionar- those retiring on becoming married. ies, female missionaries, and missionaries with train- Age at death was recorded for 537 (38%) of the ing in health care, the proportion range within age missionaries studied. This was noted by decade for groups was 7% or less, and the range of the mean age Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 those aged between 20 and 59 years, with a separate at death less than 6 years. category for those aged over 60 years. These figures The recorded age at death within four decades are recorded in Table 9. The representation of sub- (20-29; 30-39; 40-49; 50-59) and those aged over group totals within these subsets ranged from 11% 60 years for missionaries appointed to different sta- (14 female nurses) to 83% (39 ordained male doc- tions, areas, countries, subcontinents, and continents tors). Overall 392 (73%)died over the age of 60 years, is shown in Table 10. the next largest number, 55 (10%),died between 30 Among the 63 (36% of subgroup) appointed to and 39 years, and the mean age at death was 67.4 Calabar, the highest relative proportion of deaths were years. recorded between 20-29 years (10%)and for 30-39 The 42 nonordained males (ZOO/, of subgroup) years (21%);the lowest mean age at death (60.2) was produced the highest proportions of deaths between also recorded. Similarly the highest relative propor- 20 and 29 years (21%)and 40 to 49 years (29%),the tions for the 40-49 (14%) and 50-59 (86%) age

~~Table 10 Age at Death by Mission Location Age (YT) Total % of Mission 20-29 30-39 40-49 50-59 >60 Mean Known Overall Subgroup~~

~~Location % % % YO YO YO (%)~~

~~Calcutta 0 0 14 86 0 73.5 21 (4) 26 N.E. India 0 1 10 6 83 72.4 71 (13) 34 N.W. India 2 8 5 9 76 69.8 97 36 S. India 5 18 10 3 64 64.9 39 (18)(7) 39~~

~~India subtotal 2 8 8 7 76 69.9 210 (39) 35~~

Livingstonia 5 13 0 10 72 63.7 39 (7) 32 Blantyre 3 19 11 14 54 61.5 37 (7) 39 Central Africa 3 13 7 12 65 63.9 97 (18) 34 Calabar 10 21 8 6 56 60.2 63 (12) 36 West Africa 8 21 7 7 56 60.2 71 (13) 35 S. Africa 0 7 3 5 84 71.3 58 (11) 46

~~Africa subtotal 4 14 6 9 67 64.6 226 (42) 37~~

~~China 2 11 2 5 81 67.6 64 (12) 44~~

~~Jamaica 0 0 13 21 67 69.4 25 (4) 80~~

~~Other areas 0 9 0 0 91 71.5 12 (2) 37~~

~~Totals 14 (3%) 55 (loo/,) 34 (6%) 42 (87'0,) 392 (73%) 67.4 537 (100) 38~~

~~Ranges (0-10%) (0-21%) (O-14'Xo) (0436%) (O-91Yo) (60.2-73.5) (2-42%) (26-8O%) Cossar and Dow. Ill Health and Scottlsh Missionaries 25~~

~~Table 11 Age at Death by Year of Appointment Age (Yr) Total % of 20-29 30-39 40-49 50-59 >60 Known Overall Subgroup Year~~

~~1867-1879 2 8 8 8 75 62 1880-1889 1 15 10 8 65 57 1890-1899 5 14 7 7 68 53~~

~~Subtotal pre-1900 3 13 8 7 69 56~~

~~1900-1 909 1 5 4 8 81 35 1910-1 919 5 3 5 80 25 8 Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 1920-1929 2 6 3 1 78 20~~

~~Subtotal post-1900 2 6 4 8 80 25~~

~~Totals 14 (3%) 55 (lOY0) 34 (6%) 42 (So/) 392 (73%) 38~~

~~Ranges (I-SYo) (5-1 5 yo ) (3-1 0 % ) (l-8%) (65-8 1 YO) (20-62 Yo)~~

groups occurred in 21 (26% of subgroup total) mis- missionary deaths pre-1900 (21:23% due to malaria), sionaries to Calcutta and also the highest mean age at and for 19 (32%)post-1900 (6: 10% due tomalaria). death (73.5).Ten (910/)of the 11 missionaries (37% Overall these 54 deaths comprise 75% of those cases of subgroup total) in other areas (Arabia, New Hebri- with a recorded cause and 36% of the total number. des, Japan) comprised the highest relative proportion Seven (5% of the overall total) died accidentally, the for any of the subdivisions within the over 60 year majority (6)during the post-1900 period. age group. The differences between the proportions within Discussion age groups for India, Africa, and China ranged from a low of 2% (20-29 age group) to a high of 14% Certain observations affecting missionary service (over 60 years of age). are worth noting prior to detailed discussion of the The recorded age at death (five age groups) re- study findings. It is of interest that almost equal num- lated to six appointment periods is shown in Table bers of missionaries studied served in Africa (612)and 11. The age at death was recorded for 313 (56% of India (594),with only 15% serving outside these ar- the total group) missionaries appointed between 1867- eas. The majority of men (500/,)served in Africa, with 1899 and for 224 (25% of the total group) of those only 34% in India; the converse occurred for women appointed from 1900-1929. (36% Africa; 51 YO India). This unequal geographic Comparing the proportions dying during the six distribution of men and women is likely to affect com- appointment periods within each age group, there is parative studies among the missionary subgroups on little difference (4%)within the 20-29 age group, a length of service, reason for leaving, age at death and 10% difference (low 5%, 1900-1909; high 15%, cause, due to the contrasting climatic hardship between 1880-1889) in the 30-39 year group, and a 7% dif- tropical Africa and subtropical India. In addition it ference (low 3%, 1910-1929; high lo%, 1880-1889) seems likely that missionaries with medical knowledge in the 4049 year and 50-59 year age groups (low would be in a better position to protect and organize I%, 1920-1929; high 8%, 1867-1889,1900-1909). their own health care compared with other groups. The largest difference (16%)occurred within the over Balanced against this is “dedication beyond the call 60 year group with the lowest proportion (65%)in of duty,” which rendered the doctors and nurses vul- those appointed between 1880-1889 and the highest nerable to the very problems they treated in others, proportion (8lY0)in appointees between 1900-1909. such as infectious diseases. However, it is likely that Of the 151 missionaries who died in service, a all the subgroups would have a proportion with an cause of death was determined for 72 (48%)and is overdedicated approach. This may have changed with shown in Table 12, subdivided into pre- and post-1900. the passage of time, as reflected in the reduced num- Death due to infection accounted for 35 (41%)of the bers serving for more than 40 years post-1900 and 26 Journal of Travel Medicine, Volume 1, Number 1

Table 12 Mortality in Scottish Presbyterian Missionaries The findings support the hypothesis that service (1867-1929) in Africa was more hazardous to health than service Cause Pre-1900 Post-1 900 Totals Ouerall in India, and that less knowledge of health matters adversely influenced the length of service, the age at of Death (“w (“w (TO) death, and premature death. Malaria 21 (23) 6 (10) 27 (18) In sharp contrast the experience of the smallest Cholera 4 (4) 3 (5) 7 (5) subgroup, ordained male doctors, supports the hypo- Dysentery 1 4 5 (3) thetical converse. Their mission field distribution was Typhoid 2 2 4 (3) more even, Africa-45%, India -26%, China 15%, Pneumonia 2 2 4 (3) - Tuberculosis 3 0 3 (2) and all other areas - 14%. They had the smallest rela- Influenza 1 1 2 (1) tive proportion serve under 5 years (9%)and the high- Surgery 1 1 2 est over 40 years (15%)of any subgroup. This group Psychiatric 1 1 2 recorded the highest mean number of years of service Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 Appendicitis 2 0 2 Cardiac 2 0 2 (25.1) and paralleling this finding, the highest relative Renal 2 0 2 proportion of those who died in service (15%)and of Diphtheria 1 0 1 those retiring due to ill health (24%)-probably re- Plague 0 1 1 flecting advancing age and length of time spent in Sunstroke 1 0 1 hostile climates. Evidence for this is a relatively high Accidental 1 6 (10) 7 (5) Not recorded 47 (51) 32 (54) 79 (52) mean age at death, 68.5 years (79% in the over 60 age group), recorded in an 83% sample of the group. Totals 92 (61) 59 (39) 151 (100) It should be noted that ordination for medical men usually followed prolonged service in the mission field, which perhaps makes this group a self-fulfillingproph- ecy. the increased percentage of those on short-term con- However, there are marked differences between tracts. the nonordained males and ordained male doctors, The majority of females (69%)did not fall within the former being much larger (210) than the latter any other subgrouping, which compares with 28% of (47) and being recruited more from an artisan as op- the males-this largely reflects the fact that women posed to an academic background. These differences could not be ordained in the church at this time. would affect missionary selection, choice and desig- A further note is that “retiring due to ill health” nation of mission location, Christian motivation and effected a premature passage to the home country philosophy, and physical, immunologic (i.e., the ac- without financial penalty.41From our knowledge of quisition of differing antibodies from previous expo- the dedication and self-sacrifice of the group as a sure to infection), and mental resilience to illness. whole, we conclude that any who contrived this situ- Male doctors had the lowest relative proportion ation were more than balanced by those who contin- (150/,)of their group retiring due to ill health and fe- ued working despite being eligible to return on ac- male doctors the lowest (8%) for missionaries who count of ill health. A final comment is that advances died in service. This further suggests that doctors were in medical, paramedical, and technical knowledge less subject to illness and death during missionary serv- would tend to favor the experience of better health in ice than their nonmedical colleagues. Also the lower missionaries appointed at later dates. proportion of deaths among female doctors compared The nonordained male missionary group stands with male doctors probably reflects the differing dis- out for several reasons, namely that the largest rela- tribution of these subgroups between Africa (11 and tive proportion of their number served in Africa (75%), 43%) and India (67 and 33%, former and latter, re- the lowest relative proportions in India (190/,) and spectively). China (5%),and very few elsewhere (1%).This group Seventy-eight percent of the male doctors spent had the highest relative proportion of missionaries less than 20 years in service, perhaps reflecting a re- retiring for reasons other than ill health (66%), and turn to pursue professional careers in their home coun- of deaths occurring in the 20-29-year (21%)and 40- try or the effect of being the subgroup with the high- 49-year (29%) age groups; it also shared the highest est relative proportion with family ill health (lo%), relative proportion for service under 5 years (38%) thus necessitating the return home. and had the lowest mean number of years of service In contrast only 2% of the nurse missionaries re- (13.8) and mean age at death (52.1 in a 20% sample) turned on account of family ill health, a reflection of among all the subgroups. the fact that this subgroup was least likely to be ac- Cossar and Oow, Ill Health and Scottish Missionaries 21 companied by family. A further contrast is that 69% due to ill health (27%)and for death in service (20%). of female doctors spent between 5 and 39 years in A partial explanation of these findings is that many service despite manifesting the highest relative pro- less robust missionaries were selected for service there, portion (12%) of any of the subgroups retiring to as opposed to more climatically rigorous areas, or were marry. semiretired to Jamaica following ill health elsewhere.43 Looking at the influence of mission location on This is supported by the comparative figures showing the experience of missionaries, West Africa, and the highest mean number of years of service (30.4), a Calabar in particular, fits the descriptive historical relatively high mean age at death (69.4 in an 80% cliche of “white man’s grave.” Calabar had the low- subgroup sample), and the lowest relative proportion est relative proportion of missionaries serving between (7%)serving less than 5 years. 20 and 39 years (17%) and for over 40 years (l”/), Overall, 25% of the missionary total returned due shared the lowest for missionaries retiring for reasons to personal or family ill health, and a further 11% Downloaded from https://academic.oup.com/jtm/article/1/1/16/1819259 by guest on 30 September 2021 other than ill health (50%; only 38% pre-l900), and died in service. was among the highest for service under 5 years (34%), As anticipated, the average proportions for those for death in service (15%: 22% pre-1900), and for appointed pre-1900 are higher for those retiring due retirals due to ill health (24%: 32% pre-1900). In keep- to ill health (24%) and dying in service (17%),and ing with this pattern missionaries to Calabar had the lower for those retiring for reasons other than ill health lowest mean number of years in service (15.1), the (51%) compared with post-1900 appointees (18, 7, lowest mean age at death (60.2 years, 36% of this and 63%, respectively). This contrast is particularly subgroup), and the highest relative proportion of highlighted during the two decades with the two larg- deaths in the 20-29 year (10%)and 30-39 year (21%) est groups of missionaries, namely 1890-1899 (284 age groups. missionaries-25, 19, and 48 %, respectively) and Livingstonia in Central Africa shared a similar 1920-1929 (324 missionaries-15, 4, and 69%, re- reputation with a 16% mortality rate (29% pre-1900; spectively), which perhaps emphasizes the advances only 4% post-1900), and 72% serving less than 20 in knowledge of health hazards in serving abroad dur- years. The numbers serving some 350 miles further ing the 39-year period (1890 to 1929). south in Blantyre were broadly similar. In contrast, The pattern is repeated within the study time pe- the overall mortality rate at that location pre-1900 riods for the ages at death, with the highest relative was 19%, and a lower proportion served less than 20 proportions occurring in younger age groups pre-1900 years (61YO). This differing experience may have been (ls%,30-39 years and lo%, 40-49 years in appoint- influenced by the less healthy geographic environment ees between 1880-1889) and lower average relative of Livingstonia in a swampy lakeside location, and proportions in all age groups post-1900 except one the fact that a greater number of administrators as (50-59 years). The lowest relative proportion surviv- opposed to field workers served in Blantyre. ing more than 60 years were appointed between 1880- Jamaica, which recruited only fully ordained min- 1889 (65%) and the highest between 1900-1909 isters throughout the period under review, had the ( 8 1% ). highest relative proportions of missionaries returning

Table 13 Summary of Findingsfrom Studies on Missionaries Mortality rate pre-1900 > mortality rate post-1900 Retirals due to ill health pre-1900 > retirals due to ill health post-1900 Deaths from infectious cause pre-1900 > deaths from infectious cause post-1900 Missionary service over 40 years pre-1900 > missionary service over 40 years post-1900 Accidental deaths post-1900 > accidental deaths pre-1900 Mortality rate in Africa (especially West and Central) > mortality rate in India and most other areas Premature death in Africa (especially West and Central) > premature death in all other areas Morbidity rate in Africa (especially West and Central) > morbidity rate in India and most other areas Missionary service under 5 years in Africa (especially West) > missionary service under 5 years in most other areas Mean length of service in Jamaica (30.4 years) > mean length of service in all other areas Morbidity, mortality, and length of service in > morbidity, mortality, and length of service in ordained male doctors all other subgroups Premature death and service under 5 years in > premature death and service under 5 years in all nonordained males other subgroups Retirals due to ill health among male doctors < retirals due to ill health among all other subgroups Death in service among female doctors < death in service among all other subgroups 28 Journal of Travel Medicine, Volume 1, Number 1

These findings show that later appointment cou- (Department of Mathematics, Strathclyde University) for his pled with improvements in medical knowledge are statistical expertise, and to Dr. D. Fildes and staff (Depart- associated with fewer retirements due to ill health, ment of Computing Science, Glasgow University)for their help in computer programming and operation. lower mortality rates in service, and longevity in missionaries. Statistically there were no significant differences in the distribution of these findings between References Africa, India, or the other areas during the pre- and post-1900 periods, which suggests that all locations 1. Bacon F. Of travel. 1612, Essays, 18. benefited equally from medical progress in the later 2. World Tourism Organisation. Tourism compendium. years. World total. Madrid: WTO, 1987. Surprisingly, among those appointed pre-1900, 3. Communicable Diseases (Scotland)Unit. Typhoid. 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