POPULATION AS DISCOURSE: MEDICINE IN LATE COLONIAL

A thesis presented

by

Irene Yuan Sun

to

The Department of the History of Science in partial fulfillment for an honors degree in History and Science

Harvard University Cambridge, Massachusetts March 2007 ABSTRACT

Name: Irene Yuan Sun

Title: Population as Discourse: Medicine in Late Colonial Kenya

Abstract: After World War I, British doctors in Kenya began to treat Africans on a wide scale, giving rise to a population-based medical discourse new to the colony. Over the next thirty years, the discourse on population provided a vehicle for the medical community to discuss a broad range of issues in an authoritative manner. Doctors in a variety of disciplines, from nutritionists to psychiatrists, participated in observing, measuring, and describing the Kenyan African population. The concept of ‘population’ was nebulous enough to encompass a wide range of concerns, from the most practical of economic considerations to the most theoretical of questions on normality and abnormality. When Mau Mau broke out in the early 1950s, a medical explanation was adopted to explain what was instead a political phenomenon, illustrating the rhetorical appeal of the medical discourse on population for the late colonial state.

Keywords: British colonialism, colonial medicine, Kenya, nutrition, population,

ACKNOWLEDGEMENTS

Perhaps even more than the thrill of doing original research and the opportunity to think deeply about an interesting topic, I will cherish this thesis-writing process because it demonstrated to me the generosity of the academic community. Looking back at the last two years, I am astonished that so many people have so freely given of their time and energy to help a first-time researcher. Somehow the stars aligned for me to be assigned to Sarah Jansen as her thesis advisee. Through the past year, Professor Jansen has been a mentor, an intellectual inspiration, and a thought partner. She is my kindest and most honest critic, as well as teacher, example, sounding board, and sometimes-therapist. I cannot thank her enough for guiding me through this process with alacrity, wisdom, humor, and good grace. Very few thesis advisees can honestly say that they will miss seeing their advisors, but I give up my weekly hour-long spot on her calendar with the utmost regret. This thesis has had an unusually long gestation period. It began as a research paper on colonial genocides in Africa that I wrote somewhat recreationally in the fall of my junior year (inasmuch as one can actually write 40-page papers just for fun). I am grateful to Peter Buck and Jens Meierhenrich, who admirably guided me through the pitfalls and anxieties of my first major research paper. The following semester, I decided to focus specifically on the Kenya case for my junior paper for the History of Science concentration. In that endeavor, I am indebted to Caroline Elkins and Marwa Elshakry for their advice and support. In the fall of my senior year, I was lucky to have the guidance of Emmanuel Akyeampong and Arthur Kleinman in writing what became the second chapter of this thesis. Special thanks go to Allan Brandt, who took time out of his very busy schedule to help me refine my thesis proposal and revise my draft. And along the way, I am deeply grateful for insightful conversations with William Murphy, Amber Musser, Charles Rosenberg, Funke Sangodeyi, and Helen Tilley. In researching for this project, I have been extremely fortunate to have the expert assistance of Fred Burchsted at Widener Library. From navigating the perils of WorldCat to locating obscure sources, Fred was there every step of the way, knowledgeable and superhumanly patient. In addition, I am deeply grateful to Arlene Shaner and Adrian Thomas at the New York Academy of Medicine Library for being so accommodating and welcoming to a visiting researcher. In revising this paper, I was fortunate to have had a small army of assiduous proofreaders. Jason Anderson, Philip Powell, Alan Rozenshtein, and Perry Tsai generously lent their time and thoughtfulness in combing over drafts. In addition, Perry had a miraculous supply of patience, good cheer, strangely colorful binder clips, and Thai takeout, all of which were vital to me surviving this process. My love to my parents and sister, who admirably put up with this esoteric interest, my frequent grouchiness, and my erratic schedule. Thank you for understanding how much this thesis has meant to me and supporting me unconditionally. Finally, I must single out Peter Buck for special thanks. The Peter Buck approach to history (a topic is worth pursuing if you can tell a good story about it over a martini; extra points if you can make it into a joke) was what initially made me interested in history and what sustained me through some long, sunless days in the basement of Countway. He has been my mentor, friend, comedian, cook, and librarian. He has read more drafts of this thesis than I care to think about. I can only hope that this end product bears some trace of his unerring intuition and sharp insight. TABLE OF CONTENTS

Introduction: ‘To See the Wood for the Trees’ 1

Chapter I: The Population, Practically Speaking 13

Yaws and the Establishment of the Medical Service’s Credibility Nutrition in the 1920s: Importing European Assumptions and Methods Nutrition in the 1930s-1950s: Noticing the African Population Statistics and Population Control

Chapter II: What is ‘Normal’ about ‘the African Mind’? 35

The ‘Normal’ is Abnormal The ‘Abnormal’ is Doubly Abnormal Nurture over Nature, Body over Mind Uneasy Reflections: Culture, Civilization, and Responsibility

Chapter III: ‘Health,’ Medicine, and Mau Mau 59

The Expansion of the Definition of ‘Health’ ‘Health’ and Colonial Governance ‘Health’ and the African Population Mau Mau and the Medicalization of Political Problems

Epilogue: ‘No Mere Verbalisation’: 83 The Legacy of Colonial Medical Discourse

Appendix 89

Annotated Bibliography 99 INTRODUCTION

‘TO SEE THE WOOD FOR THE TREES’

“…up to the present, and for very understandable reasons, no clearer objective than the attainment of some undefined measure of improvement has been postulated. As a result, it has for long been a matter of the greatest difficulty to see the wood for the trees, or often, indeed, for the undergrowth.” — British Medical Association Kenya Branch, The Case for the Appointment of a Royal Commission on Health and Population in His Majesty’s Dependencies in Africa, 19471

This thesis rests on a simple observation: British doctors in late colonial Kenya

talked in terms of populations. They referred to the African population2, the European

population, and the Indian population. They discussed population growth rates, the

development of populations, and populations’ birth and death rates. They argued over

the origins of populations’ diseases, whether populations were healthy, and what could be

expected for populations in the future. As the quote above suggests, they did not find

talking about populations to be particularly easy, which raises the question: why did

doctors in Kenya start talking this way? What assumptions, analytical tools, and methodological underpinnings did they bring to the discussion? What were the consequences of caring for a population rather than caring for individuals? And how did

1 The Council of the Kenya Branch of the British Medical Association, Memorandum: The Case for the Appointment of a Royal Commission on Health and Population in His Majesty’s Dependencies in Africa, East African Medical Journal, Vol. 25, No. 1 (Jan. 1937), p. 30. 2 In discussing ‘Africans’ or ‘the African population,’ colonial doctors often grouped together people from various ethnicities. This thesis will specify whenever more specificity was given—for example, in a study about nutrition amongst the Kikuyu and the Masai. Overall, however, the terms ‘Africans’ and ‘the African population’ are retained because these were the terms used by the doctors themselves in discussing their work. this discourse on population change the nature of medicine and colonial governance in

Kenya?3

This thesis concerns itself with the medical discourse on the African population in

late colonial Kenya.4 I will begin in the 1920s, in the aftermath of World War I, when doctors ‘discovered’ widespread ill health amongst the African population.

Consequently, the existing Medical Service’s scope was extended to include treating

Africans in addition to Europeans, which meant that a few dozen British Medical Officers of Health set out to provide medical services for a large, geographically scattered, heterogeneous African population about which they knew virtually nothing.5 My endpoint will be the rise of Mau Mau in the mid-1950s, when systematic rebellion against colonialism brought about the beginning of the end of British rule in Kenya.6 In the intervening thirty-odd years, the concept of population arose as both a practical concern

3 In recent years, there has been quite an impressive buildup of scholarly literature on discourse in general and scientific and medical discourse in particular, due in no small part to the work of Michel Foucault. As a result, ‘discourse’ as a term now evokes a mass of technical definitions and specifications (e.g. conditions for discourse, structure and instrumentality of discourse, prohibitions to discourse, and rules of discourse, to name a few). In this thesis, however, I wish to discuss medical discourse in colonial Kenya in its most basic sense: “discourse is really only an activity, of writing in the first case, of reading in the second and exchange in the third” (Michel Foucault, “The Discourse on Language,” trans. A. M. Sheridan Smith, in The Archaeology of Knowledge (New York: Pantheon, 1972), p. 228). 4 The focus will be on colonial Kenya, but Medical Officers there had steady exchange with their counterparts in neighboring Tanganyika (modern-day Tanzania) and . Due to repeated attempts to coordinate the governance of these territories, British East Africa can also be considered a salient administrative unit. For this reason, I will sometimes discuss British East Africa as a whole rather than Kenya specifically. 5 Before this point, the Medical Service served European settlers almost exclusively. Doctors were part of British colonial institutions since the beginning of British presence in Kenya; the Imperial British East African Company, which held the original 1888 charter to develop East Africa, employed a handful of doctors. The British Foreign Office took over the assets and administration of the Company in 1895; in 1901, it employed seven doctors, three nurses, and seven hospital assistants. For roughly ten years starting in 1903, the Medical Services of Kenya and Uganda were combined in hopes of greater administrative efficiency, but this structure was thereafter abandoned. It was only after World War I that the Medical Service in Kenya dealt in any significant way with Africans, particularly in rural areas. For more on the early history of East African medical administration, see Ann Beck, A History of the British Medical Administration of East Africa (Cambridge: Harvard University Press, 1970), pp. 7-57. 6 Although the official British response to Mau Mau began in 1952, Kenya did not gain independence from Great Britain until December 12, 1963. In this thesis, I will only be concerned about doctors’ involvement in the British response to Mau Mau, particularly their explanations of Mau Mau from the mid-1950s. and a theoretical puzzle. Trained in the curative tradition of treating individual patients,

Medical Officers had to transition to a new situation in which a handful of doctors were

responsible for entire Native Reserves. This shift involved a radical zooming-out of the

medical gaze, from seeing “trees” to seeing “the wood.” In Kenya, the attempt to

reconceptualize the Medical Service’s task in population terms also led to a reevaluation

of medicine itself in Kenya—of its scope, methods, and ends. This thesis seeks to

explain the motivations for this discourse on population, characterize its content, and understand its consequences for the larger colonial project in Kenya.

The fundamental argument advanced here is that the discourse on population provided a vehicle for medical doctors in late colonial Kenya to discuss a broad range of issues in an authoritative manner. The concept of ‘population’ was nebulous enough to encompass a host of competing and sometimes contradictory considerations. This discourse spanned the spectrum from the most practical of economic concerns to the most theoretical of questions on normality and abnormality. The medical perception of the

African population bridged the gap from persons as biological sufferers of disease to

people as social specimens contributing to a redefined notion of the ‘health’ of the

colony. From the professional standpoint, doctors’ work amongst the African population

earned them a crucial place in the rhetoric of the late colonial state, although their powers

to affect concrete policy-making were less evident. When Mau Mau broke out in the

early 1950s, a medical explanation was adopted to explain this political phenomenon,

even as doctors were relegated to eliminating ticks in stockaded villages. Thus, the

appeal of population as an object of medical discourse did not lead to corresponding practical power for doctors, but it nevertheless provided colonialists with a ‘modern’ way to talk about social problems in a seemingly rational, scientific manner.

In studying the medical discourse of colonial Kenya, I have been fortunate to be able to draw on the existence of a continually published monthly medical journal. In

April 1924, a handful of doctors in Nairobi established the Kenya Medical Journal with three objectives: to facilitate communication between medical men in East Africa, to provide the latest information on tropical medicine and hygiene, and to encourage public interest in health matters.7 The Journal changed its name twice, to the Kenya and East

African Medical Journal in 1927, and to the East African Medical Journal in 1932.8

Issues of the Journal from the 1920s to the mid-1950s—amounting to some 15,000 pages—provide the bulk of primary source material examined here. In addition, scientific articles published in other journals, medical textbooks and other standalone publications, and archival documents from the are used to flesh out the picture of medical discourse in late colonial Kenya.

Throughout this thesis, I have tried as much as possible to allow the historical actors themselves to define the interrelationships within their community and the interconnections between their works. I was inspired by Bruno Latour’s approach in The

Pasteurization of France: rather than presupposing professional relationships or analytical categories, he mapped the development and transformation of these

7 “Editorial,” Kenya Medical Journal, Vol. 3, No. 1 (April 1926), p. 1. The Journal was affiliated with the Kenya Branch of the British Medical Association and was funded and printed by Rudolf Mayer, the founder and director of the East African Standard. 8 The first name change, from the Kenya Medical Journal to the Kenya and East African Medical Journal in 1927, was meant to reflect the official inclusion of the British Medical Association Branch in Tanganyika. The publication expanded again in 1932 to form the East African Medical Journal, the scope of which included Nyasaland, Uganda, and Zanzibar. For fourteen years during the 1930s and 1940s, the East African Medical Journal was the only medical publication published in British colonial Africa. connections from the discourse he examined.9 Likewise, the goal of this thesis is to trace

the idea of population from the definitions and conceptualizations proposed by colonial

doctors themselves. Certain terms—‘Africans,’ ‘race,’ and ‘the African mind’—might

seem too ambiguous or problematic for modern usage, but they are retained here because

they were salient categories in use in colonial Kenya. In addition, tracing the

development of this discourse will take us through a variety of scientific disciplines, from

nutrition studies to to ethnopsychiatry.10 It might be surprising that discussions

of African psychiatry were intimately connected to or that projects in nutrition

gave rise to medical propaganda, but the mapping of concerns within the discourse on

population reveals interconnections between analytical categories that are not obvious

today.

This thesis makes three cuts through the discourse on population: the practical

imperative to deal with the African population, the theoretical questions asked about this

population, and the connections between this medical discourse on population and the

larger project of colonial governance in Kenya. In my first chapter, I examine British

doctors’ attempts to deal practically with the African population. The results of mass

health surveys during World War I revealed an unsuspected degree of ill health amongst

Africans, leading to the posting of Medical Officers to native reserves in the aftermath of

9 As Latour wrote in his introduction, “The analyst does not need to know more than they [the historical actors]; he has only to begin at any point, by recording what each actor says of the others. He should not try to be reasonable and to impose some pre-determined sociology on the sometimes bizarre interdefinition offered by the writers studied. The only task of the analyst is to follow the transformations that the actors convened in the stories are undergoing.” From Bruno Latour, The Pasteurization of France, trans. Alan Sheridan and John Law (Cambridge: Harvard University Press, 1988, Paperback edition, 1993), p. 10. 10 If this amalgamation of medical subdisciplines makes us uncomfortable, it would be wise to keep in mind that due to the extreme paucity of medical personnel, doctors in East Africa were forced to deal in a range of specialties other than their own. For example, J. C. Carothers, a general practitioner by training, ended his career as a well-respected expert on African psychiatry and along the way even occasionally dabbled in dentistry. The wide breadth of Carothers’ medical interests is evident in his psychiatric work, which was heavily influenced by environmental and nutritional studies. the war. The decision to treat the African population stemmed from the economic need

to ensure a healthy labor force—to understand the African population as both a resource of the state and an object of state control. Medical discourse revolved around two

primary concerns: disease and dietetics. The yaws campaign in the 1920s wiped out an

economically costly disease and established the Medical Service’s credibility. Nutrition,

however, proved to be more of a puzzle. On the one hand, J. L. Gilks and John Boyd Orr

made a strong case for the adoption of universalist assumptions and the application of

research methods used in Europe to the Kenyan context. On the other hand, doctors’

understanding of the problem was frustrated by puffed-up babies in the reserves who

defied clear-cut diagnosis and disease classification. Indeed, the protein deficiency

disease kwashiorkor sparked decades of debate and no small amount of confusion for the

British medical community.

The second chapter turns to the theoretical problems of studying a population,

chief among which was the question of how to define the ‘Normal.’ Motivated by fears

of ‘maladjustment’ in the African population, ethnopsychiatrists sought to characterize

the so-called ‘African mind,’ which was conceptualized as deficient in comparison to the

‘European mind.’11 In the 1930s, a pathologist and a psychologist performed group studies in an effort to understand the ‘Normal’ African brain and intellect. Their

conclusions characterized the African brain as being abnormally small and the African

intellect as being inferior in comparison to the European ‘Normal.’ A further strain of

research on the African mentally ill revealed that they too were ‘peculiar’ according to

11 Although the term means very little scientifically today, ‘the African mind’ was the object of research for psychiatrists in colonial Kenya from the 1930s through the 1950s. As ethnopsychiatrist J. C. Carothers wrote in 1953, “it is not only legitimate but valuable to discuss the African mind…there run some general themes which are both strange and fundamental” (J. C. Carothers, The African Mind in Health and Disease (Geneva: World Health Organization, 1953), p. 7). European standards: Africans showed a low overall of mental illness, and the

patterns of specific mental illnesses differed strikingly from those in Europe

and America. In explaining these differences, ethnopsychiatrists increasingly relied on

cultural and environmental explanations, which in part drew upon the nutrition research discussed in Chapter I. By the 1950s, the consensus of the discipline was to understand

‘deficiencies’ in ‘the African mind’ as resulting from the African culture and

environment. In this respect, psychiatric discourse in East Africa moved away from essentializing inferiority as an inherent biological property. This postulate—that mental illness was shaped by culture—gave rise to reflections not only on Africans, but also on

European civilization. Thus, in the space of a quarter of a century, the idea that Africans were ‘maladjusted’ came to implicate European culture as well as ‘the African mind.’

Finally, the third chapter attempts to elucidate the functions of the medical discourse about population within the larger framework of British governance in late colonial Kenya. The medical community’s discussions of African overpopulation in the

1940s demonstrated its hubris: doctors claimed that they had caused the entire problem by lowering the death rate. They also argued that the medical community should take the leading role in fixing the population problem, for the solution was more ‘health.’ As a concept, ‘health’ had been reinvested with a host of meanings seemingly new to Kenya, including management, prevention, and ‘positive health.’ Influenced by the British social medicine movement and the establishment of the World Health Organization, doctors in

Kenya transformed the definition of ‘health’ from the description of the individual’s disease-free bodily state to an aspiration of societal wellbeing. Although these concepts seemed new to Kenya, I argue that they dovetailed neatly with the existing activities of the Medical Service. Since the late 1920s, doctors had given themselves the right to comment on education and other aspects of colonial governance in which they had no direct expertise. In addition, they had been ‘propagandizing’ directly to the African population on matters of hygiene, health, and living habits. By the 1950s, the medical discourse about the African population had come to occupy a singular and contradictory place in the British rule of Kenya. As the case of Mau Mau demonstrated, medical explanations were privileged over political ones, but doctors had very little impact on policy-making. The seemingly rational, scientific discourse of doctors was appealing for the late colonial state on the level of rhetoric, but on the level of concrete action, doctors ended up dealing more with ticks than with humans.

Although the individuals and debates described here are specific to Kenya, the rise of population as an object of state concern and the adoption of the public health paradigm has strong parallels elsewhere, in both the West and other colonies. In nineteenth-century Europe and the United States, the state increasingly dealt with matters of hygiene, sanitation, and prevention, particularly in situations.12 The

accompanying rise of health as a civil right to be administered by governments called into

question the same issues of social control and coercion that it did in Kenya a century later.

12 For a broad discussion of public health, see Dorothy Porter, Health, Civilization and the State: A history of public health from ancient to modern times (London: Routledge, 1999). The American experience is investigated in Barbara Rosenkrantz’s Public Health and the State. In this book, she discusses the rise of ‘health’ as a societal ideal in nineteenth-century Massachusetts; see Barbara Rosenkrantz, Public Health and the State: Changing Views in Massachusetts, 1842-1936 (Cambridge: Harvard University Press, 1972). One example of the rise of state intervention in health matters as a consequence of is cholera in nineteenth-century New York; see Charles E. Rosenberg, The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago: University of Chicago Press, 1962, 1987). For a wider discussion of the history of state planning, see James C. Scott’s Seeing Like a State: How Certain Schemes to Improve the Human Condition have Failed (New Haven: Yale University Press, 1998). In the twentieth century, the influence of the social medicine movement on public health administration was also evident in other contexts.13 Within colonies, the

connection between governance and hygiene has been elucidated by Warwick Anderson

for the American colonization of the Philippines and Alison Bashford for the British rule

of Australia.14 Anderson’s and Bashford’s works are also a part of the growing literature

on the relationship between colonial medicine and colonial power. Taking as a starting

point Michel Foucault’s ideas on biopower and the contribution of professional

knowledge to the managed conception of the state, this literature simultaneously applies

his theories in conceptualizing colonial medicine and tests its limits against the

specificities of colonial situations. Megan Vaughan’s Curing their Ills: Colonial Power

and African Illness is an impressive analysis of the contribution of biomedical knowledge

to European power in colonial Africa.15 Jonathan Sadowsky uses psychiatry as a lens to

view the larger social history of colonialism and forges a fascinating connection between

asylum policy and indirect rule in colonial Nigeria.16 Similarly, Jock McCulloch’s sweeping analysis of colonial psychiatry in Africa uses the discipline to explore the fundamental concerns of the colonial enterprise.17

A number of authors have written about aspects of the Kenyan story covered here.

Ann Beck’s books deal at great length with the administrative side of medicine in

13 See Diane B. Paul, Controlling Human Heredity: 1865 to the Present (Amherst, New York: Humanity Books, 1998) and Dorothy Porter, ed., Social Medicine and Medical Sociology in the Twentieth-Century (Amsterdam: Rodopi, 1997). 14 Warwick Anderson, Colonial : American Tropical Medicine, Race, and Hygiene in the Phillipines (Durham: Duke University Press, 2006); Alison Bashford: Imperial Hygiene: A Critical History of Colonialism, Nationalism and Public Health (New York: Palgrave Macmillan, 2004). 15 Megan Vaughn, Curing their Ills: Colonial Power and African Illness (Cambridge: Polity Press, 1991). 16 Jonathan Sadowsky, Imperial Bedlam: Institutions of Madness in Colonial Southwest Nigeria (Berkeley: University of California Press, 1999). 17 Jock McCulloch, Colonial psychiatry and ‘the African mind’ (Cambridge: Cambridge University Press, 1995). colonial East Africa.18 Michael Worboys points out that malnutrition in the colonies was

‘discovered’ in Kenya between the two World Wars.19 Examining a research proposal

from Kenya on “native backwardness,” Helen Tilley identifies a shift in the colonial

research agenda in the 1930s away from projects predicated upon biological essentialist

assumptions and toward cultural and environmental explanations.20 And Lynn Thomas’s

work deals with the relationship between colonial governance, reproductive politics, and

attempts to control the population in Kenya.21

I hope that within this impressive array of works on public health and colonial medicine, there is room for one more tract on medicine in colonial Kenya. The particularities of colonialism in Kenya deserve to be examined in greater detail; only

Tilley’s article and Thomas’s book focus on Kenya specifically. Beyond the uniqueness

of place, however, I hope this work will set itself apart in its approach towards

understanding colonial medicine. The books above are focused on medical work in

colonial situations, but they end up being as much or more about the colonial state than

about medicine. Similarly, source-wise, the current literature admirably incorporates a

variety of diverse source material, from court proceedings to government documents, but

nowhere is a single sustained body of medical discourse examined. This is not meant to

be a critique, but merely an observation of a small gap in the historiography in which this

18 Ann Beck, A History of the British Medical Administration of East Africa, 1900-1950 (Cambridge: Harvard University Press, 1970) and Medicine, Tradition, and Development in Kenya and Tanzania, 1920- 1970 (Waltham, Mass.: Crossroads Press, 1981). 19 Michael Worboys, “The discovery of colonial malnutrition between the wars,” in David Arnold, ed., Imperial Medicine and Indigenous Societies (Manchester: Manchester University Press, 1988), pp. 208- 225. 20 Helen Tilley, “Ambiguities of Racial Science in Colonial Africa: The African Research Survey and the Fields of Eugenics, Social Anthropology, and Biomedicine, 1920-1940,” in Benedikt Stuchtey, ed., Science across the European Empires, 1800-1950 (Oxford: Oxford University Press, 2005), pp. 245-287. 21 Lynn Thomas, Politics of the Womb: Women, Reproduction, and the State in Kenya (Berkeley: University of California Press, 2003). See in particular the first two chapters, “Imperial Populations and ‘Women’s Affairs’” and “Colonial Uplift and Girl-Midwives.” thesis will hopefully fit. The existence of the East African Medical Journal offers an opportunity to understand the internal world of doctors and the inner process of the generation and development of scientific ideas, as well as their incorporation into larger matters of colonial governance. Although the discussion of medical discourse leads naturally to issues of colonial administration and state power, my core focus remains simple: how doctors talked in late colonial Kenya.

CHAPTER 1

THE POPULATION, PRACTICALLY SPEAKING

“…we feel it out duty to point out that the present ideals of a medical service are not those of 30 years ago. We do not expect our doctors to spend their time merely treating a few sick folk in hospital or out-patient clinic. A far more important part of their duty is the seeking out and treating of disease throughout the districts committed to their charge. We also expect them to initiate and develop every other measure calculated to improve the health of the whole of the population.” — J. H. Sequiera, 193322

Imagine the scene: a young Medical Officer, freshly anointed a doctor by a British university, arrives for his assignment in . He has probably never before seen a black person, but he is assigned to care for the health of an entire native reserve.

What diseases does he see? Which ones should he tackle first? What assumptions and methodologies does he bring to bear on the challenges he faces? What should he do to treat his patients in the most efficient and cost-effective manner?

Although many colonial personnel had lived in Kenya for much longer than my hypothetical medical novice, the thirty-six Medical Officers under the employ of the

Kenyan Medical Service in the early 1920s faced similar situations and similar questions.

In the aftermath of World War I, these medical men were charged with improving the health and productivity of a sizeable, geographically scattered, and largely unknown population. Influenced by the ‘discovery’ of poor health and poor physique among

Africans brought to light by mass conscription during World War I, these doctors set out to tackle the problems of infectious disease and malnutrition. As Medical Officer and

editor of the East African Medical Journal J. H. Sequiera wrote, it was not enough any

22 J. H. Sequiera, “Vital Statistics in Digo District: A New Departure,” East African Medical Journal, Vol. 10, No. 5 (Aug. 1933), p. 169, italic in original. longer to await diseased patients to declare themselves to medical authorities. Doctors were now expected to familiarize themselves with the African population, research its diseases, and actively promote its health. But the African population held surprises for

Western medicine—as Medical Officers working on nutritional problems found out, the corpus of medical work in Europe could not prepare them for all that they would encounter in the Kenyan native reserves.

Colonial medical discourse was powerfully shaped by doctors’ experiences and observations in World War I, which was the turning point between the “white man’s medicine” of the nineteenth century and the paradigm of public health that would follow.23 During the Great War, doctors cast Africans in population terms for the first time and established enduring research questions. Large numbers of Kenyan men were conscripted into service for the British as carriers, which occasioned the first medical study of Africans as a population.24 In the absence of motorized transport or pack animals, carriers hauled equipment and supplies across grueling distances. They were invariably underfed and overworked to the point of exhaustion.25 Not surprisingly, the

23 This distinction between “white man’s medicine” and public health is borrowed from David Arnold, “Introduction: disease, medicine and empire,” in David Arnold, ed., Imperial Medicine and Indigenous Societies (Manchester: Manchester University Press, 1988), p. 13. 24 Recruitment for the Carrier Corps occasioned the first mass health screening in Kenya and the ‘discovery’ that the African population was not nearly as healthy as previously assumed. In 1915, the Carrier Corps conducted compulsory medical examinations of its male conscripts in Kenya under the Compulsory Military Service Ordinance. Before this point, doctors had only been concerned with the health of the African population during epidemics. The results were alarming: thirty to forty percent of young males were rejected for service because they were medically unfit (Marc Dawson, “The Anti-Yaws Campaign and Colonial Medical Policy in Kenya,” International Journal of African Historical Studies, Vol. 20, No. 3 (1987), p. 417). Many of these potential conscripts were debilitated by tertiary yaws or organic heart disease. These findings implied even higher rates of ill health and disability in the larger population, since obviously unfit young men were not even examined. This ‘discovery’ of ill health of populations due to military conscription has strong parallels elsewhere, including in Europe and America. See Diane Paul, Controlling Human Heredity: 1865 to the Present (Amherst, New York: Humanity Books, 1995), p. 7 and Dorothy Porter, Health, Civilization and the State: A history of public health from ancient to modern times (London: Routledge, 1999), p. 171. 25 The workload of the Carrier Corps was nothing short of brutal: on average, each man had to carry a load of forty pounds or more for over fifteen miles a day across rough terrain. Whenever there was a delay in death rate in the Carrier Corps was horrendously high. The first mortality records in

1917 logged over one hundred deaths every day. Overall, 46,618 men from East Africa

died during World War I, of which only 4,300 were direct casualties in the armed

forces.26 The chief recorded causes of death were diseases such as dysentery,

pneumonia, and , to which exhaustion and malnutrition contributed powerfully.

In this way, World War I set into motion two research agendas that would survive long

into peacetime: dietetics and epidemic disease.

For medical men, the Carrier Corps during the Great War was a grim laboratory in which to observe the effects of varied diets, or lack thereof. Early in the East Africa campaign, the decision was made to feed porters nothing but ‘mealie meal,’ or cornmeal.

In addition, because the porters had to carry their own rations, the tendency was to minimize their food load so that they would have more capacity for other cargo. These two factors combined for appalling rates of malnutrition, which led in turn to widespread disease and death. In describing the situation years later, a doctor in the military wrote of the “inhumanity and folly” of these proposals and called them “unforgivable.”27

Influenced by concurrent nutrition studies in Europe, doctors in the military began to study the relationship between diet and labor productivity.28 What little experimentation

the column, the porters were required to stand and wait without putting their loads down. As C. J. Wilson, the first editor of the East African Medical Journal, described life in the Carrier Corps: “Frequently the porters in a column would arrive in camp hours after dark, when the main body had long been settled comfortably for the night. Whatever rations were available would then be issued: it can be imagined how little hope there was of the food being properly cooked at that hour of the night. The night was often more than half done before there could be any chance of sleep; and long before dawn the weary, half-starved porters would be packing their loads for the next day’s journey.” From C. J. Wilson, “Reminiscences of the Last East African Campaign,” East African Medical Journal, Vol. 16, No. 8 (Nov. 1939), p. 283. 26 Ann Beck, A History of the British Medical Administration of East Africa, 1900-1950 (Cambridge: Harvard University Press, 1970), p. 59, 63. 27 Wilson, “Reminiscences of the Last East African Campaign,” p. 283, 282. 28 Rationing of food in Europe resulted in an unprecedented interest amongst the global scientific community in dietetics. With undernourishment in continental Europe as a major public health issue, scientists experimented with new food sources and various nutritional combinations of foods. The with rations permitted to these doctors showed overwhelmingly that the most “efficient”

carriers were ones fed on a diet “almost as mixed as that of the European.”29 Thus, by

both negative demonstrations of the dire effects of malnourishment and positive

demonstrations of the labor productivity resulting from adequate diets, World War I set in

motion a medical interest in dietetics and nutrition that intensified in the post-war years.

One of the chief reasons for this concern over diet was its contribution to epidemic diseases through the ranks. Before the war, the prevailing opinion held that

Africans rarely, if ever, suffered from typhoid. Doctors in the military, however, heard of

more and more men in the Carrier Corps complaining of incapacitating diarrhea, often

with blood—symptoms suggestive of typhoid. They were not allowed to waste valuable

medical resources to treat a theoretically nonexistent illness in Africans, but the

complaints became so frequent that something had to be done. “Against all orders, and in

great secrecy,” the medical men built a small hospital near the camp at Longido West,

hidden in the bush.30 There, doctors discovered that typhoid was amongst the

Carrier Corps, a diagnosis that was confirmed with blood samples smuggled out for

laboratory analysis. Reviewing the mortality rates of African troops after the war, the

Director of Medical Services in Kenya and a visiting researcher concluded, “The African

native is thus by no means the ‘noble savage’ that he is frequently supposed to be. He is

prone to infectious disease and he is too frequently an individual of poor physique.”31

appearance of deficiency diseases led to major research efforts on vitamins, which were little understood before the Great War. For a summary of the influence of this global research agenda on the East African medical community, see “Editorial,” Kenya and East Africa Medical Journal, Vol. 7, No. 2 (May 1930), pp. 27-28. 29 J. L. Gilks and J. B. Orr, “The Nutritional Condition of the East African Native,” Kenya and East Africa Medical Journal, Vol. 4, No. 3 (June 1927), p. 87. 30 Wilson, “Reminiscences of the Last East African Campaign,” p. 285. 31 Gilks and Orr, “The Nutritional Condition of the East African Native,” p. 89. It is with these concerns about nutrition and epidemic disease that medical services for Africans were established in the aftermath of World War I. Under the leadership of Principal Medical Officer John L. Gilks, medical centers began to be established in the reserves in 1920. As of 1923, the Medical Service in Kenya had in its employ 36 medical men, who were, at least nominally, in charge of the health of an

African population estimated at two and a half million.32 This new mandate required an unprecedented expansion of staff, which occurred throughout the 1920s but not nearly at the rate required.33 In 1927, the first appointment of a Medical Officer of Health to a

Native Reserve was made.34 Never before had government-employed doctors been in such close contact with the African population.35

For the next several decades, British medical discourse centered around the two problems of the African population that had come to light during World War I: disease and diet. The campaign against yaws, an endemic infectious disease, in the 1920s met with overwhelming success and won the Medical Service legitimacy both with the

African population and within the colonial administration. Their work on ‘native

32 For the size of Medical Service, see “Departmental News,” The Monthly Journal of the Kenya Medical Service, No. 1 (June 1923), p. 3. For estimates of the African population in the mid-1920s, see “Editorial: The Pax Britannica and the Population,” East African Medical Journal (Feb. 1947), p. 74. 33 In 1926, the largest single expansion of the Medical Service to date was commenced, with an unprecedented number of new hires, including two Senior Medical Officers, three Senior Sanitation Officers, ten Medical Officers, three Sanitation Officers, and three bacteriologists (see “The Annual General Meeting of the Kenya Branch of the British Medical Association,” Kenya and East Africa Medical Journal, Vol. 3, No. 11 (Feb. 1927), p. 324). 1929 added another twelve Medical Officers and twelve Nursing Sisters, as well as four Sub-Assistant Surgeons (see “Kenya Medical Department Estimates, 1929,” Kenya and East African Medical Journal, Vol. 5, No. 10 (Jan. 1929), p. 330). By the mid-1930s, the Medical Service comprised the largest single department of the British government in Kenya outside of “Administration.” Lord Hailey’s African Survey listed 124 colonial staff members and an additional 38 local employees in the Medical and Health Service (Lord Hailey, An African Survey: A Study of Problems Arising in Africa South of the Sahara, (London: Oxford University Press, 1938), p. 226). 34 J. L. Gilks, “A Medical Review of Kenya during 1927,” Kenya and East Africa Medical Journal, Vol. 4, No. 11 (Feb. 1928), pp. 333-337. 35 As with other colonial situations, medical missionaries had long lived in African-dominated areas. In Kenya, this tradition dated to the late nineteenth century. It was only in the 1920s, however, that Medical Officers of Health employed by the colonial government were posted to native reserves, usually for several years at a time. nutrition,’ however, produced far more questions and research problems than answers

and practical results. One strand of dietetics research assumed universal nutritional

problems and sought to apply methods from Europe to the Kenyan context. Working

amongst the African population, however, Medical Officers encountered diseases

distinctly unfamiliar to Western medicine. African populations were different from

European populations in striking ways, and the ‘discovery’ of the protein deficiency

disease kwashiorkor gave rise to no shortage of nosological debate and internal confusion

within the British medical community. Increasingly, doctors working in the native

reserves realized how little they knew about the population in front of them, giving rise to

new statistics-based studies in the 1930s. The advent of statistics in colonial medicine

promised new strategies for the promotion of health in the colony but also met with

African resistance because of its potential to augment the state’s powers of coercion and

surveillance.

YAWS AND THE ESTABLISHMENT OF THE MEDICAL SERVICE’S CREDIBILITY

The questions of disease and labor efficiency survived the Great War and

intensified in its aftermath, as the colonial government needed ever larger numbers of

African workers for white settlers’ farms, the Kenya-Uganda Railroad, and the Magadi

Soda Company. The most visible problem to the government, employers, and laypeople

was tropical disease; malaria, hookworm, yaws, and a whole host of other ailments

regularly incapacitated large chunks of the African (and indeed European) population.

There was a horrifying panoply of problems to deal with: in Nairobi, the seven Medical

Officers of Health dealt with malaria after the rains, pneumonia during the drier months, and dysentery during the wetter months.36 The “worst epidemic of malaria that the

country had known” occurred in 1926, starkly illustrating the extent of anti-malarial

measures that had yet to be taken and the economic need to prevent such debilitating

health crises in the future.37 When it came to these issues of labor productivity, British

businessmen increasingly turned to the expertise of medical men. As the owner of a large

Kenyan estate wrote to the British Medical Association in 1927, “the future of the estate

will depend on the continuance of the work now being done in the Reserve. This is

having the effect of helping us to get labour locally—and healthy labour at that.”38

Under pressure from economic interests, there was no way for the Medical

Service to ignore malaria, but this disease proved to be a thorny issue because there was

no agreement as to the appropriate way to carry out mosquito eradication or preventive

campaigns. In addition, the massive doses of prophylactics and the clearing of swamps required for effective anti-malarial measures were expensive. As a consequence, the decision was made to focus the first colony-wide medical initiatives for Africans on

clearly treatable infectious diseases with high economic impact. In this respect, one

disease stood out: yaws.

Yaws (also called frambesia tropica) is a tropical disease that commonly affects

humans during childhood. Its pathogen, Treponema pertenue, is closely related to the

syphilis pathogen and is passed through bodily contact.39 The disease causes skin lesions

36 C. V. Braimbridge, “Some Remarks on the Relation Between Rainfall and Prevailing Diseases in Nairobi,” Kenya and East Africa Medical Journal, Vol. 6, No. 3 (June 1929), pp. 73-74. 37 “The Annual General Meeting of the Kenya Branch of the British Medical Association,” Kenya Medical Journal, Vol. 3, No. 11 (Feb. 1927), p. 325. Also see “Editorial,” Kenya and East Africa Medical Journal, Vol. 5, No. 4 (Aug. 1928), p. 137. 38 “The Annual Meeting of the Kenya Branch of the British Medical Association,” Kenya and East Africa Medical Journal, Vol. 4, No. 11 (Feb. 1928), p. 333. 39 Well into the 1930s, there was some controversy over whether or not yaws was in fact a separate disease from syphilis. As a small example, the noted microbiologist, syphilis expert, and philosopher of science and hyperkeratosis, the abnormal thickening of the skin. Although yaws is not fatal, the

disease proceeds to destroy bone, cartilage, and soft tissue if left untreated, incapacitating

approximately 5 to 10 percent of infected people.40 The pictures taken by a doctor in the

Kikuyu Reserve in the 1920s show vividly that the disease could be severely debilitating

(Appendix, Figures 1.1-1.3).

By all accounts, yaws was endemic amongst rural African populations,

particularly the Kikuyu, the largest ethnic group in Kenya. In some communities, the

incidence of the disease was as high as eighty percent.41 In 1920, colonial medical officials decided to make yaws the first African disease for treatment on a mass scale.

Clinical experiments had proven the effectiveness of arsenic-based drugs, and local experiments confirmed that novarsenobillon (NAB) in particular worked well, so colonial health authorities were confident of their ability to wipe out the disease if given the resources.

The Medical Service aimed to use the yaws campaign to popularize Western biomedicine in the Native Reserves, whose inhabitants at that time spurned Western medicine in favor of traditional healing practices.42 Commenced in 1921, the anti-yaws

campaign ran into initial reluctance but soon gained momentum as word spread of the effectiveness of Western drug therapy. J. C. J. Callahan was the Medical Officer in charge of one district in Kikuyu Province, an area heavily affected by yaws. Yaws camps

that were free and open to the public were erected throughout the district. These camps

Ludwik Fleck commented in his 1935 book that there was unresolved ambiguity in the classification of syphilis and frambesia tropica. See Ludwik Felck, Genesis and Development of a Scientific Fact, ed. Thaddeus J. Trenn and Robert K. Merton, trans. Fred Bradley and Thaddeus J. Trenn (Chicago: University of Chicago Press, 1979, Paperback edition, 1981; originally published 1935), p. 172, footnote #45. 40 Dawson, “The Anti-Yaws Campaign,” p. 421. 41 C. J. Hacket, “Yaws,” in E. E. Sabben-Clare, D. J. Bradley, and K. Kirkwood, eds., Health in Tropical Africa during the Colonial Period (Oxford: Clarendon Press, 1980), p. 83. 42 Dawson, “The Anti-Yaws Campaign,” pp. 420-21. served the dual purpose of treating patients and training African dressers. Under

Callahan’s supervision, African dressers learned to distinguish between yaws and other

similar diseases, to recognize the three stages of yaws, and to give NAB injections. Once

their training was complete, the dressers took over a yaws camp of their own or were sent

out amongst the population to treat individuals with yaws too far advanced to travel to a camp.43 Using this system, Callahan and the African dressers he trained managed to treat

113 yaws cases in November and December of 1921. Despite this slow start, the medical

team cared for 3,419 patients in 1922, and in 1923, an additional 6,075 cases were

treated.44 Perhaps even more importantly, Western biomedicine had gained some

measure of trust with the African population. Callahan described the “popularity of treatment” and noted that his yaws patients increasingly came from adjoining districts after hearing about the effectiveness of Western drug therapy.45

All in all, 24,233 cases of yaws were treated in Kenya by the Medical Service in

1922. This number grew to 64,344 the following year, as word of the effectiveness of treatment spread.46 The treatment of the roughly twenty-five thousand cases in 1922 cost

£4,000—a small figure compared to the economic impact of the disease. The anti-yaws

campaign demonstrated the Medical Service for Africans at its most effective: it reached

a significant proportion of the population in a short amount of time, it virtually eliminated a formerly debilitating disease, and it was cost-effective to boot.

43 J. C. J. Callahan, “Some Observations on Framboesia Tropica, Made in a District of Kikuyu Province, Kenya,” East African Medical Journal, Vol. 3, No. 3 (June 1926), p. 87. 44 Ibid., p. 63. 45 Ibid., p. 88. 46 J. A. Carman, “Bismuth in Yaws and Syphilis: A Report upon a Series of Cases Controlled by Serological Tests,” Vol. 5, No. 6 (Sept. 1928), p. 187. The success of the yaws campaign paved the way for funding and support for the

treatment of other tropical diseases, including hookworm, relapsing fever, and tropical ulcer. In the ensuing years, the Medical Service was able to build upon the credibility of

the yaws campaign in order to professionalize medical care in the colony and push out

other practitioners. In 1928, Medical Officers in the Coast Province embarked on a

hookworm elimination campaign and ran into fierce resistance from local traditional

healers.47 However, the “manifest benefit following the efforts of the doctors” allowed

the campaign to proceed successfully “without any resort to compulsion.”48 In the end,

over 50,000 out of 53,000 people examined in the Coast Province were treated for

hookworm disease.49 Vaids, hakims, ‘witch-doctors,’ and other traditional healers had

long been part of the landscape of medical care in Kenya, and the colonial government

had even tacitly acknowledged the importance of alternative practitioners in light of the scarcity of medical personnel in the late-nineteenth and early-twentieth centuries.50 With these campaigns against tropical disease, however, the Medical Service began to systematically push out traditional healers. In an editorial in December 1941, the East

African Medical Journal Editorial Board complained of malpractice amongst vaids and hakims and argued that they should not be allowed to practice any longer.51 Closely

related was the passage of the Poisons Rules in 1943, which made certain classes of drugs

47 There is a strong parallel between the Brits’ hookworm eradication campaign in East Africa and the Rockefeller Foundations’ hookworm eradication campaign in the southern United States in the early twentieth century. See E. Richard Brown, “Public Health in Imperialism: Early Rockefeller Programs at Home and Abroad,” American Journal of Public Health, Vol. 66, No. 9 (1976), pp. 897-903. 48 “Hookworm in Kenya,” Kenya and East Africa Medical Journal, Vol. 5, No. 12 (March 1929), p. 396- 397. 49 “Hookworm in Kenya: British Preventive Campaign,” The Times, 01 Dec. 1928 (Issue 45065), pg. 11, col. A. 50 Vaids and hakims refer to Hindu and Muslim healers, respectively. They were legally allowed to practice under Section 19 of the Kenyan Medical Practitioners’ and Dentists’ Ordinance. 51 “Editorial: Vaids and Hakims,” East African Medical Journal, Vol. 18, No. 9 (Dec. 1941), p. 257. into controlled substances and required detailed prescriptions for their distribution.52

British doctors in Kenya had proven the mettle of their trade with the yaws and hookworm campaigns and were reaping the fruits of their success in establishing a new dominance of medical care in Kenya.53

NUTRITION IN THE 1920S: IMPORTING EUROPEAN ASSUMPTIONS AND METHODS

Besides infectious disease, diet was the other major point of concern raised by medical experiences in World War I. The links between nutrition and economic development were obvious to doctors, but the solution to the puzzle of how best to improve nutrition in order to achieve development was far less apparent. The topic of nutrition in the African population called forth not only technical questions, but also racial and evolutionary ones. In these debates, the pioneering research of J. L. Gilks and

John Boyd Orr, which applied methods from Europe to research in Kenya, was a strong statement against the use of theories of racial difference in medicine. They set the tone for malnutrition research in the colonies by forcefully linking malnutrition with susceptibility to infectious disease and by advancing universalist assumptions of human .

One of the discussions that World War I set in motion was that of the relationship between diet and labor productivity. A shortage of labor in East Africa immediately after the war contributed to the sense of urgency in this investigation; there was a consensus among doctors that the Medical Service should lead efforts to improve labor quality, in

52 “The Poisons Rules,” East African Medical Journal, Vol. 21, No. 4 (April 1944), pp. 123-124. 53 Of course, the Medical Service never succeeded entirely in pushing out traditional healers. Even to this day, alternative practitioners form an important part of the fabric of medical care in Kenya (in a similar fashion, homeopathy and alternative medicine exists alongside biomedicine in the West). However, there is no denying that tolerance in official circles of traditional healing systems declined sharply in Kenya with the rising influence of the colonial Medical Service described here. large part by discovering the optimal diet and convincing Kenyan employers to adopt it.

On June 10, 1925, C. J. Wilson, the President of the Kenya Branch of the British Medical

Association and the editor of the East African Medical Journal, led his colleagues in a

discussion on “Native Diets.” Wilson began by pointing out the fact that in 1917, the

death rate in the African Rifles Carrier Corps had been 400 per 1000 per annum, but it

dropped after the adoption of better rations in October of that year. Turning to present

problems, he went on to postulate that most Africans outside of the Reserves were “on

the borderline of food deficiency,” which contributed to disease susceptibility and

inability to withstand hard manual labor.54

The ensuing conversation, however, revealed more questions than answers. At

the top of the list were two fundamental unknowns: what do Kenyan Africans actually eat, and what ought they eat? The statements that followed quickly turned into a list of

subsidiary questions: do Africans need as much protein as Europeans? Is maize of more

nutritional value to Africans than to Europeans? Is the endurance of Africans due to their

carbohydrate-dominated diet? Are Africans more susceptible to protein deficiency than

Europeans? What is the relationship between evolution and diet? As Wilson put it, “By

evolution should not an African be more a meat eater than a European? I am perfectly

certain that primitive man did not live on nuts; he must have consumed quantities of meat

when he could get it. The African, being presumably of a more primitive type than the

European, should therefore be adapted for meat eating.”55 Another doctor, R. W. Burkitt,

disagreed with this assumption of racial difference, asserting that “there is no real

54 “Native Diets,” Kenya Medical Journal, Vol. 2, No. 5 (Aug. 1925), p. 126. 55 Ibid., p. 135. difference, as a work machine, between the native and the European.”56 Nutrition thus

became a battleground for the question of whether or not assumptions of racial difference

should be adopted in determining the nutritional needs of populations.

Fortunately for these doctors, John Boyd Orr, who was visiting Kenya as the

Director of the Rowett Research Institute in Aberdeen in order to assess the nutritional

aspects of livestock feed, found some extra time to consider humans as well. Orr was

well on his way to an influential career in nutritional science; he would later be appointed

the first director of the United Nations Food and Agriculture Organization. At this

juncture, he helped the British Medical Association Kenya Branch establish a concrete

research agenda for the study of dietetics, to be conducted in collaboration with the

Medical Research Laboratory in Nairobi. The two goals of this research scheme were to

improve “native physique” and to lower the incidence of disease by altering diet. In

justifying the need for this research, Orr relied on economic arguments.57 In an address

given to the British Medical Association Kenya Branch, he asserted that prevention of

malnutrition by providing adequate diets would be cheaper than curative disease

treatment and concluded that research in nutrition was both “commercially sound” and

“urgent.”58

The resulting report, co-authored by Orr and J. L. Gilks, the Principal Medical

Officer of Kenya colony, set the tone for future dietetics research in two important ways.

First, the authors forged a strong link between malnutrition and susceptibility to disease.

In their preliminary article that was published in both the Kenya and East African

56 Ibid., p. 146. For a history of the conceptualization of humans as work machines, see Anson Rabinbach, The Human Motor: Energy, Fatigue, and the Origins of Modernity (New York: Basic Books, 1990). 57 John Boyd Orr, “Dietetics with Special Reference to Mineral Requirements,” East African Medical Journal, Vol. 3, No. 1 (Apr. 1926), pp. 4-14. 58 Ibid, p. 13, 14. Medical Journal and the Lancet, a section on “The Prevalent Diseases” of Africans

preceded the section on “The Dietary,” which was then followed by concluding thoughts

on “Disease and Primitive Methods of Life.”59 The authors linked homogeneous,

carbohydrate diets, particularly vegetarian diets, to poor physique, susceptibility to

disease, and . Their full report, which appeared four years later,

reinforced this point with a comparison between the largely vegetarian Kikuyu and the

meat-eating Masai.60 The authors’ main finding was that the Masai enjoyed better health and were less plagued by infectious disease.

Secondly and closely related, Gilks and Orr explicitly rejected any assumptions of

racial differences in nutritional needs or disease susceptibility. Methodologically, Orr

brought to Kenya the use of nutritional surveys previously developed and applied in

Britain. Thus, the Gilks and Orr study was a direct transplantation of a research approach

from the mainland to the colony. As such, it represented a shift away from tropical

medicine’s treatment of colonies and their people as essentially different—as exotic

subjects that required different approaches than Europeans or Americans.61 Rejecting the

sort of race-based reasoning used by C. J. Wilson in the earlier British Medical

Association discussion of dietetics, Gilks and Orr assumed a universal human response to

malnutrition and disease. If Africans at first glance seemed “unduly susceptible to

disease,” it was because they were malnourished, not because they were racially

59 J. L. Gilks and J. B. Orr, “The Nutritional Condition of the East African Native,” Kenya and East African Medical Journal, Vol. 4, No. 3 (June 1927), pp. 85-90 and J. L. Gilks and J. B. Orr, “The Nutritional Condition of the East African Native,” The Lancet (1927), pp. 560-562. 60 J. Boyd Orr and J. L. Gilks, Studies in Nutrition: The Physique and Health of Two African Tribes (London: 1931), cited in Michael Worboys, “The discovery of colonial malnutrition between the wars,” in David Arnold, ed., Imperial Medicine and Indigenous Societies (Manchester: Manchester University Press, 1988), pp. 210-211. 61 Worboys, “The discovery of colonial malnutrition between the wars,” pp. 208-225. inferior.62 Gilks and Orr even concluded with a direct comparison of Kenyan Africans and British whites: “at least amongst some of the tribes the native population is no better physically and no less susceptible to disease than Britain’s.”63

By the late 1920s, then, Gilks and Orr had pushed forth a universalist research agenda on nutrition that sought to treat all populations and contexts—colonial or not— with the same assumptions and methods. It would remain to be seen how well this approach would hold up against the realities of working amongst African populations in the native reserves.

NUTRITION IN THE 1930S-1950S: NOTICING THE AFRICAN POPULATION

The clear-cut assumptions and lines of attack put forth by Gilks and Orr were representative of only one side of the story of nutritional research in colonial Kenya. As much as doctors would have liked to be able to straightforwardly apply European medical knowledge to Kenya, the fact remained that Kenya was not Europe, and the African population looked very different from the European population. As colonial doctors worked among the African population, they noticed conditions new to Western science.

Nothing in their university studies or European experiences could have prepared them for the sight of off-color babies with distended bellies suffering from kwashiorkor. Often occurring in communities with predominately carbohydrate diets, kwashiorkor is a childhood deficiency disease, now generally believed to be caused by insufficient protein intake. It is a symptomatically striking disease, with swelling of the limbs, skin discoloration, and hair depigmentation (Appendix, Figures 1.4-1.5). Children with kwashiorkor show extreme apathy to their surroundings and are unusually still, which

62 Gilks and Orr, “The Nutritional Condition of the East African Native,” p. 561. 63 Gilks and Orr, “The Nutritional Condition of the East African Native,” p. 561. made colonial doctors worry that the disease caused “mental changes” in addition to

physical ones.64 The history of Western medicine’s engagement with kwashiorkor—its attempts to identify, diagnose, and treat the disease—was one of massive confusion and fierce controversy.

Kwashiokor was also known as ‘Gillan’s Oedema’ because Medical Officer

Robert U. Gillan published a June 1934 account of cases of unusual oedema in children on the Kikuyu reserve in Kenya.65 He described twelve cases, most of them in children

two to three years old, and identified oedema—the swelling of limbs due to excess

fluid—as the chief distinguishing feature, with pallor and scaliness of the skin and

depigmentation of the hair as secondary characteristics. Worryingly, the children

“presented a picture of extreme irritability and misery” and seemed to lose all interest in

their surroundings. Gillan tentatively ventured toxemia originating from the small

intestine as the cause because many of his cases suffered from diarrhea as well.

A month later, two doctors working on another native reserve, John A. Carman

and M. A. W. Roberts, noted that a common disease amongst the Jaluo was very similar

to the one described by Gillan.66 The local name was ‘swao,’ and symptoms included

color change of the skin, paling and falling out of the hair, and oedema. However, the

ages of the afflicted children ranged from three to six months old, much younger than

Gillan’s cases. Carman and Roberts tentatively speculated that anemia and malaria were

the primary causes of death and relegated food deficiency to minor status as a

64 H. C. Trowell, J. N. P. Davies, and R. F. A. Dean, Kwashiorkor (London: Edward Arnold, 1954), pp. 100-101. 65 Robert U. Gillan, “An Investigation into Certain Cases of Oedema Occurring Among Kikuyu Children and Adults,” East African Medical Journal, Vol. 11, No. 3 (June 1934), pp. 88-98. 66 John A. Carman and M. A. W. Roberts, “Social and Health Conditions Among the Jaluo, with Special Reference to Maternal and Infant Welfare,” East African Medical Journal, Vol. 11, No. 4 (July 1934), pp. 121-122. contributing factor, but declined to draw any definite conclusions, noting that “[i]t is

unfortunate that witnesses giving widely different accounts, confused the issue so much,

that the way was not clear for a careful investigation of typical cases.”67 Indeed, the

recognition of “typical cases,” along with “typical” symptoms and “typical” diagnostic criteria, would prove to be the subject of much debate.

A full year elapsed after the publication of Gillan’s article—during which many other scientists had taken to calling the condition ‘Gillan’s Oedema’—before the realization was made that the same disease had already been described by Cicely

Williams in 1931 in a maize-eating community in the Gold Coast (Ghana). However, she did not note pallor of the skin or depigmentation of the hair, and she postulated that this condition was due to some form of food deficiency. Adding to the confusion, doctors in

Uganda, South Africa, and other parts of Africa had been referring to the disease by yet another name, “malignant malnutrition.”68

Once these various parts of the medical community realized that they were referring to the same condition, a raging nosological debate over whether Gillan’s

Oedema/kwashiorkor/swao/malignant malnutrition should be classified as a separate

medical condition ensued. Medical Officers D. V. Latham and R. Y. Stones, from

Tanganyika and Uganda, respectively, wrote in to describe similar cases in their

jurisdictions and to offer early support for classifying these cases as a new disease.69 H.

C. Trowell, a Medical Officer in Kenya and later in Uganda, mounted a spirited argument

67 Ibid., p. 121. 68 Adding yet another layer of confusion, doctors in South America primarily called the disease “Oedematous multiple-deficiency dystrophy” and “multiple-deficiency dystrophy.” Trowell, Davies, and Dean take seven pages in their book to list out all the various reports on kwashiorkor published throughout the world under dozens of names (Trowell, Davies, and Dean, Kwashiorkor, pp. 2-8). 69 D. V. Latham, “Gillan’s Oedema,” East African Medical Journal, Vol. 11, No. 11 (Feb. 1935), pp. 358- 360. R. Y. Stones, “Correspondence,” East African Medical Journal, Vol. 12, No. 4 (July 1935), pp. 113- 114. that the disease was actually a form of pellagra—niacin deficiency disease.70 By the late

1930s, the two sides had taken shape, with Trowell vigorously defending the pellagra

classification and Cicely Williams arguing for its classification as a separate disease.71

While the nosological controversy raged, the more pragmatic members of the medical community focused on strategies for identification and treatment, which were apparent long before the identity of the disease was established; in 1938, Kenya Medical Officer and East African Medical Journal editor James H. Sequeira wrote an article detailing diagnostic criteria and treatment instructions for “infantile pellagra, ‘Gillan’s Oedema,’ and ‘kwashiorkor.’”72 In fact, it would take decades for Trowell to concede that

kwashiorkor was a protein malnutrition disease.73

STATISTICS AND POPULATION CONTROL

Doctors in Kenya successfully dealt with debilitating tropical disease on the one

hand and were frustrated by questions of nutrition and dietetics on the other. Related to

both concerns was a new emphasis on mass data collection and statistical analysis.

Starting in the 1930s, doctors in Kenya increasingly kept statistics in hopes of gaining

insight into research problems and extending their control over the African population.

Increasingly, research questions were cast and answers were given in population terms.

For example, the old colonial preoccupation with growth, development, and physique

70 H. C. Trowell, Archiv. Dis. In Childhood, Vol. 12, No. 70 (Aug. 1937), reviewed in “Pellagra in East Africa,” East African Medical Journal Vol. 14, No. 10 (Jan. 1938), pp. 316-327. 71 “Infantile Pellagra: Kwashiorkor,” East African Medical Journal, Vol. 18, No. 8 (Nov. 1941), pp. 253- 255. Also see H. C. Trowell, “A Case of Pellagra of the “Infantile” Variety in a Ruanda Adolescent Showing Signs of Deficiences of Nicotinic Acid, Riboflavin and Nutritional Macrolytic Anaemia,” East African Medical Journal, Vol. 18, No. 10 (Jan. 1942), pp. 289-294. 72 James H. Sequeira, “Cutaneous Manifestations of Vitamin Deficiency,” East African Medical Journal, Vol. 15, No. 4 (July 1938), pp. 104-105. 73 Trowell, Davies, and Dean, Kwashiorkor and H. C. Trowell and D. B. Jelliffe, Diseases of Children in the Subtropics and Tropics (London: Arnold, 1958). resurfaced in one of the first medical population studies in East Africa when M. Michael

Shaw published a 1933 paper titled “The Birth-Weight of Africans.” For the study, he

measured the weights of 750 African children under the age of two years in and around

Nairobi and found that African children weighed, on average, a full four ounces less than

European children. He ended his article with a plea for more monitoring of African

children, not only of their weights, but also of their growth trajectory.74

Closely related to this desire to talk about Africans in population terms, Medical

Officers aspired to amass a comprehensive pool of statistics on the African population.

Vital statistics “are urgently required for that greater understanding of racial

characteristics which is essential both to native progress and to intelligent treatment of individual and race by ourselves [Medical Officers],” wrote H. L. Gordon, a doctor in

Kenya, in 1933.75 Statistics was a way for the state to monitor and inspect the population

in hopes of achieving the rational, enlightened rule that was seen as the objective of the

modern state.76 As Gordon wrote, “That the system of identification should be placed on

a scientific footing and extended, that Statistics should receive acknowledgment of their

vital importance, that the health programme should be reorganized, widened, and made a

chief concern of government—these are measures in the best interests of the Colony,

especially of increased production, which are required by the twentieth century principle of Trusteeship.”

74 M. Michael Shaw, “The Birth-Weight of Africans,” East African Medical Journal, Vol. 10, No. 1 (April 1933), pp. 32-34. 75 H. L. Gordon, “Native Registration and Statistics,” East African Medical Journal, Vol. 10, No. 2 (May 1933), p. 62. 76 As Ian Hacking has argued, the power of the modern state was tied to statistics and the production of a new sort of ‘objective knowledge.’ Closely related to the functioning of the modern state were new technologies for monitoring populations. See Ian Hacking, The Taming of Chance (Cambridge: Cambridge University Press, 1990). In 1933, the most ambitious statistical project yet attempted in Kenya was

completed in Digo District.77 This was the first project of sufficient reach to allow for

accurate calculations of morbidity and mortality.78 A team of African “sanitary teachers”

were sent out amongst the populace to perform basic medical functions, inspect huts, and

collect census data. Death rates and causes of death were collected by age group, which

proved to be no small feat given the fact that the Western calendar was not used widely

amongst the populace.79 The collection of these data also provided an opportunity for

Medical Officers to evaluate their work in the district. The report indicated

improvements in the area of nutrition and incidence rates of anemia, hookworm disease,

and yaws, which were “declining with the education of the people into the necessity for

early treatment.”80 On the flip side, the report uncovered high rates of and

gonorrhea, the prevalence of malarial parasites, the poor dental condition of the

population, and the need for a maternity clinic.

Seen in a different light, the new emphasis on statistics represented a new and

unwelcome encroachment by doctors into familial life and personal decisions of

reproduction and childcare, since the gathering of census data was combined with

inspections of Africans’ homes. In the 1930s, the medical community argued for the

expansion of the kipande identification system and the establishment of an accompanying

data collection apparatus that used registration certificates and fingerprint

77 J. H. Sequiera, “Vital Statistics in Digo District: A New Departure,” East African Medical Journal, Vol. 10, No. 5 (Aug. 1933), pp. 130-144. 78 Ibid., p. 144. 79 To circumvent this problem of ascertaining ages in Western calendar years, a translation chart was devised that matched African categories to European ages. For example, “Children able to walk but not yet trusted to herd goats” corresponded to 1-5 years old. See Sequiera, “Vital Statistics in Digo District,” p. 145. 80 Ibid., p. 147. identification.81 The goal was to compile “a concise dossier” of “family, personal, and

medical history” for each person. The proposed system’s potential to be manipulated for coercive purposes was not lost on the African population; Gordon noted that there was “a feeling that the system is meant to be used only to the disadvantage of the individual.”82

In addition, Medical Officers used the results of statistical studies that showed high infant mortality to push for an increase in their own authority in the formerly private matters of reproduction and childcare. New ante-natal clinics and health visitors were charged with monitoring both African children and their parents. Medical Officers argued that the new regime of child welfare necessitated questioning and sometimes overriding maternal instincts.83 Mothers could no longer be trusted to care for their own children; instead,

they needed state education in “mothercraft.”84 Statistics in medicine helped transform

reproduction from a private affair to a national interest; as Shaw wrote in 1932, the new

ideal was the “production of children who, physically and mentally, will be assets and not

liabilities to their native country.”85

This new emphasis on statistics in 1930s medical discourse was also indicative of

fundamental uncertainties about how to understand and treat the African population.

After the heady success of the yaws campaign, colonial doctors stumbled into the

frustrations of nutrition research. Even as they expanded their control over the African

population, the case of kwashiorkor illustrated that the notion that European medicine

81 H. L. Gordon, “Native Registration and Statistics,” East African Medical Journal, Vol. 10, No. 2 (May 1933), pp. 61-62. 82 Ibid., p. 61. 83 Ibid., p. 286. 84 For more about colonial officials’ attempts to control women and reproduction in Kenya, see the first, second, and fourth chapters of Lynn Thomas’s book (Lynn Thomas, Politics of the Womb: Women, Reproduction, and the State in Kenya (Berkeley: University of California Press, 2003), pp. 21-78, 103-134. 85 M. Michael Shaw, “Child Welfare,” Kenya and East Africa Medical Journal, Vol. 8, No. 10 (Jan. 1932), pp. 286. could be straightforwardly applied to Kenya smacked of a certain naïveté. In colonial

Kenya, medicine was perhaps easier done than said, for doctors in East Africa began producing practical successes long before they reached any fundamental consensus about the nature of the African body, mind, and environment.

CHAPTER II

WHAT IS ‘NORMAL’ ABOUT ‘THE AFRICAN MIND’?

“We have no Normal. And without that, psychiatry is an empty name.” — Donald Mackay, 194886

“‘Normality’ in the African, even from the standpoint of alone, is a rather meaningless abstraction.” — J. C. Carothers, 195387

In the previous chapter, I traced the emergence of the medical discourse on

population out of practical concerns in the early years of the twentieth century in East

Africa. Disease and diet research dealt with Africans’ bodies, but an increasing number

of voices asserted that African minds should not be neglected. “On the mental evolution

of the African depends the whole future of East Africa,” declared a Kenya Medical

Journal editorial in 1926.88 Psychiatry’s concern with the mental adaptation of

individuals to their society tapped into the colonial state’s anxieties about the

‘maladjustment’ of its subjects. Urbanization, industrialization, and detribalization all contributed to the sense of urgency in appeals for psychiatric studies. In 1931, the

Director of Medical Services in Kenya worried about how to “enabl[e] the tribes to function efficiently under changing conditions of life.”89 A decade and a half later, the

problem was still acute: “If we do not face the problem now, and deal with maladjusted

86 Donald Mackay, “A Background for African Psychiatry,” Vol. 25, No. 1 (January 1948), p. 2. 87 J. C. Carothers, The African Mind in Health and Disease (Geneva: World Health Organization, 1953), p. 33. 88 “Editorial,” Kenya Medical Journal, Vol. 3, No. 8 (Nov. 1926), p. 211. 89 Quoted in H. L. Gordon, “The Intentional Improvement of Backward Tribes,” East African Medical Journal, Vol. 11, No. 5 (Aug. 1934), p. 144. individuals, the problem will face us in another generation and we shall have a

maladjusted nation to deal with.”90

But how could doctors prevent ‘maladjustment’ in a largely unknown population?

As Medical Officer Donald Mackay so emphatically put it, the problem of defining the

‘Normal’ for African populations headed the list of theoretical issues that needed to be

solved before psychiatry could become a meaningful discipline in East Africa. The

problem was that psychiatrists in Africa had no notion of whether disease categories

derived from the European population could legitimately be applied to the African

population. Unlike in the diagnosis of infectious disease, there were no universal

biochemical markers that marked off a binary between illness and wellness. As late as

1948, the issue remained unresolved: “We have so far judged our mental cases on their

departure from the European Normal, if we have judged them at all. Or else we have

judged them on their departure from a Normal which we do not know,” chided Mackay.91

Reviewing psychiatric work in Kenya in the past twenty years, Mackay called for the

medical community to work harder to establish the African ‘Normal’ by conducting

population studies of ‘the African mind.’92 Nothing could be neglected; psychiatry had

to understand the African’s “background, his faiths, his hopes, his fears, his sex life—and

everything else that makes up the mosaic of his mental environment.”93 Only “hard,

grinding study” of quantitative data could establish the African ‘Normal’ and legitimize

psychiatry in the colony.

90 Mackay, “A Background for African Psychiatry,” p. 3. 91 Ibid., p. 3. 92 The alternative was in-depth psychoanalyses of individuals. For example, in 1937, South African psychiatrist Wulf Sachs published an in-depth psychoanalysis of John, a black South African, whom he had met with every week for over two years. See Sachs, Black Hamlet (London: G. Bles, 1937). 93 Mackay, “A Background for African Psychiatry,” p. 2. Mackay critiqued the preconceived notions of racial inferiority that he found in

the existing literature on the ‘Normal’ in Kenya. “The present situation is chaotic,”

Mackay wrote. “Where we should be acquiring a body of closely studied and worked-out

fact, we find a garbled mass of platitudes. ‘The African is just like a child!’ Ye Gods!!

Behold Science in Africa!...Complacency and pseudo-scientific observation.”94 Mackay

went on to urge psychiatrists to observe African mentality firsthand rather than relying on

second-hand accounts of surface characteristics. “We have been content to be

platitudinously condescending about him [the African],” he lamented.95 In this plea, he was reacting against the long history of European study of the primitive by psychologists and social theorists such as Durkheim, Freud, Marx, and Weber, all of whom speculated freely about ‘primitive’ cultures but none of whom had actually set foot in a ‘primitive’ land.96 “[A] little dilettante reading of other European authors, some who know less than

ourselves about the African,” would not do any longer.97

This chapter reviews the attempts in colonial psychiatric discourse to make sense

of what it meant for Africans to be ‘Normal’ or ‘Abnormal.’ As ethnopsychiatrist J. C.

Carothers’ quote above suggests, the notion of normality was a confusing and elusive

concept for colonial doctors in Kenya. In the 1930s, a neuroanatomist and a psychologist

tried to quantitatively establish the ‘Normal’ for the African population. Their results

established a characterization of the ‘Normal’ African as distinctly abnormal and inferior

to Europeans and white Americans. The 1940s, however, saw a shift in research away

from studying presumably ‘Normal’ Africans to studying the mentally ill. The two

94 Ibid., p. 2. 95 Ibid. p. 2. 96 Jock McCulloch, Colonial psychiatry and ‘the African mind’ (Cambridge: Cambridge University Press, 1995), p. 2. 97 Mackay, “A Background for African Psychiatry,” p. 2. Medical Officers in charge of Mathari Mental Hospital in Nairobi, H. L. Gordon and

Carothers, conducted the first studies of the incidences of various psychiatric disorders

amongst Africans and emerged with a distinct picture of the ‘peculiarity’ of mental

illness in Africans. As it turned out, colonial psychiatry in Kenya construed mental

illness in Africans as doubly abnormal: first in the sense that it affected a minority of the

African population, and secondly in that it deviated from European patterns of mental

illness.

In explaining the abnormality of both ‘Normal’ and ‘Abnormal’ Africans,

psychiatrists in Kenya relied increasingly on cultural and environmental explanations.

Two lines of reasoning emerged in Carothers’ work in particular: African minds were

being strained by rapid changes in their social environment due to European colonization,

and African minds were the product of a dangerous physical environment plagued by

disease and malnutrition. In this way, medical discourse in colonial Kenya moved away

from racialist biological explanations toward an environmentally focused conception of

the mind—a move that would occasion some uneasy reflections not only about African

mental health, but also European culture and civilization. By the late 1940s,

‘maladjustment’ implicated Europeans as well as Africans; originally the fear of impending African mental deterioration that motivated psychiatric research in East

Africa, the concept came to embody anxieties about the effects of European colonization itself.

THE ‘NORMAL’ IS ABNORMAL

Through the work of F. W. Vint and R. A. C. Oliver, the medical disciplines of

anatomy and psychology contributed to the characterization of the African ‘Normal.’ Over the course of the 1930s, groups of Africans were measured, tested, and scrutinized

in order to derive statistical averages and distributions. Slowly, the ‘Normal’ of the

African population came to be understood in its deviation from the European ‘Normal.’

The ‘African mind’ was perceived to be markedly different in at least two quantitatively

demonstrated ways: its physical characteristics and its intellectual capabilities. Through these studies, colonial medical discourse cast the African ‘Normal’ as the European deviant.

In the early 1930s, pathologist F. W. Vint produced a widely-cited

neuroanatomical analysis of brains of Kenyan Africans. 98 Vint was a highly

accomplished medical student at Belfast who had also served in the military during

World War I and achieved the title of lieutenant. His specialty was pathology, and in

1936, he was appointed Senior Pathologist by the colonial government in Kenya. Vint had been a Medical Officer in the colony for seven years when he embarked on his study of “The Brain of the Kenya Native,” in which he analyzed one hundred adult male

African brains obtained from autopsies.99 On the macroscopic level, he weighed and

measured the heights and lengths of the brains and reported their key visible features. On the microscopic level, he sectioned the tissue in order to carry out cell counts and observe cell size and closeness of packing. Finally, he compared all his measurements and observations to those of European brains. In one detailed table, Vint listed the average

98 F. W. Vint, “The Brain of the Kenya Native,” Journal of Anatomy, Vol. 68 (1934), pp. 216-223. An earlier version appeared in the East African Medical Journal two years prior. See F. W. Vint, “A Preliminary Note on the Cell Content of the Pre-frontal Cortex of the East African Native,” East African Medical Journal, Vol. 9, No. 2 (May 1932), pp. 30-49. 99 Vint’s choice of subjects betrayed his implicit definition of the African ‘Normal.’ He wrote, “Only brains that appeared to be normal were used.” He ended up using only brains from adult males that were uneducated and had never been incarcerated, either in a mental hospital or in a prison (Vint, “The Brain of the Kenya Native,” p. 216). measurements of various parts of African brains, which included a column listing the “% increase or decrease compared with the European brain.”

Vint’s key finding was that African brains were, on average, 10.6% lighter than

European brains. Weights of African brains classified by age suggested that the African brain stopped growing earlier in adolescence than did the European brain. African brains measured smaller in 26 out of 33 categories, with the greatest difference occurring in the supragranular and granular layers in the forebrain, which showed a 36% decrease between Europeans and Africans.100 In particular, the cortex in Africans was found to be narrower than in Europeans. Vint was careful not to draw any conclusions from his finding that African brains were smaller than European brains; in fact, his article was conspicuous for its lack of comment on the matter. It would be up to others to draw inferences about race and intelligence from Vint’s results.

Almost concurrently to Vint’s neuroanatomical study, R. A. C. Oliver, a visiting researcher to Kenya funded by the Carnegie Corporation, conducted a research project that sought to establish the intelligence of ‘Normal’ Africans.101 He reviewed the existing literature on “cultural achievement” and Vint’s work on brain size at great length, but the originality of the paper arose from the fact that he conducted intelligence tests with groups of African and European schoolboys. He tested roughly one hundred boys between the ages of 15 and 20 from each group.

In devising his “General Intelligence Test for Africans,” Oliver was cognizant of the difficulties of constructing a test that would be valid across cultural lines. He rejected

100 Ibid., p. 221. 101 This study was published in two parts in the East African Medical Journal. See R. A. C. Oliver, “The Comparison of the Abilities of Races: with Special Reference to East Africa,” East African Medical Journal, Vol. 9, No. 6 (Sept. 1932), pp. 160-175 and Vol. 9, No. 7 (Oct. 1932), pp. 193-204. any tests that relied on linguistic expression, either spoken or written, because the use of one language over another might favor one group unduly. More fundamentally, language

“occupies a different place in the cultures of different groups, some peoples resorting to

verbal expression more readily than others.”102 But he recognized that even the use of

pictures, toys, and symbols might be problematic, for “these objects too are not equally

familiar in different cultures.”103 In addition, “the whole institution of tests is a European

one,” and even such innocuous aspects as writing with a pencil may bias the test towards

one culture.104 With these misgivings, he created a non-verbal test in which subjects had

to process pictures, numbers, letters, and other symbols. For example, one section asked

participants to cross out parts of a picture that did not belong.105

Oliver found that the average African scored 15% lower on his intelligence test than the average European. The distribution of the scores of the two groups revealed significant overlap, with approximately 15% of Africans reaching or exceeding the mean

European score. Taken together with the fact that research in America suggested that

African Americans performed on average 20% below white Americans on intelligence tests106 and Vint’s finding that African brains were on average 10% smaller than

European brains, Oliver concluded preliminarily that his data “seem[ed] to suggest” that

102 Ibid., p. 170. 103 Oliver continued, “The seeing of pictures as standing for things is a habit which is learned, and one which most European children, for example, have more opportunity of learning than most African children. Similarly, the actual symbols used in tests may be as unfamiliar to European children as to African children, yet European children are probably much more accustomed to the mere use of symbols as such. The case is the same with blocks; most European children are accustomed to playing with shaped pieces of wood more than most African children are. We have only to compare the European child’s equipment of toys, blocks and picture books with the scanty odds and ends an African child plays with before he is sent out to herd goats, to see how much more familiar with such test material the European may be. Such material may be admirable for distinguishing among Africans themselves, but quite unsuitable for making comparisons between Africans and Europeans,” ibid., pp. 170-171. 104 Ibid., p. 171. 105 Ibid., p. 173. 106 T. R. Garth, “A Review of Race Psychology,” Psychology Bulletin (1930), pp. 27, 5, 329-356, cited in Oliver, “The Comparison of the Abilities of Races,” pp. 165-169. “the average cerebral and mental development of natives of East Africa is in the

neighbourhood of 85 per cent of that of Europeans.”107

Thus, despite initial uncertainty, the disciplines of neuroanatomy and psychology in the 1930s concurred that the African ‘Normal’ was deviant by European standards.

The work of Vint and Oliver established a picture of the ‘Normal’ African brain as being underweight and the ‘Normal’ African intellect as being substandard. This line of research would not survive, however, for in the ensuing decades, psychiatric discourse shifted its focus from the African ‘Normal’ to the African ‘Abnormal.’

THE ‘ABNORMAL’ IS DOUBLY ABNORMAL

Starting in the late 1930s, research on ‘the African mind’ in Kenya came to be

dominated by studies of the mentally ill. The reason was largely circumstantial: Vint, the

author of the neuroanatomy study above, was a pathologist in charge of the Medical

Research Laboratory in Nairobi; to him, the study of Kenyan brains was a diversion from

his normal research interests. R. A. C. Oliver, who conducted the intelligence tests of

African and European schoolchildren, was a visiting researcher and soon left Kenya. It

was up to two directors of a mental hospital in Nairobi, H. L. Gordon and J. C. Carothers,

to continue the research on ‘the African mind.’ Gordon was a medical doctor with a keen

interest in psychology who entered the psychiatric profession formally in 1929 as a

private consultant for Mathari Mental Hospital in Nairobi. The hospital was

overcrowded and short on staff, and it hired Gordon primarily to take care of the

European patients. Gordon ended up staying on for the next eight years before he had to

retire due to failing health. His most notable achievement was the lowering of the death

107 Oliver, “The Comparison of the Abilities of Races,” p. 203. rate at Mathari from 10 percent to 4 percent.108 His successor, Carothers, also had no formal training in psychiatry, but would spend twelve years in charge of both Mathari

Mental Hospital and His Majesty’s Prison in Nairobi. Before these positions, he had been a government Medical Officer working in various parts of Kenya for nine years. By the late 1940s, he was well on his way to being acknowledged as the “foremost authority on mental illness in the African.”109

Not surprisingly, Gordon’s and Carothers’ viewpoints centered not on the African

‘Normal,’ but rather on the mentally ill with whom they had daily contact. Over the course of the next decade, their epidemiological studies revealed a very different incidence pattern of psychiatric disorders in Africans than in Europeans or Americans.

Put in a different way, these psychiatrists found that the already ‘Abnormal’ mentally ill in Africa were doubly abnormal when compared to the European ‘Abnormal.’

On December 18, 1935, less than two years after Vint’s and Oliver’s studies, H.

L. Gordon gave a talk to the British Medical Association in Kenya regarding the incidences of various types of mental illness in Africans. This research, which was also published the following year in the East African Medical Journal, was the first survey in

East Africa of Africans suffering from mental illness.110 Gordon examined the

distribution of mental illnesses amongst 120 African patients of Mathari Mental Hospital

and compared the disease incidence of this group against that of Europeans.111 Gordon’s

African patients showed two striking differences from Europeans: a lower incidence of

108 McCulloch, Colonial psychiatry and ‘the African mind’, pp. 21-23. 109 Ibid., p. 1. 110 H. L. Gordon, “An Inquiry into the Correlation of Civilization and Mental Disorder in the Kenya Native,” East African Medical Journal, Vol. 12, No. 11 (Feb. 1936), pp. 327-335. 111 Ibid., p. 329. ‘affective’ disorders and paranoia and a worryingly high incidence of ‘adolescent’

disorders.

His first major finding was that the incidence of “affective” (later known as

manic-depressive) disorders was radically lower in Africans than in Europeans. There

was an order of magnitude of difference between the two groups: 1.6% of Gordon’s

African patients suffered from “affective” disorders, compared to 16% of Europeans.112

Within this group of disorders, there were a few Africans suffering from mania, but none from depression. Gordon did not even venture an explanation: “Why? Answer is not possible; we are too ignorant of normal Native mind.”113 In addition, Gordon observed only one paranoid case, who turned out not to be “Bantu” African at all but rather came from the Red Sea region. Again, he declined to even try to account for “the complete absence of this group” in Africans, citing again the lack of the understanding of the

African ‘Normal.’114

In contrast to the incidence of affective disorders, Gordon found a surprisingly

high incidence of “adolescent” disorders. Gordon called this category “adolescent”

because the preponderance of his young patients was afflicted: out of the 42 young adults

in his study, 62% were affected.115 Gordon’s renaming of this disease category reflected

uncertainties about its definition in the larger psychiatric community. As Gordon noted,

this illness had been called Dementia praecox, but this name had been going out of

fashion since World War I. Schizophrenia was the more accepted contemporary term.

Whatever the name, Gordon described three examples of this “splitting of personality” in

112 Ibid., p. 328. 113 Ibid., p. 329. 114 Ibid., p. 330. 115 Ibid., p. 330. Africans, all of whom professed what were to Gordon delusional beliefs.116 What was particularly disturbing to Gordon was the combination of European knowledge and traditional African beliefs; “[s]craps of European Knowledge are very often jumbled with witchcraft and magic,” he wrote.117 He worried that this disease was becoming more common amongst Africans. He cited the jump in its incidence during World War I, and even during peacetime, he believed “adolescent” disorder to be on the rise due to rapid urbanization and detribalization.118

Gordon’s successor at Mathari Mental Hospital, J. C. Carothers, took up his

methodology and many of his questions. In 1948, the same year that Mackay published

his appeal for a new emphasis on psychiatry of the normal African, Carothers published a

two-part study on mental disease in Africans, “A Study of Mental Derangement in

Africans, and an Attempt to Explain its Peculiarities, more Especially in Relation to the

African Attitude to Life,” which was a vastly more ambitious version of Gordon’s 1926

study.119 Its verbose title betrayed the tension inherent in Carothers’ endeavor to portray the African population: amongst Africans, mental derangement, which was by definition already an abnormal state, was considered doubly ‘peculiar,’ and these ‘peculiarities’ arose organically from the very way that Africans approached life. This study examined

116 In Gordon’s words: “A Kikuyu clerk preached me a fervent sermon in Swahili punctuated by disgraceful English. A Kisii teacher professed to own three schools and a church, to have the Holy Virgin as his wife, and yet also a licence issued by the Kisumu magistrate to kill me. To another Kikuyu the clock on my table was the Deity, the hands were St. John and St. Paul; nevertheless he priced the clock at only two shillings,” ibid., p. 330. 117 Ibid., p. 330. 118 Ibid., p. 332. 119 This study was published in two parts in the East African Medical Journal. See J. C. Carothers, “A Study of Mental Derangement in Africans, and an Attempt to Explain its Peculiarities, More Especially in Relation to the African Attitude to Life,” East African Medical Journal, Vol. 25, No. 4 (April 1948), pp. 142-166 and Vol. 25, No. 5 (May 1948), pp. 197-219. Also, similar studies had been published for the African population in Nyasaland in 1936 (H. M. Shelley and W. H. Watson, “An Investigation concerning Mental Disorder in the Nyasaland Natives,” Journal of Mental Science, Vol. 83 (Nov. 1936), pp. 701-730) and in Uganda in 1944 (E. M. K. Muwazi and H. C. Trowell, “Neurological Disease among African Natives of Uganda,” East African Medical Journal, Vol. 21, No. 1 (Jan. 1944), pp. 2-19). the mental illnesses experienced by the 609 Kenyan Africans admitted to Mathari Mental

Hospital in the five-year period between January 1, 1939 and December 21, 1943.

Carothers classified his patients into nine categories of mental illness, plus one additional

class of “unclassified psychoses.”120 For comparison purposes, Carothers primarily relied on figures for African Americans in the state of Massachusetts.

Carothers’ chief finding was that the total incidence of mental illness was conspicuously low amongst Africans: 3.4 per 100,000 of the population per annum, compared to 57 in England and Wales, 72-86 for Massachusetts citizens of all races, and

161 for African-Americans in Massachusetts.121 Carothers considered the possibility that

the mentally ill in Africa were often cared for by traditional healers or by family

members, but he still concluded that there was at least a ten-fold difference between the

rates of mental illness of Africans and British. The greatest difference in incidence that

Carothers found between the African and non-African groups was in the class of manic-

depressive psychoses (what Gordon had earlier called “affective disorders”). Like

Gordon, Carothers found a surprisingly low incidence of these mental illnesses: 0.13 per

100,000 per annum for manic-depressive disorder, compared to 13.4 amongst African

Americans.122 Even more striking was the fact that there had been no cases of depression

at Mathari in the previous five years.

In this way, psychiatric discourse in colonial Kenya elucidated a pattern of mental

illness in Africans conspicuous in its difference from those of Europeans and of

Americans. Africans seemed to suffer far less from psychiatric disorders, in the

120 The nine categories were organic psychoses, epilepsy, mental defect, psychopathy, schizophrenia, paranoia, manic depressive, involutional melancholia, and psychoneuroses (Carothers, “A Study of Mental Derangement in Africans,” p. 156). 121 Ibid. p. 148. 122 Carothers, “A Study of Mental Derangement in Africans,” p. 203. “affective” or manic-depressive psychoses in particular. In addition, schizophrenia among young men seemed to be on a worryingly steep rise. The next challenge was to explain these ‘peculiar’ aspects of African mental illness.

NURTURE OVER NATURE, BODY OVER MIND

Gordon referred to “backwardness,” and Carothers pointed to “peculiarities.” As

I described above, in the 1930s, ‘the African mind’ came to be characterized as

‘Abnormal’ by European standards. But in explaining its ‘Abnormality,’ should explanations be rooted in the biological or the environmental realms? Gordon in 1934 was unsure; in a talk given to the Kenya Society for the Study of Race Improvement, he discussed both Africans’ “biological heritage,” in particular “the evolution of the new brain,” as well as their “environmental heritage” and “social heritage.”123 He concluded

that “[t]he only thing we can be sure of at present is that the condition we call

backwardness is not due to nature alone, not due to nurture alone, but to some

combination of the two; and modern knowledge leads us to expect nature to

preponderate.”124 Over the next decade, however, explanations of ‘peculiarities’ of ‘the

African mind’ would increasingly be rooted in nurture, not nature. In the 1940s and

1950s, Carothers would gradually shift the mode of analysis away from biological and

racial explanations toward cultural and environmental theories. Two particular lines of

reasoning gained credence in psychiatric discourse: Africans were experiencing

maladjustment due to the rapid introduction of European civilization, and ‘the African

mind’ was the product of the diseased, malnourished African body.

123 H. L. Gordon, “The Intentional Improvement of Backward Tribes,” East African Medical Journal, Vol. 11, No. 5 (Aug. 1934), pp. 143-156. 124 Ibid., p. 149. The increased focus on environmental factors was a result of the growing feeling

within the scientific community in the interwar years that overtly racialist science could

no longer be supported. Theorists within the fields of psychology, social science, and

anthropology expressed growing dissatisfaction with the vagueness of race as a

classification scheme and increasingly questioned the validity of the biological criteria that made up the concept of race.125 In the East Africa case, Helen Tilley has argued

convincingly that the rejection of Gordon’s proposal for research into “native

backwardness” by the African Survey in the late 1930s represented a key shift in the

larger colonial research agenda away from projects driven by biological essentialist

ideas.126 Given the new scientific zeitgeist, it was not surprising that Carothers in 1948

shied away from overtly racial explanations in explaining the “peculiarities” he observed in the African mentally ill. “[I]t does not seem necessary to invoke genetic factors, as our problem can surely be answered without reference to these,” he wrote. “Environmental factors alone could supply the answer.”127 This strand of environmental reasoning would

be expanded further still in his 1953 monograph on mental health and illness in Africans.

In explaining the incidences of specific mental illnesses, Carothers invoked the

African social and cultural environment. Recall the puzzle posed by Gordon in 1936:

125 The most widely cited definition of race with regard to Africans in the East African medical literature is C. G. Seligman’s Races of Africa (first edition published in 1930). In it, he made the distinction between “Hamitic,” “Nilotic,” and “Bantu Negroes” (C. G. Seligman, Races of Africa (London: T. Butterworth, 1930). Using Seligman’s classification, Carothers characterized Kenya’s African population as being composed mainly of “Bantu Negroes,” with some representation from the “Nilotic,” “Half-Hamitic,” and “Hamitic” groups as well (Carothers, “A Study of Mental Derangement in Africans,” pp. 145-146). Many British doctors in East Africa also referred to Diedrich Westermann’s The African Today and Tomorrow, which integrated Seligman’s racial classification into a wide-ranging anthropological discussion of African cultures, traditions, and beliefs; see Diedrich Westermann, The African Today and Tomorrow (London: Oxford University Press, 1939). 126 Helen Tilley, “Ambiguities of Racial Science in Colonial Africa: The African Research Survey and the Fields of Eugenics, Social Anthropology, and Biomedicine, 1920-1940,” in Benedikt Stuchtey, ed., Science across the European Empires, 1800-1950 (Oxford: Oxford University Press, 2005), pp. 245-287. 127 Carothers, “A Study of Mental Derangement in Africans,” p. 209. why did Africans suffer so little from “affective” (manic-depressive) disorders? The

environmentally conscious Carothers of 1948 ventured a cultural explanation:

In any race it would seem that the attitude of the manic is, “I am a wonderfully successful and important person and my success is entirely due to myself,” while that of the depressive is, “I am a miserable failure, and this is entirely my own fault.” The two conditions have this in common—a strong sense of personal responsibility…Perhaps the most striking difference between the European and African cultures is that the former demands self-reliance, personal responsibility, and initiative, whereas there is no place in the latter for such an attitude.128

Therefore, manic-depressive disorders were rare amongst Africans because they were acculturated to be less self-reliant, responsible, and inventive than Europeans. Carothers characterized traditional African culture as relying on supernatural explanations, stifling individual responsibility, and suppressing personal initiative with its rigid social structure. According to his explanation, the subordination of the individual by the group eliminated the sense of pride that might lead to mania and the sense of guilt that might lead to depression.

A similar line of reasoning was increasingly invoked to explain the rise of schizophrenia amongst Africans. Commenting on “adolescent” disorders in 1936,

Gordon used a two-part, environmental and biological explanation. He cited the rapidly changing social environment as the cause of biological degeneration, which in turn caused the disorder:

The extraordinary stresses and strains of the war produced a huge crop of the adolescent disorder from front and rear; amazing cases; very difficult we found them, and too often incurable. In peace man is always devising new blows to knock out his frontal brain; in my early days the breakdowns flowed freely after the numerous religious revivals and hallelujah meetings of those times; in my later days equally freely from the life of cocktail and night club. One culprit is always at work.129

128 Ibid., p. 214. 129 Gordon, “An Inquiry into the Correlation of Civilization and Mental Disorder in the Kenya Native,” p. 332.

Gordon located the primary causes of the disease in changes in the social environment—

war, religion, and urbanization—but retained a biological mechanism—the breakdown of

the frontal brain—as the middle step that connected environment and mental illness.

This middle step disappeared completely by the time Carothers wrote his article

on the incidence of mental disorders amongst Africans in the late 1940s. By this time,

the social and cultural environment alone was sufficient to explain the incidence of

schizophrenia, without reference to . Carothers explicitly rejected essentialist

explanations, asserting that there was “no need to assume that the difference in attitude

[between Africans and Europeans] is intrinsically racial.”130 He wrote that regardless of

race, “certain types of personality in a certain age-group tend to respond to environmental

difficulties with a schizophrenic syndrome.”131 Similar to his explanation for manic- depressive disorder, he invoked a characterization of traditional African life as having a

“large, complicated and rigid social organization.”132 The breakdown of this structure

caused schizophrenia, and given the rapid changes to African life caused by European

contact, “it is merely surprising that schizophrenia is not even commoner.”133

For Carothers, “primitive” African culture was “characterized by its unity and

coherence,” which explained his finding that the overall incidence of mental illness

among Africans was less than one-tenth of those of Europeans, Americans, and African-

Americans.134 The arrival of Europeans, however, threatened to shatter this equilibrium

between ‘the African mind’ and its cultural environment. Both Gordon and Carothers

130 Carothers, “A Study of Mental Derangement,” p. 214. 131 Ibid., p. 165. 132 Ibid., p. 205. 133 Ibid., p. 165. 134 Ibid., p. 205. saw the increasing rates of mental certification that they observed at Mathari Mental

Hospital to be the result of industrialization, urbanization, and detribalization caused by

European colonization. As early as the 1930s, Gordon pointed out the disturbances brought about by European rule, particularly in wartime. He saw dangers in peacetime as

well, chiding Europeans for introducing potent alcohol, Asians for Indian hemp

(marijuana), and Arabs for Catha (Khat).135 Commenting on the impact of European civilization on Africans, he wrote, “I prefer to think of it as a series of pressures; pressure

of the developed upon the undeveloped mind; pressure of thought, emotion, behaviour; of

intellect, imagination, foresight; of suggestion and example; of venerable codes, customs,

and national ideals, founded on a religion of truth, justice and love—all forming an

unprecedented experience for the Native brain involving inevitable adjustment or

inevitable catastrophe.”136

Carothers agreed with Gordon’s assessment that Africans were likely

experiencing maladjustment to European cultural and social influence. He pointed out

that the “[t]he tribes, irrespective of race, that are most detribalized are those with the

highest certification rate [of mental illness].”137 Carothers chose to interpret this fact as

evidence of the tremendous impact of European civilization on Africans rather than

indicative of a reporting bias in which detribalized groups with more contact with

Europeans were more likely to be treated at a mental hospital and thereby certified

mentally ill. “[T]he East African native has…an immense admiration for European

institutions and manner of life, so that contact with this alien culture is rapidly destroying

135 Gordon, “An Inquiry into the Correlation of Civilization and Mental Disorder in the Kenya Native,” p. 329. 136 Ibid., p. 333. 137 Carothers, “A Study of Mental Derangement in Africans,” p. 155. his own,” he wrote. “The conflicts and difficulties engendered by this tendency might

well be expected to be a potent source of mental breakdown.”138

In addition to explanations focusing on culture and society, a further line of

environmental reasoning appeared in the 1950s, when psychiatric discourse began to

emphasize the physical effects of the African environment on the body. In the early

1950s, Carothers was commissioned by the World Health Organization to write an

extensive tract on ‘the African mind.’ Although he only spent nine months researching

for this work, he traveled extensively across Africa, Europe, and the United States to

meet physicians and other experts. His contacts included H. Aubin and P. Gallais, two of

the leading physicians from Francophone Africa, ethologist Konrad Lorenz, and

anthropologist Margaret Mead.139 In the resulting work, The African Mind in Health and

Disease: A Study in Ethnopsychiatry, disease and malnutrition—the twin evils that so

occupied the attention of the Medical Officers discussed in Chapter I—served a key

explanatory function in ethnopsychiatry’s conception of the ‘deficient’ ‘African mind.’

Carothers devoted over a third of the book to “The Physical Background of the

African,” a wide-ranging discussion of physical anthropology, the African environment,

and bodily disease. By environment, he meant the interactions of five factors: geography,

climate, infection, nutrition, and culture.140 He managed to find significance in

everything from the “hostility of the countryside” to the “monotony of scene” in

Africa.141 In particular, Carothers invoked the post-World War I research on disease and

dietetics, reviewed in Chapter I, to explain ‘deficiencies’ in the African mind.

138 Ibid., p. 153. 139 McCulloch, Colonial psychiatry and ‘the African mind’, p. 58. 140 Carothers, The African Mind in Health and Disease, p. 21-56. 141 Ibid., p. 22. Carothers went into great detail on infectious diseases, which he discussed in their

order of importance for psychiatry in Africa. Syphilis, trypanosomiasis, and malaria

were the most high-impact diseases, with “their insidiously debilitating effects, which

may be ephemeral but are often life-long,” he wrote. “Few Africans are free from all of

these, and it would be easy to find examples of persons infected concurrently with

malaria, hookworm, bilharziasis, ascariasis, and taeniasis, with a haemoglobin level of

about 30% and yet not complaining of ill health.”142 In this way, the post-World War I

medical fixation on infectious disease found its way into the psychiatric discourse of the

1950s.

Having convinced his reader that the African body was disease-ridden to an

abnormal level, Carothers weakened the prototypical African body further with his

lengthy discussion on nutrition.143 Establishing a link between the ‘deficient’ mind and the weak body was a way to avoid racialist explanations. “[M]alnutrition is almost universal in Africa and is being increasingly recognized as fundamental in African psychiatry,” wrote Carothers.144 Protein, vitamin A, and vitamin B deficiencies posed

acute problems. In addition, he warned that kwashiorkor “give[s] rise to such a variety of visceral lesions which may be permanent and irreversible, and so far-reaching in their effects on the body and mind of many apparently ‘normal’ Africans.”145 Here, he cited

the work of Dr. H. C. Trowell, a seminal figure in the research into kwashiorkor

discussed in the first chapter. From the first ‘discovery’ of the illness, Trowell and other

142 Ibid., pp. 32-33. 143 I am indebted to Funke Sangodeyi’s unpublished term paper, “Diet as Destiny in Colonial and Post- Colonial Africa: Nutrition and ‘the African Mind’” (Harvard, 2007), for identifying this line of reasoning in Carothers’ work. 144 Carothers, The African Mind in Health and Disease, p. 33. 145 Ibid., p. 60. doctors had been disturbed by the extreme apathy of children with kwashiorkor.

Carothers shared Trowell’s fear that infants and children may only appear to recover,

when in fact they become scarred for life, as evidenced by the prevalence of cirrhosis of

the liver in post-mortem autopsies of Africans. Carothers played up this line of reasoning

further by citing a Kenya Medical Officer in his opinion that “[t]he mental changes found

in kwashiorkor are the most consistent and probably some of the most important of all

changes found in the disease.”146 Even worse, full recovery was not possible: “stunted

growth” was unavoidable, and “the retardation which must occur in many little children

from this cause is likely to be permanent to some degree.”147

Psychiatric discourse postulated that, together, disease and malnutrition predisposed Africans to mental illness; as Carothers wrote, they “promote a continuing

background of ill health which must increase the liability to mental breakdown from

other causes, and which may indeed be one factor in the mental attributes of the so-called

‘normal’ African.”148 The two factors were seen to reinforce each other: infestation with

worms contributed to chronic malnutrition, and in turn, malnutrition increased

susceptibility to infectious disease. The resulting weak African body caused a

correspondingly “high degree of lethargy” in the mind.149

UNEASY REFLECTIONS: CULTURE, CIVILIZATION, AND RESPONSIBILITY

As I have described above, Gordon and Carothers came to explain the

‘peculiarities’ of ‘the African mind’ in large part by its inability to acculturate to the

146 Malcolm Clark, “Kwashiorkor,” East African Medical Journal, Vol. 28, No. 6 (June 1951), pp. 229-236. The citation appears in Carothers, The African Mind in Health and Disease, p. 111. 147 Carothers, The African Mind in Health and Disease, p. 111. 148 Ibid., p. 24. 149 Ibid., p. 112. changing cultural and social environment brought about by European rule. But acculturation to European civilization and potential maladjustment were also the original concerns that motivated psychiatric research in colonial Kenya. Worried about the effects of the rapid changes caused by colonialism on the African population, doctors in

Kenya set out to understand first the ‘Normal’ and then the ‘Abnormal’ African. To explain the cause of abnormality in the African mentally ill, they moved away from racial and biological explanations and towards cultural and environmental ones—resulting in their curious position of seeing maladjustment as a finding of the very research it motivated. In Carothers’ work in particular, the fact that “the African is going through a period of cultural transition” was both an impetus for psychiatric research and a finding of that same research.150

Maladjustment as a research finding, however, did occasion some ruminations on the value of European civilization that maladjustment as a research motivation did not.

Carothers, for one, realized that his explanation that European culture precipitated mental illness in Africans was at least as much a reflection on European culture as it was on

African culture. Reflecting on the low incidence of mental disorders in Africans, he wrote that “the rarity of insanity in primitive life is due to the absence of problems in the social, sexual and economic spheres…its frequency in Europe and America is due to the multiplicity of such problems.”151 Commenting on the vastly higher rates of depression among Europeans, he wrote, “One is led to wonder, therefore, whether the occurrence of this psychosis is not bound up in the some way with the possession of a certain attitude to

150 Carothers, “A Study of Mental Derangement in Africans,” p. 147. 151 Ibid., p. 209. life.”152 And although Africans did not measure up to European standards of analytic

thought, Carothers ended his work by suggesting that conscious, rational thought may not

be the only legitimate way, and certainly not the healthiest way, to experience the world:

[The African] uses his whole brain more effectively than does [the European]; he uses phantasy and reason. European integration is essentially a conscious one and depends on a cleavage between conscious and unconscious elements of mind which is far less sharp in Africans. Advantage does not lie wholly with the former. The European technique depends on the denial, in adult conscious life, of desires and phantasies which are thus relegated to a world of darkness and of dreams, but which emerge, only too often, to determine patterns of thinking and behaviour which are incomprehensible or even incapacitating from the subject’s conscious point of view. There is internal conflict, and a sacrifice of personal to social peace and happiness…There may be other sacrifices.153

Carothers’ skeptical and self-conscious gaze fell on his fellow Europeans as well as on

his African subjects: although this notion is somewhat romantic, the comparison with

Africans showed the rigor but also the dangerous implications of the European way of

life. In Carothers’ analysis, no race or culture came off well, for Europeans were

inventive but depressed, and Africans were primitive but mentally at peace—at least, they

were before the unsettling influence of European civilization.154

In the space of twenty years, the concept of ‘maladjustment’ had been reinvested

with anxieties about Europeans as well as about Africans. Embedded in colonial

psychiatry’s uneasy reflections on European culture and civilization were new, pressing

concerns about the effects of European colonization and the impact of European

civilization upon the African population. These worries would lead to new research

152 Ibid., p. 214. 153 Ibid., p. 172. Italics in original. 154 This romanticizing of ‘the primitive’ brings to mind Enlightenment ideas about the corrupting influence of civilization. For a discussion of Rousseau’s idea of the ‘noble savage,’ see Dorinda Outram, The Enlightenment (Cambridge: Cambridge University Press, 1995), pp. 66-68. Carothers seemed to be aware of the reference and even tried to distance himself from it, writing that “the old idea of the happy-go-lucky uncultured savage has been recognized as false long since” (Carothers, “A Study of Mental Derangement in Africans,” p. 153). Despite the disclaimer, it is unclear how his reflections on ‘the African mind’ differed from older ideas of the ‘noble savage.’ questions about the efficacy of British colonialism in the late 1940s and 1950s: have

Africans ‘progressed’ under British rule, and what was the proper way to manage the development of this changing population? In the next chapter, I will explore this topic further by tracing the role of medical ideas in debates of colonial administration.

CHAPTER III

‘HEALTH,’ MEDICINE, AND MAU MAU

“The present position…offers, by reason of current activities in local government, town planning, and general development of the Colony, an unrivalled opportunity to think, not parochially, but colonially and scientifically.” — Kenya Medical Journal Editorial, 1926155

Scientific colonialism: the phrase may be an oxymoron to us today, but this idea expressed the goal of medical men in East Africa stated in its most expansive terms. By mid-century, colonialism as an institution was beginning to crumble, as indigenous independence movements were appearing with increasing rapidity. Kenya was such a young colony—in fact, the youngest in the British empire—that the white settlers there

felt they had at least another generation before the end of their rule. But with the rise of

organized Kikuyu discontent, the demand to modernize—to shrug off the ‘parochialism’

of the old extractive colonialism and to bring in a new era of rational, enlightened,

‘scientific’ rule—was urgent. Medicine was situated at the heart of this attempted transformation of the colonial state. Its early successes in wiping out previously devastating infectious diseases such as yaws won the medical community the trust and cooperation of many Africans, and its rhetoric of rational management seemed to offer the best hope for the modernization of colonialism.

The post-World War II era, however, presented its own set of challenges for the

medical community. In the late 1940s, doctors ‘discovered’ the extent of the overpopulation problem in East Africa and experienced a moment of profound panic and self-blame. During World War II, there had been no comprehensive reviews of the health

155 “Editorial,” Kenya Medical Journal, Vol. 3, No. 7 (Oct. 1926), p. 181. situation in Kenya because a large portion of the already scarce medical resources and

staff was diverted to war efforts. After the war, a Committee on Health was charged with

making recommendations for the creation of a ten-year health plan as part of the

Development Planning Committee. One of the Committee’s fundamental questions

concerned “vital trends”: “was the population static, increasing, or decreasing and, if either of the latter, at what rate?”156

The answer was frightening: the population was estimated to be growing at 1.5%

to 2.3% per annum. This fact was nothing short of terrifying for all parties involved—

doctors, educators, administrators—for it meant that the Kenyan population of roughly

four million would double in thirty to forty-six years. Given the already distressing

plunge in the fertility of the soil—an estimated drop of 50% in the next twenty-five

years157—the fear that “KILLING FAMINES OF A MAJOR ORDER WILL OCCUR

AND BE RECURRENT in East Africa [capitals in original]” was all too real.158

What gave rise to this overpopulation problem? The Kenyan medical community was blunt in blaming itself, though not without a hint of pride at the magnitude of the problem and thus of the impact of its work. As the outgoing Director of Medical

Services in Kenya, A. R. Paterson, wrote in 1947:

We reduced the death-rate, and more particularly the death-rate from infectious disease without reducing the birth-rate. I don’t know what we reduced it to but that we must have reduced it considerably is beyond doubt. We were successful partly because it was a very easy thing to do, every one, black, or white, is

156 The Council of the Kenya Branch of the British Medical Association, “The Case for the Appointment of a Royal Commission on Health and Population in His Majesty’s Dependencies in Africa,” [dated December 1947], East African Medical Journal, Vol. 25, No. 1 (Jan. 1948), p. 35. 157 A. R. Paterson, “The Human Situation in East Africa. Part II: Towards a Population Policy.” East African Medical Journal, Vol. 24, No. 4 (April 1947), p. 145. 158 The Council of the Kenya Branch of the BMA, “The Case for the Appointment of a Royal Commission on Health and Population,” p. 43. Capitals in original. The influence of a recently published pamphlet on decreasing land fertility by two District Officers in Kenya is evident here; see H. E. Lambert and P. Wyn Harris, The Kikuyu Lands (Nairobi: Government Printer, 1945). anxious to escape the grave, and so we had all the people on one side. But an important point is that my successor [as Director of Medical Services] is going to go on reducing it. Possibly (and I think, probably) more rapidly than has ever been done in the case of any population anywhere before, whether black, or brown, or white. 159

According to Paterson, medicine’s very effectiveness caused the colony to be faced with

such a fearsome, looming overpopulation problem. But the magnitude of the problem

also demonstrated the power of medicine, for in the short space of two decades, a handful

of doctors had transformed a shrinking population into a fearsomely expanding one.

Along the way, they achieved the singular distinction among colonial governmental

departments of gaining some measure of trust with Africans. For these reasons, doctors

felt that despite the fact that they created this overpopulation problem, they should be the ones to lead the efforts to solve it.

Their answer was more “health,” not less: in 1947, the Council of the British

Medical Association Kenya submitted a 45-page memorandum urging the formation of a

Royal Commission on Population to investigate how the population problem could be solved by promoting the “modern conception of health.”160 The government must aspire to be the “good physician” for the whole of the population by planning carefully and acting decisively.161

But ‘health’ as a concept had undergone an all-encompassing redefinition in the

previous two decades. In this chapter, I examine how doctors in Kenya expanded

‘health’ into a term that embodied not only pathology within the bounds of the individual,

but also wellness within society as a whole. In the 1940s, influenced by the social

159 A. R. Paterson, “The Human Situation in East Africa. Part I: On the Increase of the People,” East African Medical Journal, Vol. 24, No. 1 (Feb. 1947), p. 83. 160 The Council of the Kenya Branch of the BMA, “The Case for the Appointment of a Royal Commission on Health and Population,” p. 30. 161 Ibid., p. 61. medicine movement, they made ‘health’ into an ideal that included such concepts new to

East Africa as management, prevention, and positive health. Conveniently, the central

tenets of this new paradigm of ‘health’ complemented the activities of the Medical

Service of the past twenty years: lobbying to include medical goals on the agendas of

other administrative departments and publicizing hygienic habits and healthy lifestyles

amongst the African population. The rise of Mau Mau—the infamous peasant revolt that consumed the Kikuyu in the 1950s and eventually toppled British colonialism in

Kenya—illustrated both the attractiveness and the abstractness of colonial medical discourse. The colonial government adopted a medical explanation of what was instead a political and economic crisis, but it never followed through with any of the doctor’s recommendations. The medical discourse had achieved the right of rhetoric—pride of place in narrating the development of colonial rule—but without corresponding powers to affect concrete policy.

THE EXPANSION OF THE DEFINITION OF ‘HEALTH’

The 1940s saw the rise of a seemingly new, population-based conception of

‘health.’ Medical discourse self-consciously shifted focus from treatment on the

individual level to planning on the societal scale. In 1943, the British Medical

Association in Kenya at its annual meeting adopted a resolution stating that “the health of

the people depends primarily upon the social and environmental conditions under which

they live and work, upon security against fear and want, upon nutritional standards, upon

educational facilities, upon the faculties for exercise and leisure, and upon a healthy spiritual and political outlook on life both international and individual.”162 World War II demonstrated the destructive power of science, adding urgency to doctors’ attempts to create a new paradigm of humane knowledge in service of society. Influenced by the social medicine movement that was gaining momentum in Britain at the time, doctors in

Kenya committed themselves to a broad definition of medical work, one that included not only curing diseases, but also intervention on the social and political level. Their hope was that this new, broad approach would affect more people more quickly than curative medicine could. Because of this expansion of the aims and methods of medical work, a whole host of concepts hitherto new to Kenya was introduced into medical discourse, including health management, preventive medicine, and positive health. But as I will describe later, these seemingly novel concepts imported from Britain in the 1940s conveniently dovetailed with the medical community’s activities in the past twenty years and thus served to provide additional modern-sounding justification for the Medical

Service’s longstanding activities.

To many doctors, the late 1940s were a reminder that scientific knowledge needed to be harnessed for the benefit of humanity. In East Africa, railroad building and the

World Wars had taken an appalling toll on human life. Social medicine seemed to offer hope that destructive science could be redeemed.163 At the close of World War II, the destruction enabled by scientific knowledge weighed heavily on psychiatrist H. L.

Gordon’s mind:

162 “British Medical Association, Kenya Branch,” East African Medical Journal, Vol. 21, No. 4 (April 1944), p. 125. 163 Social medicine was an interdisciplinary approach to medicine and public health that tried to combine the methodologies of both medical and social sciences. For a review of the social medicine movement in twentieth century Britain, see Dorothy Porter, ed., Social Medicine and Medical Sociology in the Twentieth Century (Amsterdam: Rodopi, 1997). Chemistry and Physics, pregnant with atomic bombs, were carried off by Industry and Commerce to civilize Africa. Their import permits, classed as “social welfare goods” listed smoke, smuts, stinks, dust and dirt, as humble gifts to propitiate the Municipality and Railway; and for the Old Order, tons of quackery, mashed information, masochistic education, and rehabilitation in prewar Jamal Purbhai jodhpurs. But Social Medicine arose; Chemistry and Physics sobbed into her arms; she curetted them, and reclaimed them from the destruction to the upbuilding of human life; then she spoke to all whom it might concern: “Take note! Town planning, location of factories and railways and their conduct, food, drink, housing, medication, education, information, health preservation, all social welfare—these and more are my affairs, you know not what you do”!164

In this way, social medicine channeled the already present recognition in Kenya of the ineffectiveness of the “Old Order” of colonialism that sought merely to extract resources without investing meaningfully in the colony. The atomic bombs had been detonated less than three months prior—a dire reminder of the fearsome power of science untempered by human concerns. Indeed, in late 1945, there seemed to be an urgent need to ground science in a value system based on “the upbuilding of human life.”

To Gordon and other East African doctors, social medicine seemed to offer such a promise. In 1942, the Nuffield Trust founded the first chair for Social Medicine at

Oxford University, and John Ryle, a pivotal figure in the founding of the field, was appointed to the position. In East Africa, his ideas resonated strongly with a medical community that eagerly sought health solutions on a mass scale:

The importance of Social Medicine to Kenya can scarcely be over-rated; her fate is involved…Kenya is on the way to pay the penalty for neglect to study her population; but Social Medicine can replace guesswork by knowledge; it is the instrument with which social policy and development may be based upon scientific knowledge for the first time. The dream of some of us here for almost twenty years can now be realized.165

164 H. L. Gordon, “The Importance of Social Medicine to Kenya,” East African Medical Journal, Vol. 23, No. 1 (Jan. 1946), p. 4. 165 Ibid., p. 2. Social medicine resonated with British doctors in Kenya because of its population-level

focus and its claim that doctors must influence social and economic policy. In addition,

one of the central tenets of social medicine was an emphasis on the environment’s

influence on human health. In Kenya, this idea closely resembled the tendency,

identified in the previous chapter, to locate origins of mental and physical attributes in

environmental rather than racial causes.

Practically, social medicine called for doctors to embrace a new, management-

based conception of healthcare. In 1950, R. C. Browne, Nuffield Professor of Industrial

Health at the University of Durham, was invited to summarize the methods and aims of a

social medicine program for East Africa. In the resulting article, he asserted that the

“management of health is a wider conception than mere pharmacological treatment.”166

Indeed, clinical treatment was only one part of a broad scheme of healthcare that should cover all aspects of life; “[t]he ætiology, and hence the prevention of the mass of mortality and ill-health,” wrote Browne, “is clearly through a combination of education, nutrition and sanitation.”167 This realization required the introduction of medical advice

into diverse departments of colonial administration. Medical men should be the

architects of a new, healthy society: “The health of a community is a function of wise

administration guided by medical and other appropriate advice,” wrote Browne.168

A second concept that gained credence in East Africa due to the rise of social medicine was prevention. In the early 1950s, a Medical Officer for Health in Nairobi presented an economic argument for focusing efforts on prevention and even ventured to

166 R. C. Browne, “Social Medicine in England and East Africa,” East African Medical Journal, Vol. 27, No. 2 (Feb. 1950), p. 70. 167 Ibid., p. 71. 168 Ibid., p. 72. say that preventive medicine was more important than curative medicine.169 Browne

agreed wholeheartedly: “Preventive and clinical medicine must work hand in glove, but

in a country with primitive sanitary standards, where the commonest diseases are

preventable and where the methods for preventing them are known it is of the utmost

importance to invest the limited financial resources available in a wise preventive

policy.”170

The ultimate goal of social medicine was the achievement of positive health. As

G. V. W. Anderson, Medical Officer in Kenya, explained in a paper read to the East

African Medical Conference on February 20, 1949:

Normal health can be said to be that state where man is at one with his environment. Disease is where he is at war with it or it with him. But peace is not a state of the absence of war. It is a positive, creative condition where the whole man is bent to achieve a maximum. War is not a state of the absence of peace, but the presence of malignancy. The creation of a state of positive health then is more than the removal of an enemy; it is a new state of life, a new creation.171

In order to achieve this maximal, creative state of health, mere preventive and curative medicine were necessary but not sufficient. Similar to the line of reasoning within the psychiatric discourse described in the last chapter, the attainment of positive health depended not only on the individual, but also on the cultural, physical, and social environment.172 Administratively, positive health implicated all manner of governmental

departments: “Positive health lies in recreation, physical education, housing, nutrition,

169 A. T. G. Thomas, “The Future of Preventive Medicine in Nairobi,” East African Medical Journal, Vol. 28, No. 8 (Aug. 1951), pp. 318-328. 170 Browne, “Social Medicine in England and East Africa,” p. 171, italics in original. 171 G. V. W. Anderson, “Emotion as a Basic Factor in Physical Disease,” East African Medical Journal, Vol. 26, No. 6 (June 1949), pp. 146-147. 172 Ibid., p. 154. eugenics, education, employment, town-planning and perhaps, by far the largest factor of

all, mental health.”173

The creation of the World Health Organization in 1946 served to reinforce this

new, expanded notion of ‘health.’ The British Medical Association in Kenya

enthusiastically adopted the WHO’s definition of health as “a state of complete physical,

mental and social well-being and not merely the absence of disease and infirmity.” This

formulation was cited in the opening of the Association’s 1947 Memorandum for the

Appointment of a Royal Commission on Health and Population.174 In 1949, C. E.

Mortimer, the Agricultural Commissioner for Land and Settlement and Member for

Health and Local Government of the British Medical Association Kenya, gave a talk at

Makere in Uganda in which he urged the adoption of this expansive

definition of health. Echoing the creed of social medicine and the rhetoric of the WHO,

he presented humans as physical, mental, and spiritual beings and emphasized the need to

treat them in the context of their communities.175

But in effect, how new were these ideas of social medicine, management,

prevention, and positive health to Kenya? In the next two sections, I argue that in fact,

these concepts had been in circulation within colonial medical discourse since the late

1920s, particularly in the Medical Service’s dealings with other administrative

departments and with the African population. Social medicine from Britain and the

173 G. V. W. Anderson, “Medical Practice after the War,” East African Medical Journal, Vol. 19, No. 7 (Oct. 1942), p. 208. 174 The Council of the Kenya Branch of the BMA, “The Case for the Appointment of a Royal Commission on Health,” p. 30. 175 C. E. Mortimer, “A Layman’s View of a Doctor’s Job,” East African Medical Journal, Vol. 26, No. 5 (May 1949), pp. 100-108. World Health Organization, then, provided authoritative outside justification for medical

approaches already in use in Kenya.

‘HEALTH’ AND COLONIAL GOVERNANCE

The vision of a new, ‘healthy’ Kenya of the future required not only the efforts of doctors, but also the cooperation of the rest of the colonial administration. Doctors in

Kenya had never been shy about making their views known to other parts of the colonial

government. Starting in the late 1920s, the medical community gave themselves the right

to comment on a whole host of issues not straightforwardly medical. The example of

education will illustrate how doctors increasingly commented on matters in which they

had no direct expertise.176 And with a few misgivings, the other departments agreed, at

least in principle, that medical concerns and scientific research should inform their work.

The astonishing success of the yaws campaign, described in Chapter I, legitimized

the Medical Service both in its own eyes and in the view of other administrative units.

Speaking before an audience that included the governors of the East African colonies in

1936, Gordon made no pretense at modesty: “Your Excellencies of East Africa…your

men of science are out and away the most valuable and important people in your

Colonies.”177 Later, Gordon advised his medical colleagues, “In this phase of post-war confusional derangement be sane scientific stoics still. Have faith in the stable intelligent minority. Teach them and help them to lead Kenya by means of a social policy and wise

176 Due to space constraints, I choose to focus on the Education Department, but a similar cases can be made for agriculture, town and urban planning, and veterinary services. 177 H. L. Gordon, “A Rumination on Research and Eye-Wash,” East African Medical Journal, Vol. 13, No. 4 (July 1936), pp. 110-119. measures based upon scientific knowledge to an infinitely truer and fuller life in the great age that is coming.”178

In practice, this sentiment meant that medical men increasingly commented on

issues outside their immediate area of expertise. The Education Department in particular

found itself inundated with the opinions of Medical Officers. A. R. Paterson, the Deputy

Director of Sanitary Services in Kenya, gave a talk entitled “The Education of Backward

Peoples” to the Centenary Meeting of the British Medical Association for the

Advancement of Science in September 1931 in which he defined education as “the

improvement of a community.”179 He found the mission-type education offered in Kenya

thus far to be wholly unsatisfactory because of its limited aims. Paterson invoked the

profound concerns about African ‘maladjustment’ within the psychiatric discourse

discussed in the last chapter to argue that the goal of education should be much broader:

The problem of education in Africa is, in short, how to enable backward peoples, whose civilization is in many respects admirably adapted to ensure their survival under primitive conditions of isolation, to function efficiently under the very different conditions which are resulting from the removal of that isolation and from their incorporation in a world community, and how to enable them to bear effectively the responsibilities which that incorporation involves.180

According to Paterson, education should not be limited to academic subjects, but should be expanded to include hygiene and sanitation instruction, disease prevention, and proper homemaking.

There was a significant amount of interchange between the Medical Service and the Education Department of colonial Kenya. In 1945, the Commission on Higher

Education in the Colonies (the Asquith Commission) published its report, which listed

178 Gordon, “The Importance of Social Medicine to Kenya,” p. 12-13. 179 A. R. Paterson, “The Education of Backward Peoples,” Kenya and East African Medical Journal, Vol. 8, No. 11 (Feb. 1932), p. 306. 180 Ibid., p. 302. better nutrition, sanitation, and hygiene, as well as the establishment of schools of medicine, as essentials for the improvement of education in British colonies. In particular, the psychiatric discourse reviewed in the last chapter resonated with educational ideals. In 1934, H. L. Gordon defined education as “the control of nurture to obtain the best possible development of nature.”181 At least a few prominent educators agreed: writing in 1954, Miriam Janisch of the Kenya Education Department concurred with her medical colleagues in the definition of her mission: “To develop to the full the physical, mental and spiritual powers of the child.”182 She explicitly cited the importance of the field of psychiatry; only in understanding the mental capabilities of the African and the influence of traditional culture could educators rationally plan teaching strategies and devise an appropriate educational structure. “The solution of so many problems both of physical health and mental capacity hang on the development of the science of the study of the mind,” she stated.183

Janisch might have welcomed the input of her medical colleagues, but others were less enthusiastic about the Medical Officers’ expanded agenda. In fact, from early on, the eagerness of some of the doctors to change social structures earned them fierce critics who accused them of being socialists. In 1927, the East African Standard reported that a member of the legislative council accused the Medical Service of “attempting all kinds and every kind of socialistic activity in the Reserves, in his opinion for no other purpose than windowdressing.”184 The editorial that month in the East African Medical Journal

181 H. L. Gordon, “The Intentional Improvement of Backward Tribes,” East African Medical Journal, Vol. 11, No. 5 (Aug. 1934), p. 145. 182 Miriam Janisch, “The Purpose of the Education of the African Child,” East African Medical Journal, Vol. 31, No. 4 (April 1954), p. 170. 183 Ibid., p. 169. 184 Quoted in “Editorial,” Kenya and East African Medical Journal, Vol. 4, No. 8 (Nov. 1927), p. 231. protested vehemently: “We fail to see how real improvement can be effected, except by systematic effort to improve social conditions…‘Socialistic activity,’ directed by the medical authorities towards improvement in sanitary conditions, is the form of enterprise most likely to secure the greatest asset which any country can possess, a healthy population.”185

‘HEALTH’ AND THE AFRICAN POPULATION

The Education Department was not the only recipient of the Medical Service’s preaching; starting from the late 1920s, Africans themselves heard plenty about health and hygiene. The doctors were, in their own words, “taking the horse to the water” by creating a “propaganda” program to pontificate to the African population.186 At least in their own opinions, their efforts were well-received, as African villagers ate English stew and African leaders budgeted more money for hospitals and medical staff. Although there were dissenters to the new regime of social medicine even within the medical community, it seemed that ‘health’ was an issue that could unite both Africans and

Europeans.187

185 Ibid., p. 231. 186 A. R. Paterson, “‘Taking the Horse to the Water’: An Experiment in Propaganda, Illustrated,” East African Medical Journal, Vol. 20, No. 7 (July 1943), pp. 247-252. 187 This is not to say, however, that there was no internal dissent within the medical community on ‘propaganda’ specifically and the approach of medicine more generally. It is clear, though, that these critiques were advanced by an embattled minority pushing for the return of out-of-fashion traditional curative medicine. A. J. Keevil and L. H. Cane, self-titled “Ordinary Doctors,” wrote a scathing letter to the East African Medical Journal in 1949 attacking social medicine and its ideal of ‘positive health.’ They particularly objected to social medicine’s insistence that doctors also be ‘health propagandists’ who get to know patients and their homes in order to right unhealthy living conditions and check any potential signs of disease. “If the people themselves are not to be trusted to use their common-sense by applying to a doctor when they feel the beginnings of disease,” ranted Keevil and Cane, “is it likely that gratuitous medical visiting will do anything except create a nation of hypochondriacs?” More generally, they disagreed with the tenets of social medicine: “We submit, Sir, that this modern insistence on ‘social medicine’ is no more than a medical fashion reflecting the prevalent political fashion called ‘socialism’: the idea that individuals are to be submerged into a collective whole called the ‘community’ or the ‘state.’ We are to be de- humanised into abstract units in a system.” See A. J. Keevil and L. H. Cane, “A Doctor’s View of a Because ‘health’ depended on both personal hygiene and society-wide sanitation,

doctors in Kenya decided that they needed to teach a new way of living to the African

population. In 1929, to spread the word on hygiene and cleanliness, the Medical Service budgeted for a new item—₤2,200 for “Propaganda.” This included the purchase of a cinema camera and projector for showing health films and the setting up of a model

village at Kavirondo.188 Also starting in the late 1920s, various campaigns against

helminthic diseases began to include education on latrine construction and sewage

disposal.189 In the 1940s, when DDT and gammexane spraying began to be used in

malaria, relapsing fever, and onchocereasis control, a film on DDT produced by the East

African Sound Studios was shown to villagers to extol the virtues of this public health program.190

Starting in the 1930s, the Medical Service also began to organize health fairs in

Nairobi and Mombasa. From January 13 to January 17, 1930, an estimated 15,000 people attended the first Health Exhibition held in Nairobi.191 The event featured

opening speeches by the governor of the colony and Neville Chamberlain, former

Minister of Health.192 Its slogan was “A Healthy Africa,” and it featured eleven sections of displays: “Townplanning, Housing, House Drainage and Plumbing, Meat and Food

Inspection and Control, Clean Milk, Dietetic Economy, School Medical Inspection,

Communicable Diseases (Malaria, Plague, Intestinal Worms, etc.), Laboratory Methods

Layman’s Lecture” (Letter to the Editor), East African Medical Journal, Vol. 26, No. 8 (Aug. 1949), p. 237. 188 “Kenya Medical Department Estimates, 1929,” East African Medical Journal, Vol. 5, No. 10 (Jan. 1929), pp. 330-332. 189 For example, the Digo District hookworm campaign in the last 1920s. See “Hookworm in Kenya,” Kenya and East African Medical Journal, Vol. 5, No. 12 (March 1929), pp. 394-397. 190 P. C. C. Garnham, “The New Insecticides,” East African Medical Journal, Vol. 25, No. 1 (Jan. 1948), p. 7. 191 “Editorial,” East African Medical Journal, Vol. 6, No. 11 (Feb. 1930), p. 311. 192 “The Nairobi Health Exhibition,” East African Medical Journal, Vol. 6, No. 11 (Feb. 1930), p. 330. in the Diagnosis of Diseases, Maternity and Child Welfare, and Hospitals and

Dispensaries.”193 The exhibits included live snails and rats, “enormous” models of

tapeworms, layouts of proper housing, and free blood examinations “while you wait.”194

Shortly thereafter, Mombasa had its own ‘Health Show and Baby Week’ to promote

cleanliness and hygienic habits. The many exhibits were presented in several languages to accommodate the heterogeneous European, Asian, and African audience. The carnival-like atmosphere was captured by photographs printed in September 1930 in the

Kenya and East African Medical Journal (Appendix, Figures 3.1-3.2).

Given the prolonged concern with improving nutrition in Kenya traced in Chapter

I, it is not surprising that medical propagandists focused their attention on improving dietary habits. In 1943, due to the shortage of corn and potatoes that were commonly used in African cooking, the Medical Service carried out an experiment to popularize

‘English’ vegetables such as carrots, turnips, leeks, cabbage, and cauliflower amongst the

Kikuyu in an effort to avert malnutrition and famine.195 The government spent ₤100 to

set up a food exhibition in Kiambu Market, with cooking demonstrations and samples

“for issue at a nominal charge” (Appendix, Figures 3.3-3.7). The experiment was

apparently a success; for the two months of its duration, plates of stew were sold in large

quantities, and even “the old men of the conservative type” partook (Appendix, Figure

3.8).196

The leaders of these African villages seemed similarly enthusiastic about the work

of the Medical Service. Since the success of the yaws campaign of the 1920s described

193 Ibid., pp. 331-332. 194 Ibid., p. 332. 195 Paterson, “‘Taking the Horse to the Water’: An Experiment in Propaganda,” pp. 247-252. 196 Ibid., p. 248. in Chapter I, the support of African leaders for health projects was a constant refrain in

district and colony-wide reports. In his 1928 annual review, the Director of Medical

Services in Kenya remarked upon of the unprecedented interest in health matter by local

native councils and their willingness to fund medical projects.197 For example, in

Baringo District in the early 1930s, the Native Council agreed to fund two dressers

themselves—no small task on their small budget. From treating 731 patients in 1928, the

increased staff and facilities took in 16,030 patients in 1931.198 Likewise, in Elgeyo-

Marakwet district, the local Native Council voted to fund the upkeep of the hospital and dispensary.199 One of the most well-known conservative leaders of the African

community, Chief Warũhiũ, co-wrote an article in the East African Medical Journal

supporting the collaboration between Africans and Europeans in medical work.200 Health was an issue that all three races in Kenya, despite their different value systems, could agree was important; the authors urged cooperation across age and racial lines on this all- important matter.

MAU MAU AND THE MEDICALIZATION OF POLITICAL PROBLEMS

The medical community in Kenya seemed successful in marshalling a consensus

among colonial administrators and Africans that ‘health’ was a worthy goal, but it

remained to be seen whether medicine’s humane aspirations could manifest themselves in

concrete action. The 1950s presented such an opportunity—Mau Mau was the biggest

197 J. L. Gilks, “A Medical Review of Kenya during 1927,” Kenya and East African Medical Journal, Vol. 4, No. 11 (Feb. 1928), p. 333-337. 198 Kenya National Archives Reel #67, Political and District Record Books, Baringo Political Record Book, p. 00524. 199 Kenya National Archives Reel #67, Political and District Record Books, Elgeyo-Marakwet Political Record Book, p. 01311. 200 Chief Warũhiũ and B. M. Gecarga, “Co-Operation between Europeans and Africans in Medical and Social Work,” East African Medical Journal, Vol. 25, No. 9 (Sept. 1948), p. 374. challenge to British governance in Kenya yet. Materially, the Medical Service had little impact on the British administration’s response to Mau Mau; its one ‘success’ was in eliminating tick-born relapsing fever. Rhetorically, medical men were more influential—

the colonial government adopted J. C. Carothers’ medicalized explanation of this political

problem. But his narrative, although compelling, remained just that—a story that had no

bearing on the tangible British response to Mau Mau.

Although British settlers in World War II-era Kenya believed that they had at

least another generation of rule in the colony, many Kenyans themselves thought

otherwise. After World War II, rising Kikuyu dissatisfaction with British rule and

frustration over land shortage manifested itself in a mass peasant movement called Mau

Mau.201 The movement started in the late 1940s with widespread oathing rituals; in

1952, killings of British settlers and African colonial sympathizers began to be attributed

to Mau Mau, and the British government declared a State of Emergency. The double-

pronged British response was brutal; it involved both a military attack on militarized Mau

Mau insurgents, as well as a massive detention camp and stockaded village system for

civilians that lasted almost a decade.

The medical community was not shielded from the violence that Mau Mau

wrought; in fact, two of the earliest and most publicized murders of the Mau Mau crisis

had ties to the medical community. On October 9, 1952, Mau Mau adherents pretending

201 The literature on Mau Mau is one of the largest in African history; I will only point to a few beginning points here. Caroline Elkins’ recent book, Imperial Reckoning, covers the civilian side of the British response to Mau Mau (Caroline Elkins, Imperial Reckoning: The Untold Story of Britain’s Gulag in Kenya (New York: Henry Holt, 2005). David Anderson’s book focuses on the military history—the ‘dirty war’ against Mau Mau insurgents; see David Anderson, Histories of the Hanged: The Dirty War in Kenya and the End of Empire (New York: Norton, 2005). For a succinct exploration of the place of Mau Mau in subsequent political, historical, and cultural discussions in Kenya, see E. S. Atieno-Odhiambo, “The Production of History in Kenya: The Mau Mau Debate,” Canadian Journal of African Studies, Vol. 25, No. 2 (1991), pp. 300-307. to be policemen shot Chief Warũhiũ—the co-author of the 1948 article calling for

cooperation between Europeans and Africans in medical work. The Chief, one of the

most prominent of the Kikuyu to oppose Mau Mau, was murdered in the backseat of his

Hudson sedan as he was being driven from Nairobi to the village of Gachie; the

murderers were never apprehended (Appendix, Figure 3.9).202 Three and a half months

later, on January 24, 1953, the Ruck family was murdered in their home. The family was

brutally hacked to death by their trusted servants, and grisly images of six-year-old

Michael were transmitted around the world in the international press (Appendix, Figure

3.10).203 His mother, A. Esmée Ruck, was the first Kenya-educated woman to qualify as

a doctor and had worked in the Native Civil Hospital. At the time of her death, she was running a local dispensary for Africans. Understandably, the news of her death shook the

Kenyan medical community to the core; her obituary in the East African Medical Journal grieved, “That the gallant trio should be deliberately and successively killed in one night by savage primitive weapons is a tragedy indeed for Kenya.”204

Despite its discourse of individual and social wellbeing, the Medical Service did

very little to curb British brutality regarding Mau Mau. In fact, the medical community

tacitly lent its support to the inhumane British policies. During the State of Emergency,

the British government forcibly displaced large portions of the civilian population into

stockaded villages. Ironically, this blatant violation of human rights provided health

officials the opportunity to eliminate tick-borne relapsing fever, a public health menace

that had largely resisted their efforts at eradication thus far. Prior to the 1950s, officials

had carried out small-scale projects to replace bedsteads, particularly among the Meru, to

202 Elkins, Imperial Reckoning, p. 31. 203 Elkins, Imperial Reckoning, p. 42. 204 “Obituary: Dr. A. Esmée Ruck,” East African Medical Journal, Vol. 30, No. 3 (March 1953), p. 124. limited success. Mau Mau presented the opportunity to carry out mass-scale action

against tick-borne relapsing fever. Colonial medical expert C. Teesdale saw the

elimination of the disease in Kenya as “a sequel to the measures undertaken by the Kenya

Government to deal with the and the declaration of the state of

emergency in November 1952.” He continued:

The policy of bringing the peasant population into stockaded villages resulted in the evacuation of large numbers of huts infested with Ornithodorus moubata [the pathogen that causes tick-borne relapsing fever] and caused a break in the of the disease. This move alone would probably have proved of only temporary benefit had it not been for the institution of regular searches for ticks in the new villages.205

In the villages, colonial health officials conducted routine inspections of dwellings. In the event that ticks were found, the house was sprayed with 0.5 percent Gammexane dusting powder. Infected humans were treated with spirochetal drugs, and new housing and beds were installed. As a result, between 1952 and 1955, a 90% reduction of the disease was reported for the Central Province.206 This success against tick-borne

relapsing fever, however, was of course less impressive when considered in the context

of the widespread physical and psychological atrocities committed against the Kikuyu in

these same villages.

But what caused Mau Mau in the first place? Three doctors published three

opinions on the matter: two were political explanations, and the third was a medical

account. The difference in their viewpoints reflected the diversity of British doctors’

experiences in Kenya and the range of political opinions within the medical community.

205 C. Teesdale, “Tick-Borne Relapsing Fever: The Present Position in Kenya,” East African Medical Journal, Vol. 42, (1965), p. 531. 206 Charles M. Good, “Man, Milieu, and the Disease Factor: Tick-Borne Relapsing Fever in East Africa,” in Gerald W. Hartwig and K. David Patterson, eds, Disease in African History: an Introductory Survey and Case Studies (Durham: Duke University Press, 1978), p. 74. And the choice of explanation adopted by official circles illustrated the appeal of medical

explanations for the late colonial state. The first of these accounts was written by

Christopher Wilson, a doctor, resident of Kenya for over forty years, and member of the

Kenyan Legislative Council. In 1954, he wrote Kenya’s Warning: The Challenge to

White Supremacy in Our British Colony, in which he blamed Mau Mau upon British

administrative errors.207 John Wilkinson, a doctor on the Church of Scotland Mission

Hospital in Tumutumu, wrote an article that same year attributing Mau Mau to the widespread political discontent amongst the Kikuyu.208 Contrary to these governmental

and political explanations, ethnopsychiatrist Carothers chose instead to medicalize the

movement by locating its causes in the instability of ‘the African psyche.’209

It is not surprising that Wilson, as a member of the Kenyan legislature, favored

governmentally focused explanations for Mau Mau. In Kenya’s Warning, he detailed a

long history of administrative errors, starting from the first allocations of land to white

settlers, which did not take into account the fact that seemingly unsettled areas in the

White Highlands had in fact been cultivated by Kikuyu who were only driven out at the

turn of the century by smallpox and famine. The largest administrative mistake,

however, was the increased sympathy within the British government in the years leading

up to Mau Mau with Jomo Kenyatta, the Kikuyu Central Association, and the Kenya

African Union. According to Wilson, rather than committing themselves to slow and

steady progress, the British administration had been seduced by these Africans into

believing that quicker development was possible. As the review of his book in the East

207 Christopher Wilson, Kenya’s Warning: The Challenge to White Supremacy in Our British Colony (Nairobi: 1954). 208 John Wilkinson, “The Mau Mau Movement: Some General and Medical Aspects,” East African Medical Journal, Vol. 31, No. 7 (July 1954), pp. 295-314. 209 John C. Carothers, The Psychology of Mau Mau (Nairobi: Government Printer, 1955). African Medical Journal put it, “this young Colony was harassed by those who wanted

the African to run before he could walk.”210 Thus, in Wilson’s analysis of Mau Mau, the brunt of the blame for the Mau Mau movement should be placed on poor governmental administration.

John Wilkinson, of the Church of Scotland Mission, likewise used a political

explanation to explain Mau Mau; but working intimately amongst the Kikuyu on the

Reserves, he focused much more attention on factors within the African community

itself. Under a section entitled “The Salient Features of the Movement,” the first item

read, “The Mau Mau movement is primarily a political movement…Its aims are political

and the movement is primarily a political movement…It is not a return to savagedom,

though it uses the methods of the savage to overcome opposition.”211 Wilkinson

identified two major political aims: unification of the Kikuyu and the creation of an all-

black Kenya under Mau Mau leadership. Wilkinson also characterized Mau Mau as an

“opposition movement,” the goal of which was to combat all aspects of European living,

particularly Christianity, but even down to the minutiae of cigarette smoking and

European-style clothing. To him, the “terrorism” employed by Mau Mau was the means

to an end: politics was at the heart of the movement, not savagery and violence.

In contrast to these political interpretations of Mau Mau, the official explanation adopted by the colonial government medicalized the issue. J. C. Carothers, the ethnopsychiatrist discussed in the last chapter, was called out of retirement to diagnose

the problem. He located the origin of Mau Mau in the state of transition of ‘the African

mind’:

210 J. A. Carman, “Christopher Wilson, Kenya’s Warning [Review],” East African Medical Journal, Vol. 31, No. 5 (May 1954), p. 251. 211 Wilkinson, “The Mau Mau Movement,” pp. 298-299. [Mau Mau] arose from the development of an anxious conflictual situation in people who, from contact with the alien culture, had lost the supportive and constraining influences of their own culture, yet had not lost their “magic” modes of thinking. It arose from the exploitation of this situation by relatively sophisticated egotists.212

As I described in the last chapter, Carothers’ work helped create a psychiatric discourse

that cast the African population as being in a fragile state of transition between

‘primitivism’ and civilization. Africa had changed at an alarmingly fast rate, and these

transformations threatened mass maladjustment. Carothers described the mental state of

Africans as one of profound mental “insecurity” and “bitterness.” In addition, because

the transition to European-style civilization had yet to be completed, the Kikuyu had been influenced by Europeans into changing much of their social structure, but they still held superstitious beliefs. Their trust in “magic” and “witchcraft” accounted for the particular power that oaths held over the oathtaker’s loyalties, even in cases in which he/she had been reluctant to take the oath. The fragile state of ‘the African mind,’ therefore, provided fertile ground for the dissemination of Mau Mau ideology by a few insidious agents.

Despite this dire description, Carothers remained hopeful that the Kikuyu could be rehabilitated. Although he supported the detention camp scheme, he believed that loyalists should be given the choice of where to live. He also lobbied for stable accommodations for women and children in townships and towns; only in this way— family by family—could a stable Kenyan society be built. His third major suggestion was to improve education for Africans; in his view, “character training” and religious education must receive much greater emphasis in schools. Carothers’ final recommendation concerned not Africans, but Europeans: “Christianity contains the

212 Carothers, The Psychology of Mau Mau, p. 15. principle that all men are equal under God, with equal rights. African people in transition attach more importance to example than to precept, but here in Kenya they do not think they see the practice of this principle by people who are white.”213 To change Africans, therefore, the British in Kenya must change their own example to reflect the ideals and religion they professed.

Carothers’ recommendations were never taken seriously by the British colonial government in Kenya, despite their own commission and rhetorical support of his report.

Even so, The Psychology of Mau Mau was the most widely-read of the explanations of the movement within Kenya and the British administration; its review in the East African

Medical Journal even opened with an apology: “The indications are that to review Dr.

Carother’s [sic] report is a work of supererogation, for most people would appear to have purchased and read it.” But even though Carothers’ practical suggestions were never adopted, it is significant that the British government in Kenya chose his medicalized account of Mau Mau over alternative, politically focused explanations. This choice and the popularity of the report amongst the British in Kenya reflect the contradictory position that medicine had come to occupy in British colonial ideology. The record of the medical men of Kenya had earned them the power of narrative—of explaining what before would have been considered social and political phenomena—but they were still powerless to influence concrete policy-making in the biggest crisis of the British administration of Kenya.

Together, the tick-borne relapsing fever campaign and Carothers’ explanation of

Mau Mau illustrate the unique position that medicine had come to occupy for the governance of Kenya as a colony. On the one hand, medical accounts were privileged

213 Ibid., p. 26. over other explanations, even in situations in which doctors themselves offered strictly political explanations. The tick-borne relapsing fever campaign was indicative of the ideological importance of medicine; this curious humanitarian endeavor in the midst of larger human rights violations showed the centrality of medicine to the justification of colonial governance. Even in the midst of gross human rights abuse, a health improvement campaign was an endeavor to be funded, for the pretence of rational rule must be maintained. On the other hand, Carothers’ policy recommendations regarding

Mau Mau were never taken seriously, and the ‘benefit’ of being tick-free was trivial compared to the brutality of the larger British response to Mau Mau. On the whole, doctors managed to say quite a lot but do very little about Mau Mau. Medical discourse in Kenya remained largely that—rhetorical justification for the colonial state. EPILOGUE

‘NO MERE VERBALISATION’: THE LEGACY OF COLONIAL MEDICAL DISCOURSE

“…historians have constantly impressed upon us that speech is no mere verbalization of conflicts and systems of domination, but that it is the very object of man’s conflicts.” — Michel Foucault, 1970214

In the first half of the twentieth century, doctors in colonial Kenya dealt with epistemological, historical, political, scientific, and social issues. The resulting medical discourse spanned the spectrum from the practical question of how to manage the health of a sizeable population to the theoretical question of how to define normality. Many of the specific debates—kwashiorkor or ‘propaganda,’ for example—and certainly the overriding context of colonialism, might seem rather distant to us today. And doubtlessly we would like to distance ourselves from those British doctors who sought to explain the

‘deficiency’ of African brains and who tacitly supported the brutality of the British government during Mau Mau.

I would like to end, then, with a few remarks to bridge at least part of the gap between ‘us’ and ‘them.’ Specifically, I would like to suggest that several of the concerns of colonial medical discourse have survived to this day, and in some instances, colonial doctors’ ways of talking about these topics sound strikingly like our own. This is not to say that modern-day doctors, politicians, and administrators are necessarily responding in the same way as their historical predecessors did. I merely hope to point out two strains of thought and one historical condition that have persisted, for better or worse: the focus on population, the language regarding malnutrition, and the power

214 Michel Foucault, “The Discourse on Language,” in The Archaeology of Knowledge (New York: Pantheon, 1972), p. 216. imbalance between Africa and the West. I leave my reader to form his/her own opinion

on this modern state of affairs; I would just like to sketch out a few of the ways in which

we live in the legacy of colonial medical discourse. These current issues place us close—

perhaps uncomfortably so—to the concerns of British doctors in colonial Kenya, in the

ambiguous space where facts meld into values and power verges on abuse.

In discussing African affairs, modern-day governments, aid organizations, and

doctors still speak in terms of populations. Reporting from Zimbabwe recently, R. W.

Johnson of the London Review of Books wrote, “And indeed in Zimbabwe, as elsewhere,

demography is destiny.”215 As in colonial Kenya, today’s projections of into the future

invariably involve projections of population. Present-day Africa contains examples from

both ends of the spectrum of population problems: Zimbabwe worries about depopulation

while Rwanda worries about overpopulation. In describing the former, Johnson

compares the current population figure of ten million to the projected figure of eighteen

million “had nothing untoward happened”—an example of how expectations and

judgments of modern states are predicated upon statistical knowledge of the

population.216 Rwanda, on the other hand, deals with the other extreme in its fears of

imminent overpopulation. Rwandan officials in 2007 give the same reasons for worrying

about population growth as British doctors in Kenya did in 1947: strain on already scarce

educational and medical resources and increasing pressure on the land.217 A law limiting

couples to families of three children or fewer is being drafted, and a new plan that stipulates that every woman who visits a hospital or health center must undergo

215 R. W. Johnson, “In Time of Famine,” London Review of Books, 22 February 2007, p. 33. 216 Ibid., p. 32. 217 Stephen Kinzer, “After So Many Deaths, Too Many Births,” New York Times, 11 February 2007. counseling on family planning will soon be adopted.218 In the questions that these plans

evoke about the coerciveness of the government in legislating familial life, these current

events remind us that the concerns and strategies of late colonial administrators are not so

far away from our modern worries.

The language that colonial doctors used to describe a central problem of African

populations—malnutrition—has also survived. Dr. Ade Omololu, the Director of the

Food Science and Applied Nutrition Unit in Nigeria, gave a talk on “Food, Famine, and

Health” at the University of Ibadan in 1974. His description of the insidious effects of malnutrition is strikingly similar to those of the earlier generation of colonial nutritionists: “Present studies all over the world have shown that the children who survive and get over their childhood malnutrition may never attain their mental and intellectual potential.”219 As described in Chapter II, colonial doctors worried about malnutrition

both for its bodily and mental effects; they talked about “stunted growth” and

“retardation which…is likely to be permanent to some degree.”220 The present-day media still uses this descriptive language when talking about malnutrition in Africa:

…almost half of Ethiopia’s children are malnourished, and most do not die. Some suffer a different fate. Robbed of vital nutrients as children, they grow up stunted and sickly, weaklings in a land that still runs on manual labor. Some become intellectually stunted adults, shorn of as many as 15 I.Q. points, unable to learn or even to concentrate, inclined to drop out of school early…Their hunger is neither a temporary inconvenience nor a quick death sentence. Rather, it is a chronic,

218 Ibid. and “World Briefing Africa: Rwanda: Three-Child Limit Planned,” New York Times 15 February 2007. 219 Ade Omololu, Food, Famine and Health: An Inaugural Lecture Delivered at the University of Ibadan on Tuesday, 29 January 1974 (Ibadan, Nigeria: University of Ibadan Press, 1974), p. 10, cited in Funke Sangodeyi, “Diet as Destiny in Colonial and Post-Colonial Africa: Nutrition and ‘the African Mind’,” (Unpublished student paper, Harvard University, 2007), p. 1. 220 Malcolm Clark, “Kwashiorkor,” East African Medical Journal, Vol. 28, No. 6 (June 1951), p. 230, and J. C. Carothers, The African Mind in Health and Disease (Geneva: World Health Organization, 1953), p. 111. lifelong, irreversible handicap that scuttles their futures and cripples Ethiopia’s hopes to join the developed world.221

Regimes have changed all over Africa, but when it comes to the issue of food and

nutrition, the now-independent governments and media organizations are still using the

same reasoning and language developed by their colonial forbearers.

Finally, the issue of population control has continued to raise questions about the

enduring power imbalance between African nations and the West. In 1981, the World

Bank made the adoption of a plan for a National Council on Population and Development

(NCPD) a condition for its approval of a structural readjustment loan to Kenya. The

Kenyan Ministry of Health opposed this fertility-reduction proposal, which included

requirements of staffing by outside NGOs and the approval of certain decisions by the

World Bank. The Ministry was overridden, however, and the very same day that Kenya

agreed to the NCPD, it received the World Bank funds.222 This incident illustrates the ongoing preoccupation with population control by groups both within and without Kenya and raises questions about the sovereignty of African nations in the post-colonial world.

Today, population is still a site for the exercise of concern, control, and perhaps coercion, as well as an arena for the contestation of power between Africans and

Westerners. In describing current problems, governments, doctors, and aid agencies still

employ the language developed by the nascent Medical Service generations ago. So, as

problematic as some of the ideas and actions of the British medical community in Kenya

seem today, much of their discourse looks, in retrospect, decidedly modern, in that our

221 Michael Wines, “Malnutrition is Cheating its Survivors, and Africa’s Future,” New York Times 28 December 2006. 222 Matthew Connelly, “Seeing Beyond the State: The Population Control Movement and the Problem of Sovereignty,” Past and Present, No. 193 (Nov. 2006), p. 231. society struggles to think through the same questions that colonial doctors dealt with over half a century ago. ANNOTATED BIBLIOGRAPHY

PRIMARY SOURCES

THE EAST AFRICAN MEDICAL JOURNAL, 1923-1956 The East African Medical Journal (and its previous incarnations) form the bulk of the primary source material examined in this thesis. It began as the departmental newsletter of the colonial Medical Service in 1923. It became a monthly-published journal, the Kenya Medical Journal, under the auspices of the British Medical Association (BMA) Kenya Branch in April 1924 and was printed and funded by the East African Standard Company. In 1927, it changed its name to the Kenya and East African Medical Journal in order to reflect the formal inclusion of the BMA Tanganyika Branch. In 1932, the name changed yet again to the East African Medical Journal to include the formation of an editorial board with members from Kenya, Nyasaland, Tanganyika, Uganda, and Zanzibar. It has been continuously published under this name ever since.

Volumes up to Volume 23 (1946) were accessed at the New York Academy of Medicine Library. Volumes from 1946 onward were accessed at Countway Library at Harvard University.

The Monthly Journal of the Kenya Medical Service, No. 1 (June 1923) Kenya Medical Journal, Vols. 2-3 (April 1925 – March 1927) (The first volume is missing from the New York Academy of Medicine Library and could not be obtained through interlibrary loan.) Kenya and East African Medical Journal, Vols. 4-8 (April 1927 – March 1932) East African Medical Journal, Vols. 10-33 (April 1934 – December 1956) (Volume 9 is missing from the New York Academy of Medicine Library. Select articles, such as R. A. C. Oliver, “The Comparison of the Abilities of Races: with Special Reference to East Africa,” Vol. 9, No. 6 (Sept. 1932), pp. 160-175 and Vol. 9, No. 7 (Oct. 1932), pp. 193-204, were able to be obtained through interlibrary loan, but Volume 9 was not reviewed in full because it was not accessible in the U.S.).

GOVERNMENT DOCUMENTS The government documents reviewed here deal with concerns about population in the 1940s. The fear of overpopulation was particularly acute in light of the barrier it presented to the development goals set forth in Colonial Development Acts. Lord Hailey’s African Survey was the most comprehensive administrative review of the African colonies conducted during British colonialism.

Colonial Development Act of 1929 Colonial Development and Welfare Act of 1940 Colonial Development and Welfare Act of 1945 Colony and Protectorate of Kenya, Report of the Development Committee, Vol. 1 (Nairobi: Government Printer, 1946). Colony and Protectorate of Kenya, Report of the Development Committee, Vol. 2. Appendices including Reports of Development Subcommittees (Nairobi: Government Printer, 1946). The Council of the Kenya Branch of the British Medical Association, Memorandum: The Case for the Appointment of a Royal Commission on Health and Population in His Majesty’s Dependencies in Africa, printed in East African Medical Journal, Vol. 25, No. 1 (Jan. 1937). Lord Hailey, An African Survey: A Study of Problems Arising in Africa South of the Sahara, (London: Oxford University Press, 1938). Lambert, H. E. and P. Wyn Harris, The Kikuyu Lands (Nairobi: Government Printer, 1945). Royal Commission on Population, Report (London: His Majesty’s Stationery Office, 1949).

KENYA NATIONAL ARCHIVES This set of documents consists of local governmental reports, usually filed annually. The reports cover a broad range of administrative concerns, but typically have sections dealing with medicine, health, and epidemic disease. They begin in the early twentieth century and extend into the 1940s. The Gregory et al guidebook is indispensable in going through this material, which in some instances displays rather dubious organization. The microfiche was accessed through a loan from the Center for Research Libraries, Chicago.

Political Record Books, Reels 67-82 of the Kenya National Archives Microfiche Gregory, Robert G., Maxon, Robert M., and Leon P. Spencer, A Guide to the Kenya National Archives (Syracuse, N.Y.: Syracuse University, 1968).

NEWSPAPER ARTICLES I did not do a comprehensive review of periodicals. The articles listed here were either discussed in the East African Medical Journal or are present-day depictions of population problems in Africa.

“Hookworm in Kenya: British Preventive Campaign,” The Times, 01 Dec. 1928, pg. 11, col. A. “World Briefing Africa: Rwanda: Three-Child Limit Planned,” New York Times 15 February 2007. Gordon, H. L., “The Native Brain. Observations in Kenya. A Comparison with Europeans [Letter to the Editor],” The Times, 08 December 1933, p. 15, col. E. ______. “The Native Brain. Problems of African Education [Letter to the Editor],” The Times, 22 January 1934, p. 8, col. B. Johnson, R. W., “In Time of Famine,” London Review of Books, 22 February 2007, p. 33. Kinzer, Stephen, “After So Many Deaths, Too Many Births,” New York Times, 11 February 2007. Wines, Michael, “Malnutrition is Cheating its Survivors, and Africa’s Future,” New York Times, 28 December 2006.

MEDICAL AND SCIENTIFIC WORKS There were two criteria for inclusion on this list; either these were works by members of the medical community in East Africa not published in the East African Medical Journal, or these were works widely cited in the East African medical literature. Examples of the former category are J. C. Carothers’ monographs on ‘the African mind.’ In the latter category are C. G. Seligman’s and Dietrich Westermann’s books on race in Africa, which were often quoted in the East African medical literature.

Carothers, J. C., The African Mind in Health and Disease (Geneva: World Health Organization, 1953). Gelfand, Michael, The Sick African (Capetown: Stewart, 1944). ______. The Psychology of Mau Mau (Nairobi: Government Printer, 1955). Gilks, J. L. and J. B. Orr, “The Nutritional Condition of the East African Native,” The Lancet (1927), pp. 560-562. Sachs, Wulf, Black Hamlet (London: G. Bles, 1937). Seligman, C. G., Races of Africa (London: T. Butterworth, 1930). Shelley, H. M. and W. H. Watson, “An Investigation concerning Mental Disorder in the Nyasaland Natives,” Journal of Mental Science, Vol. 83 (Nov. 1936), pp. 701- 730. Trowell, H. C., Archiv. Dis. In Childhood, Vol. 12, No. 70 (Aug. 1937). Trowell, H. C., Davies, J. N. P., and R. F. A. Dean, Kwashiorkor (London: Edward Arnold, 1954). Trowell, H. C. and D. B. Jelliffe, Diseases of Children in the Subtropics and Tropics (London: Arnold, 1958). Vint, F. W., “The Brain of the Kenya Native,” Journal of Anatomy, Vol. 68 (1934), pp. 216-223. Westermann, Dietrich, The African Today and Tomorrow (London: Oxford University Press, 1939). Christopher Wilson, Kenya’s Warning: The Challenge to White Supremacy in Our British Colony (Nairobi: 1954).

SECONDARY SOURCES

Abbott, George, “A Re-Examination of the 1929 Colonial Development Act,” Economic History Review, Vol. 24, No. 1 (Feb., 1971), pp. 68-81 Argues that the 1929 Colonial Development Act arose out of the economic desire to boost unemployment domestically. Armstrong, David, “Public Health Spaces and the Fabrication of Identity,” Sociology, Vol. 27, No. 3 (1993), pp. 393-410. Deals with the spacial aspect of public health projects; discusses the connection between control and medicine. Anderson, David, Histories of the Hanged: The Dirty War in Kenya and the End of Empire (New York: Norton, 2005). History of the British military response to Mau Mau insurgents. Uses court documents, intelligence reports, and interviews to reconstruct the Mau Mau trials. Anderson, Warwick, Colonial Pathologies: American Tropical Medicine, Race, and Hygiene in the Phillipines (Durham: Duke University Press, 2006). History of American hygienic programs in the Philippines. Argues that these public health programs were related to a conception of Filipinos as a ‘contaminated race.’ Covers medical and sanitation programs dealing with hookworm, leprosy, and malaria. Arnold, David, “Introduction: disease, medicine and empire,” in David Arnold, ed., Imperial Medicine and Indigenous Societies (Manchester: Manchester University Press, 1988), pp. 1-27. Enumerates the ways in which medicine and disease are fundamental to understanding the nature and trajectory of imperial rule. Argues that disease was an area that both exhibited Europeans’ technical superiority and bodily vulnerability. Details the practical, economic, and ideological reasons for colonial public health programs. Atieno-Odhiambo, E. S., “The Production of History in Kenya: The Mau Mau Debate,” Canadian Journal of African Studies, Vol. 25, No. 2 (1991), pp. 300-307. Reviews how the memory of Mau Mau has affected subsequent debates and discussions in the cultural, political, and social spheres in Kenya. Bashford, Alison, Imperial Hygiene: A Critical History of Colonialism, Nationalism and Public Health (New York: Palgrave MacMillan, 2004). Examines medical practices in Australia and argues that colonial health was intimately connected with the discourses of hygiene and quarantine. Beck, Ann, A History of the British Medical Administration of East Africa, 1900-1950 (Cambridge: Harvard University Press, 1970). Elucidates the political considerations that went into the creation of the medical administration and its growth until independence. ______. Medicine, Tradition, and Development in Kenya and Tanzania, 1920-1970 (Waltham, Mass.: Crossroads Press, 1981). History of development schemes and colonial medicine from 1920 to independence in Kenya and Tanzania. Less useful than her other book for my topic because it deals quite a bit with Tanzania and post-independence issues. Brown, E. Richard, “Public Health in Imperialism: Early Rockefeller Programs at Home and Abroad,” American Journal of Public Health, Vol. 66, No. 9 (1976), pp. 897-903. Argues that early Rockefeller Foundation programs in public health carried on the imperialist tradition of reinforcing dominant capitalist interests and advancing notions of ‘backwardness’ in the periphery. Examines the Rockefeller hookworm eradication campaigns in the southern United States, which has strong parallels to British efforts in the 1920s in East Africa. Conklin, Alice, A Mission to Civilize: The Republic Idea of Empire in France and West Africa, 1895-1930 (Stanford: Stanford University Press, 1997). History of the mission civilisatrice of French colonialism; argues that this ideology and French republicanism are intimately connected. Connelly, Matthew, “Seeing Beyond the State: The Population Control Movement and the Problem of Sovereignty,” Past and Present, No. 193 (Nov. 2006), 197-233. Gives broad history of population control in the twentieth century. Argues that population control was not a state-driven project, but rather fueled by activist groups and NGOs. Characterizes population control movements as “representing certain people as requiring control” (203). Dawson, Marc, “The Anti-Yaws Campaign and Colonial Medical Policy in Kenya,” International Journal of African Historical Studies, Vol. 20, No. 3 (1987), 417-437. Analyzes the anti-Yaws campaign in 1920s Kenya, during which the Colonial Administration mounted a widespread effort to root out the rural disease. Argues that this campaign helped Western medicine gain more acceptance in Kenya. Interesting to this project because it describes the economic and political considerations of the Colonial Administration when dealing with Africans’ health issues. Dikötter, Frank, “Race Culture: Recent Perspectives on the History of Eugenics (Review Essay),” American Historical Review, Vol. 103, No. 2 (Apr. 1998), pp. 467-478. Treats eugenics not as a scientific phenomenon, but rather a diffuse discourse that recast social issues in biological terms. Eugenics portrayed society as an organic body guided by biological laws, leading easily to the notion that individual rights should be subordinated for the greater social good. Emphasizes broad appeal of eugenics, not only to Western nations, but to peripheral areas such as the American South and China as well. Elkins, Caroline, Imperial Reckoning: The Untold Story of Britain’s Gulag in Kenya (New York: Henry Holt, 2005). First work to map out the detention camp system in 1950s Kenya and assert that the British response to Mau Mau verged on genocide. Fleck, Ludwik, Genesis and Development of a Scientific Fact, ed. Thaddeus J. Trenn and Robert K. Merton, trans. Fred Bradley and Thaddeus J. Trenn (Chicago: University of Chicago Press, 1979, Paperback edition, 1981; originally published 1935). Argues that science is socially motivated. Demonstrates the need to pay attention to professional habits in science, such as those created by journals and societies. Gives history of syphilis, in particular the emergence of the etiological concept of this disease and the development of the Wasserman test. Foucault, Michel, The Birth of the Clinic: An Archaeology of Medical Perception, trans. A. M. Sheridan Smith (New York: Vintage, 1994). Charts the transformation of the order and production of medical knowledge in the eighteenth century. Argues that medicine radically restructured the special properties of the body. ______. Discipline and Punish: The Birth of the Prison, trans. Alan Sheridan (New York: Vintage, 1995). History of penal institutions and the transformation of the idea of ‘punishment.’ Pays particular attention to changing views on the purpose of spectacle and the function of the body in punishment. ______. “The Discourse on Language,” trans. A. M. Sheridan Smith, in The Archaeology of Knowledge (New York: Pantheon, 1972), pp. 215-237. Concise overview of Foucault’s conception of discourse. Covers the types of prohibition, the changing role of the author, the impact of institutions and disciplines, and the conditions for discourse. ______. The History of Sexuality: An Introduction. Volume 1, trans. Robert Hurley (New York: Vintage, 1990). Broad history of the discourse on sexuality in the past three centuries. Identifies a reconstitution of sexual confession into scientific and medicalized terms and discusses how the discourse on sexuality has functioned in relation to institutions of power and repression. ______. “The Politics of Health in the Eighteenth Century,” in Paul Rabinow, ed., The Foucault Reader (New York: Pantheon Books, 1984), pp. 273-289. Perceptive analysis of the rise of public health in eighteenth century Europe as an extension of the reach of state power. Explores the relationship between science (particularly statistics and population studies) and power, the medicalization of the family and the privileging of the child, the establishment of standards of normality, and the link between hygiene and management. Good, Charles M., “Man, Milieu, and the Disease Factor: Tick-Borne Relapsing Fever in East Africa,” in Gerald W. Hartwig and K. David Patterson, eds, Disease in African History: an Introductory Survey and Case Studies (Durham: Duke University Press, 1978). Examines history, spread, and treatment of tick-borne relapsing fever in Kenya, Tanzania, and Uganda. Hacket, C. J., “Yaws,” in E. E. Sabben-Clare, D. J. Bradley, and K. Kirkwood, eds., Health in Tropical Africa during the Colonial Period (Oxford: Clarendon Press, 1980), p. 83. History and epidemiology of yaws in tropical Africa. Hacking, Ian, The Taming of Chance (Cambridge: Cambridge University Press, 1990). Regards the rise of statistics as a new form of knowledge that harnessed the idea of ‘chance’ and paradoxically made it seem less unpredictable. Argues that as a result, people have come to be conceived of in terms of distributions around the normal that follow objective laws. Iliffe, John, East African Doctors: A History of the Modern Profession (Cambridge: Cambridge University Press, 1998). History of the medical profession in eastern Africa from mid-19th century to today. The chapter on the early years of Makerere Medical School is particularly relevant. Keller, Richard, “Madness and Colonization: Psychiatry in the British and French Empires, 1800-1962,” Journal of Social History, Vol. 35, No. 2 (2001), pp. 295-326. Review of histories of colonial psychiatry in India, British Africa, and French Africa. Locates literature of colonial psychiatry at intersection of Michel Foucault’s ideas about madness and civilization and Edward Said’s ideas about knowledge and power. Reviews Megan Vaughan’s Curing their Ills, Jock McCulloch’s Colonial psychiatry and ‘the African mind’, and Jonathan Sadowsky’s Imperial Bedlam. Latour, Bruno, The Pasteurization of France, trans. Alan Sheridan and John Law (Cambridge: Harvard University Press, 1988, Paperback edition, 1993). Uses a semiotic approach of reading publications and articles in order to allow historical actors to define their own interrelations; treats science as a social phenomenon. Argues that hygiene was a social movement that adopted Pasteur’s science to further its goals for social change. Pasteur, on the other hand, transformed the hygienic movement by relocating and isolating the microbe in the laboratory. McCulloch, Jock, Colonial psychiatry and ‘the African mind’ (Cambridge: Cambridge University Press, 1995). Argues that the new colonialism of the twentieth century centered around a vision of the African mind, whereas the old colonialism of the nineteenth century focused on the African body. Includes particularly useful chapter on Carothers’s study of Mau Mau. Meredith, David, “The British Government and Colonial Economic Policy, 1919-39,” Economic History Review, Vol. 28, No. 3 (Aug., 1975), pp. 484-499. Examines the economic motivations for colonial development schemes. Murphy, Philip, Alan Lennox-Boyd (London: I.B. Tauris, 1999). Biography of the colonial secretary during the latter half of Mau Mau. Details his aristocratic background and detestation of the notion of self-governance for British colonies in Africa. Odhiambo, E.S. Atieno, and John Lonsdale, eds., Mau Mau and Nationhood (Oxford: James Currey, 2003). Collection of essays that deal with diverse aspects of Mau Mau. Includes a chapter by Caroline Elkins, written before her book, that sketches the Kikuyu detention system. Also includes an interesting chapter by Joanna Lewis about the treatment of Mau Mau in the British popular press. Outram, Dorinda, The Enlightenment (Cambridge: Cambridge University Press, 1995), pp. 66-79. Wide-ranging overview of the Enlightenment. The section specified here deal with the Enlightenment’s conception of the ‘primitive’ and the exotic, particularly Rousseau’s idea of the ‘noble savage.’ Paul, Diane B., Controlling Human Heredity: 1865 to the Present (Amherst, New York: Humanity Books, 1998) A concise overview of the history of eugenics in Europe and America. Suggests that eugenic ideas still have currency today through the modern discipline of medical genetics. Pierce, Chester M., Felton J. Earls, and Arthur Kleinman, “Race and Culture in Psychiatry,” in Armand M. Nicholi, Jr., ed., The Harvard Guide to Pyschiatry, 2nd ed. (Cambridge: Harvard University Press, 1988), pp. 735-743. Review of strategies to deal with race, ethnicity, and culture in psychiatric practice in the U.S. today. Asserts that psychiatrists must be aware of patients’ race, ethnicity, and culture and faults the DSM-IV for failing to recognize the importance of race and racism to mental health. Porter, Dorothy, Health, Civilization and the State: A history of public health from ancient to modern times (London: Routledge, 1999). Broad history of public health in Europe and the U.S. Shows the nineteenth century as the turning point in which health became a right administered by the state and disease prevention became professionalized. Covers eugenics, hygiene, and social medicine as movements that bridged science and politics. ______. “Introduction,” in Dorothy Porter, ed., Social Medicine and Medical Sociology in the Twentieth Century (Amsterdam: Rodopi, 1997), pp. 1-31. Overview of the difference between nineteenth and twentieth century social medicine movements in Britain. Points out that the interdisciplinary approaches pursued by social medicine adherents often produced more conflict than cooperation. Rabinbach, Anson, The Human Motor: Energy, Fatigue, and the Origins of Modernity (New York: Basic Books, 1990). History of the rise of the conception of humans as work machines in the nineteenth century. Explores the application of mechanistic principles of physics and engineering to the human body. Rosenberg, Charles E., The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago: University of Chicago Press, 1962, 1987). Treats medicine as lens that reveals larger societal attitudes. Covers the rise of public health in the United States and the accompanying rise of statistical analyses and increasing willingness to legislate health. Argues that the formation of the New York City Metropolitan Board of Health was the first instance in the U.S. of a municipality successfully preventing an epidemic. ______. “Introduction. Framing Disease: Illness, Society, and History,” in Charles E. Rosenberg and Janet Golden, eds., Framing Disease: Studies in Cultural History (New Brunswick, New Jersey: Rutgers University Press, 1992), pp. xiii-xxvi. Uses “frames” as a concept to understand the relationship between disease and society. Stresses both the biological realities of disease and the role of society, politics, and morality in perceiving disease and shaping the illness experience. Rosenkrantz, Barbara, Public Health and the State: Changing Views in Massachusetts, 1842-1936 (Cambridge: Harvard University Press, 1972). Covers a century of medical history in Massachusetts in which public health arose as a responsibility of the state. Sadowsky, Jonathan, Imperial Bedlam: Institutions of Madness in Colonial Southwest Nigeria (Berkeley: University of California Press, 1999). Uses the history of British asylum policy in colonial Southwest Nigeria to explore tensions in the colonial conception of African culture. Devotes a significant part of the book to a highly original discussion of the writings of the ‘mad.’ Sangodeyi, Funke, “Diet as Destiny in Colonial and Post-Colonial Africa: Nutrition and ‘the African Mind’,” (Student paper, Harvard University, 2007). Surveys the relationship between dietetics and psychiatry in twentieth-century Africa. Argues that malnutrition was a way for Carothers and other ethnopsychiatrists to explain difference in ‘the African mind’ without reverting to racial reasoning. Scott, James C., Seeing Like a State: How Certain Schemes to Improve the Human Condition have Failed (New Haven: Yale University Press, 1998). Explores the ideological underpinnings of modern states, particularly ‘high modernism’—a ‘scientific’ belief that mass-scale social engineering can affect ‘progress.’ Simpson, A. W. Brian, Human Rights and the End of Empire (Oxford: Oxford University Press, 2001). History of the European Convention on Human Rights; also deals briefly with the United Nations and the Universal Declaration of Human Rights. Thomas, Lynn, Politics of the Womb: Women, Reproduction, and the State in Kenya (Berkeley: University of California Press, 2003). History of the relationship between the state and the women over bodily and reproductive rights in Kenya. The first two chapters, “Imperial Populations and ‘Women’s Affairs’” and “Colonial Uplift and Girl-Midwives,” are particularly relevant to the colonial context. Tilley, Helen, “Ambiguities of Racial Science in Colonial Africa: The African Research Survey and the Fields of Eugenics, Social Anthropology, and Biomedicine, 1920-1940,” in Benedikt Stuchtey, ed., Science across the European Empires, 1800-1950 (Oxford: Oxford University Press, 2005), pp. 245-287. Uses the negative response of the African Survey to H. L. Gordon’s proposal from Kenya to study “native backwardness” to argue that between the 1920s and the 1940s, race as a biological category fell out of favor with the British central colonial administration. Instead, social and environmental categories gained credence. Vaughan, Megan, Curing their Ills: Colonial Power and African Illness (Cambridge: Polity Press, 1991). Analyzes biomedicine in colonial Africa as a culturally constructed system of many intersecting and sometimes conflicting discourses. Argues that the nature of biopower was fundamentally different in Africa because the ‘Other’ already existed in the form of the African. Watts, Sheldon, Epidemics and History: Disease, Power and Imperialism (New Haven: Yale University Press, 1997). Points out that the West caused many instances of epidemics and health crises around the world; implicates imperialist regimes in particular. ______. Disease and Medicine in World History (New York: Routledge, 2003). Broad history of medicine since ancient times; argues that public health concerns are a recent phenomenon. Worboys, Michael, “The discovery of colonial malnutrition between the wars,” in David Arnold, ed., Imperial Medicine and Indigenous Societies (Manchester: Manchester University Press, 1988), pp. 208-225. Locates the identification of malnutrition as a problem in the Third World in the inter-war period. Starting from research done in British East Africa, colonial regimes ‘discovered’ malnutrition and undernutrition as an agricultural, economic, educational, and technical problem. Argues that this research is a move away from tropical medicine’s assumption of colonial peoples as exceptional and towards universalist assumptions of human physiology.