Adell Jr.. Patton. Physicians, Colonial Racism and Diaspora in West Africa. Gainesville: University Press of Florida, 1996. xx + 343 pp. $49.95 (cloth), ISBN 978-0-8130-1432-6.
Reviewed by Elisa von Joeden-Forgey (University of Pennsylvania)
Published on H-Africa (August, 1997)
How Europe Underdeveloped African Medicine
"West Africa's developing peripheral relation with the core of Europe in control of the world order meant a delay in the development of a medical and scientific community comparable to that in the core region" (p. 91). The central preoccupation of Adell Patton's Physicians, Colonial Racism, and Diaspora in West Africa, as revealed by the quote, concerns the severe limitations that have been placed on African biomedicine since the nineteenth-century, and the ways people have resisted and overcome them. His interest in and commitment to autonomous African scientific enterprise has resulted in a carefully researched, far-reaching and very successful study of the professional history of Anglophone, African physicians in West Africa in the nineteenth and twentieth centuries. Complimented by many instructive figures, maps, tables, and appendices, the book is an indispensable resource for anyone interested in the history of medicine and public health policy, professionalization and institution-building, and the African Diaspora.
Patton tells us in his preface that the idea for this book grew from an encounter he had while researching in the Public Record Office in London. There he found several colonial-era complaints written by African physicians, African students of medicine in Britain, and some sympathetic colonial authorities, who charged the British colonial government with racial discrimination. The acrimonious tenor of these letters--he explicitly mentions one written by the eminent Sierra Leonean physician Mayfield Boyle, Sr.--started him on a researching adventure that took him to Sierra Leone, Nigeria, Ghana, Tanzania, Zanzibar, and to various locations in the United States and Britain. Extensive interviews with African and former British colonial physicians and participant-observation research in clinics and hospitals supplement archival and library sources. Following the logic of his research, which included a serious consideration of Africa's current health situation, Patton has aimed his work toward "the general public," including scholars of African history, but also policy makers, health care providers, and world health officials. His history, then, like most good history, is also an argument about the present, and one encased in an extremely accessible and readable narrative style.
He argues that despite the great strides made during the hopeful era of decolonization, the strictures placed on African physicians under colonial rule have had deleterious consequences for the health of Africans today. To illustrate this, he includes in his introduction a table showing the disparity between the ratios of population per physician in the United States (593: 1) and, for example, Sierra Leone (p. 20, 858: 1). The key problem under colonialism was what he calls "corporate patronage," which "delayed the rise of African medical professionalism and most of the organizational features associated with this form of collegial authority. In addition, it contributed to the delay in medical autonomy discernible even today in African nations" (p. 20). Corporate patronage formally and informally restricted the professional opportunities of African physicians in comparison with their white peers, and seriously limited the scope and impact of their contributions to biomedical research and policy.
African achievements contributions are impressive nonetheless, especially in light of colonial discrimination. I was interested to discover, for example, that James Africanus Horton first brought attention to the toxic effects of mercury compounds, which were frequently used to treat fevers and often led to death, and that John Farrell Easmon was the first to tie "blackwater fever" (hemoglobinuric fever) to falciparum malaria (1884). Patton's discussions of these contributions constitute some of the most penetrating sections of the book, and a longer treatment of the intellectual history of these physicians is needed.
Not only does the task require a high level of mobility on the part of the researcher, but also a degree of proficiency in African, European, North American, and Soviet history. On the one hand, there are many pitfalls to the demands of such a study. The first chapter, "African Physicians in Time Perspective," is indicative of the identity crisis such breadth can cause: Patton attempts not only to flesh out complicated theoretical issues and present the historical context for the rest of the study, but also to address topics that are not substantially followed-up, such as inter-professional conflict between biomedical and popular healers in Africa, the role of women physicians, and the differences between the Anglophone and Francophone medical traditions in West Africa. All these issues are absolutely relevant to this book, particularly because they relate to the lives the book chronicles, which is why Patton includes them; they are nevertheless treated in a perfunctory manner.
Still, Dr. Patton has risen to the challenges of his topic by writing a very open and evocative narrative. To negotiate the cosmopolitanism of the African medical profession, Patton has chosen to write its history via the method of collective biography. The professional biographies of seven generations of West African physicians become the narrative center of the book: Patton weaves analysis and interpretation around them, while providing the reader with a panoramic historical view in the preface, introduction, and two preliminary chapters.
The result is a book as cosmopolitan in style as its subjects were in life. Its animating theme is intra-professional conflict, which Patton successfully uses to tie each chapter together, but he thankfully also pursues other topics, such as colonial discourses on black sexuality, British colonial urban policy, local social systems (i.e., in Lagos and Freetown), and the nature of racism in Canada and the Soviet Union, inasmuch as they bear upon the lives he is chronicling. He draws from a wide array of scholarly literature, but his theoretical contribution is to the sociology of professionalization, bureaucracy and the civil service, as well as to the scholarship on African health and healing. He points out that, based on his evidence, "[c]ommunalism and intra-professional conflict as a recurring and binding theme must be reviewed--pushed to a state of renewal, imposed on new constructs (in and outside of Africa) and organizational developments, or used in the revisions of earlier ones with regard to the professions" (p. 251). I would add that his evidence seriously calls into question as well our very concept of professionalization, insofar as it has been tied to ideas of modernity and scientific progress that are contradicted by the experiences of African physicians in the colonies and abroad.
The earliest African physicians trained in Western biomedicine had substantial Diaspora experience. Thus Sierra Leone, a colony originally founded by the British for the purposes of settling recaptured slaves, became the most important "frontier medical community" in West Africa. In the nineteenth century, the two principal suppliers of doctors to the West African coast were the British Army Medical Service and the Colonial Office. Initially, Africans were trained in biomedicine as assistants in European pharmacies in Freetown and elsewhere (called the "dispensary system" of medical training). However, as the mortality rates of European physicians became a public health issue in the late eighteenth century, the British began sending mission-educated Africans for schooling in Britain. It was not until the 1850s, however, when the shortage of medical officers in the Gold Coast and Sierra Leone became recognized, that Africans began to be trained in large numbers in Britain. The Freetown Creole community, educated in Church Missionary Society schools, benefited by providing physicians for much of West Africa.
The first generation of African physicians trained abroad (1790s-1845) encountered few of the professional obstacles that would confront later generations. For example, William Fergusson, who received his training at Edinburgh, eventually became governor of Sierra Leone. With his death in 1846 began a new era for African medicine and a new generation of African physicians (1853-1880s). Although Africans were being trained abroad in greater numbers, the discovery of the use of quinine against malaria (1854) increased the survival rates of young British physicians and established a rivalry between African and European physicians working in West Africa. Pseudo-scientific racism and fears of black sexuality consolidated European privilege. The opportunities open to Africans were dramatically altered by intra-professional conflict based on skin color. By the 1890s, Africans were being barred from higher posts in the colonial medical service. Thus the third and fourth generations (1880s-1900, 1900-1912) found increasing obstacles to advancement, which became institutionalized in the colonial medical reforms of 1901. Africans were restricted from becoming officers in the new West African Medical Staff (WAMS), thereby reversing "several decades of mutual cooperation and collegiality among European and African doctors" (p. 130).
This brings us to Dr. Mayfield Boyle, one of whose letters inspired Patton to write this book. Boyle studied at Alabama A & M College and Howard University, receiving his MD in 1902. In 1909 he wrote his famous letter to the British Colonial Office which reads in part: "Never have West Africans been so wantonly insulted as when the Departmental Committee alleged the inferiority of West African Native Doctors to European Doctors...We hold that while we are British subjects we are Africans and certainly ought in Africa, if nowhere else, enjoy life, liberty, and the pursuit of happiness without the encroachment of Europeans ... West African Scientific Doctors are the reflectors of medical schools in Great Britain and Ireland. Their education was obtained not only at great costs but at the feet of the masters of those very Europeans recommended to supersede West Africans in West Africa. Unless the processes of training of West Africans abroad differ from those of Europeans--Englishmen in particular--or unless the Departmental Committee is prepared to show by some new process of reasoning or evidences of scientific research that the `sable livery' of [the] African is indicative of inferiority, Your Majesty will, in the face of the declarations of the schools which have conferred upon West Africans the degrees of proficiency to pursue their professional calling, admit that the report is but a culmination of an infernal scheme of selfish aggrandizement long fomenting in the circles of European negrophobists" (p. 150).
Members of the fifth generation (1912-World War II) continued the fight begun by Boyle and his colleagues, by consistently challenging the rules governing WAMS, aided by organizations such as the Anti-Slavery Aborigines' Protection Society. Many of these physicians had studied in the United States, and began to assail the British Medical Council's (BMC) practice of recognizing only those MDs trained in BMC-approved universities. World War I and the Influenza pandemic were opportunities for African physicians to demonstrate again and again their equality to their European colleagues. They petitioned the colonial governments, formed associations in the name of furthering group rights, established international networks and applied for positions from which they were barred.
The sixth generation (World War II-1950s) witnessed an increase in opportunities. With the end of the war and the growth of social services in British West Africa, there was an increased need for doctors. African doctors began to be employed in larger numbers, and many who had been barred from positions because they had studied in universities not recognized by the BMC, were able to return to West Africa to practice medicine.
The Cold War ushered in yet another generation (1957-85), and a new era in intra-professional competition, this one between African physicians trained in the West and those trained in the Soviet Union and Eastern Europe. The data that inform this final chapter comprise some of Patton's most original contributions to the literature. Soviet training emphasized early specialization and work in teams, and newly independent governments had to find ways to incorporate these physicians, who had been supported by Soviet scholarships, into a medical system based on the assumption of training in general medicine, as had been the British and North American practice.
The greatest need in Africa was not for specialized care, but for basic services, and many posts could only be staffed by one doctor and a few assistants, rendering team-oriented treatment an impossibility. As Eastern bloc-trained professionals gradually came to outnumber their Western-educated colleagues in places like Nigeria, Sierra Leone, Ghana and Gambia, they adapted their training while advocating medical reform, including government control of drug distribution and pricing, and the elevation of nursing standards.
Patton writes in a powerful epilogue:
Today's scientific public centers in West Africa and in Africa in general are in a state of decline. However, efforts must be made to stabilize and to restore them to the standards that marked the independence era in 1960, and medical standards must be included. Today, most nation-states have high infant mortality rates that astound the imagination, and most of the surviving children, who constitute the future of Africa, are suffering from malnutrition ... In some countries newly trained African doctors are already being rushed into practice for either the government or as private practitioners without diplomas in tropical medicine. This results in everyone suffering: the children, the patients, the nurses, and the doctors ... There are no easy solutions to government deficits and mounting health problems. A start could be made by the West through debt forgiveness and rescheduling of loans. This should be followed with aid to scientific and medical centers, which ought to consist of not only the redistribution and reallocation of various supplies but also provision of the most up to date scientific journals and books to mitigate the existing book famine. Democratic African governments need to participate: they must gain the confidence of the West and international donors by stamping out corruption and inefficiency in their governments, stopping the funneling of funds abroad, and showing African self-help initiatives of investments in small-scale development projects to the world instead (pp. 254-55).
The formidable obstacles which hampered the projects of West African physicians has led, according to Patton, to a dual medical system, in which the African elite are treated by European-trained doctors in the cities, and rural villagers and the urban poor receive care from popular healers. Moreover, it has seriously impeded the study of tropical medicine by locating it outside of Africa and African agendas. Had more power been allowed the generations following William Fergusson, perhaps biomedicine would indeed have moved further and more comprehensively from urban areas and elite social groups to the majority of Africans. Certainly, one could argue that endemic diseases, such as malaria, and specific approaches to them, such as a malaria vaccine, would have received more research attention. If Horton's book, The Diseases of Tropical Climates and their Treatments (1874) is any indication, it is reasonable to believe that the biomedical tradition in Africa may have integrated more popular treatments. However, inter-professional conflict between African physicians and popular healers may have hampered any real intellectual and pragmatic coalitions.
For Patton the answer to Africa's public health problems must be the extension of autonomous and professional biomedical practice through increased aid and government responsibility. While it would be foolish to deny the importance of this, the history of biomedicine in Africa raises interesting questions about its role in the coming century. Patton himself calls for more research on "scientific publics" in Africa, which we assume must include popular as well as biomedical approaches to physical and social health. What will be the roles of popular practitioners, not only in Africa, but also in western societies, such as the United States, where "alternative medicine" is becoming increasingly valued by lay persons? How can the tradition of inter-professional competition between popular and biomedical healers in Africa, and elsewhere, be redirected to more useful pursuits? What will be the scientific contributions of autonomous, well-funded African medical institutions? Though Afro-pessimism seems to have gripped the minds of many scholars and policy makers, Patton's work demonstrates that the possibilities are exciting and realistic.
. Of particular documentary interest are Patton's four appendices:
"Colonial List of Qualifying Foreign Medical Schools for the Medical Register"; "West Africa's Relations with the Soviet Bloc, July -September 1959"; "Ghanaian Physicians Trained in the USSR and the Eastern Bloc, 1984"; "Sierra Leone Doctors Trained in Soviet and Eastern-Bloc Universities, 1984 and 1967-76."
. Patton derived this information from the PC Globe (1987-89), and it is based on UN Reports 1990.
. See: Melson, Robert and Howard Wolpe. "Modernization and the Politics of Communalism: A Theoretical Perspective," American Political Science Review 64:4 (December 1970): 1112-30; Larson, Magali Sarfatti. The Rise of Professionalism. Berkeley: University of California Press, 1977; Abbott, Andrew. The System of Professions: An Essay on the Division of Expert Labor. Chicago: University of Chicago Press, 1991; Last, Murray and G. L. Chavunduka (eds.) The Professionalisation of African Medicine. Manchester: Manchester University Press, 1986; Feierman, Steven. "The Social Roots of Health and Healing in Modern Africa," African Studies Review 28:2-3 (June-September 1985): 73-148.
. See Headrick, Daniel R. The Tools of Empire: Technology and European Imperialism in the Nineteenth Century. Oxford: Oxford University Press, 1981.
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Elisa von Joeden-Forgey. Review of Patton, Adell Jr.., Physicians, Colonial Racism and Diaspora in West Africa.
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