natural treatment for the disease of dysentery

prof: okay,well let's begin. and, as you know,in our class one of the topics, or themes, that we'reconsidering is intellectual history. and lurking in the background,of course, is the big question of medicine itself and what itis. what is medical science? what does it mean to have amedical science? well, this morning we'll beconsidering that.

is medical science purely thetechnical application of neutral knowledge? or should we think of it as acultural institution, also, built by dominant socialgroups in society, that in some way may reflecttheir worldview, sometimes may embody theirprejudices, and may promote their interests? and at least we should ask thequestion, if we accept the biomedical paradigm of disease,what are the implications of

that acceptance? what are the costs? what are we giving up? so, that's the big issue. and today what i'd like to dois to look at a subset of the bigger problem,and this is the medical specialization that's known as"tropical medicine." it emerged in the 1890s,in a period, that is, of--it gained rapidlyenormous prestige and influence,

and is still a major subfieldin medicine. the discipline thus far hasundergone three periods in its the first is the one that we'regoing to be concentrating on this morning,and that's the period from roughly the 1890s until more orless the first world war. that marks the real heyday oftropical medicine, the time when it was thecutting edge of medical science, when it made a series of majordiscoveries, and served the most obviouspolitical purposes.

it was followed in its historyby a second period, that lasts more or less fromworld war i until the 1970s, the next half-century oftropical medicine. and during this period thediscipline loses a lot of its scientific momentum. tropical medicine came to beconfined essentially to parasitology,and at this period, the dynamism in medical sciencemoved instead to microbiology and such offshoots asimmunology,

and that boosted such majordevelopments as antibiotics and a series of effective vaccines,and that attracted the lion's share of research funds. so, tropical medicine,in the period from the first world war to the 1970s,made relatively few major, major discoveries. then, after world war ii,and accelerating from the 1970s,we see a third phase, ushered in by such things asdecolonization and a new

attention to public health inthe third world, and with it a new influx ofresearch funds through the world health organization and powerfulfoundations like the rockefeller and macarthur foundations. well, what i want to do thismorning is to look critically at tropical medicine. and by that i don't mean for oragainst. what i want to do instead is tolook at why it arose as a discipline when it did.

what interests did it serve? what were its implications? and i'm going to argue thattropical medicine, and particularly in thisformative early period before the first world war,was clearly socially constructed. this is a period that coincideswith the high tide of colonial expansion, the age of thescramble for africa. and tropical medicine gaveexpression to an imperial view

of the world,and it marked the relationship, in medical terms,between western europe, on the one hand,and asia and africa on the other, and between the unitedstates and latin america. as a discipline,it served as a major instrument also in promoting europeanexpansion overseas, and american hegemony in theamericas. in its applications,and in the policies it promoted, tropical medicine wasnot only value-neutral science;

it was also an instrument ofpower, and we need to bear that in mind. now, the emergence of tropicalmedicine marked a transition, a transformation,from something that had preceded it,and that i hope won't be confusing. but from the middle of theeighteenth century, more or less,until the closing decade of the nineteenth century,there had been an older

tradition that can be summarizedunder the label of "diseases of thetropics." and there were a couple ofclassic statements of this older tradition. one was a work,an important work, by james lind,an eighteenth-century physician,who wrote "an essay on diseases incidental to europeansin hot climates," and this was built on theexperience of europeans in the

west indies. and then there was another workby james johnson called "the influence of tropicalclimates on european constitutions,"built on the experience of europeans in india. what these works,and other ones of their kind, meant in the expression"diseases of the tropics"was something particular. they meant that in the colonialworld--

in, that is,the area of hot climate, as it was expressed at thetime--europeans were subject to special diseases as challenges,that arose as a result of conditions peculiar to warmclimates, and to the resulting conditionsof temperature, humidity and local ecology. under those conditions,the diseases that would afflict europeans were not,however, different in nature from those familiar at home.

the diseases of hot countrieswere heightened in their virulence,perhaps, and the constitutions of white people were nowsubjected to new and unfamiliar stresses that made thempeculiarly vulnerable in these climates to disease. but the issue was simply--inthe era, should we say, of diseases of the tropics--wassimply one of degree, rather than kind. the diseases of the tropicswere simply intense variants of

familiar disease processes. and there was an educationalcorollary to that, which was that physicians whohad studied general medicine, in european medical schools,were fully equipped to treat the entire spectrum of humandiseases wherever they occurred. diseases of the tropics weren'ta special category. they were simply heightenedversions of familiar maladies. in other words,the concept of diseases of the tropics presupposed auniversality of a single medical

discipline that viewed thediseases of the tropical world as posing problems of degree,but not of a thoroughly different kind. we should also say that thisidea of diseases of the tropics already did have embodied in itsome troubling and important questions that had to do with acolonial or imperial and racial view of the world. european bodies,the concept presupposed, were different in some way fromthose of asians and africans.

they weren't intended for theconditions prevailing in the colonies, and so the questionwas, were the tropics in fact inhabitable for europeans? you can see this in expressionslike "darkest africa," "teeming asia"--those imply dangerous places--and even more theexpression of "the white man's grave." and, so, the question waswhether settling in the tropics was going to be possible.

was it simply that europeansneeded a period of seasoning-- another term of the time--oracclimatization, after which they'd bestress-hardy and able to survive in these new settings? physicians who dealt withdiseases of the tropics thought of themselves as performing anindispensable service, one that was useful to europeanstates, and especially to explorers,travelers, settlers, colonialadministrators,

and of course sailors andsoldiers. the service was to provideassistance and advice during the time of acclimatization,advice on exercise, diet, clothing and housing;in short, everything that new arrivals would need to protectthemselves from the rigors of the new environment. but the 1890s marked atransition to something different--from this view of diseases of the tropics,to something that sounds subtly

different,but was profoundly so, and that is tropical diseasesand tropical medicine. now, what was implied in thistransition, this transformation? it was a vision of the world inwhich asia and africa, for europeans,or possibly latin america, for u.s. citizens, were conceived in areally charged fashion as harboring disease that wereconceptually different from other diseases,that could not be treated by

physicians who had graduatedfrom european medical schools unless they had undergonespecial postgraduate training. and the implication too was adifferent form of hygiene. and there was a work that was afoundational text for this new medical specialty,one of the most influential medical works of the whole ofthe nineteenth century, and one that had enormousinfluence on the relations of the metropolitan powers to theircolonial dependencies. this work was by this man,a british physician named

patrick manson,who came to be known as the father of tropical medicine. the work that caused the stirwas called-- it's an enormous,fat volume--entitled tropical diseases:a manual for the diseases of warm climates. and it was written in 1898,which isn't an accident. and it wasn't also an accidentthat the father of tropical medicine was british,or that britain became the

world center of the newdiscipline, britain at the time being theworld's leading imperial power. now, what were the backgroundconditions that promoted the emergence of this whole newmedical sub-discipline? a first, as we said,was britain's position as a great colonial power. there were others,as well, that lay behind this new medical specialism. one was something we've alreadydealt with, and that is the germ

theory of disease and thetriumph of contagionism over anticontagionism. the germ theory had a number ofpossible implications. one was the idea,as we've seen, of clinching the concept ofdisease specificity. and tropical medicine was builton the premise that some diseases lurking in africa andasian now needed new classifications,belonging in special categories, and that tounderstand them--

and here was another of itsimplications-- you needed physicians who weretrained at special institutions, and had a specializedcurriculum, and that they could be dealt with by specificspecial remedies and measures of hygiene that were different fromthose that had been successful in bringing about a mortalityrevolution in europe. as you'll remember when weexamined the theories of max van pettenkofer,the germ theory marked the end of an alternative approach tomedicine,

one that had flourished atmid-century, particularly in continentaleurope, but was intellectuallyvanquished by the laboratory methods of bacteriology,and later parasitology. this was the idea of socialmedicine, associated with a radical german physician,rudolf virchow. for social medicine,medicine was a collective enterprise in which it wasimportant for physicians to treat not only individualpatients,

but society as a whole,dealing with issues of sanitary conditions,poverty, nutrition, social justice. well, the germ theory ofdisease was a setback for social medicine,and i'm going to argue that tropical medicine went even astep further in the turn from that direction. it argued that in the tropicalworld the chief problem-- and we're talking with theperiod down to world war i--

the chief problem was topreserve the health of european settlers. as a discipline,until much later in its life, tropical medicine largelyignored the general health of indigenous societies. this also came to meansomething somewhat sinister, when the logic was applied tothe global north and south, and black/white relationships. it seemed to suggest that thebodies of africans and teeming

asians were medically dangerous,that they were the reservoirs for diseases that posed seriousnew threats for europeans. and there was an implication,a possible strategy for hygiene,and that was that perhaps the best way forward was foreuropeans and indigenous peoples to be segregated in theirhousing arrangements, that europeans should live inthe tropical world in special enclaves where the latestprophylactic measures would be applied.

whereas natives,or indigenous peoples, could be left as they had beenfound. alternatively,if you read some of the literature produced by works ofeuropean writers such as somerset maugham,you'd see that the europeans were advised to take to thehills during the dangerous summer months,leaving dangerous natives behind. but we shouldn't forget thattropical medicine,

at the turn of the century,was also where the scientific action and excitement in medicalscience were taking place. beyond the germ theory ofdisease, tropical medicine embodied the various latestdevelopments, and above all the new scienceof parasitology. and it attracted some of theleading figures, indeed, in the development ofmicrobiology to enter this new discipline. this was true,for example,

of robert koch,who came, made a voyage, to italy to study parasitologyin the form of malaria, and then set off for thecolonial world. pasteur at this time had justdied, but his institute sawaffiliates or satellite institutes set up at saigon,at tunis, algiers, in the 1890s,all preaching the new discipline of tropical medicine. and pasteur's most famous andable disciple,

�mile roux,became a specialist in this new to understand it,we need to remember two major breakthroughs. the first was by patrick mansonin 1883. at that time,he discovered something that was radically new. he was dealing with the diseaseof elephantiasis, and he found that the filarialworm that causes it is transmitted by mosquitoes;the first example of a vector

borne disease transmission. this was epoch-making in thatrespect. and it was also a movement frombacteria or-- though it wasn't known at thetime-- viruses, to more complex lifeforms, the interaction of humans withbiologically more sophisticated protozoa or helminths or worms,and with insect vectors. diseases could now be seen tobe part of a much more complicated process,and with complicated life

forms. then there was,following this, the establishment of themosquito theory of transmission for malaria,which took place during the end of the decade of the 1890s,with two figures, who were working independentlyof each other, but in 1898 established thatmalaria was a parasitical disease,transmitted by certain species of mosquitoes.

so, malaria--which is a diseasethat we'll be dealing with after the spring break--was of decisive importance in the establishment of tropicalmedicine, and malaria was the diseasethat was at its heart and its center. the two people were initaly--and we'll be coming back to this in a couple of weeks,when we resume classes--in italy there was giovannibattista grassi, who made a very elegantdemonstration,

and a very convincing one,that human malaria was transmitted by mosquitoes. and he did so by experiments inwhich he introduced just one variable in the exposure,during the warm summer months, of large populations to bitinginsects. he protected,by screening, or later by chemical means,select groups of people, while everyone around them wasfalling ill of malaria. they lived in exactly the sameconditions as those around them,

except for one variable;that they weren't subject to the bites of flying insects. and thereby he established thatit was indeed insects, mosquitoes, and certain typesof mosquitoes; we'll be returning to that. not all mosquitoes,just anophelene mosquitoes, and certain species of them,that transmitted the disease of malaria. at the same time,ronald ross,

a british physician in india,was working instead with malaria among the avian--that is, birds--avian malaria, where he demonstrated that ittoo was transmitted by the bites and he argued,by analogy, that human malaria was probably transmitted bymosquitoes as well. now, this was the age of aferocious imperial rivalry, and ross was the first britishscientist to discover the pathogen of a major disease,and he became a national icon, the british answer to pasteuror koch.

he won the nobel prize,and along with manson became one of two decisive figures inthe founding of the discipline of tropical medicine. it was quite interesting thatthere was an extraordinary collaboration between manson andross in india, where ross wrote home what hewas finding under his microscope in india,and sent that back to manson, who worked with him insuggesting new directions for his research,and pushed him forward.

so, in many ways the discoveryof the transmission of malaria belonged to manson as well asross. well, in any case,malaria became the template, the ideal type of tropicaldiseases. and in manson's great workmalaria occupies the largest amount of space in the volume;the reasons being that it was a perfectly vector-transmitteddisease, a perfect parasitic disease. the plasmodium that causes it,as we'll see in a couple of

weeks, lives in a closed cycle,and never exists free in the environment. human beings don't happen uponit, and the plasmodium has an extremely complicated lifecyclein both man and mosquito. and the involvement of themosquito also is scientifically complicated;in other words, it was useful and importantthat grassi was a naturalist, was well as a physician. parasitology was scientificallyinteresting, and intellectually

so. to study malariology,one needed to be a physician, but also an entomologist,a naturalist, and to have a knowledge of thebasic sciences. so, in 1898,for a whole generation, parasitology replacedbacteriology as the cutting edge of medical science,and it became the foundation of this new discipline,the rising discipline of well, if that's how it emerges,what is the new discipline?

manson defined tropicalmedicine in his great work. for him, it was a specialdiscipline, with diseases of an area defined by geography andwarm climate. diseases there,he said, were unlike the diseases of the temperate zone,and they require therefore a special medical discipline todeal with them, and they require physicians whoare specially trained in post-graduate institutes. for that reason,tropical medicine emerged

outside of established medicalschools, because it presupposed thatphysicians needed a special curriculum and training to dealwith diseases that were conceptually different. for example,in 1898, in association with joseph chamberlain,the secretary of state for the colonies--and you can see the role of the state in the promotion of thisnew discipline, which was seen as important forthe promotion of imperial

interests--and with the collaboration of patrick manson--there was founded the london school of tropical medicine,with the specific intention of training colonial medicalofficers in a new medical discipline;or very closely associated was the liverpool school of tropicalmedicine. another idea that manson saidwas essential to the new discipline was that tropicaldiseases were caused not usually by bacteria but by more complexbiological agents,

with complexlifecycles--protozoa and helmets--and that they were transmitted by insect vectors,like mosquitoes or the tsetse fly. malaria had pride of place. it was the ideal type toillustrate this, and it's the first disease thatmanson discusses in his work, and the disease he discusses atgreatest length. there were others of this type,like trypanosomiasis,

which was african sleepingsickness, which was caused by a parasitealso that multiplies in the human bloodstream and causesskin eruptions, anemia, chronic fever,debilitation, lethargy and perhaps coma anddeath. it was transmitted by thetsetse fly. or there was schistosomiasis,caused by worms, with the snail as itsalternative host. or leishmaniasis,or yellow fever--a viral

infection, it was laterdiscovered--transmitted by a certain species of mosquito. well, so far,if you were reading manson's work,you would've found the diseases i've just mentioned would be theones that you would've encountered,and there was a kind of logical coherence to what they were. diseases of places with warmclimates, transmitted by mosquitoes, caused not bybacteria but rather by more

complex life forms. but manson then goes on. and what we see then issomething of a grab bag of diseases, that don't seem tohave much of a scientific connecting link. he mentions certain infectiousbacterial diseases, some of them very familiar toyou already: bubonic plague, asiatic cholera. he adds leprosy.

he then moves on to certainnutritional diseases: pellagra,which is caused by a deficiency of niacin,if your diet consists not of wheat,but exclusively of corn; or beriberi,or certain fungal diseases. and he even calls heatstroke atropical disease. another background factor wasinstitutional. should we call it theinstitutionalization of this new medical discipline?

that is, it coincides with thehigh point of european expansion. and this wasn't just acoincidence. it was an important instrumentin the domination of africa and india,for instance, as important as gun powder,enabling settlers to run mines and plantations,traders to travel, administrators to govern,missionaries to preach, and soldiers to perform theirduties.

for this reason,tropical medicine rapidly attracts governmental backing,certainly in the british case, and institutional support andassistance, from powerful economicinterests, with concerns in the tropical world. so, these institutions--inbritain we've already talked about the london school oftropical medicine, the liverpool school oftropical medicine, the royal society of tropicalmedicine and hygiene.

and it's embedded in a newmajor journal, the journal of tropicalmedicine and hygiene, founded in 1895. in france, we see the pasteurinstitute; in the united states,such institutions as johns hopkins,the rockefeller institute--and in particular its internationalhealth division-- the american academy oftropical medicine, the american society oftropical medicine.

and in the u.s.,there were a couple of distinctive features. one was the association oftropical medicine with the military, and its leadingfigures, walter reed and william gorgas, were in fact armyofficers. and it was in the westernhemisphere too that yellow fever replaced malaria as thequintessential tropical disease. some of the institutional linkscan be seen in specific cases. an example that's recently beenstudied,

somewhat intensively,is the relationship of the harvard department of tropicalmedicine to the colonial establishment of american powerin liberia, and in particular the firestonerubber plantations. and one can see there the clearrole of tropical medicine in promoting,if we like, the expansion of company interests to extractresources from liberia. this was an importantillustration of the uses that tropical medicine could be putto.

well, what were some--if that'swhat tropical medicine was as a discipline--what were some of its implications,the implications of the worldview that it suggested? one is that africa,asia and latin america had something in common. this was an artificialconstruction of european imagination. they were seen as reservoirs ofdiseases that threatened europe;

europe protected by theramparts of civilization and medical science. so, tropical medicine embodied,down to a later period--certainly in this perioddown to the first world war--a eurocentric worldview. it was initially not responsiveto specific locations, as the tropics wereartificially constructed as some single homogeneous place. the natives of the tropics werealso conceptualized as somehow

dangerous, harboring a vastarray of lethal and highly contagious diseases. another implication was thattropical medicine was concerned, in the early decades of the newcentury, primarily overwhelmingly,with the help of europeans-- settlers, administrators,missionaries and soldiers. there was little concern forthe health of the indigenous population. indeed, the medical problems ofthe colonial world that received

attention were those thatthreatened europeans, not the health problems of theindigenous population. there was little attention tothe social and economic determinants of what we mighttoday call third world problems of health,such as poverty, labor conditions,malnutrition. and there was a neglect ofmajor diseases that were often the major health problems of thelocal population; say dysentery or gonorrhea,pneumonia, tuberculosis.

in recent years,in fact, the blindness of the past has even resulted in newinternational attention to a group of diseases,termed neglected tropical diseases,that cause large-scale suffering such as poverty,low productivity, poor pregnancy outcomes,but that for decades received little funding or attention frompolicymakers. more ironically,a major issue, not considered after world wari,

as i said, was the impact ofcolonialism itself on the inhabitants of the tropicalworld; that is, there was no attentionto the way in which colonialism itself contributed toenvironmental degradation; or promoted labor mobility inunsanitary conditions; the way in which it promotedunplanned urbanization, low educational attainment andpoverty. in fact, this period,the first period of tropical medicine,from 1890 to just after the

first world war,was a time, one of the times, of the greatest epidemiologicaldisasters in the tropical world, with virgin soil epidemics,like smallpox and measles, and the impact of what wascalled constructive imperialism. railroads, roads,trade, the transportation revolution,all enabled a pandemic of bubonic plague,from the 1890s to 1920, and epidemic influenza,in 1918 and '19, to occur in the tropical worldas well.

colonial wars,the involvement of the colonies in the two world wars,had major disease impacts. so did the ecological impact ofrailroads, factories, mines and plantations,and the recruitment of migrant labor. so, just as in the case that weexamined at greater length in your reading of north america,disease played an important part in european expansion. another implication was publichealth policy.

in europe and north america,hygiene had given rise to a broad-gauge sanitarian movement;one that reformed urban living conditions through what we mightcall-- and introducing a new jargoninto our course-- horizontal programs of publichealth; that is, improvements thatdealt with living conditions across a broad spectrum ofdiseases. we've seen that in the sanitarymovement. in the tropics,instead, metropolitan powers

applied a different vision ofwhat was called vertical hygiene, or tropical hygiene. now, vertical campaigns ofpublic health targeted instead single diseases,and they were designed to protect, above all,europeans against the most menacing epidemics. that was tropical hygiene, then;something different from what was practiced at the same timein europe, was one of the implications.

another implication was a newprestige and authority for physicians. ross and koch,for example, now became advisors tometropolitan governments, as did manson. it meant also--anotherimplication was perhaps what we might call selective historicalamnesia. many of the diseases identifiedas tropical had only recently been present in europe,and they weren't eradicated by

temperature,but by broad social and economic improvements. malaria itself had been aeuropean disease, as you know,bubonic plague and cholera also. and then tropical medicine wasclearly an instrument of cultural and ideologicalhegemony. it was a justification andrationale for colonialism. europeans felt that they hadhealth and civilization to

offer, and that medicine was ameans of winning acceptance of the colonial presence. so, tropical medicine provideda narrative of european progress,rationality and civilization overcoming ignorance,superstition, darkness and the witchcraft ofnatives. patrick manson was veryexplicit in his vision of the relationship of medicine andempire. in a simple sentence hedeclared, "i believe in the

colonization of the world by thewhite race." well, that was the early periodof tropical medicine, between 1890,more or less, and just at a period after thefirst world war. later we see a transformationin the discipline. and i don't want to argue thatit's the same today as it was at the eve of the first world war. radical changes in tropicalmedicine came through a number of influences.

one was the second world waritself, which was in part--and althoughthere were deep contradictions involved in it--it was in part, at least, a war againstracialism. the discipline was affected bydecolonization, also by the rise of americanhegemony after world war ii, with new priorities. it was influenced byglobalization as an explicit idea,and its implications that we

all live in a single diseaseenvironment, and that what happens indistant parts of the world are also vitally important for theentire world population. and then there was--what wasvery important also was a transformation in funding. because of those factors,around and during the 1970s, the world health organizationintroduced a major new emphasis on tropical diseases,and with it, in 1975, a major new researchproject.

the same happened with therockefeller foundation in the 1970s, and then the macarthurfoundation thereafterwards. and this meant a new dynamismscientifically for the discipline of tropical medicine,and also with that a major attention,reversing an earlier trend, with an emphasis on globalhealth programs that would be applicable everywhere,and that would include major attention to the health of thepopulation of indigenous peoples in areas that had been neglectedby an earlier phase of tropical

medicine. and, so, the entire discipline,if we like, was transformed after world warii, and became something that nolonger embodied a colonial position,and no longer embodied the idea that it was the bodies ofeuropeans that deserved privileged protection,rather than the health of indigenous peoples in otherparts of the world. so, tropical medicine was avery important instrument of

colonial power in the perioddown to the first world war, and it was slowly transformedin the inter-war period, and radically so after worldwar ii. i hope you'll bear that in mindas you think about the issue of what are the implications ofmedical science; and what are its implicationsfor the kinds of society and the world that we live in?