Local negotiation and imperial imposition

The idea of medicine as an advancing frontier of western power and knowledge has been a recurrent trope in recent colonial history. Beginning with the army and white civilian community, western medicine spread into the surrounding countryside, physically as well as metaphorically colonising the landscape, infiltrating indigenous societies in the cause of conquering disease. But, while the general process is clear, questions remain as to how comprehensive this process was, how far politics and economics fashioned the medical frontier, and how far the advance of "sanitary civilisation" entailed local negotiation as much as imperial imposition.

In examining colonial Sudan, Heather Bell is wary of drawing hasty conclusions. A concept of frontiers helps her to illuminate the ways in which a small, at first essentially military, medical service extended colonial authority into areas far removed from Khartoum. But Bell repeatedly emphasises the weaknesses of the colonial order. Even when, as in their sleeping-sickness campaigns, the authorities tried to coerce and control the population, their power ultimately rested on Sudanese consent.

Bell is also suspicious of "political economy" approaches to colonial health and medicine, arguing that financial gain was not the only imperative behind attempts to extend medical control: an ambition to advance the frontiers of medical knowledge might be no less compelling. Sudan might at first appear a somewhat marginal site for investigating colonial medicine, but Bell shows that in several respects it is worthy of particular notice.

In 1903 Henry Wellcome (patron saint of modern medical history) established a research laboratory in Khartoum, thereby making Sudan a centre for the investigation of tropical diseases for three decades. Attempts to transform central Sudan into a major cotton-growing region brought medical officers face-to-face with the problems of managing the health of the labouring classes and the changed disease environment immigration and irrigation produced.

Sudan was caught up, too, in the intensive sleeping-sickness campaigns that had far-reaching effects elsewhere in central Africa, and, through the unexpected discovery of yellow fever, the Sudanese experience also illustrates the growing internationalisation of public health in the inter-war years.

We see Sudan through a series of cross-cutting perspectives that illuminate the diverse but fractured nature of colonial medicine.

Bell's multi-stranded understanding of colonial medicine is rich in archival detail, but at times the scope of her discussion seems unduly restricted. Aside from a brief account of their Syrian assistants, most of the book is devoted to the background, views and activities of British doctors. We learn in passing of Sudanese resistance to some medical measures, but there is little attempt to represent indigenous views of health and disease. There is some redress for this in the final chapter, which, alongside midwifery training, discusses Sudanese attitudes to female circumcision. But even here what is striking is not the remorseless advance of the medical frontier, but colonial self-circumscription, for the colonial authorities, still fearful (decades after the defeat of the Mahdi) of a religious backlash, treated circumcision with political caution rather than medical concern. The episode further shows how women, alike as medical agents and subjects, were made secondary to the priorities of the male-oriented colonial medical order.

David Arnold is professor of South Asian history, School of Oriental and African Studies, University of London.