Medicine and Colonialism in Sri Lanka
KeywordsWestern Medicine Public Health Program Plantation Industry Immigrant Worker Rockefeller Foundation
It has been argued that Western medicine introduced by European colonizers and missionaries saved millions of lives in Africa, Asia, and the Americas (Comaroff & Comaroff, 1992). In this context, Western medicine represented a higher civilization and social order that lifted people to modern ways of life. David Livingstone, known for his religious zealotry, chose a medical career to heal the suffering of Africans: “In the glow of love which Christianity inspires, I soon resolved to devote my life to the alleviation of human misery… and therefore set myself to obtain a medical education, in order to be qualified for that enterprise” (Livingstone, 1858; Moffat, 1969). Medical missionaries believed that the eradication of fatal diseases among the indigenous people would encourage the “heathens” to embrace Christianity. Commenting on the effort to establish a public health department in India by the British colonial government in the mid-nineteenth century, Florence Nightingale observed that “it was not only a noble task but also a part of a mission to bring a higher civilization into India” (Cook, 1914). Even though Western medicine was regarded as an integral part of culture, medical services were rarely extended to the masses without reservations.
Several studies have argued that medicine and medical services in the colonies evolved in response to political and economic needs of Western imperialism. They suggest that medicine played a critical role in the expansion of imperialism in the late nineteenth and early twentieth centuries (Arnold, 1988; Headrick, 1981). Medicine, as it was introduced to non-Western societies by imperial forces, was an instrument of political, economic, and cultural domination. With the expansion of European colonialism in Asia, Africa, and Latin America, the threat of tropical disease became a major obstacle to colonial rule. New medical sciences were developed to deal with diseases such as cholera, malaria, dysentery, and yellow fever for the protection of the European troops and administrators from diseases originating in the indigenous communities (Kavadi, 1999). Radhika Ramasubban, who has done an extensive analysis of the origin and the development of Western medicine in British India, suggests that the main concern of British colonial policy was to protect the health of the British army and the European civilian population living in India. As a result, colonial medical policy in India created medical “enclaves,” leading to the exclusion of local populations. Such policies were justified by the colonial administrators who contended that the Indians were “superstitious and backward” and would not accept modern medicine even if it were offered (Ramasubban, 1988).
It became clear that the health of the European personnel, particularly members of the military, could not be protected by measures directed at them alone when there were epidemic diseases among the native populations (Turshen, 1984; Worboys, 1988).
The increased trade and political interactions with the colonies led to a heavy traffic of people and materials across the continents. As a result, the increased vulnerability of Europe itself to epidemic diseases stemming from the tropics became a matter of concern (May, 1958).
The supply of raw materials for the industries in Europe and North America was dependent upon the productivity of the colonial labor force. Therefore, to sustain the capitalist economic development in the West, it was necessary to improve the productivity of the people in the colonies (Emmanuel, 1982).
The expansion of the market and future investments by the industrialized countries in these colonies were dependent upon the receptiveness of the masses to Western cultural and social values. Hence, the ability of Western medicine to eradicate diseases in these societies would “reduce the cultural autonomy of the agrarian people and make them amenable” to Western values and lifestyles (Brown, 1976).
Against the background of these recent interpretations of the role of medicine in colonial rule, we examine the impact of British colonial economic policies on the health of the colonial labor force in the plantation sector of Sri Lanka (formerly known as Ceylon) as a case study. The laissez-faire policy of the colonial government enabled the British planters to ignore even the most basic sanitary requirements such as latrines on the plantations in order to maximize profit. As a result, the plantations became breeding grounds for many parasitic and infectious diseases found on the island during the late nineteenth and early twentieth centuries. When the International Health Board (hereafter IHB) of the Rockefeller Foundation arrived in Sri Lanka in 1916 to set up a hookworm control campaign, there was an epidemic of hookworm infection on the plantations and the neighboring villages.
The British captured the Kandyan Kingdom of Sri Lanka in 1815, slaughtering thousands of natives and destroying scores of villages (Marshall, 1982\1846). Dr. Henry Marshall, a senior medical officer of the 89th Regiment that led the war against the Kandyan Kingdom, wrote that “the incursions of our troops into the Kandyan territory… were calculated to fill the population with the most unfavorable opinions of our justice and humanity, and to confirm the worst prejudices against the European race.” As Marshall predicted, the bitterness of the war persisted among the Kandyan Sinhalese for a long time. When the British established plantation industries in central Sri Lanka during the mid-nineteenth century, the Kandyans refused to work on the estates. To fill this deficit, laborers were brought from the southern Indian state of Tamil Nadu for the year-round work in the plantation industry. Unlike in other British colonies, such as Mauritius and the West Indies, where the Indian labor had been employed since the early nineteenth century, the colonial government never directly participated in the recruitment of Indian estate labor for Sri Lanka. The authorities maintained that Sri Lanka was close enough to India to leave such recruitment to private economic enterprises (Kodikara, 1965). The estates’ agents, or Kanganies, recruited the laborers in India. The number of laborers recruited gradually increased with the expansion of the plantation industries: coffee in the years 1841–1880, tea in the years 1890–1910, and rubber in the first two decades of the twentieth century. By the turn of the century, about 100,000 workers and their families arrived annually in Sri Lanka (Heiser, 1936; Philips, 1955).
The Prevalence of Hookworm Disease
The Rockefeller Foundation initiated the hookworm control campaign in the early 1900s, when the disease was a major health problem in the southern United States (Fosdick, 1952). The public health program was started in the South for the purpose of integrating its agricultural territory into the more stable, industrial economy controlled by the capitalists in the North. John D. Rockefeller Sr. and his close advisors believed that the disease, illiteracy, and unemployment in the South were not only causing political and civil unrest but also contributing to the sluggish economy. By improving the health and education of the whole population, beyond racial boundaries, the Rockefeller Foundation expected to expand its industrial and commercial base in the South (Brown, 1979).
The political and economic interests of the Rockefeller philanthropists were certainly not limited to the United States. They clearly recognized the interrelationship between their own personal economic interests and those of the capitalist class and the global economy in general. Consequently, with the experience of controlling hookworm infection in the South, the International Health Board of the Rockefeller Foundation (hereafter the IHB) willingly extended its capital to other countries, particularly to the British Empire. Frederick T. Gates, who was one of the architects of the Rockefeller philanthropies, wrote to John D. Rockefeller Sr. in 1905 stating that the hookworm control campaign was one of the “special programs that has direct physical and economic benefits, and a means of creating and promoting influences” (Brown, 1976). The concept of health, for the Rockefeller philanthropists, was clearly an economic term embedded in the capitalistic pursuit of global economic and political domination. They had the foresight to understand that disease has no geographical or cultural boundaries. In relation to the hookworm control program in Sri Lanka, Dr. Victor Heiser, the director of the public health program of the IHB in the East, maintained that “disease never stays at home in its natural breeding place of filth, but is ever and again breaking into the precincts of its more cleanly neighbors…. It should also have been evident to employers of colonial labor that human life had a direct monetary value… even though it might vary greatly with age and race” (Heiser, 1936). The Rockefeller philanthropists believed that if health could be achieved in the British colonies, which included the largest share of the global market, Western industrial capitalists could not only expand their trade to those countries but also influence the national political affairs of those nations. In this context, they expected that medicine would help unify and integrate the emerging industrial economies and their social and cultural values with those of less developed agrarian societies and legitimize capitalist activities by diverting attention from structural and other environmental causes of disease (Brown, 1976).
The government offered a favorable administrative framework.
The agricultural industry provided an effective economic medium.
The island delimited a large, but discrete, area.
The geographic location of Sri Lanka in the East might tend to help spread the new knowledge and its benefits (Philips, 1955).
By implementing a hookworm control program for a selected group of people in the country, the IHB expected to achieve high visibility and recognition in the international community. Furthermore, by eradicating hookworm infection among the workers in the plantation industry, the Health Board believed that it could help increase productivity (Brown, 1976). In his speech to the Planters’ Association in Kandy on May 12 1916, Dr. Howard, a project advisor of the hookworm control campaign in Sri Lanka, specifically mentioned the economic benefits of the hookworm campaign. “It is of immense importance to the planters and estate owners since their profit must be dependent upon the efficiency of the labor with which they operate. Further, not only would the efficiency rate of the treated laborers increase by 20–40 %, but also they were less likely to return to India necessitating the importation of others to replace them” (RAC, 1916).
The cultural and political aspects of the location of Sri Lanka were equally important for the Rockefeller Foundation. Sri Lanka, as the center of Theravada Buddhism in the East, was identified as an important cultural “laboratory” for a public health campaign of Western medicine, the success of which could be used by the Rockefeller Foundation as an example to highlight the benefits of Western culture (Jayawardena, 1988).
Organization of the Project
To reduce the cost of annual recruitment of new workers by reducing morbidity and mortality.
To cut down hospital expenses by reducing the rate of hospital occupancy.
To increase the rate of fertility among female workers and to produce a native-born permanent labor force by treating anemia.
To increase daily productivity by reducing the number of sick workers (RAC, 1916).
By the end of 1922, over 600,000 people had been treated. The rate of infection dropped dramatically, and hookworm related deaths in the island declined to their lowest level of 415 per million persons in 12 years. The reduced hospitalization among workers showed the planters the economic benefits of the campaign. Annual reports emphasized the increased productivity and the reduced absenteeism. “There have been indications that the health of many has improved since the treatment. There has been an increased capacity for work” (RAC, 1918). Reports were carefully worded to avoid any misunderstanding that could jeopardize the confidence in Western medicine or the work of the Rockefeller Foundation. For example, in the case of death following treatment, the locally recruited dispensers were accused. “Careless administration of treatment… may have caused one or two deaths in the hookworm campaign. There were mistakes and instances of irresponsibility on the part of some of the local staff, but all known emergencies were met by the doctors with an almost perfect record of medical success” (RAC, 1917). American doctors working in the field often interviewed plantation management to get their reaction to the increased productivity as a result of the treatment. One planter reported that “the whole labor force is healthier… there has been very little sickness lately and… one outcome of the treatment is the pending heavy increase in the birth rate. My coolies on the whole have great faith in the treatment” (RAC, 1918).
The construction and improvement of latrines and line compounds in order to meet basic sanitary requirements.
The mass treatment of all employed laborers annually until the reinfection declined to a negligible level.
The establishment of quarantine camps in South India, where the plantation workers originated, to treat them before leaving for Sri Lanka (RAC, 1925).
The Rockefeller Foundation’s hookworm control campaign on the plantation began with the understanding that the planters would take the appropriate measures to improve the sanitary conditions on the estates. However, these preventive measures required some spending which the planters did not want to undertake. As a result, the rate of reinfection continued to increase in the plantation areas. In one district alone (Matale), a year after the workers had been cured, the rate of reinfection was 88 % among a total of 3,000 persons examined (RAC, 1920a). The field doctors reluctantly admitted that the planters were unwilling to improve sanitary conditions, though they were happy to see that the laborers were being treated. In their annual reports, they recommended sanitary reforms as a fundamental requirement for the prevention of the disease. However, these cogent recommendations of the field doctors were not matched by sufficient will on the part of the IHB officials, whose mandate was to negotiate with the government and planters. For political reasons, financial contributions were approved so long as good will continued to prevail between these parties. For instance, in recommending $5,000 for a plantation company to provide treatment for their laborers, Dr. Jacocks, a senior representative of the IHB in Sri Lanka, wrote to the New York office, “I asked Dr. Rutherford [PCMO] for his opinion as to whether the granting of such a contribution by the Board at Government’s request would help to ‘heal the break’ [original emphasis] between Government and the planters. He said that he thought it would, as it should be evident to planters that the aid could not have been granted without Government consent. He thought further that a more kindly reciprocal feeling between planters and Government would follow” (RAC, 1920b). Perhaps even in a more crucial ideological sense, presented with the choice of pressing for fundamental sanitary development or continuing medical treatments, the IHB officials consistently authorized the latter, which it favored due to its bias toward curative medicine. Instructing on how to spend the $5,000 grant, Dr. Jacocks stated, “this sum to be used for post treatment as well as first treatment” (RAC, 1920b). Despite the apparent failure of the hookworm control campaign on the plantations, the IHB felt it had achieved its goal by demonstrating the relationship between the treatment for hookworm disease and increased productivity. Therefore, in 1922, the IHB decided to close its program on the plantations (Hewa, 1995).
While medicine and medical services were developed to overcome the threat of tropical diseases, these medical services were not extended to the people of the colonies until it was realized that the repeated outbreak of epidemics in the colonies would not spare the European troops and administrators. Moreover, the diseases in the colonies eventually found their way to Europe through trade. For example, the spread of cholera from India to Europe between the period of 1816 and the 1880s was a major concern that directly influenced the scientific research of John Snow, Louis Pasteur, and Robert Koch (May, 1958). While the health of the Europeans was always the first priority of colonial policy, the health of the indigenous people, as long as it did not threaten the economic and political interests of the empire, was ignored. Indian labor was exploited extensively for the expansion of the empire in Asia, Africa, and the Pacific in the same manner as African slavery was used to build the colonial economy in America and the Caribbean.
As shown, the hookworm epidemic in Sri Lanka was the result of a colonial labor policy which compromised the basic sanitary requirements of the workers for the purpose of maximizing profit. Although there was nothing inherently evil in the medical services provided by the IHB in Sri Lanka or anywhere else for that matter, the predominant interests of the IHB – as epitomized by its partiality for curative medicine – effectively precluded the success of their campaign to cure disease at their source. This curative bias of the IHB official changed over time as they continued to work in Sri Lanka. This was evident in the subsequent Health Unit Program (Hewa, 2005) begun in the late 1920s that became the foundation of the primary care system developed in the last 75 years in Sri Lanka.
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