Matthew Heaton and Mridula Ramanna have developed two detailed books on the shaping of health and medical care in former British colonies of Nigeria and India. Both books contribute toward a fuller understanding the history of medicine, science technology studies and medical anthropology.
A strength of both books is that the authors depict Nigerians and Indians as agents affecting health and medical knowledge and not just as recipients of ill-thought policy. Nigerian psychiatrists had a significant influence on the shape of international psychiatry, and Indian bio-medical physicians played a considerable role in shaping the public health. Both authors reveal the ways that healthcare policy and processes, which shaped public health for the body and the mind, were contested by the state, a diverse ‘public’, the media, prevalent ideas in Britain all of whom had to compete for their place in the shifting centre stage.
Heaton provides a finely nuanced literature review demonstrating that Nigerian psychiatrists were active agents in decolonizing the knowledge locally, destabilizing the colonial racist hierarchy by embedding themselves as elites in the production of knowledge. They also contributed to the production of politicized health knowledge abroad, which had a decolonizing intent with its link to pan-Africanism and anti-racism. Professionalizing of African psychiatry in Nigeria, and the effect it had outside of Nigeria was a decolonizing process, Heaton argues. Psychiatry was also a location to explore the ebbs and flows of universal disease categories, and their treatment and the contribution of Thomas Adeoye Lambo to the World Health Organization and the shape of culturally sensitive psychiatric treatment was a significant contribution of the book. Lambo early on recognized the impacts of rapid socio-and economic change on the rise of psychological maladjustment and contended that any human being experiencing this would be affected not just the assumed ‘African mind’ and he promoted the cooperation of nations in developing treatment methods for migrants. Also, worth noting is that Heaton’s writing is crystal clear and pays tribute to the contribution of Anthropological studies of Nigerian health and wellness.
Ramanna’s book contains fine details and descriptions from the archival record, but detracting from this is an overall lack of analytical rigor to contextualize the materials and provide a more in-depth critical reading of them. The book feels like scattered chapters rather than an intended whole that characterizes Heaton’s finely crafted book. A positive is that Ramanna provides an array of possible leads that subsequent scholars could follow up on, but it would behoove the reader to themselves link the materials to the broader literature on Indian science and technology and history of medicine. Chapters 4 to 6 are excellent reproductions from the journal Economic and Political Weekly which may explain the relative absence of an overarching analysis of the gathered data that they all have been accumulated into book form as an afterthought.
Ramanna claims to want to go beyond ‘normative boundaries’ and reveal the nuances of public health, but the book doesn’t succeed in this regard. In fact, in my reading, Ramanna’s analysis falls squarely into a political liberal view of healthcare as the dominant view of the day and shared by the author. While at points critical of the narrow view taken by physicians, Ramanna seems to favour methods of bio-power (education and behaviour modification) as the main form of preventive care and a curative system only marginally covered by state funding. At many places in the book, Ramanna uses terms like ‘improvement’ (37) that some policymakers implemented ‘rising standards’ of health and sanitation that could not be ‘matched’ (41). Heaton, on the other hand, applauds Lambo and other Nigerian psychiatrists work to link individual psychology with the nation’s overall development, and to see that preventative health structures would have a long-term positive effect on the social and economic costs of long-term care.
Here and there, Ramanna reveals public and media consciousness against vaccines as prevention and the need for improved sanitation in India for the working class and the public and notes that the media recognized that discrimination was at play when Europeans, living in well ventilated, clean homes, were not recommended to be inoculated. Ramanna also acknowledged that both inoculation and the creation of cordon sanitaries were there to protect European economic and trade interests. But these seem more anecdotes to the successes of dominant western biomedical health infrastructure put in place at the curative-level. Ramanna seems to view the efforts in Bombay to recognize the links between poverty and ill health in a marginal or cursory way, and the central tendency of the analysis is mild to overt support of such approaches. The work of W.W. Peter is referred to as ‘most inspirational’ (45) when he walked through villages and towns with massive models of insects behind the infections and chanting ‘boil all water’, despite crowds being unhappy about these messages. In the latter case, Britain’s conception of ‘cleanliness’ and ‘hygiene’ as superior to local notions is a repeated theme in the books as is Ramanna’s sentiment that physicians played a rightfully central role in overseeing these processes of behaviour modification that emerges throughout the book (135).
A theme that both books share is that the emergent bio-medical experts were self-conscious about the ways that their cultural norms were varied and did not fit with the biomedical and public health models of Europe. Both authors provide ample evidence that policies that were implemented that were culturally inappropriate or insensitive were rejected by the public at first such as being hospitalized at all (104). For example, one that stands out noted by Ramanna is the pits for human waste sanitation being at first rejected as ‘graves’ but soon widely implemented (41).
While any study of health would promise the interrogation of health concepts, Heaton provides a much richer tapestry concerning the health categories of Nigerians and colonial ethno-psychiatrists whereas Ramanna offers more information of the content of the bio-medical beliefs and practices that took shape and that they were, at times, resisted without really detailing convincingly why. Heaton points out that a preoccupation of Nigerian psychiatrists was to dispel colonial ethnopsychiatric pseudoscience and develop an array of tactics to create more incorporative egalitarian universalistic models. Chief among which was ameliorate the more barbaric injustices encountered in colonial biomedicine by accepting and embracing local beliefs and practices of health and illness.
Like Nigerian psychiatrists, emergent Indian physicians established their organizations to study local cultural-based health practices. But unlike in Nigerian psychiatric associations, in many cases, these agencies such as the Bombay Sanitary Association and the Bombay Medical Congress sought to root out beliefs that diverged from the biomedical and moralized conceptions of health and hygiene from Europe and especially from Britain. At times, Ramanna seems to applaud these efforts. On the other hand, Heaton praises the pioneering work of Lambo to establish cutting-edge village-based care institutions developed with maximum cultural sensitivity for Nigerians suffering from cognitive dissonance. Before Lambo’s work, colonial psychiatrists did not question whether Europeans and Nigerians had distinct psychologies, but only why Africans seemed to have so many ‘negative’ (46) characteristics that did not fit with European understandings. For a long time in the nineteenth and twentieth centuries, ‘Africans’ were lumped together as a homogenous unit in medical thinking of Europe and social Darwinist racial thinking of the day. Moreover, he elucidates the pivotal role played by Nigerian psychiatrists to reject the idea of an ‘African mind’ (43) that was common in the in the mid 1950s or a little bit later of a ‘Nigerian personality’ (125) and its purported links to a collectivist society (124) that was assumed by an older generation of colonial and Nigerian psychiatrists.
Heaton also compellingly reveals the ways that ‘traditional’ Nigerian healers dealt with various forms of mental distress that were believed to be caused by the evil eye, witchcraft, and sorcery that the individual-based internalizing psychiatric models of the day could not deal with. Heaton reveals that Nigerian psychiatrists were operating at two different levels: one based on the universalistic psyche using existing psychiatric frameworks, and they also had to be able to articulate their approach in a manner that was commensurate with local cultural understandings. In the latter regard, many Nigerian physiatrists believed that it was key to ally with traditional healers.
In exploring public health in colonial Bombay, Ramanna also shows the ways that some practitioners struggled with local beliefs, but perhaps the one thing that Ramanna does well in the book is to thoroughly describe the different forms of knowledge in circulation: the state, the media, the public, various religious and caste forms of knowing, the emergent bio-medical outlook, and that of traditional healers such as Muslim Hakims and Ayurvedic Vaids and so on. It is up to the reader to interpret all of this, however. Ramanna also shows the ability that different public interest groups had in Bombay to resist the bio-power, to insist on health policy their way, and to insist for a rightful place for Ayurveda, Unani and other forms of traditional Indian health. But, again, there are so many details it is difficult to get a broader view of the situation. Heaton also deals with different layers of belied such as that of colonial ethno- psychiatrists, emergent Nigerian psychiatrists, Nigerian immigrants and students in England, traditional healers, international psychiatrists and so on.
Both books provide important information about the ways that health practice and policy were actively shaped within the former colonies. Both authors offer incredible detail to give a bird’s eye view of these processes and carving a space for people who played pivotal roles but who seldom get recognition in the western histories of medicine and science. Heaton’s analysis deals squarely with colonization of the mind, and so too does Ramanna at a fundamental level, but Heaton is more critical of this, whereas, Ramanna seems far less critical and much more approving. Heaton’s book is vastly better crafted and more readable, despite its rigorous use of theory, than Ramanna’s. But the latter book compensates in breath-taking archival details what it lacks.
