The eight essays collected in Beyond the State: The Colonial Medical Services in British Africa come as welcome contributions to the growing literature on medical health services in British Africa. Far from being a unified health provider, the authors emphasise the varying levels of cooperation—sometimes willing but often uneasy—between the British Colonial Medical Services (CMS) and several non-state stockholders. As such, the work provides valuable insights into the complicated relationship between the objectives and policies of the centralised government in London, on the one hand, and the realities of implementing them in colonies that were frequently underfunded and poorly resourced. The outcome was colonial doctors, and administrators often took practical steps to establish formal and informal relationships with a range of medical agencies and health providers.
By focusing on the history of medicine in colonial Africa, Beyond the State aims to develop discussion in two directions. Firstly, as Anna Greenwood states in the introduction, the essays provide an “academic springboard” whereby attention can move away “from the compartmentalisation to which colonial historical debate is prone” (2). The volume’s thematic focus on “tensions” within the CMS and the institution’s relationships with other agencies successfully demonstrates the untidy reality of Empire and how common binaries in the existing literature, such as “black and white, elites and non-elites, heroes and villains”, are unhelpful (2). Secondly, the collection aims to address recent calls for more comparative studies in the history of medicine, as opposed to numerous single-site case studies that populate the discipline. The cases included in this volume are from a broad range of territories in British Africa—Kenya, Nyasaland (modern Malawi), Nigeria, Tanganyika (modern-day Tanzania), Uganda and Zanzibar—which goes a long way to achieving this aim despite still only touching on a small portion of the empire more generally.
Three of the eight essays examine the relationship between the CMS and medical missionary societies in British Africa. These essays convincingly demonstrate how the work of missionary doctors was more than just supplementary. By contributing “specialist knowledge, language skills, equipment and personnel, mission doctors “went beyond filling a gap in state provisions” and helped to shape the colonial medical services themselves (19). For example, Yolana Pringle’s contribution, using a chronological approach, examines the collaborative relations between the Uganda Colonial Medical Services and the Church Missionary Society in the years before 1940. Focusing on Mengo Hospital as a case study, Pringle demonstrates how missionary doctors had “dual roles” that not only allowed them to spread their evangelical message and extend their professional range but also to contribute and manage government health campaigns actively.
Continuing with the discussion on medical missionaries and the CMS, Markku Hokkanen moves the focus onto Nyasaland for the period between 1891 and 1940. His study, contrary to Pringle’s essay, highlights the conflicts as well as the collaborations between the two health providers in this context. Interestingly, these conflicts typically took place in private. The consequence, as Hokkanen shows, is an image of colonial medicine as a unified enterprise in Nyasaland, but one that hides deeper fractures between the CMS and the missionary physicians. This chapter demonstrates that colonial medicine cannot be reduced merely to a “dualism” between state and church, secular and spiritual. Instead CMS medical officers and missionary doctors took part in a complex imperial network that shared resources, the division of labour and collaborated on issues regarding African medical education. The final contribution regarding missionary medicine, provided by Mike Jennings, analyses the passage to post-colonial ideas of development. Using Tanganyika as its case study, this chapter offers the original point actorsthat colonial medicine was a progressively formalised joint endeavour between state and non-state , such as missionary health providers. This point impacted the way in which the post-colonial voluntary sector in Tanzania developed after independence. Jennings’s contribution posits a compelling argument that missionary societies were the originators of the voluntary sector and a fundamental part of new histories of welfare and development, especially concerning NGOs.
Anna Greenwood contributes two chapters to the work that not only demonstrate the limits of CMS cooperation but also highlight its fixation on appearing in complete control. Her first essay, co-authored with Harshad Topiwala, shows how the Kenyan Colonial Medical Services undertook a substantial policy change regarding the employment of Indian doctors in the 1920s but managed to keep this out of public gaze. This valuable chapter challenges the image that the Colonial Medical Services consisted nearly exclusively of European staff. On the contrary, in the early history of the Protectorate, non-white individuals had a range of responsibilities and roles within the colonial medical department that was not limited to the lower echelons. In fact, there were nearly twice as many Indian as there were European doctors in the years before 1923. Greenwood’s second chapter focuses on the case of the Zanzibar Maternity Association (ZMA), a local organisation designed to care for expectant mothers. Despite having helped to establish the ZMA in 1918, the CMS turned hostile after it refused to become an official adjunct. The case successfully serves as the books single example of outright non-cooperation.
Matthew Heaton’s contribution moves the discussion onto the interactions between the Colonial Medical Service and private business. In this fascinating chapter, Heaton examines how British officials would have Nigerian immigrants repatriated back to the colony by the private shipping company, Elder Dempster, if they were deemed to be insane. To facilitate the repatriation of a colonial subject, a series of negotiations had to take place between the state, the colonial medical departments and Elder Dempster itself. This case study shows how even private business helped to sustain fundamental racial assumptions about the correct and appropriate treatment for mentally ill African immigrants. Instead of receiving treatment in the metropole, they went back to the fringes of the empire where they were thought to belong.
Shane Doyle’s essay returns to the theme of cooperation and reveals the extent to which non-medical research that existed outside of their discipline influenced CMS policies and practices. To justify certain decisions or practices, Doyle shows how the medical departments in Uganda and Tanganyika consulted the work of social scientists such as anthropologists, psychologists, and ethnographers. These scientists, mostly affiliated with the East African Institute for Social Research, provided insights that guided and legitimised CMS policies and practices aimed at social diseases such as sexually transmitted infections.
Beyond the State provides a valuable contribution to the subject of colonial medicine in the first half of the twentieth century and would make a useful source for researchers and undergraduates interested in the details of colonial medicine in operation. Although the volume largely neglects the experiences of African patients (Pringle’s essay does include some discussion of patient cases from Mengo Hospital) or doctors and only touches briefly on the final years of empire, the book nevertheless delivers on its aims. It not only presents a significant analysis of the complexities, tensions, and challenges in administering medicine in the colonies but also shows the diversity of approaches and stakeholders involved in different territories controlled by the British Empire in Africa.
