Prior to its internationalisation in the second half of the nineteenth century, health governance across Europe and the Ottoman Empire was carried out by a polycentric patchwork of regional sanitary councils. These councils had emerged from decades of diplomatic entanglements between the Levant and Europe, and involved both local and foreign medical experts.Footnote 1 In 1831, Alexandria had set up the first such council; in 1835 Tunis followed suit; in 1838 Constantinople; and in 1840 Tangier. In the fight against cholera, smallpox, yellow fever, and other diseases, these councils administered lazarettos, disinfection stations, and strict quarantines. In tandem with medical debate concerning the aetiology of pandemic diseases, health administrations across the region multiplied and professionalised. Persian and European scientists closely collaborated, for example, at the Persian polytechnic institute Dar al-Fonun, founded in 1851.Footnote 2
By the time of the International Sanitary Convention of 1892, a tangible if modest result of the International Sanitary Conferences (ISCs) convened since 1851, sanitary governance looked much more uniform and centralised – but also much more European.Footnote 3 Ottoman and Persian sanitary councils were now staffed with mostly European medical experts, whereas the health risks and financial burdens of quarantine were primarily borne by countries in supposed sanitary ‘buffer zones’ from Persia to Egypt. Cross-regional ties with institutions like the Dar al-Fonun had receded, and in their place came an increasing dependence of expertise on accreditation by European institutions. In a global order marked by rising imperial anxieties, health governance had become a major site of struggle, particularly for increasingly marginalised actors across the Middle East, North Africa, and South Asia. At the same time, Europeans more or less took over the epistemic infrastructure of health governance, fragmenting pre-existing transregional communities of medical scientists. This lends support to critiques of the supposed European origins of international organisations (IOs).Footnote 4 But it is less clear what difference internationalisation as such made. This article therefore asks, how exactly did health governance get internationalised, and with what consequences?
The article argues that the nineteenth-century shift from councils to conferences is best understood as a case of ‘internationalisation by appropriation’, on two main dimensions. Institutional appropriation refers to the establishment of a central hub that seeks to coordinate existing agencies (the regional councils) at the expense of their authority. Epistemic appropriation, in turn, involves the redrawing of the boundaries of both the governance problem at hand (public health) and expertise. In the case of the ISCs, powerful actors used experts, and expert-based claims about what public health referred to, to appropriate a pre-existing governance arrangement. This was how expertise became a means of discriminating against the position of marginal members, or indeed to marginalise them in the first place.
This reading sheds new light on the relationship between imperial power politics and the emergence of modern IOs.Footnote 5 It also unpacks how internationalisation actually empirically manifests: the absorption into institutions that were explicitly ‘international’ did not happen automatically, but was deliberately pursued.Footnote 6 Appropriation specifies how imperial ordering concerns shaped health governance rather than simply diagnosing that they did. At the ISCs, European delegations did not simply dismiss public health concerns for the sake of imperial trade, but subjected existing regional sanitary councils to new forms of control and moulded the production and mobilisation of expertise along newly restrictive criteria.
To date, surprisingly few studies have examined how institutions such as IOs historically appropriated pre-existing governance arrangements. While the pattern has been documented by legal scholars working on institutional succession,Footnote 7 it has received limited attention in the context of international conferences and organisations.Footnote 8 Extant accounts trace the origins of modern IOs to Europe’s river commissions and public unions like the 1865 International Telegraph Union.Footnote 9 Despite the critical tenor of much of that work, we still lack clarity as to how exactly those new institutions – rather than appearing out of the blue – replaced, reclaimed, or captured existing ones. As Yao has shown, entanglements with imperial and racial hierarchies were foundational to modern IOs.Footnote 10 I build on this counterpoint in the context of health governance, where such hierarchies shaped institutional design but also actively obscured transregional origins.
My study demonstrates that the ISCs absorbed the work of earlier sanitary councils that were neither of European origin nor initially dominated by European experts. Although Europeans ultimately assumed leadership roles, the trajectory from councils to conferences diverges significantly from the assumptions of standard accounts. Based on archival research and a reinterpretation of the existing literature,Footnote 11 the article examines the 1866 and 1892 ISCs to analyse Ottoman, Persian, and Egyptian resistance to European proposals both before and after the arrival of relative scientific consensus as to the spread of cholera.Footnote 12 It shows that such resistance was nominally welcomed if based on scientific expertise, but that whenever expertise failed to align with the interpretation that cholera was the gravest threat, and a threat to Europe most of all, expertise was no longer sufficient to contest health policy. As expertise opened up a new pathway of inclusion, claims about its politicisation (i.e., its non-alignment with a dominant view) became a new pathway of exclusion. Changing parameters of inclusion and exclusion were central to the rise of international health governance – as indeed global historians tell us they were to debates on statehood and the vulnerability of borders,Footnote 13 mobility and population control,Footnote 14 or racial stigmatisation.Footnote 15
Against this backdrop, the ISCs are recognised for having laid the foundations of the modern global public health regime that culminated – via the Office International d’Hygiène Publique and the League of Nations Health Organisation – in the World Health Organisation.Footnote 16 This makes the ISCs an inherently important case for the study of IOs. Below, the article first discusses the literature on institutional inequality and expertise to develop the case for closer attention to historical dynamics of appropriation. The second and third sections empirically examine how the ISCs appropriated the work and domain of the sanitary councils. The conclusion addresses the wider potential of focusing on historical forms of appropriation for International Relations (IR) studies of expertise and institutional inequality.
Institutional inequality, expertise, and appropriation
IOs institutionalise inequalities in different ways, including by means of design features, membership categories such as permanent membership in the United Nations Security Council, or subgroups.Footnote 17 Claims about expertise underpin many such practices: experts can introduce their own hierarchies of knowledge,Footnote 18 and expert mobilisers may signal scientific neutrality to deflect contestation.Footnote 19 So, how exactly can expertise be said to relate to the institutionalisation of unequal governance?
The first clue lies in the fact that expertise is not epiphenomenal but foundational to IOs. If IOs ‘are legitimated by a myth of depoliticization’,Footnote 20 expertise is a major source of legitimacy. Whether as external advisors or as in-house staff members, experts – actors mobilised for their recognised claim to specialist knowledge – help IOs understand and respond to governance problems.Footnote 21 Today, this role is easily taken for granted, but the rise of modern IOs in the mid-nineteenth century revolved around expertise from the very beginning.Footnote 22 From the 1850s, international conventions and institutions proliferated at remarkable speed. The vast majority of these, from the International Shipwreck Society to the Universal Postal Union, from the International Meridian Conference to the International Commission on the Suez Canal, consisted either of specialist gatherings among scientists and engineers or of diplomatic meetings on highly technical questions involving extensive expert consultation.
Many of the questions these gatherings addressed were, perhaps needless to say, far from purely technical: standardising telegraphic communication, for instance, was essential to expand and accelerate imperial control. Involving the experts thus inevitably raised contentious questions about their trustworthiness, the reliability of their status claims, their objectivity, and so on. This meant that governments sometimes competed for winning the experts over for their own political aims, or alternatively that they would recruit, as experts, people who happened to side with their views.Footnote 23
Such historical accounts challenge conceptions of experts as problem-solvers,Footnote 24 as well as post-functionalist work on epistemic communities.Footnote 25 Within IOs, such work suggests, putting aside political differences and letting the evidence speak should arguably have some levelling effects. Yet as this article will show, what makes IO expert governance divisive and hierarchical is the fact that, if expertise is the price of admission, its political value increases. Powerful actors will vie for expert approval.Footnote 26 The locus of exclusion moves elsewhere. Political power now consists in shaping what counts and does not count as expertise. This is where appropriation comes into play.
Two dimensions of appropriation
Appropriation is integral to the historical emergence of IOs, and inseparable from the question of expertise. Despite this, IR scholars have not explicitly conceptualised it at much length.Footnote 27 To state the obvious, international governance arrangements build on precedents, blueprints, regional predecessors, or existing local institutions. This implies that their making involves some measure of appropriation. Such patchworks can become meaningful entities in their own right, but they can also erase the histories of their own making.Footnote 28 In the case of telecommunications, for instance, the 1865 International Telegraph Union absorbed pre-existing Western European and Austrian-German Telegraph Unions.Footnote 29 So, how exactly did this work in the case of public health?
Empirically, I first bracket the question of actor intention, which we cannot infer based on the mediated and selectively recorded information stored in the archives. Second, I conceptualise two main dimensions of appropriation: epistemic and institutional (see Table 1). Their sequencing and relative significance conceivably vary from case to case. Epistemic appropriation revolves centrally around the role of expertise. Given its importance to how IOs operate, we can expect the knowledge infrastructures that IOs rely on to be subject to appropriation. This should affect how expert knowledge gets produced, what kinds of accreditation and forms of expert status get recognised, and thus ultimately what kinds of expertise get mobilised and heard at sites of international policymaking. Epistemic appropriation discursively entails problem construction; and practically alters the terms of expert mobilisation.
Epistemic and institutional appropriation.
Table 1 Long description
Two columns compare epistemic appropriation and institutional appropriation across two rows labeled discourse and practice. Under epistemic appropriation, the discourse row lists, problem construction, and the practice row lists, expert mobilisation. Under institutional appropriation, the discourse row lists, membership ranking, and the practice row lists, institutional design.
Institutional appropriation refers to how an international institution (whether conference, commission, or fully fledged IO) arranges its own role vis-à-vis existing institutions: it may seek to merely coordinate them, more intrusively to restaff them, or most radically to replace them. As scholars working on IOs and on hierarchy have demonstrated, historically specific registers of hierarchy – civilisational or racial, in particular – can get built into IOs.Footnote 30 Institutional appropriation is one avenue by which this may happen. It discursively introduces membership rankings and ascending strata of legitimation, where the legitimacy of an international institution takes precedence over that of a regional institution, and so on. Practically, institutional appropriation works through institutional design choices such as the composition of committees.
Following this conceptual frame, the remainder of this article empirically demonstrates how, and with what consequences, the ISCs appropriated the pre-existing sanitary councils in terms of their institutional infrastructure, and by reframing what counted as expertise and as public health. Rump elements of what had been appropriated remain intact: as we will see, it was precisely by relying on the labour of the existing sanitary councils that implementing a centralised international sanitary regime was possible. As a result of appropriation, however, Eurocentric sanitary internationality set the terms and limits while claiming the credit.
Appropriation in the time of cholera
How did delegates at the ISCs appropriate public health? This section turns to the 1866 and 1892 ISCs, selected to provide two snapshots at two key stages in the internationalisation of health governance. Prior to 1866, the ISCs had already begun to appropriate health governance both epistemically and institutionally. Disease control in the Levant was born in part in imperial struggles for putting a stop to the ‘white man’s grave’. In 1831, France’s national Conseil Supérieur de Santé had been moved from the Ministry of the Interior to the Ministry of Agriculture and Commerce, signalling an emphasis on trade.Footnote 31 The council’s director, Philippe de Ségur, a former aide-de-camp of Napoleon’s, soon suggested placing Algerian health matters too under the auspices of the French council. By 1834, he proposed that, for the sake of uniform health governance, ‘deputies of all the countries that border on the Mediterranean’ ought to gather to issue ‘an international sanitary settlement’.Footnote 32 This has led some historians to argue that ‘under cover of internationalism, France consolidated its own reforms and promoted them as a model for the Mediterranean’.Footnote 33
Yet such a conclusion is doubly dissatisfactory. First, it assumes that internationalisation could not have been genuine here because it merely provided a convenient alibi for imperial designs. This implies that internationalisation proper is normatively superior to, and distinguishable from, internationalisation as cover. This assumption remains untested. Second, it downplays non-Western agency, neglecting the rationales that led governments across the Levant to embrace sanitary engagements with Europe. The Gulf region, and its Persian-Ottoman borderlands in particular, were crucial for trade flows and the transit of Asian pilgrims to Mecca, making it an important site of both European and Ottoman imperial reach. The mid-century internationalisation of public health may be better understood as a reaction to the existing, but regionally decentralised and thus less easily controlled, sanitary councils.Footnote 34
These councils had been around since the 1780s, and carried out the full range of sanitary policies that the ISCs later sought to standardise and coordinate. They were transnational institutions that involved local, regional, and foreign authorities, including diplomats and medical specialists. And it was on their practical work of running lazarettos, enforcing and policing quarantines, setting up disinfection stations, as well as certifying the sanitary status of individual ships, that the ISCs would rely. The real innovation in the history of public health took place at the regional councils, not in the conference rooms of the ISCs.
Against this background, the French government convened the first ISC in 1851.Footnote 35 It was marked by disagreement about quarantines and cordons sanitaires. Over its course, French, Austrian, and British delegates stressed the chief goal of health governance to be ‘the defence of Europe against an evil originating in Asia’.Footnote 36 The conference focused on cholera’s threat to Europe despite higher mortality rates elsewhere.Footnote 37 Although no conclusive agreements were reached in 1851 (a convention was drafted but never ratified), its basic priorities shaped future ISCs.
The 1866 Constantinople conference
Subsequent conferences paralleled successive waves of the cholera epidemic: the first two conferences in 1851 and 1859 (both in Paris) convened during the third wave (1846–1860); the 1866 Constantinople and 1874 Vienna conferences gathered during the fourth (1863–1875); and the 1881 Washington, 1885 Rome, and 1892 Venice meetings took place during the fifth wave of cholera (1881–1896). The 1866 meeting included more non-European delegations than other ISCs. As had become standard, it included diplomatic and specialist delegations: each country sent one or more plenipotentiaries along with one or more medical experts (see Table 2).Footnote 38
Delegates at the 1866 international Sanitary Conference, Constantinople.
Table 2 Long description
Countries are listed in rows with two columns of names and roles: Diplomatic Delegates and Expert Delegates. Austria lists Vetsera as diplomatic delegate and Dr Sotto as expert delegate. Belgium lists Count Noidans as diplomatic delegate, with no expert delegate named. Spain lists Antonio Maria Segovia as diplomatic delegate and Dr Pedro Felipe Monlau y Roca as expert delegate. Papal States lists Brunoni as diplomatic delegate and Dr Ignazio Spadaro as expert delegate. France lists Count Lallemand as diplomatic delegate and Dr Pierre Fauvel as expert delegate. Great Britain lists The Honourable M. W. Stuart as diplomatic delegate and two expert delegates, Dr Edward Goodeve and Dr Edward Robertson Dickson. Netherlands lists Keun as diplomatic delegate and Dr Julius Michael Millingen as expert delegate. Greece lists Kalergi as diplomatic delegate and Dr G. A. Maccas as expert delegate. Italy lists Alessandro Vernoni as diplomatic delegate and two expert delegates, Professor Federico Bosi and Dr G. Salvatori. Persia lists Mirza Malkom Khan as diplomatic delegate and Dr Sawas Effendi as expert delegate. Portugal lists Edouard Pinto de Soveral as diplomatic delegate and Dr Bernardino Antonio Gomes as expert delegate. Prussia lists M. H. Krause as diplomatic delegate and two expert delegates, Testa and Dr Muhlig. Russia lists Dr Lenz as diplomatic delegate and two expert delegates, Dr Pelikan and Dr Bykow. Sweden and Norway lists Oluf Stenersen as diplomatic delegate and Dr Baron Hubsch as expert delegate. Ottoman Empire lists Ali Pasha as diplomatic delegate and two expert delegates, HE Salih Effendi and Dr Bartoletti. Egypt, noted as Ottoman Empire, lists Dr Salem Bey as expert delegate, with no diplomatic delegate named.
Sources: ISC, 1866; Santainés-Borredá, ‘Florence Nightingale’; Anonymous, ‘Edward Goodeve, M.B., Deputy Inspector-General, Bengal Army. The British Medical Journal 2:1038 (1880), p. 832; Anonymous, ‘Edward Goodeve’, The Indian Medical Gazette 16:1 (1881), p. 20; E. D. Dickson, ‘On Cholera in Persia, 1866–68’, Transactions of the Epidemiological Society in London 3:2 (1874), pp. 257–64; Özgür Yılmaz, ‘Forty-Eight Years in Ottoman Service: General Inspector of Quarantines Dr Bartoletti Efendi and His Activities (1840–1888)’, Journal of Ottoman Civilization Studies 21 (2024), pp. 283–312.
Epistemic appropriation in 1866
Let me zoom in on epistemic appropriation at the 1866 ISC in terms of discursive shifts (problem construction) and practical shifts (expert mobilisation). These did not unfold in a sequence or entirely separately: expert mobilisation in 1866, for example, built on redefinitions of the problem of public health already established previously. Contrary to conventional characterisations of the ISCs as primarily diplomatic, the role of specialist delegates was not purely advisory. Experts had their own vote, sometimes voted against their diplomatic colleagues, and they also convened in separate specialist sessions. Even more, as Ottoman foreign minister Ali Pasha put it in his 1865 invitation to the United States, the conference was ‘not at all of a diplomatic character, and is composed of competent men’. The latter would merely ‘be aided by’ diplomatic delegates.Footnote 39
Many of the European delegates already worked in the Ottoman capital as members of its Superior Health Council (including the British, Italian, Dutch, and Prussian delegates). Despite such prior working relationships, most sessions were marked by sharp distinctions between ‘East’ and ‘West’. Expertise was stratified, starting from the training and education of expert delegates: while most had been trained in their respective national academies, universities, and hospitals, expert knowledge production did in part centre on institutions in Paris, London, and Edinburgh. Dutch medical specialist Julius Michael Millingen (1800–1878) was in fact an English physician (famous for having treated fellow philhellene Lord Byron at his death) of part-Dutch origin trained in Edinburgh; Portuguese specialist Bernardino António Gomes (1806–1877) had been part-trained in Paris; and Ottoman expert Étienne Grégoire Bartoletti (1809–1895) was a former Italian priest who had received his medical training in Naples. Compared to the more often locally trained officers at the regional sanitary councils, this clustering around a few European schools and universities already points to the effects of epistemic appropriation on knowledge production and its shifting centres of gravity.
The occasion for the 1866 gathering was an outbreak of cholera in Mecca, then the capital of the province of Hejaz (one of the Saudi dominions in parts of present-day Saudi Arabia and Jordan). What or who was to blame for the occurrence and transmission of cholera, and what interventions would best tackle it, remained subject to debate. This was a debate about problem construction. Many continental European powers insisted on strict quarantines, whereas the British opposed this for trade reasons and mobilised anti-quarantine scientists promoting the controversial miasma theory of contagion. Spanish medical expert delegate Pedro Felipe Monlau y Roca (1808–1871), a philosopher whose medical training was largely limited to following (one might say, appropriating) Florence Nightingale’s pioneering work on hygiene and sanitation, likewise believed that bad air and a lack of ‘spiritual’ hygiene were responsible for the spread of cholera.Footnote 40
Settling these medical questions would have dramatic consequences for international trade as well as for imperial power. The British agreed that cholera was a matter of trade: ‘national health is national wealth’, as the official 1866 conference report noted – even if costly, public health measures would pay off as investments in long-term prosperity.Footnote 41 The real disagreement was over whether protecting the former could trump the latter; under what circumstances; and whether or not this required quarantines. Leaving cholera unchecked, as French expert delegate Fauvel stressed, would undermine commerce more than quarantine could: ‘the damage caused’ by restrictive measures would be no more than ‘a momentary disturbance’ and ‘once the quarantine were lifted, trade would immediately resume an activity which could compensate for the loss previously suffered’.Footnote 42 The French delegation had thus changed its position; a divergence from the British that would hamper negotiations for decades to come.
Cholera was also constructed as a threat to imperial power. Nothing less was at stake, or so a majority-European subcommittee on ‘hygienic measures’ reported, than ensuring that ‘modern civilisation’ could ‘prevail’ over ‘the hygienic institutions of the primitive East’.Footnote 43 Practically, this called for strict population surveillance as per colonial blueprints such as the sanitary councils in Calcutta, Madras, and Bombay,Footnote 44 or the sanitary passport system of the Dutch Indies.Footnote 45 The purpose of those arrangements had been, as Dr Goodeve, expert for British India, explained, ‘to watch over the sanitary condition of the European and indigenous population’. To deal with these populations, it was key ‘above all not to renounce coercive measures’.Footnote 46 Coercion and control of local ‘hygiene’, to the British, would be far more effective than quarantine. The convenient implication was that maritime transport could continue relatively unhampered, reserving the harshest restrictions for India instead. Given the Mecca outbreak, the conference targeted ‘the dangers of pilgrimage’, official proceedings mentioning pilgrims at least 210 times.Footnote 47 Suspicion was quickly extended to any non-sedentary population.Footnote 48 A particular kind of expertise – reaffirming the Eurocentric interpretation of public health – took centre-stage, while there was in fact no evidence that nomadic and religious migrations were causal factors in spreading cholera.
Institutional appropriation in 1866
How did such epistemic appropriation affect institutional practice? While the two dimensions of appropriation are not neatly separable, it is nonetheless useful to unpack how the 1866 gathering’s restrictive redefinition of public health expertise, and of its recognition and mobilisation, affected institutional design and decision-making.
Table 2 shows European delegates in the overwhelming majority.Footnote 49 While the number of experts per delegation was proportionate, official minutes reveal that speaking time was vastly disproportionate.Footnote 50 The advice of European experts was heard and deliberated upon at great length, whereas non-European expert arguments were consistently being sidelined. This imbalance was reinforced – a sign of institutional appropriation – through the composition of subcommittees convened on questions such as ‘hygiene’ or ‘measures to be taken in India’, many of which included and/or were chaired by European experts only. One committee on ‘measures to be taken in the Orient to prevent new invasions of cholera in Europe’ was chaired by the French diplomat Lallemand with the assistance of Greek diplomat KalergiFootnote 51; another committee concerned with Mecca pilgrims was presided over by British diplomat Stuart.Footnote 52
European delegates amplified these inequalities by questioning the performance of some national sanitary administrations, on the one hand, and praising the superior performance of international arrangements, on the other. These delegates also made clear that by ‘international’ they in fact meant European-dominated.Footnote 53 An appendix to the conference minutes recounts a discussion among delegates regarding the creation of a ‘sanitary establishment’ at the entrance to the Red Sea on the Suez peninsula (the Suez Canal, under construction at the time, was the implied reference). Such an institution would have to be strictly ‘international’. Inspired by the Constantinople Superior Health Council, which likewise was staffed by 50% European officers, the idea was to have an official body of ‘an international character’ that ‘should be founded and maintained at common expense by the Powers concerned and placed under the supervision of a Joint Council on which a delegate from each of these Powers would sit’. The crux was that ‘the international character is a sine qua non condition’, and while ‘the [Ottoman] Porte or the Egyptian Government could assume the direction’ this would have to be ‘under the control and with the assistance of Europe’.Footnote 54
The proposal met with resistance, not least given that a Suez-centred health council would directly compete with Egypt’s own sanitary council in Alexandria (majlis umûm al-sihha) which laid claim to being the world’s oldest sanitary establishment.Footnote 55 Whereas most resolutions of the conference had been passed unanimously or with strong majorities, the idea of an international sanitary commission at Suez received four no-votes (the British diplomat, the British specialist, the Dutch diplomat, and the Russian specialist) and three abstentions (the Dutch specialist, the Persian diplomat, and the Ottoman diplomat). Still, the episode betrayed the underlying appropriative logic of internationalisation as, in effect, Europeanisation – and the extent to which practitioners explicitly argued in these terms.
The participation of expert delegates depended not simply on their expertise, but on alignment with the prevailing interpretation: that cholera was the gravest threat, and that the chief object of that threat was Europe. This is precisely how expert governance was nominally open but practically exclusionary, reproducing an international sanitary hierarchy. This hierarchy relied on matching epistemic with institutional appropriation: by mapping, that is, onto a Eurocentric problem construction new registers of ranking, and thus explicitly rendering unequal, different conference delegations. In 1866, two concepts discursively contributed to this effect: hygiene and competence. The imperial genealogy of the concept of hygiene has been documented in rich detail.Footnote 56 In 1866, references to hygiene were persistent (minutes contain at least 117 mentions of the term) and also turned into markers of ‘civilisation’. At the 24th session on 13 August 1866, several delegates lengthily explained why and how hygiene, in terms of sanitary infrastructure but also ‘customs’ and ‘manners’, could indicate civilisational status. Portuguese expert delegate Gomes pointed out that hygiene ‘frankly is civilisation’.Footnote 57
If hygiene was a measure of achievement, sanitary competence was the required proof. Debate focused on the role and appropriate place of ‘intermediary countries’ in a hierarchy of sanitary safeguards, culminating in a geography of disease containment. The conference’s Third Commission had two main tasks to this end: to devise measures to be taken in India; and measures in ‘intermediary countries between India and Europe’.Footnote 58 Persia, Hejaz, and Egypt played significant roles as less advanced buffers, whereas Russia was instead ranked as a more competent bulwark.
These rankings resulted from judgements about gradations in sanitary competence – derived from cultural attitudes, population size, urban density, as well as technical infrastructure. By land, Afghanistan and Persia were considered key intermediaries; by sea, these included Singapore, Iraq, Oman, Hejaz, and Egypt. Much of the debate centred on Persia, considered an attractive outpost for the externalisation of sanitary control: according to the Third Commission’s report, a place with ‘very favorable conditions to put a barrier to invasion by the disease’. Its competence however was considered ‘very doubtful’.Footnote 59 Questioning the sanitary competence of individual countries was a means of circumscribing their ability to contest and thus have agency over sanitary policy.
In the case of Egypt, the policy effects of appropriation were striking. To prevent cholera from entering Europe via the Red Sea, delegates openly pondered ‘measures against Egypt to safeguard Europe’.Footnote 60 If necessary, Egypt needed to be cut off from all trade and communications to stop any carriers of the disease from passing on to Europe. Intermediaries had to pay a steep price for their support of European health. This was justified as follows: ‘The more closely to the original source of the disease quarantine and other prophylactic measures against cholera are applied, the less expensive these measures would be and the more one could count on their effectiveness (assuming proper application) from the point of view of the preservation of Europe.’Footnote 61 Egypt would have to accept international oversight through a commission heavily staffed by Europeans; and being cut off from global commerce in severe cases, as determined by that commission.
For Persia, it was likewise thought to be necessary ‘to first of all establish a health system organised on the model of that which functions in the Ottoman Empire, that is to say composed of a central administration supported by a half-European Health Council, and having under its direction health offices scattered over important points in the country’.Footnote 62 Buffer states would receive something in return: Persia ‘would certainly be less ravaged by cholera; furthermore it would be entitled to the recognition of its neighbours and of all of Europe’.Footnote 63 Recognition by Europe was the reward for conforming to competence rankings. Compare this to Russia, which was treated as a trusted bulwark instead. Decisions about monitoring and regulating quarantines in the Caspian Sea were best left to the Russian imperial government: ‘the Russian Government is a much better judge than us in this matter, and … it lacks neither the competent men nor the means of action’.Footnote 64
Appropriation had shrunk the space of contestability, yet experts from marginalised delegations were occasionally able to subvert the discriminatory logic of appropriated expertise. Persian expert delegate Sawas Effendi, for instance, reproduced the ISC hierarchy only in order thus the more vocally to disagree with European proposals. At the 38th session on 17 September 1866, he first argued that yes, there was an undeniable contrast between East and West: ‘in Europe, boundaries are well-drawn’ and ‘the population is above all civilised and as a result raised to obey the law’. In the East, by contrast, ‘there is complete ignorance’, a lack of ‘border institutions or authorities’ and ‘nomadic’ inhabitants ‘who don’t have the slightest respect for the law, be it sanitary or civil: to the contrary, they do their utmost to break it’. Yet this meant, Sawas concluded, that shifting the burden of quarantines and cordons to areas outside Europe was precisely the wrong move: such ‘restrictive measures are more easily and more completely carried out in Europe than in the East’.Footnote 65
Persian diplomatic delegate Mirza Malkam Khan made no secret of his opposition to the proposed internationalised Persian sanitary council: policing pilgrims would ‘raise storms of hatred in the Moslem world and create the most serious difficulties for oriental governments’.Footnote 66 Malkam Khan feared that Persia ‘could lose all sovereignty over its own sanitary affairs and would place significant coercive powers in the hands of European nations over internal and commercial affairs of the country’.Footnote 67
In Constantinople, East–West distinctions had replaced prior council collaborations between European and Levantine medical professionals. Internationalisation by appropriation replaced a regional patchwork of sanitary councils across which collaborations among experts with local knowledge had flourished. European delegates acted in relative unison, sharing and propagating an interpretation of cholera as an Oriental threat to Europe. Platformed experts were consulted on commercial questions and questions of competence that their expertise did not directly apply to. Expert objections by non-European delegations, meanwhile, were sidelined.
The 1892 Venice conference
What if the appropriation of public health expertise in 1866 was simply due to the fact that this was early days for health governance? To account for this possibility, this section fast-forwards to the 1892 Venice conference. In the interim, much, of course, had changed in world affairs. In 1869, the Suez Canal had been inaugurated, drastically shortening the time for troops and goods to be transported between Europe and India. IOs meanwhile had mushroomed: the 1863 International Committee for Relief to the Wounded had been renamed the International Committee of the Red Cross in 1876; while the Universal Postal Union was established in 1874 following the example of the 1865 International Telegraph Union. Simultaneously, and certainly not separately, European imperialism organised itself, not least via the Brussels-based 1894 International Colonial Institute.Footnote 68
By 1892, moreover, medical scientists had come to agree that the spread of cholera was not, as British free traders had long insisted, due to miasma but, as bacteriologists Robert Koch and Louis Pasteur had successfully proven, due to germs. This was widely accepted since at least the 1884 and 1885 Berlin scientific conferences on cholera, but it had taken around a decade until it became a consensus view in the – no less nationally and politically divided – scientific community.Footnote 69 Despite this, ISC delegates still systematically platformed appropriated public health expertise, discriminating against experts from delegations ranking lower in the sanitary competence hierarchy.
Epistemic appropriation in 1892
The 1892 conference in Venice convened at the height of the fifth cholera wave, this time without a Persian delegate.Footnote 70 Throughout the 1880s, the fifth epidemic had claimed the lives of around 250,000 Europeans, compared to about 268,000 deaths in Russia; 60,000 in Persia; and 58,000 in Egypt.Footnote 71 The disease had spread across East and Southeast Asia throughout the 1880s and arrived in Egypt in 1883. Spain, France, and Italy were hit in 1884 and 1885; and, via Russian maritime routes, the disease ravaged Germany in 1892.Footnote 72 Cholera was, in the words of Egypt’s expert delegate Miéville, ‘an unseen messenger flitting through the streets, who wilfully and without reason signs to the Angel of Death to strike down this one or that one or a whole household … without justice, fitness, or cause’.Footnote 73
Austria-Hungary had taken the lead in putting together the conference, with Italy as the host. Compared to 1866, the number of military, or military-adjacent, delegates had noticeably decreased. This attests to a shift in the constitution of health governance as a policy domain, adding another layer of metamorphosis to earlier ministerial reassignments – for example in 1830s France, where health policy (as noted) had been moved from the Ministry of the Interior to the Ministry of Agriculture and Commerce. Table 3 shows that the relative number of non-European experts was proportionate; but as in 1866, conference minutes reveal that speaking time was not. Likewise, non-European expert-based objections were discounted. Subcommittees also sidelined non-European experts on various questions, including by means of decisions about who was endorsed to chair expert sessions.Footnote 74
Delegates at the 1892 International Sanitary Conference in Venice.
Table 3 Long description
Countries are listed with names and roles for two columns, Diplomatic Delegates and Expert Delegates. Germany lists Count Leyden as diplomatic delegate and Dr Kulp as expert delegate. Austria Hungary lists Count Kuefstein and Ch. Gsiller as diplomatic delegates, with Dr Hagel and Dr Justyn Karlinski as expert delegates. Belgium lists E. Beco as diplomatic delegate, and the expert delegate cell states that Beco doubled as specialist. Denmark lists Count Knuth as diplomatic delegate, with no expert delegate listed. Spain lists Silverio Baguer de Corsi y Ribas, Count Baguer as diplomatic delegate and Dr Cortezo as expert delegate. France lists C. Barrere as diplomatic delegate, with Prof Paul Camille Hyppolite Brouardel, Prof Adrien Proust, and Dr Catelan as expert delegates. Great Britain lists James W. Lowther as diplomatic delegate and Dr Mackie as expert delegate; Greece lists Georges Argyropoulos and Dr Zancarol; Italy lists Count Arco, Marquis Carcano, and Mayor as diplomatic delegates, with Dr Pagliani and Dr Andrea Torella as expert delegates and no expert delegate listed for Mayor. Netherlands lists Lord P. J. F. M. van der Does de Willebois as diplomatic delegate and Dr Wilhelmus Pieter Ruysch as expert delegate; Portugal lists Count Macedo as diplomatic delegate with no expert delegate listed; Russia lists HE Yonine and Baron Wrangell as diplomatic delegates with no expert delegate listed; Sweden and Norway lists De Bildt as diplomatic delegate with no expert delegate listed. Ottoman Empire lists HE Ahmed Bey as diplomatic delegate and lists HE Arif Bey, Colonel Charles Bonkowski Bey, and Dr Haireddin Bey as expert delegates. Egypt, noted as Ottoman Empire under British occupation, lists Boutros Pasha as diplomatic delegate and lists Sir Walter Frederick Mieville and HE Dr Mahmoud Sidky Pasha as expert delegates.
Sources: ISC, 1892; Mauro Capocci, ‘Uno spazio sanitario coloniale. L’Italia nel Conseil Sanitaire Maritime et Quarantenaire di Alessandria d’Egitto (1895–1910)’, pre-print (Università di Pisa, 2023); FO, Venice; Justyn Karliński, Über die geschichtliche Entwicklung der internationalen Gesundheitspflege und deren weitere Aufgaben (Wilhelm Braumüller, 1895); Miéville, Queen and Khedive.
On behalf of the host country, the Count of Arco opened the first session declaring that those states ‘marching at the head of progress’ came together in the common pursuit of a ‘grand humanitarian idea’.Footnote 75 Behind the scenes, the Austro-Hungarian delegation had taken ‘special measures to encourage the participation of an ever-reluctant Britain’.Footnote 76 British Prime Minister Salisbury had received assurances from the Austro-Hungarian ambassador in London that anything deemed ‘unacceptable to English interests’ shall be excluded from discussions in Venice.Footnote 77 To the chagrin of the French, on 29 July 1891, Austria-Hungary and Britain had signed a prior protocol stipulating that ‘English ships destined for a port of the United Kingdom, whether infected or not, shall be free to traverse the Suez Canal’ without any quarantine detention.Footnote 78
From this inauspicious starting point, the conference obsessed over the Suez Canal and Egypt. Crucially, Egyptian autonomy had been severely curtailed by the British invasion following the 1882 Anglo-Egyptian War. The Khedivate of Egypt formally retained its status as a province of the Ottoman Empire but was under de facto British occupation.Footnote 79 This also meant that Salisbury approached the 1892 conference as a trade meeting rather than a public health conference. Briefing his medical delegates Lowther and Mackie, he put things bluntly: ‘Measures intended primarily for the protection of health in Egypt, or for the accommodation of Mahommedan pilgrims, do not concern general navigation interests.’ Shipping came first. As for any amendment to regulations, ‘you will endeavour to render it as little onerous as possible to shipping interests’.Footnote 80
Salisbury was well aware that, nonetheless, expertise was the name of the game. ‘The scientific men in whom Continental Governments place confidence,’ he complained to the British delegates, ‘entertain opinions which, in our judgment, are erroneous’. Who the experts were, exactly, was of the utmost concern: ‘the extent to which cholera is supposed to prevail upon ships coming from the East will depend very much upon the school in which the medical man shall have been trained, and the nationality to which he belongs’. Britain wanted ‘men to whom no suspicion of undue preference in the exercise of their duties can be attached’; and naturally that meant that they could not be French.Footnote 81 As the Lancet obliquely noted, ‘French anglophobia’ may have been getting in the way of negotiations.Footnote 82
The French delegation ‘took immediate exception to the terms of the Anglo-Austrian protocol’.Footnote 83 As French specialist delegate Adrien Proust (father of the novelist) put it, ‘the shipping companies of other States would be justified in reclaiming a favour which would place them, from the point of view of the duration of the journey, in a state of marked inferiority’.Footnote 84 Several others, notably Belgium and the Ottoman Porte, considered the British suggestion nowhere near sufficient: it required extensive sanitary protections at the port of arrival, something Britain but not all other European governments could afford; and it offered no protections against false declarations.
Salisbury stressed that Egyptian control over its sanitary council was a matter of ‘impartiality’, but betrayed his real concern when insisting that his demands be heard not least since British shipping tonnage in 1890 amounted to 77% of total canal traffic.Footnote 85 Corporate interest from the shipping sector was in fact significant enough that the Director of the Peninsular and Oriental Steam Navigation Company, Sir Thomas Sutherland (the 1865 founder of the Hongkong and Shanghai Banking Corporation) personally travelled to Venice to advise ISC experts. Reporting back to Salisbury at the conclusion of the conference, Lowthie and Macker were full of gratitude and expressed their ‘thanks to Sir Thomas Sutherland, M.P., Chairman of the Peninsular and Oriental Steam Navigation Company, who travelled to Venice at considerable inconvenience to himself in order to place at our disposal his intimate knowledge of the details of British shipping communications with India and with the Far East’.Footnote 86
The role of French expert delegate Proust is another telling example of the role of expert mobilisation as a key factor of epistemic appropriation. Proust was a well-respected scientist, but also intensely preoccupied with what he saw as an Oriental invasion. In the year of the Venice meeting, he published a book titled La défense de l’Europe contre le choléra, in which he wrote of Persia as a sanitary danger zone inhabited by ‘savage, if not ferocious, populations’.Footnote 87 His main concern was a lack of obedience among its inhabitants, putting sanitary surveillance at risk.Footnote 88 ‘[T]he habit of universal obedience’, he wrote, ‘has left in Persia, as in the entire Orient, an immutable civilization.… Man counts for nothing in the East.’Footnote 89
To Proust, suffering in non-European disease containment zones was an acceptable price for the continued free flow of commerce – both because suffering among the ‘savage tribes’ was self-inflicted, and because the flow of commerce drove civilisation: cutting off shipments between Europe and Asia would have been ludicrous, ‘as if, to protect his subject from the invasion of cholera, the doctor took it into his head to suspend the circulation of the blood!’Footnote 90 Proust continues, incidentally, to be celebrated by the WHO today as ‘the doyen of international relations in the field of health’.Footnote 91 At the ISCs, he also was a guardian of appropriation: a gatekeeper of European expertise against entire countries viewed through the register of pandemic threat.
Institutional appropriation in 1892
How did the epistemic appropriation of public health at the 1892 conference, by means of both problem construction and the mobilisation of experts like Adrien Proust, relate to institutional dynamics like the reification of member rankings and modifications in the composition of subcommittees?
The French response to the Anglo-Austrian protocol was to introduce a second set of ex ante demands that went on to constrain the Venice negotiations: a push for reform of the Egyptian sanitary council at Alexandria, centred on a reduction in the number of Egyptian members from nine to three. Egyptian resistance mounted over two questions in particular: the distribution of financial burdens for a reformed sanitary council in Egypt; and tensions between internationality and representation.
First, throughout the Venice meetings, Egypt expressed a clear stance against the French proposal, with strong criticism of what its delegates Boutros Pasha, Dr Miéville and Dr Mahmoud Sidky Pasha considered excessive burdens. The British delegation initially insisted on retaining significant Egyptian representation, since Miéville and many other Egyptian members of the Alexandria council were British de facto colonisers of the Egyptian sanitary administration. As the Franco-Egyptian Le Bosphore Egyptien put it in 1884, ‘Great Britain has been pleased to parade her noble sentiments towards humanity by placing at the head of the Maritime and Quarantine Council a loyal servant of her Gracious Majesty the Queen.’ Indeed, the paper provocatively added, ‘Egypto-English officials increase at such a rate that we may very likely find, in but a short time, nothing but Englishmen in the Egyptian Government Departments.’Footnote 92 In an exclusionary twist, the French now used the British occupation as a reason to demand reduced Egyptian representation on the Alexandria sanitary council, suspecting that Egyptians would primarily echo British interests.
Egyptian delegates made no secret of their emphatic opposition to such plans. Boutros Ghali Pasha (1846–1910) was a notable protagonist in this context.Footnote 93 At the ISC, he stood out as a vocal critic of European expectations for Egypt to accept reduced representation and increased financial contributions. The burden on Egypt went even further, as he pointed out: disembarking passengers aboard contaminated ships on Egyptian territory would not only stretch Egyptian sanitary capacities to breaking point, but also pose considerable sanitary risks to the country.Footnote 94
Over the course of further negotiations, European delegates concluded that since Egypt’s territory was concerned, Egypt should pay for any financial needs beyond the allotted budget of the Council. ‘Maintaining this obligation’, Boutros Pasha replied with indignation, ‘seems to me hardly justified in the face of the reduction in the number of Egyptian delegates. I therefore express all the reservations of my Government against the non-removal of this financial burden’. French delegate Barrère simply replied, in a revealing use of the first-person plural: ‘We want to protect Europe, but in the first instance we protect Egypt. There is therefore compensation and you only pay a part.’Footnote 95 European delegates rallied behind Barrère. Without further statement, having been silent throughout the discussion, the head of the Ottoman delegation Ahmed Bey agreed. Ottoman expert delegate Charles Bonkowski (1841–1905) was a Polish émigré to Constantinople after medical training in Paris, where he likely developed a pro-quarantine stance that would have implied support for reformed, stricter sanitary policy in Egypt. Egypt’s Boutros Pasha voiced his indignation: ‘You make of Egypt a sentry to safeguard Europe and then you tell her “Pay for it!”’Footnote 96
Second, tensions over the internationality of a reformed Sanitary Council of Egypt flared up repeatedly. At the 11th session on 24 January, the debate turned on the composition of the council and the credential required to qualify for council membership – two aspects of institutional appropriation we have encountered before. Initially, the understanding was that while the Council was supposed to ‘have an international character’ in its composition and authority, it should not ‘be international’ proper. Reference to Egyptian resistance was transparent: the Council was concerned with Egypt; it operated on Egyptian territory, but international oversight was key. This also meant reducing the number of Egyptian Council members from nine to three (ultimately four), drawing vocal resistance from the Egyptian delegates present, notably Boutros Pasha. Having been ‘created more than sixty years ago, by the initiative of the great Mohammed Ali’, over time ‘the majority of Egyptian members within the Council found itself diminished’ without however losing ‘its Egyptian character. I therefore oppose the addition of the word: ‘international’.Footnote 97
During subsequent discussions, Boutros Pasha could hardly contain his anger: ‘Not only are we reducing the number of Egyptian delegates, but we would even like to … impose the choice of its delegates on it.’Footnote 98 On the part of Europe’s powers, a preference for international oversight was intimately tied to scepticism about Egyptian competence. The prejudice ran deep. A report by the Austro-Hungarian medical expert Justyn Karliński juxtaposed, for example, ‘unknowing Arabic medics’ with ‘the wholly rational proposals of Austro-Hungarian medical delegates’.Footnote 99 The precedents cited to justify the final ‘international’ arrangement were other episodes of European intrusions upon Egyptian semi-sovereignty: the Suez Canal Zone itself; the Mixed Courts; and the Public Debt Commission.Footnote 100 Egyptian representation ended up halved (four representatives, plus an Egyptian Council President with one vote in case of a tie), against Egypt’s wish to retain more substantive representation. As we have seen, British support of Egyptian representation, at a time when Egypt was under British occupation, was disingenuous to say the least.
On the other hand, Egypt did manage to insert a minimal but favourable point on the question of non-European medical credential. Specialist delegate Miéville successfully moved for a modification to Article 13 of the Sanitary Convention concerning the Egyptian nomination to a Council delegate: for the port of Jeddah, Miéville pointed out, it would be ‘very difficult to find a doctor … who naturally must be Muslim, who meets the conditions requested by the Conference’. Once winning French support, the modification was added. The resulting final version stated that members of the Council shall be accredited ‘either by a European medical Faculty, or by the State. The delegate of the Council of Jeddah may be a medic accredited in Cairo’.Footnote 101
Finally, the 1892 ISC in Venice produced an agreement – the International Sanitary Convention – whereby all ships passing through the canal were to be classified according to whether or not they had any cases of cholera on board. The scheme stipulated that medical inspections had to be carried out to determine whether a ship was suspected of carrying cholera or not.Footnote 102 The Suez Canal – itself the product of internationalisation pursued by a French private company, funded by Egyptian debt in French banksFootnote 103 – was thus to ensure the continuation of trade flows without however spreading the disease. Monitoring the canal mattered not least since the number of pilgrims taking the sea route to Mecca had more than doubled since 1866: ‘Europeans now felt dangerously close to India’.Footnote 104
In keeping with the aspects of institutional appropriation highlighted thus far, the 1892 conference too was marked by a ‘categorisation effort’ wherein ‘the suspicious border-crosser par excellence was the Muslim pilgrim’.Footnote 105 From the point of view of the state, the categorisation of individuals through the lens of a sanitary hierarchy reinforced questions of sovereignty. From the point of view of international institutions, policing itinerant populations fed back into the formulation of sanitary priorities. The first International Sanitary Convention ended up placing a premium on controlling ‘diseases threatening the lives of colonial actors such as yellow fever, plague, and cholera’, neglecting ‘diseases brought by empire such as smallpox’.Footnote 106
Once the conference had concluded, Britain, Austria-Hungary, and France agreed to a subsequent meeting in Paris from 19 May to 9 June 1892. The French concurred that perhaps it was necessary more strongly to ‘reconcile the interests of travellers with the demands of science’.Footnote 107 Delegates agreed to modify two articles for an amended convention, adding considerable flexibility as to quarantine obligations for commercial shipping. The British stressed that all of this was really a matter foremost of ‘technical medical details’ that ‘can only be settled satisfactorily by experts’.Footnote 108 The amendments were circulated as a fait accompli among Venice participants. In a revealing twist, this was the version that was ratified as the first International Sanitary Convention.Footnote 109
After seven conferences spanning a total of 41 years, the Convention was a landmark achievement. It was also a very limited treaty, applying only to maritime quarantine regulations concerning cholera, and only to ‘westbound shipping from the East’. The Convention gave pride of place to imperial interests and the shipping industry.Footnote 110 It also reduced the number of Egyptian delegates serving on the Sanitary Council of Egypt from 9 to 4. It focused on maritime cholera transmission via the Suez Canal, for the significance of which there was no evidence. Pilgrim ships arriving in the Middle East were an important factor in the spread of cholera – but in 1892, cholera had not once arrived in Europe via the Suez Canal.
Conclusion
This article approached the internationalisation of health governance – the historical shift, that is, from sanitary councils to sanitary conferences – as a case of institutional and epistemic appropriation. Ottoman, Persian, and Egyptian experts previously involved at the Mediterranean sanitary councils in close collaboration with medical scientists from France, Germany, Britain, and elsewhere, were gradually excluded from shaping the terms of health governance. Dominant delegates at the ISCs constructed public health in terms of epidemic threats to European populations and European imperial shipping, and it privileged experts who reproduced this perspective. As a result, the conferences brought about not just a more uniform, coordinated public health regime but also a new, expert-centred hierarchy of sanitary competence.
By reading this history as a case of appropriation, the article speaks to extant work in IR and global history on the relationship between imperial power politics and the emergence of modern IOs. Studying institutional and epistemic forms of appropriation allows us to be empirically precise as to how exactly imperial ordering practices shaped health governance. At the ISCs, different imperial powers attempted to pursue functional cooperation but left a mutually beneficial imperial order intact. The internationalisation of health governance, then, cannot be understood as either the genesis of a functional cooperation regime, or purely a case of imperialism in disguise. European delegations did not simply dismiss public health concerns for the sake of imperialism, but pulled the regional sanitary councils into new forms of control while shaping expertise along newly restrictive criteria.
Future studies could broaden our understanding of appropriation by studying empirical variation across other historical IOs and other time periods. But appropriation also speaks to present-day debates over the future fate of IOs. Today, in defence against the twin threat of backlash and defunding, the benefits of IOs – mitigating information asymmetries, maintaining a basic level of diplomatic trust, as well as coordinating policy intervention to advance some shared normative goals – often get emphasised over their drawbacks, including the various ways they institutionalise inequalities between member states. Debates about their future survival foreground expertise as an inherent net positive that IOs should continue to build on in close collaboration with both in-house and external scientific advisors. Yet expertise has no such inherent quality, and overly relying on this assumption can actually obfuscate indirect forms of exclusion. Where this is the case, we cannot in fact expect expertise to strengthen IO resilience. In its ideal shape, expertise is free from prejudice. But as the history of public health governance illustrates, both its production and its integration into decision-making settings are easily subject to prejudice.
Acknowledgements
Research carried out for this article was generously funded by the Oxford Martin School as part of the Oxford Martin Programme on Changing Global Orders led by Andrew Thompson, Patricia Clavin, Andrew Hurrell, and Louise Fawcett. Many thanks for invaluable comments at different stages to Edward Keene, Jorg Kustermans, Margot Tudor, Ayşe Zarakol, Mette Eilstrup-Sangiovanni, Christian Kreuder-Sonnen, John de Bhal, Ozan Ozavci, Sam Holcroft, António Ferraz de Oliveira, and Brent Steele.
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