When Rudyard Kipling advised the United States in 1899 to ‘take up the White Man’s burden... Fill full the mouth of Famine and bid the sickness cease, his appraisal of the imperial contribution to health was more than a little optimistic. Many historians would reverse Kipling, pointing to the myriad ways in which the expansion of Empire endangered and damaged the health of colonized people through introduced diseases, unbalanced diets, and epidemics that struck down both man and beast. Advances in public health, antisepsis, and antibiotics lagged far behind the new pathways for infectious disease that advanced across land cleared for cash cropping, along new railway lines, and down the paths of labour migration. The first priority of imperial medicine prior to the First World War was to keep soldiers and officials functioning in unhealthy environments. Medical services for non-Europeans concentrated on mines and plantations. Others relied, as they always had, on traditional healers and remedies. Thanks to David Livingstone and Albert Schweitzer, Christian missions acquired an outsize reputation as conveyors of European medical science. Furthermore, it was certainly true that ‘throughout most of the colonial period and throughout most of Africa, Christian missions of one sort or another provided vastly more medical care for African communities than did colonial states’. That, however, is more a judgement on imperial neglect of medical services than on the achievements of missionary medicine. Nonetheless, in many parts of the Empire the only contact colonized people had with European medicine was through mission facilities.
As with education, evangelical rather than philanthropic imperatives guided mission medicine. Unlike literacy—a secular skill promoted as a guide to biblical truth—healing carried a heavy load of supernatural baggage. All churches regarded healing as an imitation of Christ, who had cast out devils, made lepers whole, enabled the lame to throw away their crutches, and raised Lazarus from the dead. ‘God had only one son,’ David Livingstone observed, ‘and He gave Him to be a medical missionary.’ Even scientifically trained mission doctors acknowledged the role of prayer and miraculous cures in healing. In sharp contrast to trends in the medical profession since the Enlightenment, missions refused to decouple disease from sin and morality. God’s judgement on sinners could be delivered as in days of old through plagues, droughts, and visitations by locusts. John Williams, a nineteenth-century missionary to the Cook Islands, interpreted a local epidemic as ‘a timely interposition of an all-wise and overruling Providence’. The wages of sin was death, and mankind could not expect the conquest of disease before the Judgement Day. Mission congregations boomed out Isaac Watts’s Hymn 55 with fearful hearts.
The year rolls round, and steals away
The breath that first it gave;
Whate’er we do, where’er we be,
We’re trav’lling to the grave.
Dangers stand thick through all the ground
To push us to the tomb,
And fierce diseases wait around,
To hurry mortals home.
On more than one tragic occasion missions caused or exacerbated outbreaks of disease they could not cure. The first London Missionary Society agents scoffed at Tahitians’ belief that ‘that all their mortal diseases are from the ships’ that followed Captain Cook to the southern Pacific. Within a few years all missionaries in that region watched helplessly as measles, smallpox, syphilis, yaws, and a host of other introduced diseases decimated their congregations. John Geddie of the Presbyterian mission to Vanuatu at first exulted as measles literally put the fear of God into island communities. People who saw ‘in this devastation all the wrath of God for their past wickedness’ fled their old homes and concentrated themselves around the missionary’s house—thus causing more outbreaks of disease until more than a third of the population of the island of Anumej had perished. Matthew Hale did not bring European diseases to the Aborigines of South Australia, but when he concentrated a large group at Poonindie Mission in the 1850s, death cut a fearful swath through the community. Unable to heal, the missionary went frantically about performing baptisms so that the immortal souls of the dying might find eternal life. Similar catastrophes were reenacted in twentieth-century Australia when rural whites, frightened of ‘Aboriginal’ diseases, successfully agitated for state action to close the ‘blacks’ camps’ on the outskirts of their towns. When police round-ups dumped the hapless people on missions, once again the concentration of pathogens spread illness and death.
While standard histories of medicine focus on the triumph of scientific models of disease in the nineteenth and twentieth centuries—and neglect medical missions—that same period witnessed the emergence of sects and churches specifically concerned with divine healing in Europe and North America. Christian Science and the Jehovah’s Witnesses set their face deliberately against modern surgical procedures. Seventh-Day Adventists promoted a Providentially sanctioned path to health and wholeness through diet, most famously identified with the breakfast cereals developed by their devout follower Dr John Harvey Kellogg of Battle Creek, Michigan. Early Mormons and twentieth-century Pentecostals used ‘healing handkerchiefs’ to cure diseases, citing the precedent of Acts: 19: 11-12: ‘And God wrought special miracles by the hands of Paul, so that from his body were brought unto the sick handkerchiefs or aprons, and the diseases departed from them, and the evil spirits went out of them.’ Because the theory and practice of mission medicine diverged so sharply from mainstream scientific models, it tends to be neglected by general histories of medicine and even in books devoted specifically to imperial medicine.
For all their stoic talk about God’s mysterious ways, missions acknowledged that ‘humanly speaking’, doctors had roles to play in alleviating human suffering, opening the way for evangelists and attracting hearers to missionary preaching. The idea of enlisting medical aid seemed particularly attractive in dangerous climes. In the early years a ‘call’ to tropical Africa or South Asia could be a death sentence. Out of eighty-nine missionaries sent to Sierra Leone between 1804 and 1825, fifty-four died and fourteen returned home in broken health. Sixty-two of 225 missionaries sent by the Wesleyan Methodist Missionary Society between 1835 and 1907 left their bones on West African soil. One way around the problem was to send ex-slaves born in Africa as missionaries to these deadly climates. Another was to send European doctors as medical missionaries with the double charge of ministering to sick missionaries and attracting converts. Strictly speaking a medical missionary was a missionary trained in Western medicine. The first medical missionaries had what, from a modern perspective, appears to have been very rudimentary training, as illustrated by the world’s most famous missionary doctor, David Livingstone. He studied medicine at Glasgow from 1836 to 1840 in a course with little clinical training. The stethoscope had only recently been invented and there was as yet no device to measure blood pressure. At the time two main theories of disease dominated the profession. One held that illness was caused by disorders in the blood, the other that disturbances in the gastro-intestinal tract were to blame. Like most other doctors, Livingstone gave some credence to both theories. Throughout his career he bled patients by applying leeches to their heads and abdomens. He also emphasized the importance of ‘healthy excretions’ and prescribed emetics and purgatives to rid the body of morbid substances. Although Livingstone’s training in anatomy with the use of cadavers made him a far better surgeon than the traditional African doctors he encountered on his travels, he had a limited knowledge of pharmacology. That is why he did not hesitate to take medicines recommended by Africans with local knowledge when he fell ill. Nor did Livingstone present himself as an emissary of European well-being to African misery. He believed that the people he encountered in Central Africa enjoyed generally better health than the urban masses he had known in Britain.
Medical missions grew very slowly; in 1849 it was estimated that only forty medical missionaries were at work throughout the entire world; Livingstone was one of twelve from Great Britain. According to Brian Stanley, the foundation of the Medical Missionary Auxiliary in 1902 marked a belated acceptance by the Baptist Missionary Society that ‘alleviation of physical suVering was in some sense an integral part of the overseas missionary commission of the Church’. Even so, by the 1870s doctors were beginning to emerge from among evangelized populations, undertaking their medical training in Europe and the United States. For example, in 1888 Dr John Nembula, who had studied medicine in Chicago, was back home in Natal working part-time at Adams College for Zulu boys, ‘prescribing for pupils who are ill’ and ‘teaching physiology, hygiene and penmanship’. ‘By the time of the World Missionary Conference in Edinburgh in 1910, medical missionaries were sufficiently numerous to form an annexe to the main gathering. In 1925 Protestant missions from Europe and North America employed 1,157 doctors and 1,007 nurses in overseas clinics and hospitals—even then, not a large number to be spread across the globe. Catholic medical missionaries were slower to emerge, being inhibited from clinical practice until the 1930s by canon law, which forbade clergy to practise medicine or surgery (based partly on a fear of priests being tempted by contact with female patients). With doctors supplying such a small part of mission needs, ordinary missionaries in isolated postings had to attend to their own health. Cook Islands missions in the nineteenth century had no doctors and only two personnel with rudimentary medical training. The rest of the missionaries relied on books and the experience gained through trial and error to treat themselves and other people. During an epidemic of 1827 the missionary Charles Pitman simply opened his medicine box and indiscriminately fed laxatives and emetics to the whole island population until the supply ran out. Livingstone believed he had devised a pill that worked as a general prophylactic against all tropical fevers, until a group of Central African Anglican missionaries who had been relying on the pills fell ill and died. By the turn of the twentieth century some mission boards were insisting that a doctor reside at every mission station. Others introduced short courses in medicine and surgery for missionary candidates at institutions such as Livingstone College.
Because there were never enough medical missionaries to meet demand, many, if not all, European missionaries kept their own medical kits and handed out medical advice. Paul Landau cites the case of W. C. Willoughby, a southern African missionary with no medical training who nonetheless kept a medicinal clinic open two hours each morning in 1893. Such practices continued well into the twentieth century, not because missionaries wished to impersonate doctors but because people responded to what they did. The encounter between missionary healing and practices embedded in local cultures deserves more scholarly attention than it has thus far received. People who greeted Christian evangelism with indifference or hostility often proved avid consumers of missionary medical services ranging from prayers to pills. After an early relationship with American Congregationalists turned sour, the Zulu king Mpande issued a blanket prohibition against all missionaries. The Norwegian bishop Hans Schreuder opened the way for his Lutheran mission by responding to the king’s call for medicine in 1850. Whatever it was—laxative or emetic—Mpande believed it had worked, enabling the Norwegians to plant stations in Zululand. People from diverse cultural backgrounds all over the Empire demonstrated that medicine was not part of a take-it-or-leave-it Western cultural package. Like present-day Europeans and North Americans, Pacific Islanders, Africans, and Asians could mix ‘scientific’ medicine with alternative therapies, faith-healing, charms, and snake oil. Many traditional curatives remain a first-line defence against illness in parts of the former Empire. Until the development of antibiotics, European pharmacology had little to offer the regions where most missions operated. Missionary medicine had some of its clearest victories in elementary dentistry and surgery. Missionaries were in demand as pullers of teeth in South Africa. Hyman Wilder of Natal reported in 1860 that ‘the missionaries who know how to do it have abundant practice in drawing teeth, and no accomplishment of theirs is more appreciated by the natives’. Simple surgical procedures that removed cataracts and tumours also delivered impressive cures. Other intrusions into the physical body that caused rural people to seek out missionaries were vaccination and injection. Southern African people accepted vaccination against smallpox with surprisingly little fuss in the mid-nineteenth century. The chance discovery that the external symptoms of the disfiguring tropical disease yaws could be quickly removed though injections of bismuth sodium tartrate set off mass pilgrimages in East Africa. Thousands walked long distances in search of sidano (the needle). Missionaries soon learned that such phenomena were a mixed blessing. Not understanding the pathology of the disease, people assumed that when their symptoms disappeared they could stop their treatment. If the disease recurred, many cast aside their faith in mission medicine.
From the missionary point of view, cures were never assured. Visitations of disease and miraculous recoveries both counted as manifestations of God’s Providence. The mission clinic and hospital were instruments for saving sinners, not demonstrations of European superiority or disinterested philanthropy. Just as missionaries proffered inducements to parents who would send their children to boarding schools, some hospitals and clinics deliberately kept people under medical surveillance after treatment had finished, so the work of religious conversion could be finished. While all medical missionaries were healers, not all healers were doctors. Christian missionaries of all denominations acknowledged that God might work cures and miracles though their untrained hands. Or he might not. It all depended on his unknowable plan. Firmly believing that they worked under Divine guidance, missionaries could never be sure whether they should pray to end an epidemic or simply ask that God’s will be done. Competing with traditional practitioners was a gamble that missionaries found hard to resist. Sometimes the pay-off exceeded all expectations, as when Taufa’ahau (later King George) of Tonga decided to use his own illness as a contest between the old Tongan gods and the missionaries’ power. After the Rev John Thomas administered one of the usual emetics, the king began vomiting and feared for his life; fortunately he woke the next day feeling much better and became a champion of the new faith. Healing in these circumstances could hardly be differentiated from other timely interventions by unseen forces. Faced with a fire that threatened to destroy their mission to the Aborigines, Benedictines at New Norcia in Western Australia advanced on the flames, holding aloft an image of the Blessed Virgin—and vowed to build a chapel in her honour after the winds changed. In 1932 another Catholic mission in northern Ghana conducted public prayers for rain after an extended drought. When the heavens opened, so did the hearts of the people, producing unprecedented mass conversions—at least so the local legend goes. A recent examination of the records suggests that during the same period large numbers of people were being treated at the mission dispensary for yaws and dysentery, so disease may have been the crucial factor. The distinction between the two possible motives for conversion—supernatural intervention or medical assistance—which is of great interest to the anthropologist or historian of medicine, held no particular importance for the Catholic missionaries, who simply noted the power of prayer. Nor did it matter greatly to the LoDagaa people of the region, who disregarded twentieth-century European distinctions between religion, magic, and medicine. It was relatively easy for them to assimilate their ideas about the intervention of ancestors in daily life to Catholic ideas about access to saints and angels.
The reluctance of missions to admit similarities between their own ideas of healing and those held by the people among whom they worked puzzles historians. It might be supposed that a more tolerant approach would have provided more pathways to conversion. Terence Ranger wonders why, in a period that saw a recrudescence of ‘spiritual healing’ among Church of England congregations in Britain, Anglican missions in East Africa ‘completely failed to respond to the African demand on them for spiritual healing . . . Despite all their reservations by this time about the position of the doctors, the clergy was nevertheless left offering only the hospital and the clinic as the contemporary fulfilment of the healing mission of Christ.’ There is no ready answer to Ranger’s conundrum. One possibility is that by the early twentieth century most missions and their supporters were too committed to viewing their work as a battleground between the diametrically opposed forces of Christian truth and ‘heathen superstition’. Whereas Dr Henry Callaway (later Bishop Callaway) in the 1860s had sought collaboration with African healers in South Africa, the immensely popular ‘Jungle Doctor’ books of the mid-twentieth century revolved around set-piece confrontations in which the missionary doctor (black or white) defeats ‘the witchdoctor’. Whether that genre will survive remains to be seen. Post-Second World War mission theorists rediscovered nineteenth-century fulfilment theology, which emphasized the points of similarity between Christianity and other religions, including so-called ‘primal religion’. The medical model of disease faces challenges not only from old faiths but also from Pentecostals, who have breathed new life into the old idea that illness has a moral dimension which faith alone can address.
The importance of missionary medicine to the Empire lay not so much in its quantity, which was always small, but in its bias towards rural communities with little or no access to any other European methods of healing. In many places missionaries were commonly called ‘doctor’ as well as pastor. They faced diseases that most Western medicine neglected in situations where colonial development was continually eroding general health. In the 1970s Anthony Barker looked back with mixed feelings on a South African missionary career that began in an English medical school thirty years before:
Mission hospitals were not likely to be the places where the sophisticated biochemical understandings were worked out... but theirs was the job of observation and of the working out of treatment by informed experience. In our crude ways, this is what we did. Our contribution, in those early[!] days, was to find out things about the disease. We noticed, and acted upon, the patient’s loss of temperature regulation... We checked the stools for lurking Giardia and unsplit fat... It was possible, too, without using too rosy a tinted pair of spectacles, to see a dent in childhood tuberculosis following years of patient BCG inoculation.
Yet every small triumph was clouded by the knowledge that ‘the unjust society’ in which he worked wrought more damage every day than his hospital could repair:
Our children were stunted in growth and easy prey to infectious fevers. They lost out at school because they went hungry to school: they lost out in health because they were largely unprotected from avoidable disease: nobody had given them their shots, or taught their mothers how to shield them from wasteful illness or premature death Yet I believe in our hospitals still, for the marvellous contribution they made to the relief of human suffering. They seem to have still upon them the stamp of a true obedience to the vision of a God-run, God-saved world. We ought not, because we cannot do everything, fail to do what we can.