Preface

This paper poses the question as to whether and how far it is possible to talk of epistemology in relation to a learned tradition in medicine, when that tradition is well established and is concerned to emphasize the unchanging nature of its knowledge in the struggles against its competitors in the medical market place. Some of the discussion bears upon the question of why learned medicine came to die out in England, but this issue is not the main focus of the paper.

I have not spelled out modern-day historiographic categories (for instance, epistemic or sociological, or to use more old-fashioned terms from the history of science and medicine, internal or external). They express dichotomies which for the sixteenth and seventeenth centuries are not historically grounded. (For instance, a sixteenth-century divine or politician would not have agreed that a point of religious doctrine was a matter either of epistemology or sociology – even if the latter could have been recognized at the time – though it might be seen as a blend of both. Our modern scholarly traditions and disciplinary rivalries mean that one or the other tend to be given priority.)

Introduction

The epistemology of Western learned or scholarly medicine was not completely successful; it did not produce knowledge of such certainty as to kill off all other rivals in the medical market place. It is also doubtful if in early modern Europe learned medicine was using epistemology in any heuristic sense to create new knowledge.

The title for the workshop from which this volume evolved was ‘Epistemology and the Scholarly Medical Traditions’. The original idea was to look at the question, ‘How did Galenic, Chinese and Āyurvedic doctors use written texts as authorities for their claims to knowledge?’ Contributors were left considerable freedom, however, to interpret the original title as they pleased because enforcing any particular orientation would have risked subverting our comparative enterprise before it had begun.

That proved to be a wise decision. In our very first session together, Jim Hankinson defined ‘epistemology’ as ‘a self-conscious theory of knowledge’. A little later, Judith Farquhar observed that, for a Sinologist, every word of that definition would have to be reinterpreted, ‘quite possibly including “of”. As the reader will discover, ‘epistemology’ turns up frequently, and it is indeed a troublemaker. It has a decidedly Eurocentric ring to it. In an effort to avoid some of the pitfalls associated with the term, this essay will step back a bit and reflect, historically, anthropologically and meta-epistemologically, on the ways in which these traditions have (or have not) claimed special status for their scholarly medical knowledge at various times in history.

But first, a word or two is needed about the overall strategy of the volume. All the chapters are devoted to the past except for those by anthropologists Judith Farquhar and Lawrence Cohen who talk about present-day events in China and India, respectively. In retrospect, I regret the omission of something about modern Unani medicine so as to have touched on living examples of all three traditions.

In 1928 Dr Frederick Russell, recently appointed Director of the International Health Division, reminded Dr Michael Connor, Director of the Health Division's Brazilian Yellow Fever Commission, of the Division's real objectives. ‘What we want to do’, he elaborated, ‘is to help each country establish a health organization suitable to the needs of the country … and we hope that the yellow fever work will lead to a better health organization in the states and in the nation of Brazil.’

That indeed was the original goal of the organisation founded in 1913 as a mirror of the older Rockefeller Sanitary Commission for the Eradication of Hookworm Disease from the south. Using hookworm as their weapon, both organisations hoped to awaken public interest in (1) hygiene and sanitation by which hookworm could, it was hoped, be prevented and in (2) scientific medicine, which had revealed the cause and cure of the disease. By such means both Rockefeller organisations were then prepared to follow up their hookworm demonstration work by helping to set up local health agencies to promote health, hygiene and public sanitation. ‘The purpose of our work in any country is not to bring hookworm disease under control’, Wickliffe Rose, the organisation's first Director, noted in 1917, ‘but to make demonstrations which will lead ultimately to the enlistment of local agencies in the work.’

Introduction

The development of the application and use of scientific research — including natural science, medicine and social science — in relation to government and policy-making is a twentieth-century phenomenon.

Introduction

The theme of this chapter is the influence of the United States of America on the development of international health organisations in Western Europe. The period focused upon is the short four-year span between 1918 and 1922 during which new international organisational bases were being created for the health work of the League of Nations (LN) and major conflicts were occasioned among existing organisations. It was a time of the building of new power bases and political structures in the context of the Paris Peace Conference; it was also the period in which domestic health policies were being negotiated in separate national discourses.

I will argue that American influence in international health organisations was exercised through the powerful corporate philanthropic organisations of the American Red Cross (ARC) and the Rockefeller Foundation (RF). The influence of the RF, through the International Health Board, on public health in Europe has been documented and researched. The role of the American Red Cross, under the chairmanship of Henry Davison, and its War Council has been less studied, although Howard-Jones suggests it may have been pivotal in the formation of the Health Section of the LN.

Background

The United States played a major role in the post-war construction, financing and design of what were two of the largest international health organisations in the world, the League of Red Cross Societies (LRCS) and the League of Nations Health Organisation (LNHO), the forerunner of the World Health Organisation (WHO).

Between 1918 and 1940 Latin America became a testing ground for one of the most ambitious and controversial concepts in modern public health: disease eradication. The eradication of infectious diseases in Latin America became a popular endeavour among many US public health authorities of the early twentieth century. This concern arose for a complex combination of technical and political reasons which included the success of local eradication efforts earlier in the century (e.g., those carried out in Havana and Panama at the turn of the century), the fear of Latin America infecting or reinfecting the US, and the perceived need to protect those areas of the world which the US considered under its economic influence.

Partially because of the absence during the 1920s and 1930s of an effective international framework through which Latin American countries could act on common health problems, the Rockefeller Foundation (RF) played an active role in the emergence and application of the eradication concept (the Pan American Sanitary Bureau, created in 1902, functioned until the early 1930s with a small staff and as a virtual branch of the US Public Health Service). The RF's eradication campaigns had several by-products such as the reorganisation of Latin American public health institutions, the expansion of public health services to rural areas, and the shift of the academic and technical centre of influence from France to the US.

The underlying aim of much of the work of the Social Section of the League of Nations was to improve the quality of life of women and children. Proposals put forward to reach this goal reflected assumptions about gender roles and relations as well as changing ideas about the role of the state in sustaining them. Recent comparative research on social welfare policies and programmes of western European countries and the United States between the 1880s and the end of the Second World War has demonstrated the importance of considering both the role of women in social welfare movements and the visions of gender embodied in the state-sponsored social policies that emerged. Popular notions about women's special capacity as actors in the social field also led to women's extensive participation in the social committees of the League of Nations (LN). The decision to appoint a woman, Dame Rachel Crowdy, as Chief of the Social Section was a conscious one. Unlike all other LN permanent advisory committees, women usually enjoyed equal representation on the social committees. In the same way, many government delegations to the LN Assembly included women who were then appointed to the Fifth Committee (Social Questions). The Social Section actively solicited the support of women's organisations in connection with the work of the social committees and many of their proposals were taken up by the League.

Developing a discourse

The present preoccupation with child abuse and the discussion on the best means of protecting child life merely elaborate a rhetoric whose antecedents are in the nineteenth-century child-saving movement which flourished in industrialised nations. A study of international child protection organisations illustrates the continuity of such rhetoric which moved from a sentimental depiction of victims to a medico-social scientific discourse of children at risk that expanded the concepts of victimisation, exploitation and abuse.

It is through discourse that social claims become persuasively defined and social conditions are identified and transformed into social problems whose advocates lobby for recognition of the priority of their claims.

Introduction

The Eastern Bureau of the League of Nations Health Section was established in 1925 to collect and disseminate epidemiological information. Until February 1942, when Singapore was invaded by Japanese troops, the Bureau served a variety of functions; the receipt, compilation and dissemination of health statistics, quarantine procedures and other information related to the control of disease were only part of its wider role. Its functions included the co-ordination and review of scientific research; the provision of in-service training of sanitation, public health and medical officers through staff interchanges, study tours and from 1934 annual short-course training programmes for malariologists; and sponsorship of and participation in scientific conferences and symposia. Through these various activities, the Bureau helped to identify the primary public health concerns of the region, facilitate co-operation between individual researchers and research institutions, and develop public health expertise. Less easily documented, the Bureau also played a role in fostering a sense of common purpose among countries in the region. Its primary function and central activity, however, as noted, was the collection and dissemination of epidemiological information; this is the focus of this chapter.

The Commission of Enquiry in the Far East

Epidemic disease in East Asia was first brought before the Health Committee of the League of Nations (LN) at its second session in October 1921, when the Japanese delegate, Dr Miyajima, drew attention to the incidence of pneumonic plague in Manchuria and Siberia.

Whereas the development of welfare states has been the subject of sustained academic scrutiny, international aspects of welfare have been much neglected. It is possible for national systems to retain a diversity of locally administered elements (for example, involving municipalities, social insurance corporations or occupational health schemes) while providing centralised funding and administrative and legal frameworks. But international organisations have vital roles and demand far greater attention from historians and social scientists than they have hitherto received.

As any localised system could suffer from inequalities and lack resources, and states could manipulate health and welfare issues for the purposes of political expediency, international organisations became an attractive option for promoting reforms. International bodies may remedy local deficiencies, set optimal standards and improve the quality of the systems of care and the training of personnel. While some of these functions can be fulfilled by the state, it should be recognised that the state as a provider of welfare can be problematic, because its multifunctional character may render health and welfare low political priorities, or distort welfare as caught up in the politics of interest groups and financial expediency. The interwar rise of fascist and kindred authoritarian regimes that perverted welfare systems for purposes of political discrimination and genocide was in marked contrast to the humane ideals of internationalists.

The Italian War of 1859 helped to create the Red Cross; the First World War precipitated efforts to reorganise it. These may be divided into two quite different categories: those which sought to consolidate and extend the traditional role of the International Committee of the Red Cross (ICRC) and the national societies, and those which asserted the need to create a new kind of Red Cross for the anticipated new era of peace and international co-operation. Support for the idea of a limited reorganisation came primarily from the ICRC (entirely Swiss in membership since its inception in 1863), and from the national Red Cross societies of the smaller European states; proposals for a much more ambitious reform came principally from America and Japan. What rapidly took shape was a power struggle between the Red Cross societies of the victorious Allies, led by the Americans, and the ICRC, which understandably feared for its own survival if the reformers were to triumph. In one form or another, this struggle lasted until 1928, when a settlement of the main issues was finally reached.

More was at stake in this conflict than was apparent on the surface: at its heart lay a fundamental disagreement over what role the Red Cross ought to play in modern society.

The essays in this volume arise from a recent convergence of interest in the history of international health and welfare organisations. The sheer diversity of organisations and their many-sided activities make this a rich and complex area of historical investigation, which has direct relevance to current issues in international health

Although contributors to this volume are dispersed throughout the world, an informal network arose in what is very much a new field of study. I therefore wish to express my appreciation of how contributors have co-operated to bring this volume to fruition within a relatively short period of time. The exchange of papers meant that there was much interchange on topics of mutual interest, while perspectives have remained refreshingly diverse. I am particularly indebted to contributors for comments on my introduction and my essay on social medicine. It meant that arguments were refined, and, in order to avoid duplication of analysis on central issues, several contributors generously agreed to omit material dealt with elsewhere in the volume. Their efforts have meant that an exceptionally cohesive, integrated and intellectually coherent volume has taken shape. It is hoped that this collection will provide solid foundations for other projects on twentieth-century international health that are already under way.

Between the two world wars health services in Europe and America began to extend from institutional care of the seriously mentally disordered to cover early treatment of less serious cases, after-care of recovered cases and organised care in the community. Even more ambitiously, there was an expansion of interest in prevention of mental disorder and promotion of environmental conditions to encourage positive mental health among the normal population. A variety of terms were used to describe these new approaches: in Britain a tradition of charitable and local government economic assistance shaped the emergence of ‘mental welfare’ and ‘community care’; in the United States Adolf Meyer adopted the term ‘biopsychiatry’ to reflect his holistic approach; in France the terms used were ‘mental prophylaxis’ and ‘psychotechnics’; and in the Soviet Union it was ‘psychohygiene’. However, the most popular and all-embracing term used to describe these developments was ‘mental hygiene’.

The simultaneous adoption of mental hygiene strategies was partially the result of common reactions to social and welfare problems of the interwar period. However, the pace of socio-economic and political modernisation was not even. It is therefore worthwhile considering whether parallel developments were, instead, the result of an international mental hygiene movement. This chapter will consider the extent to which there was an international movement and its interaction with national mental hygiene movements and organisations.

The Epidemic Commission of the League of Nations (LNEC) was considered at the time of its creation to be the ‘first essay in international cooperation’, in that, contrary to other health and relief organisations, its funds proceeded not from a charitable public, but from national governments. The Commission acted exclusively through local health administrations, basing its work on ‘the necessity of strengthening the public health and sanitary organisation of the country as the most effective and the most lasting means of checking the spread of epidemics’. Although the Epidemic Commission lasted little over three years (April 1920–December 1923) and worked in only five countries (Poland, Soviet Russia and Ukraine, Latvia and Greece), it marks one of the early ‘success stories’ of the League of Nations Health Organisation (LNHO) which it preceded and, indirectly, had a large part in creating.

Typhus and the First World War

The Epidemic Commission (initially called the Typhus Commission) was born to fight the louse, as the vector of typhus, a rickettsial infectious fever which leads ‘the quiet bourgeois existence of a reasonably domesticated disease’ in times of peace and flares up into epidemics when basic sanitary conditions break down.