INTRODUCTION

Anthony Sampson, author of that well-known cross between journalism and contemporary history, Anatomy of Britain, recently commented on the relationship between the two. His view was that historical perspectives and methodologies should be applied to very recent events. Otherwise, one could miss that ‘real vibrant sense of history as happening just around the corner’. This chapter, in that genre, focusses on the analysis of a very recent series of events – the advent of AIDS in the United Kingdom and the initial reactions in terms of policies and of conceptions of disease, between 1981 and 1986. It has two broad aims – first, to examine the ways in which the new disease was defined as an issue for health policy and as an issue for scientists and the public, and the ways in which expertise and experts also defined themselves in relation to AIDS. And secondly, it aims to draw from the particular instance of this analysis of AIDS policies, some more general reflections about history, in terms of content, methodologies and concepts, and the different forms of its relationship with public policy in the health area as illustrated through AIDS.

We have suggested the identification and categorisation of three distinct policy phases for AIDS in the UK. The first (1981–6) saw the slow growth of AIDS into a national policy issue. Policy was essentially, and in particular at the beginning, formed in a bottom up rather than top-down way.

In an article on ‘Cholera and Society in the Nineteenth Century’, published in Past and Present in 1961, Asa Briggs issued a ‘call for further research’ into the social history of epidemics. It is a call which has not gone unanswered in the thirty years since the appearance of Briggs's article, and of the book by Louis Chevalier on which he drew. There have been historical monographs, not only on cholera in different towns and countries, but also notably on plague, many of them very much in the Briggs–Chevalier tradition, showing how societies coped with, reacted to and interpreted short-term but intense epidemic crises. One aim of the Past and Present Conference of 1989, whose papers are printed in this volume, was hence to return to the subject and survey the development of the field.

There have, of course, been many other advances in the history of medicine and disease since 1961 which have helped to enrich the study of major pestilences in the past. They have sprung partly from that broadening of the historian's agenda which has characterised research over the past thirty years, and from a recognition that several flourishing areas of historical inquiry – from the history of population to the history of material and mental culture – share a common interest in the subjects of health and disease. The social history of diseases which are not, or not always, the cause of shortterm epidemic crises – diseases which can be endemic or chronic, such as syphilis and tuberculosis – has been illuminated.

TWO VIEWS OF PUBLIC HEALTH

What you see depends on where you look and on what you are looking for. So historians maintain when analysing the beliefs and actions of previous generations, whether in matters of health and disease or in other aspects of social life. But, of course, the same point can be made about historians themselves. Their conclusions also depend heavily on the sites they have chosen for study, on the time-frames used and on the ways in which the range of subject matter has been limited. There can be no general remedy, for no one can write about everything. We can only try new ways of cutting across our material, so producing new perspectives which may serve new purposes.

In this chapter I want to suggest a range of new perspectives, not just by drawing attention to some little-studied areas, but by drawing together a series of historical discourses which are usually conducted separately. The results can only be suggestive and tentative, but they may be helpful for readers who wish to take a broad view of medicine in Britain in the decades of the industrial revolution, and who may be wondering how certain kinds of historiography are supposed to hang together. We can begin with two views of ‘public health’.

I shall discuss first the model which was used by Edwin Chadwick and other ‘ultra-sanitarians’ in the 1840s, and which is familiar from popular histories.

The fall of the Duvalier regime in Haiti, it has recently been claimed, is the first revolution to have been caused by AIDS. In July 1982 the New York Times reported that the killer disease not only affected gays but was endemic, for reasons that seemed frighteningly obscure, in Haiti as well. The publicity subsequently accorded to this revelation ensured that the number of American tourists visiting Haiti fell from 70,000 in the winter of 1981–2 to a mere 10.000 the following season, with worse to come in the subsequent three years. Tourism was the second biggest source of income for the impoverished Haitian state, and the collapse of the industry sparked off an economic crisis with mounting unrest met by growing repression, and ending with the ousting of the president-for-life, ‘Baby Doc’ Jean-Claude Duvalier (himself by this time rumoured to be suffering from AIDS) early in 1986. AIDS is not the first epidemic disease to have been credited with overthrowing a regime. In Plagues and Peoples, his panoramic survey of the impact of disease on human history, William H. McNeill has put forward a whole range of examples of the ways in which micro-organisms have destroyed or transformed state structures in the past, from the Roman Empire to the pre-Columbian Incas and Aztecs, whose civilisation was destroyed not so much by the small bands of conquistadores under leaders such as Cortez and Pizarro as by the diseases, new to the Americas and therefore devastating in their impact, which the Spaniards brought with them.

In considering the impact of epidemic disease on a society, historians usually conceive of their task in terms of problems of mortality and such associated discontinuities as the collapse of orderly government, the flight of threatened populations and the disruption of agriculture and trade. Important as these factors are, however, they tend to obscure the fact that, in terms of the perceptions of the peoples at risk, of no less significance is the fact that epidemic disease in the past has held, and today continues to hold, some of its worst terrors in the way it challenges the ideological structures that sustain all societies.

This is not simply a matter of explaining away incomprehensible horrors. The ideological underpinnings of a social system – whether in the form of political ideology, myth or religion – serve to rationalise the physical world in terms of the priorities, agenda and claims of the society generating these structures, and they comprise an ongoing discourse of self-definition that both responds to changes in social perceptions and historical circumstances and figures in the determination of how that society will react to any further changes or new developments. As these structures encompass the very essence and cohesive elements of a society – its sense of origins, identity, purpose and future – threats of the gravest and most disruptive kind are posed by challenges that falsify the assumptions and claims made in these structures.

This chapter is concerned with ways in which outbreaks of pestilence influenced perceptions of the poor. Discussion will focus on the Italian states between the late fifteenth and the mid-seventeenth centuries, making occasional forays into other parts of Europe in search of contrasts and parallels. How did the threat of plague, and of those epidemic fevers that presaged it, ran concurrently with it or were mistaken for it, contribute to the mixture of pity and fear that characterised the attitudes of educated and authoritative people towards the poor in the early modern period? Much of the evidence will be drawn, at first or second hand, from legislative acts, and from chronicles, letters and reports compiled by clergymen and religious, by physicians, by professional men and by administrators. Their authors were generally pillars of urban society, proud that they had not fled from the plague, persons who saw in the countryside both a place of refuge for the less dutiful and stout-hearted, and a force which laid siege to the city, blockading its gates and approach roads, and withholding its supplies.

In 1630, with the onset of a terrible epidemic that was eventually to destroy more than 30 per cent of Venice's population, the Venetian senate passed two decrees intended to clear particular quarters of the city of the beggars infesting them. Issued on 22 June, the first decree seemed wholly dedicated to placating the wrath of God, of which the plague was the unmistakable sign.

Between 1896 and 1914, bubonic plague killed over 8 million people, a modest estimate which does not allow for cases which were concealed, misdiagnosed or wrongly classified. Of all the various epidemics which afflicted India in the late nineteenth and early twentieth centuries, a Kaliyuga, a period of very high mortality, stagnant, even falling population and declining life expectancy, the plague was not the most destructive. Malaria and tuberculosis killed more than twice as many people over a similar period; in barely four months, the influenza epidemic of 1918–19 accounted for twice as many; smallpox and cholera counted their death toll in millions. Yet no other epidemic evoked the fear and panic generated by the plague.

The plague epidemic prompted massive state intervention to control its spread. It also sometimes provoked fierce resistance, riots, occasionally mob attacks on Europeans and even the assassination of British officials. The vigorous and energetic intervention of the state, in itself prompted by the general panic, bore no direct relation to the virulence of the epidemic. The focus of the state's most vigorous measures was Bombay city and its Presidency between 1896 and about 1902. But plague mortality continued to rise thereafter, reached its peak between 1903 and 1907, exceeding the levels of the late 1890s by twelvefold, and proved far more lethal in the Punjab. Yet neither plague policy nor plague riots in the Punjab appear to have displayed the zeal or acquired the political prominence they achieved in Bombay.

Following are some of the more relevant items of legislation and instructions which pertained to human trypanosomiasis in northern Congo. It can be observed that the medical service itself was a direct outgrowth of the campaign against sleeping sickness.

The historian can approach the subjects of disease and medicine in a number of ways. More traditional historians of medicine concentrate on the impressive scientific achievements in Western medicine, beginning their story with medical knowledge and practices of the ancient Greeks and Romans. Other medical historians are concerned with the social history of medicine although their focus remains on technical and scientific achievements. They discuss societal relations in connection with the development of medical science and they tend to be more critical and analytical than their more traditional colleagues. Both of these groups of historians are generally of the opinion that Western biomedicine is the correct path to pursue in the effort to salve and solve the ills of mankind. A number of twentieth-century works have dealt with the history of medicine in the African context. Most have been written by former colonial or missionary medics who often follow the more traditional approach and take the form of a celebration of man's intellectual advance as demonstrated by his increasing ability not only to comprehend his environment but to shape it to suit himself. Titles such as Gelfand's Tropical Victory and Ransford's Bid the Sickness Cease espouse this notion.

What is needed now is for historians to begin to put such work back into its historical context. The study of medicine in history can result in a much richer view of man's past by pulling into the analysis the subjects of disease and medicine as two of the factors among many in the overall process of historical change. In this way, the roles of disease and medicine are fully integrated in historical explanation.

In revising my Ph.D. thesis for publication, I have tried to draw out the relevance of the study to public health issues in Africa today. While I do not concur with the view that history is prescriptive, I do believe there is much that can be learned from the past which can be of help with present-day issues. The history of medicine and public health in Africa, particularly during this century, can assist greatly in understanding some of the issues and problems confronting health workers today. The histories of epidemics, such as those of sleeping sickness, are especially helpful, highlighting as they do a broad spectrum of issues ranging from purely medical ones to political and economic considerations. In this way, the history of sleeping sickness in a region of colonial Belgian Congo, now known as Zaire, has an importance reaching far beyond the confines of African history but is of relevance also to the wider history of health in the developing world. The present epidemic of AIDS has once again reminded us of the complexities involved in monitoring health on a global scale as well as those involved when attempting to intervene in the highly sensitive and deeply entrenched cultural realm of human responses to disease. As I discuss in this volume, the declaration of an epidemic is very much a political act, but not as widely recognised are the political aspects of public health programmes.

The scientists

On 23 September 1903 the team of scientists from Liverpool arrived in the Congo Free State to begin assessing the public health situation, particularly with reference to sleeping sickness. The Twelfth Expedition of the Liverpool School of Tropical Medicine consisted of Doctors Joseph Everett Dutton, 28, John Lancelot Todd, 27, and Cuthbert Christy, 40, each of whom recently had taken part in previous trypanosomiasis research expeditions in Africa. Dutton had participated in the Third Expedition concerned with malaria in Nigeria in 1900 and in two expeditions dealing with trypanosomiasis, in 1901 and 1902, both to Senegambia. Cuthbert Christy, a most difficult and irascible man, had been briefly attached to the Royal Society's first sleeping sickness commission to Uganda in 1902. When they reached the Congo Free State, the British team was joined by Dr Inge-Valdemar Heiberg, a reserve captain in the Norwegian army, who was one of the many non-Belgian military doctors employed by the State. Heiberg's career of six terms spanned nearly twenty years. Beginning as a médecin d'expedition in the Lado enclave, he became director of the first sleeping sickness lazaret at Ibembo in 1907 and the first médecin en chef of the Congo on 28 January 1911. As an illustration of the small number of tropical health specialists at the time, Dutton and Todd were already acquainted with Heibert whom they had met in Liverpool where he had completed the new tropical medicine course in May 1903. Dutton explained, ‘We were delighted when he told us that he was put at our disposition and was to act as a guide, aide-de-camp and everything else.’

Late-nineteenth-century European concepts and practices concerning epidemic disease deeply affected the lives of millions of colonised Africans early this century. This was especially true in the Belgian Congo. The term ‘epidemic’ can be highly emotive, even political, evoking images of catastrophic mortality involving millions of deaths such as those caused by plague in early modern Europe and by the great influenza pandemic this century. Between 1901 and 1905 a sleeping sickness epidemic caused the deaths of over a quarter of a million people in Uganda. Depopulating entire regions of the country, that devastating epidemic altered for many decades the demographic pattern of the northern shores of Lake Victoria.

The decision to declare an epidemic is influenced by political factors as much as purely scientific ones as it is most often the state which declares a disease to have reached epidemic proportions. This fact was borne out in the early colonial history of parts of sub-Saharan Africa. For instance, the declaration of an epidemic could provide a new and understaffed colonial administration with important control mechanisms as there would be a rationale for the introduction of a range of highly authoritarian measures. In the Belgian Congo, sleeping sickness legislation became, in fact, a clear example of an attempt at ‘social engineering’ in Africa.

The impressive discoveries of the mid- to late-nineteenth century in the fields of bacteriology and antisepsis had a profound impact on the prevailing theories of the epidemiology of disease which had evolved over the long centuries of plague and more recent cholera epidemics.

Belgian colonials produced much rhetoric on the subject of their ‘civilising mission’ in Africa and they often rationalised, even justified, their presence in the Congo by referring to their duty to instill and nurture in Africans the European, bourgeois values of education, hard work, moral duty, selflessness, courage and patriotism. These values were not only to be taught in the abstract in schools but were to be acquired by Africans in the process of practical works. Congolese would become civilised by labouring for Europeans. But it was often to prove difficult to obtain African labour, the supply of which remained a major issue during the entire colonial experience. This was an enormous problem as the mise en valeur, or economic exploitation, of the Congo in the early decades of its existence depended almost entirely upon obtaining sufficient numbers of African labourers. The earliest instructions to state agents had stressed the significance of labour as the pivot of the Belgian ‘civilising mission’.

As we have seen, the conquest of the northern Belgian Congo was protracted and costly for African societies, but military conquest was only the beginning of many decades of real stress for many people. Administrative policies strained societies in ways which for some populations culminated in famine, disease and death. State demands for labour and tax were particularly onerous and began almost immediately upon establishment of each state post. The relationship between labour recruitment and deployment and the overall upheaval experienced by northern Congolese, especially before 1920, is crucial to an understanding of outbreaks of sleeping sickness.

In 1904, sleeping sickness was declared to be epidemic in some parts of the Congo Free State. This was the conclusion of a team of British scientists invited from the Liverpool School of Tropical Medicine to conduct a survey of health conditions in central Africa. They advised the state authorities to take immediate action to control the further spread of sleeping sickness. It was certainly not the first time the disease had been reported. The ‘sleepy sickness’ had been noted in the region in the early 1880s, and fresh outbreaks were confirmed by missionaries and travellers. But, by 1901, a terrible epidemic had spread around the northern shores of Lake Victoria and neighbouring islands in the Lake in the region of Busoga, in the adjoining Uganda Protectorate.

The declaration of an epidemic was a watershed in the history of public health for Africans in the Congo; for, more than any other one factor, sleeping sickness prompted the development of the Belgian colonial medical service. This medical service was consciously used by the Belgians as a form of ‘constructive imperialism’, with which they hoped to establish European influence. The provision of health services was considered by the Belgians to be a central feature of what they called their ‘civilising mission’ in Africa.

In discussing sleeping sickness in Africa in the early twentieth century, there are three important points. First, there was a direct link between sleeping sickness and the rapidly expanding new field of tropical medicine.