WEBVTT 00:01.860 --> 00:05.140 Prof: Okay, well let's begin. 00:05.140 --> 00:09.290 And, as you know, in our class one of the topics, 00:09.286 --> 00:13.426 or themes, that we're considering is intellectual 00:13.433 --> 00:14.473 history. 00:14.470 --> 00:19.210 And lurking in the background, of course, is the big question 00:19.207 --> 00:22.047 of medicine itself and what it is. 00:22.050 --> 00:23.470 What is medical science? 00:23.470 --> 00:27.260 What does it mean to have a medical science? 00:27.260 --> 00:32.180 Well, this morning we'll be considering that. 00:32.180 --> 00:40.140 Is medical science purely the technical application of neutral 00:40.143 --> 00:41.713 knowledge? 00:41.710 --> 00:45.690 Or should we think of it as a cultural institution, 00:45.690 --> 00:50.890 also, built by dominant social groups in society, 00:50.890 --> 00:55.760 that in some way may reflect their worldview, 00:55.760 --> 00:59.230 sometimes may embody their prejudices, 00:59.230 --> 01:03.050 and may promote their interests? 01:03.048 --> 01:07.338 And at least we should ask the question, if we accept the 01:07.338 --> 01:11.858 biomedical paradigm of disease, what are the implications of 01:11.858 --> 01:13.388 that acceptance? 01:13.390 --> 01:15.030 What are the costs? 01:15.030 --> 01:17.280 What are we giving up? 01:17.280 --> 01:21.100 So, that's the big issue. 01:21.099 --> 01:26.559 And today what I'd like to do is to look at a subset of the 01:26.563 --> 01:30.363 bigger problem, and this is the medical 01:30.364 --> 01:36.044 specialization that's known as "tropical medicine." 01:36.040 --> 01:40.550 It emerged in the 1890s, in a period, 01:40.545 --> 01:48.295 that is, of--it gained rapidly enormous prestige and influence, 01:48.303 --> 01:54.063 and is still a major subfield in medicine. 01:54.060 --> 01:59.850 The discipline thus far has undergone three periods in its 01:59.852 --> 02:00.872 history. 02:00.870 --> 02:04.660 The first is the one that we're going to be concentrating on 02:04.661 --> 02:08.181 this morning, and that's the period from 02:08.177 --> 02:13.727 roughly the 1890s until more or less the First World War. 02:13.729 --> 02:18.309 That marks the real heyday of tropical medicine, 02:18.310 --> 02:22.520 the time when it was the cutting edge of medical science, 02:22.520 --> 02:27.690 when it made a series of major discoveries, 02:27.688 --> 02:32.428 and served the most obvious political purposes. 02:32.430 --> 02:37.560 It was followed in its history by a second period, 02:37.560 --> 02:42.820 that lasts more or less from World War I until the 1970s, 02:42.818 --> 02:47.518 the next half-century of tropical medicine. 02:47.520 --> 02:52.580 And during this period the discipline loses a lot of its 02:52.577 --> 02:54.597 scientific momentum. 02:54.598 --> 03:00.228 Tropical medicine came to be confined essentially to 03:00.231 --> 03:03.751 parasitology, and at this period, 03:03.746 --> 03:09.256 the dynamism in medical science moved instead to microbiology 03:09.258 --> 03:12.658 and such offshoots as immunology, 03:12.658 --> 03:18.488 and that boosted such major developments as antibiotics and 03:18.485 --> 03:24.005 a series of effective vaccines, and that attracted the lion's 03:24.009 --> 03:25.829 share of research funds. 03:25.830 --> 03:30.850 So, tropical medicine, in the period from the First 03:30.849 --> 03:35.769 World War to the 1970s, made relatively few major, 03:35.770 --> 03:37.980 major discoveries. 03:37.979 --> 03:43.819 Then, after World War II, and accelerating from the 03:43.818 --> 03:46.998 1970s, we see a third phase, 03:46.995 --> 03:52.255 ushered in by such things as decolonization and a new 03:52.258 --> 03:57.318 attention to public health in the Third World, 03:57.318 --> 04:02.488 and with it a new influx of research funds through the World 04:02.486 --> 04:08.086 Health Organization and powerful foundations like the Rockefeller 04:08.092 --> 04:10.722 and MacArthur Foundations. 04:10.718 --> 04:15.408 Well, what I want to do this morning is to look critically at 04:15.413 --> 04:16.983 tropical medicine. 04:16.980 --> 04:21.050 And by that I don't mean for or against. 04:21.050 --> 04:26.180 What I want to do instead is to look at why it arose as a 04:26.178 --> 04:28.468 discipline when it did. 04:28.470 --> 04:31.690 What interests did it serve? 04:31.689 --> 04:34.419 What were its implications? 04:34.420 --> 04:37.640 And I'm going to argue that tropical medicine, 04:37.639 --> 04:42.379 and particularly in this formative early period before 04:42.382 --> 04:46.692 the First World War, was clearly socially 04:46.694 --> 04:48.164 constructed. 04:48.160 --> 04:53.380 This is a period that coincides with the high tide of colonial 04:53.375 --> 04:57.475 expansion, the age of the scramble for Africa. 04:57.480 --> 05:03.050 And tropical medicine gave expression to an imperial view 05:03.048 --> 05:07.068 of the world, and it marked the relationship, 05:07.069 --> 05:10.289 in medical terms, between Western Europe, 05:10.293 --> 05:14.003 on the one hand, and Asia and Africa on the 05:13.995 --> 05:19.045 other, and between the United States and Latin America. 05:19.050 --> 05:24.030 As a discipline, it served as a major instrument 05:24.029 --> 05:28.799 also in promoting European expansion overseas, 05:28.798 --> 05:33.248 and American hegemony in the Americas. 05:33.250 --> 05:36.790 In its applications, and in the policies it 05:36.786 --> 05:42.256 promoted, tropical medicine was not only value-neutral science; 05:42.259 --> 05:47.669 it was also an instrument of power, and we need to bear that 05:47.672 --> 05:48.592 in mind. 05:48.589 --> 05:54.549 Now, the emergence of tropical medicine marked a transition, 05:54.550 --> 05:57.270 a transformation, from something that had 05:57.269 --> 05:59.919 preceded it, and that I hope won't be 05:59.915 --> 06:00.655 confusing. 06:00.660 --> 06:04.000 But from the middle of the eighteenth century, 06:04.000 --> 06:08.330 more or less, until the closing decade of the 06:08.326 --> 06:12.546 nineteenth century, there had been an older 06:12.547 --> 06:17.017 tradition that can be summarized under the label of 06:17.019 --> 06:20.509 "diseases of the tropics." 06:20.509 --> 06:24.949 And there were a couple of classic statements of this older 06:24.951 --> 06:25.871 tradition. 06:25.870 --> 06:28.290 One was a work, an important work, 06:28.290 --> 06:32.720 by James Lind, an eighteenth-century 06:32.716 --> 06:36.916 physician, who wrote "An Essay on 06:36.918 --> 06:42.038 Diseases Incidental to Europeans in Hot Climates," 06:42.036 --> 06:47.246 and this was built on the experience of Europeans in the 06:47.247 --> 06:48.857 West Indies. 06:48.860 --> 06:53.420 And then there was another work by James Johnson called 06:53.422 --> 06:57.732 "The Influence of Tropical Climates on European 06:57.730 --> 07:01.620 Constitutions," built on the experience of 07:01.617 --> 07:03.727 Europeans in India. 07:03.730 --> 07:08.130 What these works, and other ones of their kind, 07:08.129 --> 07:12.139 meant in the expression "diseases of the 07:12.141 --> 07:15.881 tropics" was something particular. 07:15.879 --> 07:18.329 They meant that in the colonial world-- 07:18.329 --> 07:22.069 in, that is, the area of hot climate, 07:22.069 --> 07:26.939 as it was expressed at the time--Europeans were subject to 07:26.942 --> 07:32.382 special diseases as challenges, that arose as a result of 07:32.384 --> 07:36.344 conditions peculiar to warm climates, 07:36.339 --> 07:40.109 and to the resulting conditions of temperature, 07:40.110 --> 07:43.570 humidity and local ecology. 07:43.569 --> 07:48.389 Under those conditions, the diseases that would afflict 07:48.392 --> 07:52.592 Europeans were not, however, different in nature 07:52.591 --> 07:55.451 from those familiar at home. 07:55.449 --> 07:58.609 The diseases of hot countries were heightened in their 07:58.605 --> 08:02.275 virulence, perhaps, and the constitutions 08:02.281 --> 08:07.601 of white people were now subjected to new and unfamiliar 08:07.603 --> 08:12.733 stresses that made them peculiarly vulnerable in these 08:12.730 --> 08:15.150 climates to disease. 08:15.149 --> 08:20.829 But the issue was simply--in the era, should we say, 08:20.834 --> 08:26.634 of diseases of the tropics--was simply one of degree, 08:26.629 --> 08:28.969 rather than kind. 08:28.970 --> 08:34.540 The diseases of the tropics were simply intense variants of 08:34.543 --> 08:37.333 familiar disease processes. 08:37.330 --> 08:41.120 And there was an educational corollary to that, 08:41.120 --> 08:46.660 which was that physicians who had studied general medicine, 08:46.658 --> 08:51.918 in European medical schools, were fully equipped to treat 08:51.921 --> 08:57.841 the entire spectrum of human diseases wherever they occurred. 08:57.840 --> 09:03.370 Diseases of the tropics weren't a special category. 09:03.370 --> 09:08.190 They were simply heightened versions of familiar maladies. 09:08.190 --> 09:12.300 In other words, the concept of diseases of the 09:12.302 --> 09:17.152 tropics presupposed a universality of a single medical 09:17.149 --> 09:22.269 discipline that viewed the diseases of the tropical world 09:22.268 --> 09:28.648 as posing problems of degree, but not of a thoroughly 09:28.649 --> 09:30.799 different kind. 09:30.798 --> 09:35.728 We should also say that this idea of diseases of the tropics 09:35.725 --> 09:40.645 already did have embodied in it some troubling and important 09:40.649 --> 09:45.829 questions that had to do with a colonial or imperial and racial 09:45.826 --> 09:47.826 view of the world. 09:47.830 --> 09:51.670 European bodies, the concept presupposed, 09:51.673 --> 09:57.733 were different in some way from those of Asians and Africans. 09:57.730 --> 10:02.820 They weren't intended for the conditions prevailing in the 10:02.823 --> 10:08.013 colonies, and so the question was, were the tropics in fact 10:08.008 --> 10:10.688 inhabitable for Europeans? 10:10.690 --> 10:15.690 You can see this in expressions like "darkest Africa," 10:15.687 --> 10:19.607 "teeming Asia"-- those imply dangerous 10:19.606 --> 10:23.966 places--and even more the expression of "the white 10:23.971 --> 10:25.671 man's grave." 10:25.668 --> 10:29.518 And, so, the question was whether settling in the tropics 10:29.522 --> 10:31.382 was going to be possible. 10:31.379 --> 10:35.249 Was it simply that Europeans needed a period of seasoning-- 10:35.250 --> 10:39.860 another term of the time--or acclimatization, 10:39.860 --> 10:45.190 after which they'd be stress-hardy and able to survive 10:45.187 --> 10:47.597 in these new settings? 10:47.600 --> 10:52.010 Physicians who dealt with diseases of the tropics thought 10:52.014 --> 10:56.434 of themselves as performing an indispensable service, 10:56.428 --> 11:00.328 one that was useful to European states, 11:00.330 --> 11:04.310 and especially to explorers, travelers, 11:04.308 --> 11:07.768 settlers, colonial administrators, 11:07.769 --> 11:11.649 and of course sailors and soldiers. 11:11.649 --> 11:16.859 The service was to provide assistance and advice during the 11:16.860 --> 11:20.720 time of acclimatization, advice on exercise, 11:20.724 --> 11:25.934 diet, clothing and housing; in short, everything that new 11:25.928 --> 11:30.848 arrivals would need to protect themselves from the rigors of 11:30.851 --> 11:32.771 the new environment. 11:32.769 --> 11:37.259 But the 1890s marked a transition to something 11:37.261 --> 11:41.281 different-- from this view of diseases of 11:41.277 --> 11:45.237 the tropics, to something that sounds subtly 11:45.235 --> 11:48.275 different, but was profoundly so, 11:48.283 --> 11:53.163 and that is tropical diseases and tropical medicine. 11:53.158 --> 11:59.948 Now, what was implied in this transition, this transformation? 11:59.950 --> 12:04.190 It was a vision of the world in which Asia and Africa, 12:04.190 --> 12:07.390 for Europeans, or possibly Latin America, 12:07.389 --> 12:08.349 for U.S. 12:08.350 --> 12:13.760 citizens, were conceived in a really charged fashion as 12:13.758 --> 12:19.168 harboring disease that were conceptually different from 12:19.166 --> 12:23.596 other diseases, that could not be treated by 12:23.597 --> 12:28.537 physicians who had graduated from European medical schools 12:28.542 --> 12:33.662 unless they had undergone special postgraduate training. 12:33.658 --> 12:41.548 And the implication too was a different form of hygiene. 12:41.548 --> 12:45.858 And there was a work that was a foundational text for this new 12:45.856 --> 12:49.116 medical specialty, one of the most influential 12:49.118 --> 12:52.738 medical works of the whole of the nineteenth century, 12:52.740 --> 12:56.700 and one that had enormous influence on the relations of 12:56.700 --> 13:00.880 the metropolitan powers to their colonial dependencies. 13:00.879 --> 13:06.319 This work was by this man, a British physician named 13:06.317 --> 13:10.797 Patrick Manson, who came to be known as the 13:10.797 --> 13:14.207 father of tropical medicine. 13:14.210 --> 13:18.710 The work that caused the stir was called-- 13:18.710 --> 13:22.300 it's an enormous, fat volume--entitled 13:22.299 --> 13:27.049 Tropical Diseases: A Manual for the Diseases of 13:27.054 --> 13:29.194 Warm Climates. 13:29.190 --> 13:35.060 And it was written in 1898, which isn't an accident. 13:35.058 --> 13:39.858 And it wasn't also an accident that the father of tropical 13:39.859 --> 13:43.959 medicine was British, or that Britain became the 13:43.964 --> 13:46.934 world center of the new discipline, 13:46.928 --> 13:52.778 Britain at the time being the world's leading imperial power. 13:52.779 --> 13:58.689 Now, what were the background conditions that promoted the 13:58.692 --> 14:04.192 emergence of this whole new medical sub-discipline? 14:04.190 --> 14:08.590 A first, as we said, was Britain's position as a 14:08.594 --> 14:10.754 great colonial power. 14:10.750 --> 14:16.700 There were others, as well, that lay behind this 14:16.696 --> 14:19.856 new medical specialism. 14:19.860 --> 14:24.270 One was something we've already dealt with, and that is the germ 14:24.274 --> 14:27.994 theory of disease and the triumph of contagionism over 14:27.988 --> 14:29.458 anticontagionism. 14:29.460 --> 14:34.260 The germ theory had a number of possible implications. 14:34.259 --> 14:37.349 One was the idea, as we've seen, 14:37.351 --> 14:42.341 of clinching the concept of disease specificity. 14:42.340 --> 14:47.000 And tropical medicine was built on the premise that some 14:46.996 --> 14:51.226 diseases lurking in Africa and Asian now needed new 14:51.230 --> 14:55.000 classifications, belonging in special 14:54.996 --> 14:59.166 categories, and that to understand them-- 14:59.168 --> 15:01.758 and here was another of its implications-- 15:01.759 --> 15:06.359 you needed physicians who were trained at special institutions, 15:06.360 --> 15:10.970 and had a specialized curriculum, and that they could 15:10.966 --> 15:16.016 be dealt with by specific special remedies and measures of 15:16.017 --> 15:21.507 hygiene that were different from those that had been successful 15:21.509 --> 15:26.559 in bringing about a mortality revolution in Europe. 15:26.558 --> 15:30.968 As you'll remember when we examined the theories of Max van 15:30.969 --> 15:34.669 Pettenkofer, the germ theory marked the end 15:34.669 --> 15:38.169 of an alternative approach to medicine, 15:38.168 --> 15:40.948 one that had flourished at mid-century, 15:40.950 --> 15:43.720 particularly in continental Europe, 15:43.720 --> 15:47.290 but was intellectually vanquished by the laboratory 15:47.291 --> 15:51.401 methods of bacteriology, and later parasitology. 15:51.399 --> 15:56.109 This was the idea of social medicine, associated with a 15:56.109 --> 15:59.859 radical German physician, Rudolf Virchow. 15:59.860 --> 16:03.830 For social medicine, medicine was a collective 16:03.831 --> 16:08.511 enterprise in which it was important for physicians to 16:08.509 --> 16:12.039 treat not only individual patients, 16:12.038 --> 16:16.678 but society as a whole, dealing with issues of sanitary 16:16.677 --> 16:20.297 conditions, poverty, nutrition, 16:20.301 --> 16:22.341 social justice. 16:22.340 --> 16:26.450 Well, the germ theory of disease was a setback for social 16:26.448 --> 16:29.358 medicine, and I'm going to argue that 16:29.364 --> 16:33.734 tropical medicine went even a step further in the turn from 16:33.732 --> 16:35.092 that direction. 16:35.090 --> 16:39.220 It argued that in the tropical world the chief problem-- 16:39.220 --> 16:43.030 and we're talking with the period down to World War I-- 16:43.029 --> 16:48.059 the chief problem was to preserve the health of European 16:48.062 --> 16:49.072 settlers. 16:49.070 --> 16:54.200 As a discipline, until much later in its life, 16:54.201 --> 17:00.361 tropical medicine largely ignored the general health of 17:00.359 --> 17:03.209 indigenous societies. 17:03.210 --> 17:07.350 This also came to mean something somewhat sinister, 17:07.345 --> 17:11.975 when the logic was applied to the global north and south, 17:11.977 --> 17:14.787 and black/white relationships. 17:14.788 --> 17:20.408 It seemed to suggest that the bodies of Africans and teeming 17:20.413 --> 17:26.423 Asians were medically dangerous, that they were the reservoirs 17:26.415 --> 17:31.835 for diseases that posed serious new threats for Europeans. 17:31.838 --> 17:36.538 And there was an implication, a possible strategy for 17:36.536 --> 17:39.686 hygiene, and that was that perhaps the 17:39.692 --> 17:43.872 best way forward was for Europeans and indigenous peoples 17:43.866 --> 17:47.666 to be segregated in their housing arrangements, 17:47.670 --> 17:52.190 that Europeans should live in the tropical world in special 17:52.192 --> 17:56.482 enclaves where the latest prophylactic measures would be 17:56.482 --> 17:57.422 applied. 17:57.420 --> 18:00.440 Whereas natives, or indigenous peoples, 18:00.440 --> 18:03.540 could be left as they had been found. 18:03.538 --> 18:07.578 Alternatively, if you read some of the 18:07.576 --> 18:13.576 literature produced by works of European writers such as 18:13.578 --> 18:18.148 Somerset Maugham, you'd see that the Europeans 18:18.152 --> 18:22.262 were advised to take to the hills during the dangerous 18:22.262 --> 18:26.952 summer months, leaving dangerous natives 18:26.946 --> 18:27.996 behind. 18:28.000 --> 18:30.830 But we shouldn't forget that tropical medicine, 18:30.828 --> 18:35.758 at the turn of the century, was also where the scientific 18:35.763 --> 18:41.143 action and excitement in medical science were taking place. 18:41.140 --> 18:45.950 Beyond the germ theory of disease, tropical medicine 18:45.953 --> 18:49.733 embodied the various latest developments, 18:49.730 --> 18:54.450 and above all the new science of parasitology. 18:54.450 --> 18:57.630 And it attracted some of the leading figures, 18:57.634 --> 19:01.904 indeed, in the development of microbiology to enter this new 19:01.903 --> 19:02.993 discipline. 19:02.990 --> 19:05.350 This was true, for example, 19:05.346 --> 19:09.306 of Robert Koch, who came, made a voyage, 19:09.314 --> 19:14.764 to Italy to study parasitology in the form of malaria, 19:14.759 --> 19:18.789 and then set off for the colonial world. 19:18.788 --> 19:22.218 Pasteur at this time had just died, 19:22.220 --> 19:25.900 but his institute saw affiliates or satellite 19:25.903 --> 19:30.173 institutes set up at Saigon, at Tunis, Algiers, 19:30.174 --> 19:33.344 in the 1890s, all preaching the new 19:33.340 --> 19:36.600 discipline of tropical medicine. 19:36.598 --> 19:40.548 And Pasteur's most famous and able disciple, 19:40.554 --> 19:44.604 �mile Roux, became a specialist in this new 19:44.599 --> 19:45.979 discipline. 19:45.980 --> 19:48.920 To understand it, we need to remember two major 19:48.924 --> 19:49.954 breakthroughs. 19:49.950 --> 19:57.310 The first was by Patrick Manson in 1883. 19:57.308 --> 20:01.528 At that time, he discovered something that 20:01.529 --> 20:03.589 was radically new. 20:03.588 --> 20:08.078 He was dealing with the disease of elephantiasis, 20:08.078 --> 20:12.938 and he found that the filarial worm that causes it is 20:12.942 --> 20:19.062 transmitted by mosquitoes; the first example of a vector 20:19.061 --> 20:22.261 borne disease transmission. 20:22.259 --> 20:26.529 This was epoch-making in that respect. 20:26.528 --> 20:30.888 And it was also a movement from bacteria or-- 20:30.890 --> 20:32.910 though it wasn't known at the time-- 20:32.910 --> 20:37.310 viruses, to more complex life forms, 20:37.308 --> 20:42.768 the interaction of humans with biologically more sophisticated 20:42.773 --> 20:48.673 protozoa or helminths or worms, and with insect vectors. 20:48.670 --> 20:53.760 Diseases could now be seen to be part of a much more 20:53.759 --> 20:58.249 complicated process, and with complicated life 20:58.250 --> 20:59.250 forms. 20:59.250 --> 21:01.880 Then there was, following this, 21:01.884 --> 21:06.724 the establishment of the mosquito theory of transmission 21:06.715 --> 21:11.315 for malaria, which took place during the end 21:11.315 --> 21:15.335 of the decade of the 1890s, with two figures, 21:15.337 --> 21:18.427 who were working independently of each other, 21:18.430 --> 21:23.320 but in 1898 established that malaria was a parasitical 21:23.324 --> 21:26.664 disease, transmitted by certain species 21:26.660 --> 21:27.820 of mosquitoes. 21:27.818 --> 21:32.398 So, malaria--which is a disease that we'll be dealing with after 21:32.403 --> 21:36.043 the spring break-- was of decisive importance in 21:36.035 --> 21:39.105 the establishment of tropical medicine, 21:39.108 --> 21:44.308 and malaria was the disease that was at its heart and its 21:44.305 --> 21:45.135 center. 21:45.140 --> 21:49.450 The two people were in Italy--and we'll be coming back 21:49.453 --> 21:55.263 to this in a couple of weeks, when we resume classes--in 21:55.255 --> 22:00.535 Italy there was Giovanni Battista Grassi, 22:00.538 --> 22:04.928 who made a very elegant demonstration, 22:04.930 --> 22:09.850 and a very convincing one, that human malaria was 22:09.848 --> 22:12.718 transmitted by mosquitoes. 22:12.720 --> 22:18.590 And he did so by experiments in which he introduced just one 22:18.592 --> 22:24.412 variable in the exposure, during the warm summer months, 22:24.413 --> 22:28.463 of large populations to biting insects. 22:28.460 --> 22:30.790 He protected, by screening, 22:30.788 --> 22:35.358 or later by chemical means, select groups of people, 22:35.355 --> 22:40.545 while everyone around them was falling ill of malaria. 22:40.548 --> 22:45.098 They lived in exactly the same conditions as those around them, 22:45.101 --> 22:49.671 except for one variable; that they weren't subject to 22:49.672 --> 22:52.432 the bites of flying insects. 22:52.430 --> 22:56.860 And thereby he established that it was indeed insects, 22:56.856 --> 23:00.696 mosquitoes, and certain types of mosquitoes; 23:00.700 --> 23:02.510 we'll be returning to that. 23:02.509 --> 23:06.819 Not all mosquitoes, just anophelene mosquitoes, 23:06.821 --> 23:12.351 and certain species of them, that transmitted the disease of 23:12.354 --> 23:13.484 malaria. 23:13.480 --> 23:16.520 At the same time, Ronald Ross, 23:16.521 --> 23:22.731 a British physician in India, was working instead with 23:22.726 --> 23:28.376 malaria among the avian-- that is, birds--avian malaria, 23:28.382 --> 23:33.612 where he demonstrated that it too was transmitted by the bites 23:33.612 --> 23:35.072 of mosquitoes. 23:35.068 --> 23:38.668 And he argued, by analogy, that human malaria 23:38.670 --> 23:42.680 was probably transmitted by mosquitoes as well. 23:42.680 --> 23:47.070 Now, this was the age of a ferocious imperial rivalry, 23:47.068 --> 23:51.278 and Ross was the first British scientist to discover the 23:51.284 --> 23:56.644 pathogen of a major disease, and he became a national icon, 23:56.637 --> 24:00.507 the British answer to Pasteur or Koch. 24:00.509 --> 24:04.399 He won the Nobel Prize, and along with Manson became 24:04.397 --> 24:08.967 one of two decisive figures in the founding of the discipline 24:08.972 --> 24:10.882 of tropical medicine. 24:10.880 --> 24:15.300 It was quite interesting that there was an extraordinary 24:15.299 --> 24:19.319 collaboration between Manson and Ross in India, 24:19.318 --> 24:24.218 where Ross wrote home what he was finding under his microscope 24:24.215 --> 24:27.725 in India, and sent that back to Manson, 24:27.727 --> 24:32.207 who worked with him in suggesting new directions for 24:32.205 --> 24:34.975 his research, and pushed him forward. 24:34.980 --> 24:39.940 So, in many ways the discovery of the transmission of malaria 24:39.940 --> 24:43.000 belonged to Manson as well as Ross. 24:43.000 --> 24:46.780 Well, in any case, malaria became the template, 24:46.778 --> 24:49.898 the ideal type of tropical diseases. 24:49.900 --> 24:55.620 And in Manson's great work malaria occupies the largest 24:55.619 --> 25:02.049 amount of space in the volume; the reasons being that it was a 25:02.053 --> 25:07.553 perfectly vector-transmitted disease, a perfect parasitic 25:07.549 --> 25:08.629 disease. 25:08.630 --> 25:13.690 The plasmodium that causes it, as we'll see in a couple of 25:13.685 --> 25:18.915 weeks, lives in a closed cycle, and never exists free in the 25:18.920 --> 25:20.340 environment. 25:20.338 --> 25:25.838 Human beings don't happen upon it, and the plasmodium has an 25:25.838 --> 25:31.338 extremely complicated lifecycle in both man and mosquito. 25:31.338 --> 25:35.288 And the involvement of the mosquito also is scientifically 25:35.288 --> 25:37.968 complicated; in other words, 25:37.971 --> 25:44.371 it was useful and important that Grassi was a naturalist, 25:44.366 --> 25:47.446 was well as a physician. 25:47.450 --> 25:53.860 Parasitology was scientifically interesting, and intellectually 25:53.862 --> 25:54.382 so. 25:54.380 --> 25:57.950 To study malariology, one needed to be a physician, 25:57.952 --> 26:00.672 but also an entomologist, a naturalist, 26:00.666 --> 26:04.236 and to have a knowledge of the basic sciences. 26:04.240 --> 26:09.160 So, in 1898, for a whole generation, 26:09.160 --> 26:14.040 parasitology replaced bacteriology as the cutting edge 26:14.042 --> 26:18.282 of medical science, and it became the foundation of 26:18.279 --> 26:22.239 this new discipline, the rising discipline of 26:22.243 --> 26:24.143 tropical medicine. 26:24.140 --> 26:31.860 Well, if that's how it emerges, what is the new discipline? 26:31.858 --> 26:37.128 Manson defined tropical medicine in his great work. 26:37.130 --> 26:42.910 For him, it was a special discipline, with diseases of an 26:42.906 --> 26:47.546 area defined by geography and warm climate. 26:47.548 --> 26:50.998 Diseases there, he said, were unlike the 26:51.000 --> 26:56.190 diseases of the temperate zone, and they require therefore a 26:56.190 --> 26:59.850 special medical discipline to deal with them, 26:59.848 --> 27:04.778 and they require physicians who are specially trained in 27:04.778 --> 27:07.198 post-graduate institutes. 27:07.200 --> 27:10.920 For that reason, tropical medicine emerged 27:10.923 --> 27:14.743 outside of established medical schools, 27:14.740 --> 27:19.660 because it presupposed that physicians needed a special 27:19.660 --> 27:24.580 curriculum and training to deal with diseases that were 27:24.578 --> 27:27.038 conceptually different. 27:27.038 --> 27:31.618 For example, in 1898, in association with 27:31.619 --> 27:36.139 Joseph Chamberlain, the secretary of state for the 27:36.136 --> 27:39.046 colonies-- and you can see the role of the 27:39.050 --> 27:42.430 state in the promotion of this new discipline, 27:42.430 --> 27:46.690 which was seen as important for the promotion of imperial 27:46.690 --> 27:49.970 interests-- and with the collaboration of 27:49.973 --> 27:53.413 Patrick Manson-- there was founded the London 27:53.414 --> 27:58.704 School of Tropical Medicine, with the specific intention of 27:58.701 --> 28:03.771 training colonial medical officers in a new medical 28:03.769 --> 28:08.009 discipline; or very closely associated was 28:08.005 --> 28:12.035 the Liverpool School of Tropical Medicine. 28:12.038 --> 28:16.718 Another idea that Manson said was essential to the new 28:16.723 --> 28:22.033 discipline was that tropical diseases were caused not usually 28:22.028 --> 28:26.888 by bacteria but by more complex biological agents, 28:26.890 --> 28:30.550 with complex lifecycles--protozoa and 28:30.550 --> 28:33.640 helmets-- and that they were transmitted 28:33.636 --> 28:38.476 by insect vectors, like mosquitoes or the tsetse 28:38.480 --> 28:39.090 fly. 28:39.089 --> 28:41.759 Malaria had pride of place. 28:41.759 --> 28:45.039 It was the ideal type to illustrate this, 28:45.038 --> 28:49.578 and it's the first disease that Manson discusses in his work, 28:49.578 --> 28:53.518 and the disease he discusses at greatest length. 28:53.519 --> 29:00.289 There were others of this type, like trypanosomiasis, 29:00.288 --> 29:03.428 which was African sleeping sickness, 29:03.430 --> 29:07.870 which was caused by a parasite also that multiplies in the 29:07.874 --> 29:11.544 human bloodstream and causes skin eruptions, 29:11.538 --> 29:14.828 anemia, chronic fever, debilitation, 29:14.828 --> 29:19.618 lethargy and perhaps coma and death. 29:19.618 --> 29:23.658 It was transmitted by the tsetse fly. 29:23.660 --> 29:28.200 Or there was schistosomiasis, caused by worms, 29:28.201 --> 29:32.341 with the snail as its alternative host. 29:32.338 --> 29:36.478 Or leishmaniasis, or yellow fever--a viral 29:36.481 --> 29:41.641 infection, it was later discovered--transmitted by a 29:41.635 --> 29:44.865 certain species of mosquito. 29:44.868 --> 29:47.648 Well, so far, if you were reading Manson's 29:47.646 --> 29:50.006 work, you would've found the diseases 29:50.007 --> 29:53.167 I've just mentioned would be the ones that you would've 29:53.172 --> 29:56.292 encountered, and there was a kind of logical 29:56.285 --> 29:58.315 coherence to what they were. 29:58.318 --> 30:03.288 Diseases of places with warm climates, transmitted by 30:03.286 --> 30:08.246 mosquitoes, caused not by bacteria but rather by more 30:08.252 --> 30:10.452 complex life forms. 30:10.450 --> 30:13.410 But Manson then goes on. 30:13.410 --> 30:17.650 And what we see then is something of a grab bag of 30:17.646 --> 30:22.226 diseases, that don't seem to have much of a scientific 30:22.230 --> 30:23.960 connecting link. 30:23.960 --> 30:28.940 He mentions certain infectious bacterial diseases, 30:28.936 --> 30:34.726 some of them very familiar to you already: bubonic plague, 30:34.728 --> 30:36.758 Asiatic cholera. 30:36.759 --> 30:39.549 He adds leprosy. 30:39.548 --> 30:43.908 He then moves on to certain nutritional diseases: 30:43.910 --> 30:49.000 pellagra, which is caused by a deficiency 30:49.000 --> 30:53.120 of niacin, if your diet consists not of 30:53.115 --> 30:56.805 wheat, but exclusively of corn; 30:56.808 --> 31:01.278 or beriberi, or certain fungal diseases. 31:01.278 --> 31:08.538 And he even calls heatstroke a tropical disease. 31:08.538 --> 31:14.888 Another background factor was institutional. 31:14.890 --> 31:18.630 Should we call it the institutionalization of this new 31:18.627 --> 31:20.107 medical discipline? 31:20.108 --> 31:23.418 That is, it coincides with the high point of European 31:23.415 --> 31:24.175 expansion. 31:24.180 --> 31:27.500 And this wasn't just a coincidence. 31:27.500 --> 31:34.130 It was an important instrument in the domination of Africa and 31:34.131 --> 31:36.231 India, for instance, 31:36.232 --> 31:41.132 as important as gun powder, enabling settlers to run mines 31:41.133 --> 31:44.213 and plantations, traders to travel, 31:44.210 --> 31:48.760 administrators to govern, missionaries to preach, 31:48.755 --> 31:52.195 and soldiers to perform their duties. 31:52.200 --> 31:55.070 For this reason, tropical medicine rapidly 31:55.068 --> 31:59.568 attracts governmental backing, certainly in the British case, 31:59.569 --> 32:02.709 and institutional support and assistance, 32:02.710 --> 32:07.350 from powerful economic interests, with concerns in the 32:07.351 --> 32:08.841 tropical world. 32:08.838 --> 32:12.288 So, these institutions--in Britain we've already talked 32:12.290 --> 32:15.360 about the London School of Tropical Medicine, 32:15.358 --> 32:18.728 the Liverpool School of Tropical Medicine, 32:18.730 --> 32:23.460 the Royal Society of Tropical Medicine and Hygiene. 32:23.460 --> 32:26.720 And it's embedded in a new major journal, 32:26.723 --> 32:30.893 The Journal of Tropical Medicine and Hygiene, 32:30.886 --> 32:32.516 founded in 1895. 32:32.519 --> 32:35.849 In France, we see the Pasteur Institute; 32:35.848 --> 32:40.408 in the United States, such institutions as Johns 32:40.412 --> 32:44.022 Hopkins, the Rockefeller Institute--and 32:44.021 --> 32:48.261 in particular its International Health Division-- 32:48.259 --> 32:51.099 the American Academy of Tropical Medicine, 32:51.098 --> 32:54.298 the American Society of Tropical Medicine. 32:54.298 --> 32:57.298 And in the U.S., there were a couple of 32:57.301 --> 32:59.121 distinctive features. 32:59.118 --> 33:03.838 One was the association of tropical medicine with the 33:03.842 --> 33:09.022 military, and its leading figures, Walter Reed and William 33:09.018 --> 33:12.558 Gorgas, were in fact Army officers. 33:12.558 --> 33:18.018 And it was in the Western hemisphere too that yellow fever 33:18.021 --> 33:23.581 replaced malaria as the quintessential tropical disease. 33:23.578 --> 33:28.818 Some of the institutional links can be seen in specific cases. 33:28.818 --> 33:32.398 An example that's recently been studied, 33:32.400 --> 33:36.950 somewhat intensively, is the relationship of the 33:36.953 --> 33:42.193 Harvard Department of Tropical Medicine to the colonial 33:42.188 --> 33:46.838 establishment of American power in Liberia, 33:46.838 --> 33:51.308 and in particular the Firestone rubber plantations. 33:51.308 --> 33:56.778 And one can see there the clear role of tropical medicine in 33:56.782 --> 34:01.202 promoting, if we like, the expansion of 34:01.203 --> 34:07.293 company interests to extract resources from Liberia. 34:07.288 --> 34:12.268 This was an important illustration of the uses that 34:12.271 --> 34:15.861 tropical medicine could be put to. 34:15.860 --> 34:20.550 Well, what were some--if that's what tropical medicine was as a 34:20.550 --> 34:22.940 discipline-- what were some of its 34:22.940 --> 34:25.950 implications, the implications of the 34:25.954 --> 34:28.564 worldview that it suggested? 34:28.559 --> 34:36.009 One is that Africa, Asia and Latin America had 34:36.014 --> 34:39.664 something in common. 34:39.659 --> 34:44.009 This was an artificial construction of European 34:44.007 --> 34:45.327 imagination. 34:45.329 --> 34:52.209 They were seen as reservoirs of diseases that threatened Europe; 34:52.210 --> 34:56.820 Europe protected by the ramparts of civilization and 34:56.822 --> 34:58.452 medical science. 34:58.449 --> 35:02.539 So, tropical medicine embodied, down to a later 35:02.538 --> 35:08.048 period--certainly in this period down to the First World War--a 35:08.048 --> 35:10.358 Eurocentric worldview. 35:10.360 --> 35:15.580 It was initially not responsive to specific locations, 35:15.576 --> 35:20.586 as the tropics were artificially constructed as some 35:20.594 --> 35:23.454 single homogeneous place. 35:23.449 --> 35:29.679 The natives of the tropics were also conceptualized as somehow 35:29.681 --> 35:35.101 dangerous, harboring a vast array of lethal and highly 35:35.097 --> 35:37.547 contagious diseases. 35:37.550 --> 35:42.600 Another implication was that tropical medicine was concerned, 35:42.599 --> 35:47.309 in the early decades of the new century, 35:47.309 --> 35:51.899 primarily overwhelmingly, with the help of Europeans-- 35:51.900 --> 35:56.730 settlers, administrators, missionaries and soldiers. 35:56.730 --> 36:00.940 There was little concern for the health of the indigenous 36:00.942 --> 36:01.922 population. 36:01.920 --> 36:06.590 Indeed, the medical problems of the colonial world that received 36:06.585 --> 36:10.285 attention were those that threatened Europeans, 36:10.289 --> 36:14.519 not the health problems of the indigenous population. 36:14.518 --> 36:18.268 There was little attention to the social and economic 36:18.273 --> 36:22.613 determinants of what we might today call Third World problems 36:22.606 --> 36:25.166 of health, such as poverty, 36:25.172 --> 36:28.142 labor conditions, malnutrition. 36:28.139 --> 36:31.869 And there was a neglect of major diseases that were often 36:31.873 --> 36:35.343 the major health problems of the local population; 36:35.340 --> 36:41.920 say dysentery or gonorrhea, pneumonia, tuberculosis. 36:41.920 --> 36:45.220 In recent years, in fact, the blindness of the 36:45.221 --> 36:49.401 past has even resulted in new international attention to a 36:49.402 --> 36:53.612 group of diseases, termed neglected tropical 36:53.610 --> 36:56.850 diseases, that cause large-scale 36:56.853 --> 37:01.303 suffering such as poverty, low productivity, 37:01.300 --> 37:07.900 poor pregnancy outcomes, but that for decades received 37:07.902 --> 37:14.312 little funding or attention from policymakers. 37:14.309 --> 37:16.899 More ironically, a major issue, 37:16.900 --> 37:20.010 not considered after World War I, 37:20.010 --> 37:26.360 as I said, was the impact of colonialism itself on the 37:26.364 --> 37:30.684 inhabitants of the tropical world; 37:30.679 --> 37:35.729 that is, there was no attention to the way in which colonialism 37:35.733 --> 37:39.813 itself contributed to environmental degradation; 37:39.809 --> 37:45.319 or promoted labor mobility in unsanitary conditions; 37:45.320 --> 37:50.790 the way in which it promoted unplanned urbanization, 37:50.791 --> 37:55.191 low educational attainment and poverty. 37:55.190 --> 37:59.540 In fact, this period, the first period of tropical 37:59.543 --> 38:03.213 medicine, from 1890 to just after the 38:03.213 --> 38:07.223 First World War, was a time, one of the times, 38:07.215 --> 38:12.365 of the greatest epidemiological disasters in the tropical world, 38:12.369 --> 38:17.449 with virgin soil epidemics, like smallpox and measles, 38:17.449 --> 38:23.839 and the impact of what was called constructive imperialism. 38:23.840 --> 38:28.050 Railroads, roads, trade, the transportation 38:28.047 --> 38:32.217 revolution, all enabled a pandemic of 38:32.222 --> 38:36.482 bubonic plague, from the 1890s to 1920, 38:36.476 --> 38:40.756 and epidemic influenza, in 1918 and '19, 38:40.764 --> 38:45.054 to occur in the tropical world as well. 38:45.050 --> 38:49.040 Colonial wars, the involvement of the colonies 38:49.043 --> 38:53.573 in the two world wars, had major disease impacts. 38:53.570 --> 38:58.200 So did the ecological impact of railroads, factories, 38:58.199 --> 39:02.829 mines and plantations, and the recruitment of migrant 39:02.829 --> 39:03.719 labor. 39:03.719 --> 39:08.509 So, just as in the case that we examined at greater length in 39:08.507 --> 39:13.057 your reading of North America, disease played an important 39:13.056 --> 39:15.526 part in European expansion. 39:15.530 --> 39:21.380 Another implication was public health policy. 39:21.380 --> 39:27.650 In Europe and North America, hygiene had given rise to a 39:27.652 --> 39:33.632 broad-gauge sanitarian movement; one that reformed urban living 39:33.630 --> 39:36.430 conditions through what we might call-- 39:36.429 --> 39:41.309 and introducing a new jargon into our course-- 39:41.309 --> 39:46.159 horizontal programs of public health; 39:46.159 --> 39:51.219 that is, improvements that dealt with living conditions 39:51.219 --> 39:54.779 across a broad spectrum of diseases. 39:54.780 --> 39:58.890 We've seen that in the sanitary movement. 39:58.889 --> 40:02.959 In the tropics, instead, metropolitan powers 40:02.960 --> 40:07.980 applied a different vision of what was called vertical 40:07.976 --> 40:11.096 hygiene, or tropical hygiene. 40:11.099 --> 40:15.889 Now, vertical campaigns of public health targeted instead 40:15.885 --> 40:18.885 single diseases, and they were designed to 40:18.894 --> 40:23.124 protect, above all, Europeans against the most 40:23.123 --> 40:25.483 menacing epidemics. 40:25.480 --> 40:30.060 That was tropical hygiene, then; something different from what 40:30.061 --> 40:33.161 was practiced at the same time in Europe, was one of the 40:33.159 --> 40:34.059 implications. 40:34.059 --> 40:39.239 Another implication was a new prestige and authority for 40:39.235 --> 40:40.455 physicians. 40:40.460 --> 40:43.210 Ross and Koch, for example, 40:43.213 --> 40:48.193 now became advisors to metropolitan governments, 40:48.193 --> 40:50.103 as did Manson. 40:50.099 --> 40:55.489 It meant also--another implication was perhaps what we 40:55.494 --> 40:59.774 might call selective historical amnesia. 40:59.768 --> 41:06.188 Many of the diseases identified as tropical had only recently 41:06.188 --> 41:10.788 been present in Europe, and they weren't eradicated by 41:10.789 --> 41:13.379 temperature, but by broad social and 41:13.380 --> 41:15.120 economic improvements. 41:15.119 --> 41:19.149 Malaria itself had been a European disease, 41:19.150 --> 41:22.800 as you know, bubonic plague and cholera 41:22.795 --> 41:23.655 also. 41:23.659 --> 41:28.409 And then tropical medicine was clearly an instrument of 41:28.411 --> 41:31.581 cultural and ideological hegemony. 41:31.579 --> 41:36.549 It was a justification and rationale for colonialism. 41:36.550 --> 41:41.090 Europeans felt that they had health and civilization to 41:41.085 --> 41:46.125 offer, and that medicine was a means of winning acceptance of 41:46.126 --> 41:48.306 the colonial presence. 41:48.309 --> 41:53.359 So, tropical medicine provided a narrative of European 41:53.356 --> 41:57.836 progress, rationality and civilization 41:57.842 --> 42:01.902 overcoming ignorance, superstition, 42:01.896 --> 42:05.916 darkness and the witchcraft of natives. 42:05.920 --> 42:10.310 Patrick Manson was very explicit in his vision of the 42:10.311 --> 42:13.521 relationship of medicine and empire. 42:13.518 --> 42:19.048 In a simple sentence he declared, "I believe in the 42:19.050 --> 42:24.280 colonization of the world by the white race." 42:24.280 --> 42:29.960 Well, that was the early period of tropical medicine, 42:29.963 --> 42:32.803 between 1890, more or less, 42:32.804 --> 42:38.384 and just at a period after the First World War. 42:38.380 --> 42:42.540 Later we see a transformation in the discipline. 42:42.539 --> 42:48.449 And I don't want to argue that it's the same today as it was at 42:48.445 --> 42:51.585 the eve of the First World War. 42:51.590 --> 42:57.300 Radical changes in tropical medicine came through a number 42:57.297 --> 42:58.897 of influences. 42:58.900 --> 43:02.280 One was the Second World War itself, 43:02.280 --> 43:07.230 which was in part--and although there were deep contradictions 43:07.228 --> 43:10.378 involved in it-- it was in part, 43:10.376 --> 43:14.306 at least, a war against racialism. 43:14.309 --> 43:20.459 The discipline was affected by decolonization, 43:20.458 --> 43:28.108 also by the rise of American hegemony after World War II, 43:28.110 --> 43:31.390 with new priorities. 43:31.389 --> 43:36.259 It was influenced by globalization as an explicit 43:36.257 --> 43:39.257 idea, and its implications that we 43:39.257 --> 43:42.617 all live in a single disease environment, 43:42.619 --> 43:47.539 and that what happens in distant parts of the world are 43:47.543 --> 43:52.743 also vitally important for the entire world population. 43:52.739 --> 43:57.809 And then there was--what was very important also was a 43:57.809 --> 44:00.489 transformation in funding. 44:00.489 --> 44:06.609 Because of those factors, around and during the 1970s, 44:06.610 --> 44:11.720 The World Health Organization introduced a major new emphasis 44:11.717 --> 44:15.237 on tropical diseases, and with it, 44:15.237 --> 44:20.037 in 1975, a major new research project. 44:20.039 --> 44:25.069 The same happened with the Rockefeller Foundation in the 44:25.067 --> 44:30.457 1970s, and then the MacArthur Foundation thereafterwards. 44:30.460 --> 44:34.820 And this meant a new dynamism scientifically for the 44:34.818 --> 44:41.148 discipline of tropical medicine, and also with that a major 44:41.148 --> 44:45.068 attention, reversing an earlier trend, 44:45.072 --> 44:49.932 with an emphasis on global health programs that would be 44:49.925 --> 44:54.695 applicable everywhere, and that would include major 44:54.702 --> 45:00.202 attention to the health of the population of indigenous peoples 45:00.201 --> 45:05.791 in areas that had been neglected by an earlier phase of tropical 45:05.788 --> 45:07.028 medicine. 45:07.030 --> 45:09.730 And, so, the entire discipline, if we like, 45:09.730 --> 45:12.710 was transformed after World War II, 45:12.710 --> 45:17.390 and became something that no longer embodied a colonial 45:17.389 --> 45:21.359 position, and no longer embodied the idea 45:21.360 --> 45:25.900 that it was the bodies of Europeans that deserved 45:25.900 --> 45:30.110 privileged protection, rather than the health of 45:30.110 --> 45:33.470 indigenous peoples in other parts of the world. 45:33.469 --> 45:38.759 So, tropical medicine was a very important instrument of 45:38.764 --> 45:44.544 colonial power in the period down to the First World War, 45:44.539 --> 45:48.639 and it was slowly transformed in the inter-war period, 45:48.639 --> 45:53.169 and radically so after World War II. 45:53.170 --> 45:58.330 I hope you'll bear that in mind as you think about the issue of 45:58.333 --> 46:02.253 what are the implications of medical science; 46:02.250 --> 46:06.300 and what are its implications for the kinds of society and the 46:06.304 --> 46:07.904 world that we live in? 46:07.900 --> 46:13.000