New Haven, CT, Yale University Press, 1997; 416pp.
University of Manchester
Date accessed: 24 February, 2017
Reflections on the history of medicine in the second half of the twentieth century make much of the discipline's break with its association with the history of science, and the development of the new approaches and interests signalled by the coming of the 'social history of medicine'. How 'new' the social history of medicine actually was is debatable, but there can be no doubting the proliferation of work on topics such as patients, non- orthodox practitioners, madness, and healing and disease outside of Western cultures. Also, previously well-worked seams, such as the development of the medical profession and medical science, have been the subject of new studies and major revisions. A characteristic of much of the new work, following from its attempt to set medicine in its specific social context and its reaction to older universal histories, has been its relatively narrow focus in time and place. There are many recent studies of doctor-patient relations as revealed in casebooks or diaries, of alternative healers in particular towns, of individual asylums, and of health and medicine in specific regions or countries. A popular theme in this vein has been the history of epidemics, which has allowed historians to focus on a particular place and time, and to explore the social context of disease and medicine at a moment of social crisis. In turn, this approach has spawned a relatively new genre of the history of disease, where medical historians consider a disease over a longer period, weaving changes in understanding and management with epidemiological and cultural history. The emphasis in the new social history of medicine has very much been on the 'social' in medicine and how the wider 'society' impacts upon medicine. There have been fewer studies of the 'impact' of medicine on society, except for work around medicalisation and on how changing medical views of the body and disease have interacted with popular and elite beliefs. Particularly thin on the ground have been studies of the impact of medicine on morbidity and mortality, and beyond that investigations into the part played by diseases, or medicine, or both together, in shaping wider historical changes. This situation is in part a reaction to earlier histories of medicine that assumed changes in the medical understanding of disease automatically converted into progressive preventive or therapeutic results. Also influential has been the work of Thomas McKeown on population growth in modern Britain, who is generally read as maintaining that medical intervention had next to no influence on the fall in death rates in industrialised countries until well into the twentieth century. It should not be forgotten either that the deeply contextualised work in the social history of medicine has shown the relationships between disease, medicine and social changes to be very complex, even at the micro-level.
However, the tide is now turning and in the last five years a number of historians have returned to the write 'big picture' histories. Deservedly the best known is Roy Porter's The Greatest Benefit of Mankind (1998), a comprehensive, accessible and authoritative survey of Western medicine from antiquity to the present. Synoptic accounts have been offered in collections in theCambridge and Oxford History series, and by J. N. Hays in The Burdens of Disease: Epidemics and Human Responses in Western History (1998). Thus, in many ways Sheldon Watts's Epidemics and History: Disease, Power and Imperialism is very much of its time, a 'big picture' history of disease focusing on medicine and public health in non-Western countries. It is major work of synthesis that develops in successive chapters histories of plague, leprosy, smallpox, syphilis, cholera, yellow fever and malaria. Overall, the volume is a remarkable achievement and is packed with detail on regions and the epidemics that are not well known to historians of medicine or disease. The author's accounts of disease control measures in Muslim countries is particularly welcome. Epidemics and History is a very ambitious volume, where the main theme is the role of imperialism in creating the conditions in which major epidemics developed, and the weak responses that colonial governments made to these problems. Nothing that I say below should detract from my admiration of Watts's work, but there are issues in his approach that deserve critical comment and the accounts of the various diseases do not always match its ambitions.
Epidemics and Disease is based on assumptions that most social historians of medicine will be uncomfortable with. There are three issues that are particularly troublesome and these can each be linked to one of the themes in the subtitle: Disease, Power and Imperialism. The first is Watts's decidedly presentist approach to medical knowledge and his wish to separate the 'true' character of a disease and 'disease Constructs'. Watts defines the latter as the culturally filtered, false, even delusional, perceptions of diseases that were developed by the agents of imperialism. Watts acknowledges that science and culture are rarely, if ever, distinct realms (p. 122), but continues to work with a clear distinction between 'the real world of objective fact' (p. 139) and culturally mediated perceptions. The objection to this viewpoint is that historians have repeatedly shown that medical knowledge and practice are 'constructed' and are culturally mediated. However, they make this point not in any pejorative sense, but because medicine was and is created by humans from available intellectual and material resources, and validated through practical actions and social interactions. One could also add, of course, that the social and cultural world was and is no less 'real' than the material world and that medical knowledge changes historically; today's hard facts may be tomorrow's errors. As we will see, state-of-the-art medicine on epidemics in the first half of the nineteenth- century was miasmatist and it was the beliefs of contagionists that were said to be 'bogus' and in retreat. Second, Watts tends to overstate the power of Western imperialist countries and their agents, and underplay their lack of knowledge, the resistance they met to their schemes, and that contingent outcomes of many policies and programmes. The notion that public health programmes were driven, across centuries and continents, by an 'Ideology of Order' begs more questions than it answers. The third and related problem is the use of the term 'Development' for the whole of Western contact with other cultures, including colonial imperialism. The objection is not so much to the anachronistic term, but to the simplification of processes and motives that historians of imperialism have always presented as complex and variable.
There are additional problems, many of which stem from the author's ambitious scope. Some chapters are quite rambling and lines of argument remain implicit; thus, narratives often peter out and there are few clearly stated conclusions. All of the important diseases have been covered, and while historical epidemiology is very good, there is no explanation of why particular epidemics and regions have been chosen. Also, there is little sense of epidemics as moments of crisis, hence this volume is really about communicable diseases and history, and in my view rather the better for this.
Watts's narrative begins with the Black Death in 1347, by considering the absence of a public health responses in Europe before 1450, why formal control policies first developed in Italian states after 1450, and concluding with a discussion of the disease in American and British empires after 1850. The importance of religion in initial reactions to the plague is shown well, as are medieval assumptions about disease and its treatment. The account of plague control in fifteen and sixteenth century Europe is very detailed, but jumps from country to country and disappointingly offers no conclusions the patterns and determinants of control measures. Then the story jumps to the Middle East and the fourteenth century and after, with fascinating detail of the evolution of little known medical and disease control practices in Muslim countries. The chapter ends with the story of how, in the early nineteenth century Egypt, Muhammad Ali devised a state apparatus and disease control measures based on quarantines, that, despite the best efforts of the British anti-contagionist to thwart them, helped control the disease when implemented. The implicit argument here is a version of Ackerknecht's linking of disease control strategies to political ideologies. Thus, Muhammad Ali's regime with its 'Ideology of Order', against the advice of its wonderfully named advisor 'Dr Clot, _ a miasma man' (p. 37), favoured contagionism, while the British, committed to laissez faire, opposed such measures.
The chapter on leprosy jumps from the Middle Ages, to fourteenth century leper hunts in Europe, and then to Hawaii and the British colonial Empire in the nineteenth and twentieth centuries. It is with leprosy that the 'Construct' versus 'real' disease theme is most fully developed. Indeed, two Constructs of leprosy are identified: that of the 'leprosy as moral impurity [and] imagined disease', and a second Construct, also around impurity, with the added imperative towards the incarceration of sufferers. Against these two Constructs, Watts sets 'leprosy as Hansen's disease, i.e., clinically true leprosy'. (p. 41) The problem here can be shown by looking briefly at the reception of Hansen's bacillus. In the 1860s and 1870s, up-to-date medical opinion in Britain and its colonies, in line with anti-contagionism, moved towards leprosy being non-contagious and influential reports came out against segregation and isolation. Hansen's bacillus took many years to be accepted, and it was incorporated into a very complex aetiological and pathological picture. Leprosy was not highly contagious, hence the dominant metaphor in medicine for explaining and managing the disease was 'seed and soil': the disease required both the bacillus, in sufficient numbers and suitable virulence, and a vulnerable human constitution, which was dependent on general health, race, behaviour, inherited vulnerability, and many other factors. The Hansen bacillus was not associated with a definitive post-Koch, ontological account of the disease, that in turn defined necessary control measures. Rather, different groups within and without medicine gave it a variety of meanings; for example, some doctors argued for isolation to prevent the spread of the germ, while others maintained that the best way forward was to work for social and sanitary improvements to strengthen the human soil. Both views, and others, were legitimate deductions from available knowledge and debated as such. Which approach won the policy argument depended on a host of factors (power, interests, evidence, etc.) and then actual implementation might be shaped by other factors (economics, politics, logistics, etc.). Seen in this way, the different actions of governments and missionary agencies can be explained not as a conspiracy, but the result of negotiations at all levels. 'Constructs' were as much a part of medical discourse as political ideologies and cultural beliefs, indeed, the notion of separate spheres in unhelpful. Indeed, given the switch back to contagionism at the end of the nineteenth century, the government and missionary doctors who worked most closely with lepers, and had the greatest chance of catching the disease, often had the greatest investment in both of the leprosy Constructs identified.
With smallpox, Watts develops an important revisionist argument on virgin soil epidemics, that is a valuable corrective to recent writing on the subject. It has become commonplace in global histories of disease to explain the high mortalities of indigenous peoples after European arrival to the importation of diseases to which indigenes had no immunity. Thus, we read repeatedly of smallpox, measles, chickenpox, etc. taking a terrible toll, often decimating indigenous populations. The problem with such claims is the extent to which they imply that Europeans had specific inherited or racial immunities to these diseases. The way the human immune system is currently understood to work is that humans are born with no specific immunities, but with a general immune capacity, which allows them to respond to the billions of potential chemical and biological dangers that might enter the body. In this sense, every human is born a virgin soil baby. Specific immunities are acquired from exposure to pathogenic matter from birth onwards, aided initially as Watts points out with maternal antibodies. With some diseases, specific immunities can be 'stored' and give lifelong protection, with other diseases this capacity is relatively weak. Thus, if there was differential immunity between European colonists and indigenes, say, in the American colonies in the sixteenth century, this was due to the prior exposures that Europeans had to pathogens and the extent to which they had acquired immunities. It should not be forgotten either that European children continued to die in large numbers from the very same diseases that were killing indigenes. Also, many indigenes survived imported diseases, not as a result of a Darwinian survival of the fittest, but because time they were able to combat infections and acquire immunity. In this context, it is worth stating that many factors led to the high death rates amongst indigenes, such as, social dislocation, displacement, loss of lands, starvation, direct killing and diseases. All of this better informs the central paradox of the story for Watts, namely, that the conditions that led to the poor health of indigenes had been created by European imperialism, yet, the dominant assumption in European medical and lay beliefs was this that it was due to other factors, their racial weaknesses, cultural backwardness, ignorance and immorality.
The chapter on syphilis covers the debate on its supposed importation from the New World, how its incidence was affected by changes in social relations and urbanisation in Europe, anti-masturbation in the eighteenth century, the controversies over the regulation of prostitution, and the disease in China. It is in this chapter that the Construct - Reality distinction leads Watts to claim to be less historical than Foucault!
But in my hands, unlike those of Foucault, the word
"knowledge" is usually synonymous with false
knowledge of "the earth flat" variety. Sometimes,
when drawn from the fount of ancient wisdom (Plato,
Aristotle, Galen), this false, flat-earth knowledge
was well-intentioned ignorance. On other occasions
it was an act of duplicity deliberately practised to
reinforce authority. (p. 124)
Fortunately, such assumptions only intrude now and again into the main narrative of the chapter, as the author continues to his usual synthetic aplomb.
The final chapters are the best in the volume, being more focused and set in specific imperial contexts. Cholera and Civilization: Great Britain and India, 1817 to 1920 tells the story of cholera in India before and after the Rebellion on 1857 and links this with the experience of the disease in the metropole. However, much of this chapter is concerned with the social and economic history of each country, which unfortunately are only erratically linked to specific epidemics and their management. For example, when discussing the disease in India after the Rebellion, Watts details deteriorating social conditions and other changes that made the spread of cholera much easier, but these are not linked to specific cholera outbreaks or new issues such as pilgrimages. My reading is that the reluctance of the Anglo-Indian medical community to accept Koch's cholera vibrio was well-grounded in the 'facts' and that the choices between different sanitary policies were openly debated.
The discussion of yellow fever and malaria in chapter 6 is very detailed, and prefaced by an interesting account of the modern understanding of the aetiology and pathology of both diseases. This information is very useful in the reconstruction of the epidemiology of both diseases, though there must always be doubts about whether seventeenth century 'Yellow Jack' equates exactly with the modern disease. The juxtaposition of the discussion of both diseases in Barbados, Haiti, the United States, Brazil and Cuba is fascinating and brings together well recent work by Margaret Humphrys, Ilana Lowy, Marcos Cueto and many others. What these show, of course, is that the nature of the disease underdetermined human responses, and that public health policies were highly politicised. Indeed, political problems increased after the achievements of Carlos Finlay, Walter Reed, and William Gorgas massively raised expectations in colonies and the metropolis over what tropical medicine could achieve. In discussing tropical medicine in West Africa, Watts rightly points to the role that medical advice played in the establishment of residential segregation, though fear of malaria was not the only factor. Moreover, it is ahistorical to suggest this advice was based on 'bogus science' (p. 261-2) as John Cell has shown it reflected one reading of the contemporary understanding of the aetiology of malaria and was never exclusive, but linked with other measures as quinine prophylaxis, netting, screening houses and drainage.
The 'Afterword' is exactly what it says it is and not the concluding discussion I had hoped for. However, implicit in the 'Afterword' are the two main themes of the book: (i) that Western colonial imperialism created or has worsened many of the disease problems of the what is now the Third World; and (ii) that the disease control measures deployed directly or indirectly by Western agencies to meet these problems have in many instances been inappropriate. Few historians of Empire or medicine would disagree with either claim, though they would want add many qualifications and make the points in a less judgmental way. First, ideas and policies are only obviously 'inappropriate' with hindsight and from particular viewpoints; when introduced they were based on the best knowledge available, not 'pseudoscience' or 'bogus science'. Second, public health policies were developed in terms of judgements of what would 'work' and be 'appropriate' to political, economic or social objectives at the time. Thus, it is hardly surprising that late nineteenth century doctors, convinced of the superiority of white European civilisation and in West Africa to support the development of an export economy, developed the disease control policies they did. It is too easy and inappropriate to ridicule individuals and the agencies they worked for, the point for historians is to understand their circumstances and what made their choices 'appropriate'. It is perhaps worth emphasising that there were choices. Western medicine had within it many competing and changing ideas, which were given many different meanings, and could in turn be used to support distinct programmes and policy objectives. For example, from the 1900s it has been understood that malaria control could concentrate on attacking the parasite in humans, trying to kill mosquito vectors, breaking mosquito-human contact by anything from netting for individuals to resettling peoples, removing the environments where mosquitoes breed and live, or improving general levels of health, sanitation, diet and well-being. Also, what was 'appropriate' also varied, not just between colonisers and colonised, but between centre and periphery, government and private ventures, between different private ventures, between missionaries and governments, and between experts. Which returns me nicely to my initial points about the complexity of the histories of disease, power and imperialism.
My thanks to Michael Worboys for the good things he has to say about Epidemics and History: Disease, Power and Imperialism in paragraph two of his long review: "Overall the volume is a remarkable achievement" etc. However the comments he makes in paragraph one and from paragraphs three to eleven invite a response. I am framing this response in a way which I hope will help inform the historical profession as a whole about recent developments in cultural-medical history.
As is well known, the first major contribution to the history of disease written by a non-medical person was William McNeill's Plagues and Peoples, published in 1976. Although mildly Eurocentric (as most historical studies published in Europe and America were back then), Plagues and Peoples was a major advance on the self- congratulatory, well-intentioned antiquarian studies written by retired medical doctors before 1976. It was studies of the latter sort, rather than studies in the history of science (as Worboys claims), from which historians had to break free before an independent sub-discipline, known as the history of medicine, could take off and be recognized by the historical profession as intellectually respectable.
In his review, Worboys said that "Epidemics and Disease [sic] is based on assumptions which most social historians of medicine will be uncomfortable with." (my emp. his para 3). Indeed yes, with the passage of time the discipline of history moves on and develops new forms. I should point out here that back in the early 1980s when social history seemed to be at the cutting edge of the discipline, I wrote a Social History of Western Europe 1450-1720 from a West African perspective. The book went into a second printing and a Swedish (!) translation, and so was reasonably successful. However all that was more than fifteen years ago. As far as I can tell from reading the principal historical journals and the Times Literary Supplement, new style "cultural history" buttressed by insights from anthropology and comparative literature (following Edward Said) is now one of the most innovative and exciting forms of written history. Even though some journals still include the term "social history" in their title, social history as originally conceived of by late lamented masters (such as E. P. Thompson), has grown rather long in the teeth and has had nothing much new to say for some time. This being the case it is rather amusing to see Worboys (a self-professed practitioner of the social history of medicine) jumping to the defense (if that is what he is doing) of the post-modernist hero, M. Foucault ( his para. 8).
Worboys (para. 3) is troubled by my use of "disease constructs", a conceptual tool which my unconscious mind probably picked up from my readings in historical anthropology and comparative literature. Worboys claims that that I define "disease constructs" as "the culturally filtered, false, even delusional, perceptions of disease that were developed by the agents of imperialism." I confess that a disease construct is "culturally filtered", but I fear that the rest of Worboys' definition of Watts-style disease constructs is his own invention. It must be stressed that each Watts-style construct is disease specific, and specific in time and place. I first use this conceptual tool in my discussion of "leprosy" in medieval Western Europe. In this context, only by the wildest stretch of imagination can one talk about the use of perceptions of disease by "agents of Imperialism" as those last three words are commonly understood today. In short, I fail to comprehend Worboys' definition of a Watts' disease construct.
Worboys goes on to say (para. three) that Watts "continues to work a clear distinction between `the real world of objective fact (p.139) and culturally mediated perceptions.'" I have read and re-read my page 139, but have failed to locate the accusatory phrase "the real world of objective fact" anywhere on that page. Where I do use the phrase (my page 124) the full sentence reads: "In the real world of objective fact, the sexual authoritarianism that began to flower in the mid-eighteenth century (greatly assisted by the anti-masturbation scare) led in the next century to the near demise of literature about actual human reproductive processes." This sentence clearly has nothing to do with the reality or non-reality of any particular disease. It is interesting to note here that in his magisterial study of contagion, Peter Baldwin specifically quotes my conclusion about the 18th century medicalized fear of masturbation which, together with other factors, "combined to render prostitution one of the few traversable avenues of male sexual release." [Peter Baldwin, Contagion and the State in Europe, 1830-1930 (Cambridge U. P. 1999), 424].
Worboys claims ( para. 3) that I have "a decidedly presentist approach to medical knowledge." This allegation presumably relates to my decision, when writing the book, to establish the nature of the specific disease/diseases each chapter is about. Thus in Chapter 6, when writing about yellow fever and malaria, I discuss the understandings of those diseases set forth by medical scientists at the Cairo Conference on Tropical Medicine held in 1928. Nineteen-twenty-eight is some 69 years before Epidemics and History went to press (i.e. hardly "the present"). Similarly, in Chapter 2, Leprosy, I give extensive coverage to medical doctors' ideas about the disease in the 1890s and 1920s. Perhaps by "presentist approach" Worboys means anything which discusses the germ theory established by Pasteur and Koch more than a century ago? Ian Hocking, writing in general terms about differences between scientists and social constructionists (The Social Construction of What?, Harvard U. P., 1999) stresses the remarkable stability of scientific knowledge since the time of Newton. In a cultural-medical history of the epidemic diseases I deal with, I assume it is legitimate to posit a somewhat similar stability of knowledge since the time of Koch. To label this assumption "presentist' is to assign medical history to the tender mercies of the antiquarians, a position from which some of us (including Michael Worboys in his substantial essays -my page 384) have long been struggling to rescue the sub-discipline.
Worboys (para 3) is also troubled by my use of the trendy terms "power", "imperialism" and "Development". In the recently published issue of Past & Present no. 165 (Nov. 1999), the great medievalist, Richard Southern, is quoted (page 221) as saying that an essential requirement for the writing of history "is experience of menthe third quality is compassion for the sufferings, ambitions and delusions of both the oppressed and the oppressors." Worboys is, I understand, a long-term denizen of a north of England university, whereas I have spent seventeen of the last twenty years living in the Non-West (in Nigeria and in Egypt). As an historian, I am by definition interested in sorting out possible connections between the past actions of colonial masters and the actions of successor indigenous regimes which, very often, are largely staffed by descendants of earlier collaborators with the white invaders. In short, I am interested in the consequences of past actions. Worboys (in his north of England university) does not seem to realize the extent of the cultural impact (to say nothing of the disease impact on non-immunes) which even a few well-armed colonialists could make on an indigenous culture. May I recommend that in the absence of lived experience, he read some of the recently published accounts of the Harrowing of the North of England by William the Conqueror and his handful of followers? Here certainly is an example of how the few completely transformed the lives of the many.
Worboys (para 3) is also troubled by my use of the concept "Ideology of Order" which I apply solely to my discussions of bubonic plague. Peter Baldwin clearly understands what I mean when he states: "Watts calls the quarantinist policies first elaborated in Italy against the plague the 'Ideology of Order', an authoritarian set of interventions that disrupted the everyday lives of citizens." (Baldwin, Contagion, 30). Worboys thus seems to have lost the thread of the argument when writing: "The notion that public health programmes were driven, across centuries and continents, by an 'Ideology of Order" begs more questions than it answers." True enough, but the "notion" is Worboys' own creation not mine.
Similarly. I find it difficult to believe that Worboys read my chapter on leprosy with any understanding. When discussing the European Middle Ages, my thesis was that many (perhaps most) alleged lepers were in fact normally put-together people, people who did not have the shriveled hands and feet nowadays associated with a proper leper. However these "lepers" happened to have enemies who found it was possible to get rid of them by having them committed to a leprosarium. Thus, Worboys' long discussion about Hansen's bacillus is entirely irrelevant to my discussion of medieval leprosy. As I go on to show in the second part of that chapter, in the late 19th century, the leprosy paradigm which was cobbled together by curious readings of medieval evidence was selectively used by some imperial regimes in some places, but not in others. To expect to find a clear pattern in such matters is to ignore modern understandings of history which see it as a formless mixture of contingencies, accidents, inconsistencies etc.
At this point it would be appropriate for me to point out that a good half of each chapter in Epidemics and History is NOT about European colonial impacts on the Non-West but instead is about one or other European society and the differing perceptions of each particular disease by those who ruled and those who were ruled. This is not apparent from Worboys' review (para. 2). Indeed some of Worboys' phrases lead me to wonder if he was reviewing two or three books at the same time and got mixed up about which author said what. Thus in his comments on my chapter on bubonic plague (para. 5) he says that I conclude "with a discussion of the disease in American and British empires after 1850." In fact, the second half of the chapter deals with Egypt under the Mamluks, the Ottomans and Muhammad Ali, ending in 1844. Egypt was not part of the British or the American empires at that time: the British shelling of Alexandria and conquest of Egypt did not take place until 1882.
Still on the topic of the bubonic plague, Worboys takes me to task for not coming to definite conclusions about "the patterns and determinants of control measures" and for not coming to definite conclusions about how they fit into E. Ackerknecht's typologies (formulated in the l940s). On these particular issues Worboys should turn to Peter Baldwin's 580 page book on contagion. There he will find that although Baldwin specifically set himself the task of testing Ackerknecht's typologies, in the end he found he could not come up with definitive answers about whether they were appropriate or not.
In his discussion of my readings of cholera, and of yellow fever and malaria, and my Afterword, Worboys fails to understand the extent to which colonial medical doctors and medical scientists were not free agents. Instead they were pawns in the great game of power politics being played out by the ruling elites in the metropole. In the case of cholera and quarantine policies in India, and the sea lanes leading from India to West Europe, further research in the recently re-opened India Office (at the British Library) has convincingly shown that as of 1867, when dealing with an outbreak of cholera among 3 million pilgrims at the Hardwar Fair, the officiating sanitary officer with the government of India, James McNabb Cuningham, zealously established cordons and emergency isolation hospitals to block the movement of pilgrims, who he suspected of harboring the disease in their guts, from the great cities of the North. Then in mid-1868, on the eve of the opening of the Suez Canal, Cuningham was persuaded by those in Authority in London to adopt a new cholera ideology which was l80 degrees at variance with policies he himself had used in 1867. This radical alteration in policy and ideology (cholera now seen as a locally generated disease, not brought in by human intercourse, hence there was no need for the quarantine of shipping from Bombay) was a political decision, based on commercial considerations, which had nothing to do with the medical finding of north German or pre-1869 British scientists (my paper on this forthcoming) . And as for S. R. Christophers (para. 10) and his call for segregation in West Africa based on his claim that black African children harbored the malaria parasite but that white children and white adults did not harbor the disease, in Epidemics and History (p.263) I point out that that Christophers' own contemporary, Dr. William MacGregor, Governor of Lagos, publicly and repeatedly stated that the rapid expansion of malaria-blighted regions was not due to racial characteristics of blacks, but was instead largely due to the behavioural patterns and Development policies of white invaders-such as himself. MacGregor's statements did not go down well with Authority back home in England who saw to it that he was transferred to Newfoundland-where there was no malaria. But Authority saw to it that Christophers, the Social Darwinist, was sent to India where in one capacity or another he remained in charge of the investment-friendly British malaria programme until 1932. [for an update, see my paper in Past & Present no. 165 (Nov. 1999), 141-181].
Worboys (para 3) sees my use of the word "Development" as "anachronistic". He obviously did not understand why I always used the capital letter "D" and why I defined my understanding of this conceptual tool at the first possible opportunity (my pp. xiii-xiv). In common with Peter Baldwin (who in Contagion coined quite a few words I had not seen used before), I accept that English (on both sides of the Atlantic) is a living language, rather than a fossil preserved by some learned Academy. My use of the capital "D" was a signal that I was using the word Development in a special way. Taking the broad view appropriate to what Worboys terms "big-picture" history, I---as a denizen of a still imperialized Non-Western country----fail to see any essential difference between the Development processes Columbus and Co. had in mind (golden treasure to pay for the liberation of Jerusalem, slaves to work European-owned primary product plantations, personal wealth, and personal status enhancement) and the processes put in motion in the long-19th century Age of European Imperialism, and the processes being managed by the agencies of Globalization today-the multi-nationals, the World Trade Organization, the I.M.F, the World Bank. In all instances, wealth, power, longevity and glory ended up in the possession of the few.