Int. J. Middle East Stud. 44 (2012), 799807 doi:10.

1017/S0020743812000931

R E V I E W A RT I C L E Nancy Gallagher

MEDICINE AND MODERNITY IN THE MIDDLE EAST A N D N O RT H A F R I C A

HIBBA ABUGIDEIRI, Gender and the Making of Modern Medicine in Colonial Egypt (Burlington, Vt.: Ashgate Publishing Company, 2011) NARIN HASSAN, Diagnosing Empire: Women, Medical Knowledge, and Colonial Mobility (Burlington, Vt.: Ashgate Publishing Company, 2011) RICHARD KELLER, Colonial Madness: Psychiatry in French North Africa (Chicago: The University of Chicago Press, 2007) ANNE MARIE MOULIN and YESIM ISIL ULMAN, eds., Perilous Modernity: History of Medicine in the Ottoman Empire and the Middle East from the 19th Century Onwards (Istanbul: Isis Press, 2010) MIRI SHEFER-MOSSENSOHN, Ottoman Medicine: Healing and Medical Institutions (Albany, N.Y.: State University of New York Press, 2010) SANDRA SUFIAN, Healing the Land and the Nation: Malaria and the Zionist Project in Palestine, 19201947 (Chicago: University of Chicago Press, 2007)

In recent decades historians specializing in the Middle East and North Africa have studied endemic and epidemic diseases as well as evolving medical and public health knowledge and policy to better understand major historical transformations. The study of gender and empire, class and ethnicity, and civil society and government in the determination of medical and public health policy has yielded new insights into questions of state power, colonialism, imperialism, nationalism, modernity, and globalization. Historians have asked why, when, and how Western medicine took root in Muslim societies, which had their own complex and longstanding medical traditions. In the early modern era, new understandings of scientific knowledge led to the systematic study of natural phenomena and to new ideas about disease control. Colonial or tropical medicine aimed to advance the study of diseases unknown in the West and their prevention and cure. In Muslim majority societies, Galenic-Islamic, prophetic, and customary medical systems competed with and sometimes complemented new medical knowledge and practice. Colonial authorities and local rulers feared endemic and especially epidemic diseases that could depopulate whole regions, leading to a decline in

Nancy Gallagher is a Professor in the Department of History at the University of California, Santa Barbara, Santa Barbara, Calif.; e-mail: gallagher@history.ucsb.edu Cambridge University Press 2012 0020-7438/12 $15.00

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the number of laborers and therefore revenue. For this reason, they actively sought new preventative and curative medical interventions. Advocates of empire often justified their imperial ventures by arguing that Western medical intervention improved the health of the colonized. During the imperialist era of direct colonization, medicine became a tool of empire that facilitated the penetration of local societies. Over time, Western-trained medical practitioners, indigenous or foreign, gained moral authority over indigenous bodies, which now were controlled and regulated by state public health policy. Doctors and police enforced new laws that regulated womens reproductive capabilities, soldiers bodies, the vaccination of children, and the incarceration of the physically and mentally ill. The books under review illustrate these trends in the social history of medicine and suggest new directions for further research. I review the books chronologically by historical period.1 The first book, on Ottoman medicine from 1500 to 1700, sets the stage for the encounter with Western medicine. The second, an edited volume, addresses complex and often elusive questions of modernity in the Ottoman Empire and the Middle East. The third and fourth books take up questions of gender, empire, and nationalism in medical reform in Egypt, Syria, and India. The final two books discuss the politics of malaria eradication in British Mandate Palestine and the treatment of mental illness in colonial North Africa. Ottoman Medicine: Healing and Medical Institutions, by Miri Shefer-Mossensohn, contains four well-researched chapters on preventative and curative medicine, health and illness, medical charity, and medical institutions. Her sources are the records of the ruling elite in the three Ottoman capitals of Bursa, Edirne, and Istanbul: waqf endowment documents, annual reports of waqf foundations, firmans, medical treatises, travel accounts, . abaq t (biographies), and miniatures illustrating medical scenes. She t a explains that the Ottoman Empire was comprised of diverse cultures with medical systems that both complemented and competed with one another. Medical practices varied from region to region and were predictably more elaborate for the wealthy than for the poor. As elsewhere in the Middle East and Europe, humorism (the Hippocratic theory that a persons temperament and health are influenced by an excess or deficit of four bodily fluids: black bile, yellow bile, phlegm, and blood) underlay medical understanding. To restore the humoral balance and bring the patient back to good health, the author explains, Ottoman physicians generally began with dietary adjustments followed, if necessary, by medication. Surgery was high risk and only a last resort. Religious or prophetic medicine was based on hadith and was widely practiced among all classes. Customary or popular medicine, unlike humoral and prophetic medicine, did not derive from a written tradition; it was much used among the non-elite because it entailed inexpensive home-based remedies rather than compound medicines and other interventions prescribed for the elite. The three systems were often used simultaneously; physicians and patients alike were willing to try humoral medicine, religious medicine, and customary medicine in hopes that something would prove effective. For the Ottomans, Shefer-Mossensohn informs us, human beings were at the center of the universe and custodians of the natural world. They should both use and maintain the world that God created and aspire to maintain all forcesphysical, material, spiritual, and divinein a cosmic balance. The Ottomans were great sponsors of medical aid and other forms of charity. Assisting the sick was a religious duty incurring the gratitude

Medicine and Modernity in the Middle East and North Africa 801 and obligation of the recipients and thus in turn helped reinforce existing hierarchies as well as social harmony. Ottoman authorities preferred to found hospitals and other institutions of public welfare in the centers of major cities, where populations were dense and the need was concentrated. The facilities in Istanbul were especially large and well designed, with tranquil gardens and spectacular views. The author explains that medical and food aid were generally dispensed on the bases of social standing and vocation. Travelers without family nearby might seek care in hospitals, which perhaps in part explains why most patients, according to the existing hospital records, were Muslim men. There was, however, at least one hospital, located in Cairo, exclusively for women. Women closest to the sultan were greatly restricted in medical care; the male physician was not allowed to speak with them or to examine them directly, and surgeons were not allowed to treat them at all. Woman medical healers, however, were able to serve the women of the palace. Shefer-Mossensohn cautions that the Ottoman concept of balance should not be confused with the Western concept of holistic medicine. For Ottoman healers, the human body must be understood as existing in both a physical and a spiritual environment. Physical health and mental health were closely related: when one was out of balance, the other would be as well. Physicians therefore tried to bring the patient back to balance by considering external and internal elements. Music was considered a particularly effective treatment: hospitals sometimes had a pavilion where musicians could serenade patients with music selected for their particular medical conditions. Water was also viewed to be therapeutic, and most hospitals contained a hammam, or bath, where the patients humoral balance could be restored. A wide variety of foods and amulets were also used for preventive and curative purposes. Ottoman authorities were not in agreement about the existence of contagion. They built hospitals near mosques, which might afford protection against miasmas, but generally did not isolate the physically or mentally ill from the healthy, with the exception of lepers. The wealthy often fled plague-sicken areas, but most stayed put and trusted in providence. In the introduction, the author tells us that she chose to focus on the period from 1500 to 1700 because it covered the transition from medieval Ottoman to modern medicine. At the beginning of the era, hospitals were typically part of larger complexes (k lliye) u that were endowed by Ottoman elites and included mosques, soup kitchens, and other benevolent institutions. At the end of the era, new hospitals were modern stand-alone facilities with larger and more specialized medical personnel. The author tells us that the empire was very diverse, as were its medical systems, but generally treats Ottoman medicine as a single system. We do not learn about Greek Orthodox, Coptic, Armenian, or Jewish medical traditions, though they may have been of great importance in some areas. Were there other religious medical traditions similar to Prophetic medicine? She also states that medicine was to be a prism through which she would reconstruct social and cultural realities. Although we learn a great deal about Ottoman medicine and health, we do not get a sense of the wider social and cultural realities or how they changed over time. In her conclusion, Shefer-Mossensohn states that Ottoman medicine was distinct from Galenic-Islamic medicine in general because scholars wrote in Ottoman Turkish rather than Arabic and because hospitals took on the characteristics of the Ottoman bureaucracy and hierarchy. She then asks if Ottoman medicine was successful. She

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argues that the Ottomans took preventive medicine very seriously and that it was very effective. This might be a topic for future research. When illness did occur, the sick believed in the ability of physicians and their medicines to heal them but realized that medical treatments often failed. Physicians were paid less than religious scholars in medreses; many physicians were from Jewish, Greek, Armenian, or other minority communities, perhaps, she suggests, because of the relatively low status of the profession. This explanation seems contradictory, however, because the author has already told us earlier in the book that physicians were held in high esteem; perhaps the physicians social standing varied by time and place. In her final comment, she observes that Ottomans accepted illness and death as part of the life cycle; physicians and medicine were not expected to cure all but rather to do no harm. Again, this seems to contradict the authors earlier statements about popular views of medical efficacy. Ottoman Medicine is a well-written and richly detailed monograph that will become a standard source for specialists in Ottoman and medical history. It is the first social history of Ottoman medicine in English and is written in a delightfully accessible style. As the author states, it is not the final word on Ottoman medicine and society but rather brings together in one compact monograph much information that points the way to further research. Anne Marie Moulin and Yesim Isl Ulman ambitiously title their edited volume Perilous Modernity: The History of Medicine in the Ottoman Empire and the Middle East from the 19th Century Onwards. It is based on the proceedings of a conference held in Istanbul (no date given). In their introduction, The Particular Place of Medicine in the Debate on Modernity and Modernization in the Middle East in the 19th and the 20th Centuries, Moulin and Ulman lay out the central arguments of the collection: that the history of medicine, more than that of other fields of knowledge, enables historians to challenge the notion of an unbridgeable divide between East and West; that modernization is ongoing; and that modernity is a permanent quest for solving the global issues of science, society, and power (p. 21). The volumes articles, which are for the most part original and interesting, tend to be short research papers in English or French that make tentative suggestions for further research, the sorts of papers given at conferences for comment and scholarly exchange. We get titles such as Some Methodological Issues Concerning the Sciences at the European Periphery, Some Preliminary Thoughts about the Tanzimat and the Idea of Nature, and so forth. Despite the title of the book, not all the articles focus on medicine; I will focus on those dealing with medical history, the topic of this review essay. Mhamed Oualdi, in his article, Du hakim ren gat au e praticien europ en: Mutations didentit des m decins de cour et modernization du e e e service rendu aux beys de Tunis, du milieu du XVIIe si` cle au milieu de XIXe si` cle, e e shows that the status of Italian and French doctors who practiced medicine at the court of the Regency of Tunis improved over time. In the 17th century, European physicians in Tunis would have been expected to convert to Islam, but by the mid-19th century this was no longer the case. Rather, they were becoming more independent and gaining in status. When the bey had a European physician thrown into prison and bastinadoed in the early 19th century for announcing an outbreak of plague, public opinion roundly opposed the punishment. In Glimpses of Relationships between Hospital, State, and Medicine in NineteenthCentury Iran, Hormoz Ebrahimnejad considers the meaning of modernization in the

Medicine and Modernity in the Middle East and North Africa 803 history of medicine in Islamic countries. In Iran, reformers attempted to modernize medicine by adapting old institutions to new conditions. In medieval times, medical study took place in madrasas rather than hospitals. On the basis of an anonymous manuscript written in the 1860s that advocated clinical examination and twenty-fourhour on-duty doctors at hospitals, Ebrahimnejad asks why such reforms happened in the 19th century. He suggests that the reason was the centralization of power and the accompanying expansion of the militaryin short, the advent of the modern nation state. In Medical Modernization in [the] 19th Century Ottoman Empire with Special Reference to the Introduction of Roentgen Rays in Turkey, Yesim Isl Ulman discusses the introduction of x-ray technology into Ottoman medicine by young physicians who had studied foreign medicine. Nuran Yildirim, in Les mesures de quarantaine prises e pendant les epid mies de chol ra et leurs r percussions sur la soci t ottoman (1831 e e ee 1918), explores efforts by Ottoman authorities to control cholera. In Les quarantaines au Moyen-Orient: Vecteurs ambigus de la modernit m dicale (XIXeXXe si` cle), e e e Sylvia Chiffoleau shows the extent to which Ottoman quarantines and lazarettos were onerous and porous. Anne Marie Moulin, in Changeante modernit : L tat egyptien e e et la modernization de la sant publique (19e20e si` cles), looks at the modernization e e of public health in 19th-century Egypt and asks about the nature of modernity, again highlighting the stated theme of the volume. Nadav Davidovitch and Zalman Greenberg, in Smallpox and Variolation in a Village in Palestine in December 1921: A Case Study of Public Health, Culture, and Colonial Medicine, utilize a trove of documents and photos to show how villagers in Dawaimeh, near Hebron, reacted when British Mandate authorities attempted to forcibly vaccinate them against smallpox, which had broken out in the village. The inhabitants, who were used to variolization (inoculation with a small amount of smallpox variola to minimize the severity of the disease or to induce immunity to it) and did not trust the methods or the intentions of the British authorities, made frantic efforts to hide their children, even in caves. In Sorrow and Illness: Modern Expression of Death in Ottoman Muslim Epitaphs of the 19th Century, Edhem Eldhem finds that Ottomans more easily expressed their individual sentiments in Ottoman Muslim epitaphs as modernity freed them from the restraints and controls imposed by the Islamic tradition (p. 206). Finally, Claire Beaudevin, in Une m decine moderne coup e du pass : e e e Lexemple de l chographie obst ricale au sultanat dOman, explores the introduction e e of ultrasound and evolving concepts of the fetus in contemporary Oman. The volume is in serious need of editing. The arguments in the introduction, in particular, are often obfuscated by syntactical problems. The publisher should have asked a good editor to go over the manuscript before it appeared in print. And a conclusion summarizing the authors views on medicine and modernity would have been helpful. Still, the articles demonstrate the often novel and imaginative new research currently being undertaken in the social history of medicine in the Ottoman Empire and the Middle East. Narin Hassan, in Diagnosing Empire: Women, Medical Knowledge, and Colonial Mobility, states that the goal of her book is to use medical history to study developments such as the rise of domestic management, emerging notions of sanitation and cleanliness, progress, and the growth of textual and scientific knowledge as crucial to notions of modernity (p. 18). She focuses mostly on Victorian-era British women travelers to

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Syria, Egypt, and India but begins with Lady Wortley Montagus account of her stay in Istanbul from 1716 to 1718. In Istanbul, Montagu, as wife of the British ambassador, was invited into elite Ottoman womens homes and was much impressed by their hospitality and customs. She learned of the practice of variolization and had her son inoculated. She herself had survived the disease in London and when she returned home introduced variolization to her circles. Her account of her trip greatly influenced later British women travelers who also sought access to local womens private lives, Hassan explains that in the 19th century, British women travelers to the Middle East and India often learned to treat themselves and their families with medicines they had brought with them. A few then began to treat local women and their families, thereby gaining unprecedented access to local domestic life and a higher status than was possible at home. Some of these women, who were not medically trained at all, called themselves doctresses to enhance their medical authority. In Egypt, Lady Lucy Duff-Gordon, wife of Alexander Duff-Gordon, a well-known British civil servant and baronet, established herself as a great healer of rural inhabitants and later happily worked under the direction of a European-trained Egyptian physician. She adapted to Egyptian culture, was befriended by a local Egyptian family, and elected to spend the remainder of her life in Egypt. Isabel Burton, wife of Richard Burton, was an untrained medical healer who treated twenty to fifty patients a day in Syria for simple ailments. In India, British women doctors, mostly trained in medical schools at home, gained professional experience and built relationships with local women, some of whom were also educated in Western medical schools. British, Middle Eastern, and Indian women doctors became advocates of reforms such as the expansion of female education, new medical and public health systems, and restrictions on child and forced marriages. They were also, according to Hassan, agents of empire, whose access to private families enabled them to present a positive image of imperial power and serve as useful mediators. Memoirs of these women were wildly popular in Victorian England, and British novels glorified the British women doctors who treated natives and found adventure and romance abroad. A number of Middle Eastern and Indian women doctors trained in Western medicine also wrote memoirs; Hassan briefly mentions several in an epilogue. Again, this might be a topic for another study. Hibba Abugideiri begins her book, Gender and the Making of Modern Medicine in Colonial Egypt, by explaining that British reformers in late 19th-century Egypt brought the school for women medical practitioners (hakm ), founded by Muhammad Ali . a in 1832, under the authority of the all-male Qasr al- Aini medical school, founded by Muhammad Ali in 1827. The new British-appointed all-male faculty taught male students the practice of medicine. The male faculty also presided over an all-woman faculty that trained the female students in the practice of midwifery and nursing only. British authorities appointed British physicians and administrators to the highest positions, while Egyptian physicians remained at the lower ranks; many of the Egyptian physicians became active in the nationalist movement. As Abugideiri comments, after nominal independence was won in 1923, Egyptian physicians formed the Egyptian Medical Association and, following both colonial and patriarchal patterns, reserved the most lucrative fields for themselves, consigning Egyptian women medical workers to remain at the lowest levels. Egyptian physicians advocated training women to manage their homes scientifically, arguing that women should learn modern ideas of hygiene in order

Medicine and Modernity in the Middle East and North Africa 805 to raise healthy children. Doctors exhorted women, especially those who were pregnant or nursing, to eat healthfully and exercise daily. They came to consider themselves as the scientifically educated guardians of womens health, reproduction, and sexuality and accordingly the defenders of Egypts moral identity. Both Hassan and Abugideiri are much influenced by historians of gender and empire such as Fred Cooper, Ann McClintock, Mary Louise Pratt, and Ann Stoler. Sandra M. Sufian, in Healing the Land and the Nation: Malaria and the Zionist Project in Palestine, 19201947, explains that during the British Mandate era in Palestine, Zionist physicians and engineers believed themselves to be rescuing the land of Palestine from disease. Their efforts would save Jews from the unhealthy ghettos of Europe and bring them to Palestine, where they would build healthy bodies by farming the newly reclaimed land. Sufian tells us that because they thought diseases from the natives might be dangerous, Zionist leaders encouraged mandate authorities to enact public health policies that would remove natives from the land and separate them from the Zionist settlers. In the view of the Zionists, the indigenous population was backward, unproductive, and without real attachment to the land. Sufian relates that the Zionist colonizers considered malaria, which was prevalent in parts of the country, to be caused by neglectful agrarian practices of the indigenous population, whose watering holes and leaky irrigation ditches made ideal places for mosquitoes to breed, rather than by a natural environmental problem. The Zionists called for the removal of the Palestinian Arab peasants from the land that they had long used for pasture and to which under Ottoman law they held traditional grazing rights. The Zionist leadership then claimed that because they had drained the swamps and pools to eradicate the mosquitoes and thereby redeemed the land, they were entitled to replace the Palestinian Arabs with Zionist immigrants. Palestinian Arabs, with their own sense of national identity and well aware of Zionist intentions, tried to counter Zionist claims that they were backward or that they neglected their land. Among them, according to Sufian, was Dr. Tawfiq Canaan, a Palestinian Arab who was a prominent physician before and during the Mandate era and who lectured about malaria in German and English to scientific audiences. In a report to the Mandatory authorities, Canaan stated that Palestinian Arabs carried out their own swamp-drainage projects and worked as laborers in government malaria-control projects. Palestinian Arab landowners distributed quinine to their workers and supervised the drainage projects. They were, Canaan argues, quite able to take care of their land and their communities according to modern public health guidelines. When Zionist authorities claimed that their own efforts had improved the health of Palestinian Arabs, Canaan countered that the health of Arabs had begun to improve well before the Zionist projects began, that the main improvements in health were in Arab communities farthest from the Zionist settlements, and that Zionist settlements had no effect at all on the decreased infant mortality rate of Arabs anywhere in Palestine. Sufians well-researched book demonstrates the close connections between disease, colonization, and nationalism. In his complex and nuanced study, Colonial Madness: Psychiatry in French North Africa, Richard C. Keller explains that French psychiatrists at the turn of the 20th century came to North Africa to study and practice in what they considered an experimental space outside the bounds of civilized metropolitan society. French colonial authorities held that Morocco, unlike Frances other territories in North Africa, was to be ruled indirectly,

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with indigenous institutions functioning alongside modern ones for Europeans. French psychiatrists accordingly advanced a dual standard: substandard mental health facilities for Moroccans and modern ones for Europeans. French colonial authorities contrasted a maristan (from the Persian, bimaristan, a hospital often for the mentally ill), where mental patients were in chains, with a French-built psychiatric hospital founded in 1920, where patients were housed behind locked doors with tiny windows for frequent inspection. Keller observes that Moroccan patients had been liberated from their chains but were now housed in a harshly alienating prisonlike institution. In Tunisia, according to Keller, Guy de Maupassant visited the Sadiki hospital in 1887 and wrote eloquently about its horrors. Many other French writers wrote similar sensational and terrifying accounts of their visits to maristans or other mental hospitals; such accounts were extremely popular with the reading public. Antoine Porot, a progressive and reform-minded French psychiatrist who had practiced general medicine in Tunisia since 1907, urged colonial authorities to establish an asylum designed especially for Tunisian patients, both for their own good and for public safety. He further argued that through medicine France could extend its penetration into its colonial territories. The project was repeatedly stalled because settler leaders were reluctant to approve funds for Tunisians, but construction finally began in 1927. In 1925, Antoine Porot moved from Tunis to Algiers to take up a chair in psychiatry at the medical faculty. He lobbied to build a state of the art psychiatric hospital for Muslims that was suited to the culture, economy, and geography of North Africa. Like the asylum in Tunisia, the projected hospital was considered expensive, particularly by settler officials, but was finally approved and opened in 1930 as a showpiece to celebrate and advertise Frances beneficence to its colonies during the centenary of the 1830 conquest of Algiers. With Porot as its central figure, Algiers became a major center of psychiatric study. The Algiers school of psychiatry argued that Algerians were neurologically inferior because of the stunted evolution of the cerebral cortex. Keller observes that unquestioned assumptions about the inferiority of the native underlay the Algiers school of psychiatry that Porot founded. Since the 19th century, French settlers had considered the indigenous peoples to be inherently fatalistic, superstitious, debilitated, amoral, violent, and pathological because of their climate and race. French psychiatrists absorbed these views and assumed that North African Muslims were not compatible with more civilized settlers, so the two communities had to be separated, especially in hospitals. Keller argues that even progressive psychiatrists with utopian visions, like Porot, were (perhaps unwittingly) an integral part of a militantly racist colonial order. Colonial authorities forcibly confined many Algerians to asylums for being drug or alcohol abusers or nationalist activists. Algerian Muslims understood that the asylum was a locus of state control and avoided committing themselves and their relatives in it unless absolutely necessary. Keller also discusses Franz Fanon and other interrogators of the colonial encounter such as Albert Memmi and Kateb Yassine. Fanon had pointed out that by prohibiting the sale of medical supplies to Algerians, using doctors and psychiatrists as torturers, and requiring physicians to report the wounded, the French turned medicine into a weapon during the Algerian Revolution. After independence in 1962, French-educated Muslim staff physicians were promoted, and new physicians were trained. French-educated Algerian psychiatrists began to challenge the racist stereotypes of the colonial era.

Medicine and Modernity in the Middle East and North Africa 807 In postindependence Tunisia, in a formerly French hospital that had fallen into decay, French-trained Tunisian reformers had patients remove their confining doors, introduced art and dance therapy, and opened a market where patients could sell agricultural products to the local community. They sought common ground where doctor and patient could meet on equal footing. This method would not have worked in colonial times, when the goal was to preserve a hierarchical order and the privileges of the settler community; and it resulted in a happier, safer, and more efficacious medical facility. Taken together, the books reviewed here illustrate new directions in the social history of medicine. In addition to bringing together extensive information, Ottoman Medicine exemplifies how medicine and public health can be used as a prism on the early modern era, pointing the way for further research. Perilous Modernity offers new views on modernity and medicine as well as new sources, from x-rays to epitaphs. Diagnosing Empire and Gender and The Making of Modern Medicine in Colonial Egypt build on the work of earlier historians to show how women and gender impacted the development of modern medicine in Egypt. The final two books, Healing the Land and the Nation and Colonial Madness, demonstrate that in the only two settler societies in the region Palestine and Algeriaunquestioned notions of superiority enabled the colonizers to inflict great injustices on the indigenous peoples. In both cases, the local populations appropriated and adapted the public health and medical policies of the colonizers as a form of resistance.
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1 I previously reviewed Hibba Abugideiris book in American Historical Review 117 (2012): 3; Sandra Sufians book in H-Levant H-Net Reviews, 2008, http://www.h-net.org/reviews/showrev.php?id=22850; and Richard Kellers book in International Journal of African Historical Studies 40 (2007): 53436.