Hospitals and history

The spread of Western medicine throughout the developing world over the last century has resulted in a sometimes curious patchwork of practices: modern pharmaceuticals, X-rays and surgical techniques are used alongside or complemented by ancient medical traditions, such as Ayurveda, acupuncture, humour therapy, meditation and traditional herbal remedies. Yet, even where indigenous forms of healing are still very much alive, Western medicine has tended to become the legally and culturally dominant form of medicine.

Central to this globalisation of Western medicine has been the hospital. "Hospitals act both as a conduit for the dissemination of Western medical practices to people through curative care and as training arenas for the indigenous medical profession," explains Dr Mark Harrison, Director of the Wellcome Trust History of Medicine Unit at the University of Oxford. Dr Harrison and his team of researchers have recently been awarded a history of medicine project grant to look at how hospitals have facilitated the spread of Western medicine to the developing world in two different colonial contexts: Ceylon (now Sri Lanka) and the KwaZulu-Natal region of South Africa. The work will complement an ongoing study based at the Oxford Unit on the development of the hospital system in the Bombay Presidency of India.

Training

One of the most important roles large modern hospitals have played is in the training of indigenous medical and nursing staff to an internationally recognised level. The Oxford project will be looking at both employment conditions for medical staff in Ceylon and KwaZulu-Natal, and the degree to which they influenced the management and development of hospital systems.

"In Ceylon, the indigenous medical profession had an unusual degree of autonomy," says Dr Harrison, "reflecting a political situation in which there was widespread devolution of political and professional power to the Ceylonese." Moreover, the colonial government recognised that it lacked the resources to provide a state medical service, and that it therefore needed to encourage the development of an independent indigenous medical profession by giving hospital positions to Ceylonese rather than British practitioners. As a result, Ceylonese doctors had a much greater impact on healthcare than indigenous doctors in other colonies.

The KwaZulu-Natal region of South Africa provided a very different political context. It switched from colonial to self-governing dominion status in 1910 and was subject to Apartheid policies for most of the second half of the century. Western medicine consequently made fewer inroads into local healthcare traditions, and there were few training opportunities for an indigenous medical profession. Instead, Western medical care was provided by mission hospitals, which played extended roles in wider community health and welfare and are still, in many African countries, the only providers of healthcare.

On the ground

Despite their central position in developing-world healthcare systems, hospitals may not necessarily be the best vehicle to meet the needs of indigenous populations. Dr Harrison’s team of researchers will therefore be looking at the social, cultural and economic factors that affect use of hospital services, as well as interviewing patients to find out how well they think they have been served by the hospital system.

Sometimes hospitals are simply not accessible because of cost - the cost not only of buying healthcare, but also of travelling hundreds of miles to the nearest hospital or dispensary. "It may be a more cost-effective way of bringing health to more people to divert the money into some other areas, such as primary care, ‘barefoot doctor’ schemes, travelling dispensaries," points out Dr Harrison.

In other cases, cultural factors are a barrier. "It’s often been regarded as unacceptable for women to be seen by male practitioners, or to leave the family and go into hospital as a patient, and that obviously affects use of hospital services. In some areas specialist hospitals for women have been established." Sometimes certain conditions seen as ‘medical’ through Western eyes are not considered to be within the province of medicine at all. "In the UK since the late 1940s, we’ve tended to think of infertility as being a medical problem, whereas in many developing countries it may be viewed in fatalistic or even religious terms: either that one is simply not destined to have children, or that it may be cured by the intervention of a witch doctor, or a priest, rather than medical treatment."

The researchers will also be looking at the Western-indigenous ‘mix’ to ascertain the extent to which hospital medicine has displaced indigenous practices. "Some indigenous practices have been entirely wiped out. For surgery, or for serious diseases, which have been shown to be quickly and effectively cured by drugs, people will automatically go straight to Western practitioners," says Dr Harrison. "In other cases - particularly for strange aches and pains or something that can’t be clearly identified as a disease - there is a tendency to prefer some kind of local therapy, and these practitioners continue to thrive."

Often, there is a compromise: indigenous practitioners work alongside Western practitioners in hospitals - and each might incorporate some elements of the other, resulting in a subtle modification of indigenous, and even Western practices. Medical astrology illustrates how Western medicine can be implanted within an ancient, indigenous tradition. "Dozens of books on medical astrology are still being written and published by practitioners of Western medicine in India and Sri Lanka," says Dr Harrison. "Astrological beliefs strongly linked to the Ayurvedic tradition - that the planets affect balances and humours within the body - are deeply entrenched in their culture. Even for practitioners trained in Western medicine, those beliefs are a gut instinct. But if they feel the need to justify them, they will do so using Western scientific terms."

Sometimes the two sit less comfortably and opinion remains divided. "Several people working in the pharmaceutical industry in India and Sri Lanka have said to me that in some cases it’s better to give the whole plant, rather than the extract, the active ingredient, which on its own has potentially harmful side-effects," says Dr Harrison. "If you give the whole plant, it may contain other substances that counteract those side-effects. Those substances are lost once the active ingredient has been isolated in a chemical or pharmaceutical preparation."

Investigation of these and other questions will shed light on the co-existence of different forms of medicine in the developing world, the hegemony of Western medicine, and the significance this has had both for patients as well as doctors. It will also start to fill an important gap in medical historical knowledge about the role hospitals played in disseminating Western medical practices across the globe.