TWO

“HEALTH IS THE FIRST WEALTH”

IN THE FEBRUARY 17, 1912, issue of the Gold Coast Leader, the newspaper’s editors publicized instructions compiled by Sir Ronald Ross of the Liverpool School of Tropical Medicine. Reprinted from African Mail, a Liverpool publication founded by Edmund Morel, the instructions detailed European understandings and expectations of the necessary conditions for health “out in Africa.” The list, which was targeted primarily at European traders, missionaries, and colonial officials, detailed a range of recommendations from food safety and diet to clothing choices and exercises. The mosquito, however, reoccurred throughout the list, influencing recommendations for the storing of water, the use of fans and mosquito nets, and the planting of gardens. This focus on the mosquito was unsurprising given the author. Ross had discovered that malaria was a parasite transmitted through the bite of the Anopheles mosquito in 1898 and had spent years advocating for various forms of prevention and treatment to decrease death rates and improve overall health in tropical zones. While much of the advice presented focused on the actions that Europeans could take to protect themselves, including alteration to the environmental and living conditions of everyday life, the last line embodied a colonial approach to health that had become entrenched by the early twentieth century: “It is usually very dangerous, often deadly, for Europeans to live or sleep in houses occupied, or recently occupied by natives.”¹

In warning of the perceived danger of cohabitation, Ross echoed a persistent sentiment among tropical disease and colonial medicine specialists in which Africans were viewed as “causative agents” or “reservoirs” of disease.² To some degree, these views were connected to Victorian sensibilities about cleanliness and sanitation. As an observer from the Liverpool School of Tropical Medicine argued on a tour of Britain’s West African colonial capitals in 1900, the “native town” of Accra was “a standing menace to the health of the community at large.”³ Among the general organization of the street, the presence of animals, and the nakedness of children, these observers were fixated on the environmental conditions that were thought to foster disease. In addition to the presence of garbage and the absence of latrines, which preoccupied sanitation officials, these public health observers were often obsessed with mosquitoes. “Mosquitoes abound, and the odor is often frightful,” the Liverpool observer noted:

Every now and then one comes across a butt or other receptacle filled with stinking water, infested with mosquitoes, and infected with bacteria . . . a complete absence of any system of drainage completes what to a European eye is nothing but a noisome and pestilential district. The dangers of such neighbors to the white population is obvious, and some of the commercial community, as I have said, live very close indeed to those parts of the town. This danger is, I think, increased by the fact that the prevailing wind sweeps over and through these native dens before reaching the houses of the white inhabitants.⁴

This description echoes dominant imperial narratives about the Gold Coast—and Africa broadly—as a “repository of death, disease, and degeneration” that represented distinct forms of mortal danger for European traders, missionaries, and administrators.⁵ To a large extent, this obsession with health and the regulation of the body in West Africa was a reflection of the very real risk of death for Europeans traveling to the tropics. Even in India, where disease risk had been mitigated significantly by the late nineteenth century, British officials’ experience was “intensely physical . . . written on the Anglo-Indian physique, from the boils, mosquito bites and the altered composition of the fibres and tissues of the body, to the colonists’ characteristic clothing and confident demeanor.”⁶ If, as Collingwood argues, “Britishness in the colonial context was . . . conceptualized through a dialogue with difference,” that difference also reshaped the body itself.⁷ What’s notable in the description above, however, is its focus on the “neighbors” rather than the environment alone as the source of disease. Imperial “myths and beliefs about the supposedly dirty tastes, habits, and practices of Africans” often influenced the “practical application of scientific discoveries” in West African colonies.⁸ By the late nineteenth century, British physicians and sanitary engineers used new discoveries in the medical sciences to justify increasingly aggressive forms of regulation that transformed African bodies into “living laboratories” that could be studied and through which diseases could be isolated, mapped, and controlled.⁹ But, similar to what we’ve seen in debates over sanitation infrastructure, narratives of “dirty natives” and “diseased bodies” also often justified an expansion of cultural and economic regulation into the daily lives of African urban residents. These were new boundaries that defined what was acceptable and unacceptable, legitimate and illegitimate: all realized through the practices and policies of Accra Town Council officials and backed by the police, the courts, medical experts, and many members of the African elite, including lawyers and doctors.¹⁰

These new practices of regulation and residential segregation in the late nineteenth and early twentieth centuries marked a shift in the spatial politics of the city. Like other cities along the West African coast, European and African residents had long lived side by side in Accra.¹¹ Traders wanted to stay near their shops and customers, missionaries wanted to be close to their parishioners, and the relative itinerancy of Europeans on the coast meant that nearly everyone needed to stay near the coastal castles, which were closely connected to the Ga neighborhoods. And yet, even though Western medicine could offer little protection against tropical diseases before the twentieth century and European visitors regularly visited local healers when they were ill, this association of disease with African environments and bodies was far from new. Writing about Sierra Leone, Festus Cole argues that “since the establishment of the colony, when miasmatic theories attributed the origins of disease to the climate and noxious exhalations from putrid organic matter, up to the evolution of the germ theory and elucidation of the aetiology of malaria, West Africa’s environment and its inhabitants have been portrayed as inherently pathological.”¹² Nineteenth- and early twentieth-century medical theories about tropical disease were simultaneously part of an unfolding scientific revolution and a continuation of centuries-old practices that were often utilized to reinforce racism and imperialism. Public health experts reasoned that even if individual African residents were healthy—a baffling phenomenon for many in light of high European death rates—their way of living must be unhealthy.¹³ Medical theories that blamed “tropical miasmas” and “tropical fevers” for poor health in colonies like the Gold Coast were no longer supported within professional scientific circles or prevailing medical opinion. Yet the racial discourses of early twentieth-century colonial public health often merely repackaged these theories and attached them to a new human source—African urban residents.¹⁴ If scientific advances had increasingly helped establish distinctions between hygiene and health, sanitation and medicine, practitioners themselves were often slow to make the shift, insisting on a vision of public health that just as often actively undermined the public welfare and ignored obvious evidence drawn from experience.¹⁵

Widely known and feared as the “white man’s grave,” West African colonies were a particular target of these medicalizing, pathologizing discourses.¹⁶ The robust concentration of trade and capital investment in the Gold Coast made it a particular target of medical anxieties and public health interventions in British West Africa.¹⁷ In moving the colonial capital to Accra in the late nineteenth century, British officials cast Accra as “a colonial capital founded on the promise of health.”¹⁸ Accra’s drier climate and higher elevation promised a healthier environment for European residents. The city’s new status also brought more concentrated investment in Western medicine and a new kind of intensity of the clinical gaze imposed on African residents. Driven by an assumption in the universality of science and the promise of medical triumph, British officials believed that science could vanquish diseases that impeded “civilization,” paving the way for colonial economic and territorial expansion and, at least by the 1920s, creating a healthier African labor force that would support socioeconomic development in the colony. But the spatial and social organization of the city and the daily lives of its residents challenged many of the prevailing medical theories and practices of emerging fields of public health.

This chapter explores shifting regulations and policies related to health in Accra during this period of scientific transformation, tracing their development through the lens of diseases like bubonic plague, yellow fever, and malaria. Taken together, these policies constituted an emerging practice and profession of public health—what Roberts describes as a “unified vision of the bodily and spatial relations of illness in the tropics,” rooted in colonial anxieties about tropical disease and imperial profits and informed by a persistent racism and classism that obscured official understandings of health.¹⁹ As with sanitation and other spheres of colonial regulation, the increased public health scrutiny that urban residents faced from colonial technocrats was certainly consequential. The enactment and enforcement of regulation reshaped the organization of space and the realities of daily life among Accra residents in significant ways, from residential segregation plans to mosquito inspections. And yet, as Roberts and others have argued in relation to therapeutic practice in Accra, state regulation fell short of the kind of biopower described by Foucault. Realities on the ground contradicted Western assertions of the presumed superiority of Western science and medicine even as some members of the African elite supported the expansion and implementation of Western medical and public health regimes. These contradictions and the protests and petitions of urban residents and their representatives made clear that the power and efficacy of the medical department and the perception of colonial public health initiatives was far from certain and that alternative understandings of health and healing continued to circulate in Accra in ways that were central to the daily lives of its residents.²⁰

“UNHEALTHINESS OF THE COAST”: MEDICAL ENCOUNTERS IN THE GOLD COAST

Colonial narratives of unhealthiness, disease, and danger in coastal cities like Accra belied the rich cultural understandings of health and practices of healing in African communities. Among the various ethnolinguistic groups in southern Ghana, “medicine is understood to be material devices that not only directly heal bodily ailments but also fight off the malicious spirits that cause illness.”²¹ For the Ga these dual material and spiritual dimensions were captured in the words associated with health and healing practice: tsofa (medicine), tsofatse (healer), and won/woji (spirit).²² In the absence of more efficacious alternatives from ship’s surgeons, early European explorers and traders on the Gold Coast often participated in African healing traditions, even if their understanding of health and healing was less spiritual and more environmental: according to Curtin, “Temperature, humidity, and emanations from the soil were the sources of danger.”²³ Transformations in the late nineteenth century, however, soon redrew these relationships and understandings regarding health. As Jonathan Roberts has argued for African histories of medicine in Accra, the fervor of religion, the emergence of a medicalized colonial state, and the desire for social distinction underlay transformations in the history of healing in the city.²⁴ European understandings of healing also changed radically in the late nineteenth century, driven by the development of germ theory, which made prevention and cure of diseases increasingly viable, and new forms of colonial investment in colonies like the Gold Coast. These transformations—just like the early medical encounters—were interconnected even as new forms of colonial policy and practice sought to reinforce difference and separation. New understandings of health and medicine were also intimately connected to the past; transformation was not marked by a sudden rupture but, as Curtin argues for new European theories of disease, “It was not assimilated immediately by the public mind or even by the medical profession.”²⁵ Change took time, and many practitioners continued to cling to older theories and practices, thus incorporating them into emerging public health strategies at home and abroad. Backed by the power of the state, British colonial policies were in many ways more obviously consequential. But Africans also integrated new changes into dynamic practices of “therapeutic pluralism” that shaped colonial medicine in both direct and indirect ways.²⁶

These transformations were, in many ways, essential for British officials who sought to consolidate their authority over the Gold Coast and expand their control into the interior. West Africa’s notorious reputation as the “white man’s grave” made service in the colonies a highly risky endeavor, and the missionary societies, merchant houses, and government offices operating in the Gold Coast struggled to recruit qualified officers given the low salaries and high mortality rates.²⁷ Between 1881 and 1897, the average annual death rate for European officials in the Gold Coast was 75.6 per 1,000. For missionaries, traders, and miners, the mortality rates were even worse—an average of 81.48 per 1,000 every year between 1879 and 1888.²⁸ As Roberts notes, “Most Europeans who visited the coast were struck with fever within a few weeks. On average, half were dead within the first year. Those who survived a bout with malaria gained a temporary respite from the illness but they were still vulnerable to yellow fever, typhoid, guinea worm, and gastrointestinal illnesses.”²⁹ Long leaves for rest and recovery—the “short leave system”—provided some degree of protection for those who did sign up, but the constant cycling of staff made it impossible to build any sort of institutional knowledge or continuity of administration for colonial governments.³⁰ In 1896 alone, out of 176 officers stationed in the Gold Coast, 89 took a leave of absence, 26 were invalided, and 15 died.³¹ Trading companies and merchant houses also complained regularly to the Colonial Office, citing “polluted ponds and wells, refuse-strewn streets and yards, and open sewage pits, which stood as obvious sources of contagion.”³²

Elite African coastal residents, demanding the same kinds of development efforts that were being undertaken in British cities, often backed these calls for improved sanitary regulations and infrastructural investments. In 1895 even the editors of the Gold Coast Chronicle acknowledged the dangers that tropical diseases posed for Europeans, arguing that “something will have to be done in the matter of the present death rate among the Europeans, as it does not require a special pair of spectacles to see that the white men in the western province are passing away one after the other in a most extraordinary manner, and unless the question of improved sanitary arrangements—particularly in Cape Coast and Elmina where the greatest number of deaths must have to be recorded during the past three months—is seriously discussed, we cannot say what will be in store for us.”³³ The eastern districts, including Accra, appeared to be healthier, confirming the government’s decision to move the colonial capital farther east. But African coastal residents suffered from many of the same diseases as their European counterparts, and the arrival of European ships often brought new dangers, from smallpox to plague, which African Town Council (ATC) representatives and other public figures often complained were being ignored by British officers. In the realm of colonial policy, poor African health was recognized as a barrier to long-term social and economic progress by incapacitating large portions of the population.³⁴ Colonial and commercial development needed healthy workers, and Western medicine was expected to improve overall health and aid in the economic, social, and cultural transformation of the region—a manifestation of the “civilizing mission.”³⁵ However, the resulting solutions tended to privilege economic interests over general public health. Those results would be achieved with only the least possible investment. The “visible decimation” of the relatively small British population in coastal towns like Accra generated more urgent responses and concentrated investment.³⁶ Colonial officials obsessed over European death and invaliding rates, but there were no reliably comparable statistics for African health. British health officers argued that Africans were less likely to report births and deaths, fearing quarantine or other kinds of health interventions, and fewer Africans addressed their health needs through colonial hospitals. But leading African representatives also regularly critiqued the colonial administration for not investing sufficiently in health education, and the inequalities in resource allocation were often thrown into stark relief in the context of major health campaigns to fight epidemic diseases and malaria. Africans, it was clear, were seen as a source of disease and a health threat in colonial public health logics.³⁷ They were not the “public” that technocrats had in mind.

Colonial officials, who saw economic potential in the Gold Coast, sought to tackle the health problem, at least for Europeans, with “prophylactic action.”³⁸ Until Ross’s discovery of the mosquito vector for diseases like malaria, much of this early strategy was based on older notions of “noxious vapors.” In attempting to control odors and smells as a central public health strategy, early colonial officials often blurred the lines between sanitation, health, and social policy—a form of “sanitary salvation.”³⁹ Practices like segregation and swamp or lagoon drainage were often inspired as much by the bourgeois sensibilities of colonial officials as actual scientific research.⁴⁰ Smell was another way to mark African bodies and bodily practices as diseased. Practices like racial segregation protected European officials from diseases associated with the urban poor and with colonial subjects—health being used to justify various forms of racism and classism in the context of colonial governance.⁴¹ Colonial officers often used “health” as an excuse to intervene in various areas of daily life in order to better align urban living with Victorian/Edwardian sensibilities; these interventions for “health” came with assumptions about what constituted “well-being” and what the conditions for health actually were—an issue of contestation by various constituencies in the Gold Coast throughout much of the late nineteenth and twentieth centuries.

While some early colonial governors, including J. F. Rodgers, J. J. Thorburn, Hugh Clifford, and F. G. Guggisberg opposed policies like segregation on practical and financial grounds—it was seen as unnecessarily expensive, ineffectual, and likely to meet with opposition from African residents—leading medical officers continued to recommend it well into the 1930s.⁴² But even if particular policies struggled to take root, health did serve as a primary motivator or lever in shifting the nature of European presence in the colony. Western medicine was not particularly effective in the tropics until much later, and there was little evidence on the ground to back British assertions of their superiority besides smallpox inoculations. Public health interventions—and the responses of African residents—existed in this space in between ideological coercion and practical efficacy. British medical superiority was often expressed—the “power to govern” was often presented as the “power to heal”—but rarely demonstrated in practice, a fact that even Colonial Office officials and the Colonial Secretary Lord Chamberlain himself acknowledged.⁴³ Despite extensive efforts to count, report, and review health statistics and invest in new scientific research, compromise was more characteristic of colonial medicine than control, and Western medical knowledge did not displace or erase African healing traditions, even if they clearly ignored them in constructing new “public health mandates.”⁴⁴

“TROPICAL MEDICINE” AND THE BUREAUCRATIZATION OF PUBLIC HEALTH

The various interests and anxieties related to tropical disease were consolidated at the turn of the century through the development of new kinds of bureaucratic institutions that sought to professionalize the study and deployment of tropical medicine using new scientific theories and research methods. The Liverpool School of Tropical Medicine was founded in 1898 through a donation from Sir Arthur Lewis Jones, a prominent ship owner with trading interests in West Africa. The London School of Tropical Medicine was opened a year later by Sir Patrick Manson, medical adviser to the Colonial Office and funded through a donation from the Indian philanthropist B. D. Pettit. These new institutions were dedicated to the study of tropical diseases, which Manson, who was a pioneer in malaria research, described as “a natural division of diseases, a division which, in the case of the tropics at all events, has to be recognized in practice, and which, if we are to do full justice to the claims of diseases, of those who suffer from them, and of our national interest, we have to meet by special educational arrangement.”⁴⁵ Epidemic diseases like cholera, plague, and yellow fever existed alongside endemic diseases including, most prominently, malaria. While the epidemics often attracted more attention and intervention, endemic diseases like malaria provided the most serious threat. “When we describe a tropical country as ‘unhealthy,’” Manson argued, “we really mean that it is malarious. West Africa is unhealthy.”⁴⁶

The London and Liverpool schools targeted tropical disease as an existential threat. Manson’s dual invocation of individual suffering and national interest captured the conflicting motivations that informed emerging fields of tropical medicine and public health.⁴⁷ Thanks in part to Manson’s relationship with the Colonial Office, the London School quickly became a training ground for departing colonial officers. These new schools were part of an emerging understanding of empire advanced by Joseph Chamberlain, who advocated for a more directly interventionist approach to colonial governance during his time as colonial secretary from 1895 to 1903.⁴⁸ Having been founded by commercial interests, the Liverpool School was initially independent of the government, but within a few years it too had taken on a role as a training ground for colonial officers. Importantly, however, the study of tropical medicine also aimed to make imperial government more cost effective.⁴⁹ As Manson argued, “unhealthy” countries doubled the cost of colonial administration in places like the Gold Coast:

What with death and invaliding and the necessity for frequent leave of absence to Europe in order to avert disease, in these Colonies two men have to be employed to do the work of one, and that to induce them to accept employment these men have each to get double pay. It means that continuity of work and accumulation of personal experience which are so necessary for successful government and administration are almost impossible. It means that Government is robbed of many of its best servants just as they are becoming valuable. It means an enormous financial drain on a sorely handicapped community. In the face of these figures it is difficult to see how such Colonies can get along at all.⁵⁰

And yet, Manson says, tropical medicine promises to reverse these conditions: “Malaria is a rope round their necks, and the fact that they continue to exist, some of them to prosper even in spite of it, is testimony to their economic value and eloquent testimony as to what might be made of them and what they would blossom into were this ever-floating cloud of malaria that hangs over them dispelled. Can this cloud by any practicable means be dissipated? My answer to this question and to the same question as regards all the other diseases I have enumerated is emphatically, ‘Yes.’”⁵¹ Manson’s confidence was rooted in a growing faith in modern medicine and its ability to redress both physical and social ills. Hygiene, Bashford argues, “came to be a personal and political imperative and mission” in late nineteenth- and early twentieth-century Britain—“a noun which spawned ever more adjectives which connected the bodily and the personal to larger governmental projects.”⁵²

Both of these institutions combined medical research with public health training. This was a reflection of older public health practices that targeted the urban poor in both London and Liverpool several decades earlier, imported into a colonial context with new forms of unknown disease to more effectively “administer” colonized peoples and territories and render them “intelligible to colonizers.”⁵³ In a meeting with Chamberlain in 1901, a deputation from the London, Liverpool, and Manchester Chambers of Commerce and the Liverpool School of Tropical Medicine advocated for a diverse range of policies to address both the political/economic and moral consequences of health policy including “a) the removal and disposal of refuse, b) surface drainage of the soil and removal of bush and undergrowth in and near towns, c) removal of native huts when their presence is a menace to European residents, d) installation of sanitary regulations for observance in the coastal settlements.”⁵⁴ Investment in the health of the colonies, Chamberlain acknowledged, was essential to the success of colonial economic development programs in West Africa.⁵⁵ The research conducted in the new schools informed and justified the expansion of investments in health infrastructure in colonies like the Gold Coast while also training officers to fill those positions.⁵⁶ Ronald Ross and Patrick Manson’s research on the mosquito vector for malaria fueled the British government’s investment in research and training on tropical medicine.⁵⁷ In the first year after its opening in 1899, the London School of Tropical Medicine had already trained fifty students in the study of tropical diseases.⁵⁸ By the early twentieth century, all newly appointed medical officers were required to take the course in tropical medicine at either London or Liverpool.⁵⁹

Medicine often brought Africans “into tighter relations with governance” and constituted both a representation and tool of government power in colonies.⁶⁰ “The power to govern,” some scholars have argued, “is often presented as the power to heal,”⁶¹ allowing Europeans to live anywhere on the globe.⁶² Cities in both the colonies and the metropole became sites of experimentation, connecting medical research and public health practice with new fields of urban planning, design, and development as a part of a bureaucratization of health and healing.⁶³ These new bureaucratic and technocratic practices fused early genealogies of public health—the philanthropic-missionary and the governmental/political—in new ways that simultaneously sought to advance and restrict freedom.⁶⁴

In the colonies, the professionalization of medicine corresponded to a progressive alienation of Africans from the medical service. The Gold Coast Medical Department was founded in the 1880s, led by a physician who held the position of “principal medical officer.”⁶⁵ Between 1892 and 1897 that officer was Sierra Leonean Dr. J. F. Easmon. But British officials pushed Easmon out in 1897, and they passed over qualified African physician Dr. B. W. Quartey-Papafio in favor of a white candidate with training in “tropical medicine.” By 1902 applications were formally restricted to Europeans.⁶⁶ The high salaries and political clout of medical officers ensured that these conditions remained in place well into the 1920s. The conservatism and racism of the medical establishment was well known even among European officials. As one European (and unofficial) member of the Legislative Council complained in 1914, “Medical officers are not renowned for being broad minded.”⁶⁷ Conservatism and racism also informed more general complacency among the medical staff toward African health—a condition that left even Governor Hugh Clifford (served 1912–1919) appalled.⁶⁸

The medical service expanded through the 1920s. In 1923 the position of principal medical officer was redesignated director of medical and sanitary services (and later director of medical services), reporting directly to the governor through the colonial secretary and often serving as an official representative on the Accra Town Council. In 1919 the government created a new Sanitary (Health) Branch, which was responsible for sanitation, vaccinations, and preventive measures, and a Medical Research Institute (Laboratory) Branch, which pursued scientific investigations as well as conducted tests and postmortems. These new units complemented the work of the Medical Branch, which was responsible for all hospitals and clinics.⁶⁹ If Chamberlain had resisted early calls for substantive investment in health interventions in West African colonies, that attitude had clearly changed by the 1920s, buoyed by several decades of statistics and reporting.⁷⁰

COLONIAL SCIENCE

Tropical medicine, then, sat at the intersection of colonialism and science, which, Tilley argues, was characterized by a “complicated web of relations.”⁷¹ The need for tropical medicine specialists and the general importance of the medical sciences in the colonies justified government funding, increased the size and stature of scientific societies, the number of academic posts, and the significance of training programs.⁷² Beginning in the late nineteenth century through the Second World War, hygiene and health were increasingly seen as both personal and political imperatives.⁷³ Colonial officials, medical experts, and African elites alike argued that “health is the first wealth” and advocated for increased investment in medical services.⁷⁴ This belief was most obviously exhibited in support for public health and medicine for Europeans in Accra. Moving the colonial capital to Accra motivated increased investment in Western medicine in the city. Even if nineteenth-century medicines and medical strategies were poorly suited to dealing with tropical disease, new forms of colonial investment introduced an increasingly intense clinical gaze on African residents—a form of “sanitation syndrome” discussed by Swanson in which Black residents were thought to embody infection and disease.⁷⁵

Undoubtedly, some elite African residents welcomed the new developments. The editors of the Gold Coast Aborigines argued that the district commissioner, the health officer, and the inspector of nuisance, who were directly responsible for the town’s health, could not be entirely blamed for persistently poor health in Accra and other coastal cities “because they can only move as redtapeism directs.”⁷⁶ While the officials in charge of the colony’s health were neglecting their duties in Accra, native merchants and traders were contributing thousands of pounds of revenue to the colony, and the European population was growing. “If the building of new houses can be a criterion to judge the growth of a town by, then this town is growing in the hands of those directly responsible for this work, should be strengthened to enable them to discharge their work faithfully,” the newspaper’s editors argued.⁷⁷ However, new public health measures, introduced in the name of sanitation, were widely considered by Accra residents as both “an instrument of oppression and a tool of tyranny.” As many commentators noted, positions like “inspector of nuisances” often failed to correct behavior (accompanied by education) but rather represented yet another way to collect taxes or fees from Africans and further enrich the colonial coffers. In medicalizing life and death, the colonial state sought to justify a more intense form of surveillance of the daily life and private spaces of African residents.⁷⁸ Officials passed laws banning house burials and enforcing cemetery burial, transforming the ways that Ga communities understood spirits, the afterlife, and property.⁷⁹ Inspectors of nuisance “sent scavengers out at five in the mornings to lurk about for the apprehension of people who may be throwing nuisance at places where prisoners may also be seeing ditto-ing, or at the desk of the evening for the ‘capturing’ of poor strangers who may not even be committing any nuisance, to huddle up poor innocent boys, girls, men and women before his worship’s magisterial bench for throwing water here and there as the scavenger sometimes alleged, or for not sweeping their gates, when they will be mulleted in fines ranging from 5 shillings to 30 shillings and more, to bury at times the seasoned fish of some poor women at the beach.”⁸⁰ Meanwhile, the editors of the Gold Coast Chronicle complained in 1897 that the town was at risk of an epidemic of smallpox because the government refused to take necessary steps to vaccinate inhabitants.⁸¹

The contradictions were in many ways unsurprising in the context of an emerging practice of scientific research that saw Africa as a “living laboratory.”⁸² For colonial administrators, scientific knowledge provided “reliable information” they could use to do their work effectively, for technical officers to facilitate socioeconomic development and other Europeans to advance their own interests, and for some Africans who sought to effectively position themselves within this new form of pluralistic society.⁸³ African realities often challenged scientific “certainties” and raised questions about British imperial supremacy, but that often did little to change colonial rhetoric or policy.⁸⁴ On the contrary, these contradictions often justified further interventions in the private spaces and daily lives of African urban residents.⁸⁵ As the former assistant colonial secretary, Mr. T. H. Hatton Richards, described Accra in 1897, the city was a place of danger, yet “the first thing which strikes one arriving at Accra is the apparent absence of anything to make the place so unhealthy, and, perhaps, a casual observer might think the place could not be as bad as is generally reported.”⁸⁶ Hatton Richards argued that it was the condition of the “native town” that was at issue. The town itself and individuals within it might be healthy, but their way of living was not—both in form and practice. The 1894 fires that destroyed large portions of the town “turned out to be a blessing in disguise, so far as the native quarter of Accra was concerned.”⁸⁷ In drawing Europeans into African neighborhoods, the fires created a new form of awareness about the living conditions of the town and raised increasing awareness about the need for public health through spatial intervention.

THEORY AND PRACTICE

In seeking to make direct interventions into the daily lives and spaces of Accra residents, health policy and inspections “could produce collisions between ruler and ruler.”⁸⁸ These collisions were, on the one hand, a consequence of the delicate balance between the professionalized, technocratic practice that advocated centralized control and the local knowledge and priorities that shaped the daily lives of many residents. British officials themselves struggled to balance these demands as part of the “decentralized improvisation” of indirect rule.⁸⁹ Even as the Colonial Office issued health directives to West African governments from London, the ways in which officials within individual colonies sought to implement the directives were dictated by local political, economic, social, and cultural factors. Even Chamberlain, who eagerly wielded his power as colonial secretary, allowed governors to use their discretion in creating and enforcing policy. The Colonial Office did not create a centralized sanitary authority, but it did create an Advisory Board that administered the Tropical Diseases Research Fund in 1904 and an Advisory Medical and Sanitary Committee for Tropical Africa to oversee the selection and organization of West African medical staff in 1909. But these bodies remained well removed from the day-to-day practicalities of enforcing and implementing plans, policies, and regulations.⁹⁰

These structures reflected broader imperial approaches to scientific research. As Helen Tilley argues, emerging scientific knowledge was simultaneously “situated” in particular locations and highly mobile within, across, and between metropole and colony.⁹¹ There was, in other words, no such thing as a homogenous “colonial science” in practice. Certainly colonial officials and British technocrats aspired to create a “system of medicine that attempts to reorder the lives of subject people employing medical discourses that affirm the colonizer’s own medical, cultural, and racial superiority.”⁹² Colonial states used advances in Western medical research and practice as a “tool of empire”⁹³ that would enable them “both to conquer and to live in the tropics,” but Echenberg argues that the kinds of political, military, and economic transformations wrought through “new imperialism” also facilitated the spread of a range of diseases, including cholera, malaria, yellow fever, trypanosomiasis, and bubonic plague.⁹⁴ British scientists and colonial officials often pointed to these changes as testament to the triumph of Western medicine. However, as recent scholarship on the history of medicine has shown, “indigenous knowledge” as a theoretically distinctive body of knowledge was not “disrupted or destroyed by colonialism.”⁹⁵ Rather, Roberts argues, African residents in Accra embraced multiple forms of healing as part of a practice of “therapeutic pluralism” or “therapeutic diversity”—a direct challenge to assumptions about the universality of science and narratives of Western medical triumph.⁹⁶

As Roberts notes, scholars struggle to historicize therapeutic pluralism, hampered by the lack of indigenous sources, the impossibility of proving curative efficacy of Western versus non-Western therapeutics, and the potential to negate the agency of African patients who often creatively combined treatment regimens in search of health.⁹⁷ However, the policies—and responses to those policies—related to health and the body, centralized control and local knowledge, help us to understand to some degree the parameters of the debate. In criticizing the “inadequacy of the health laws and the unwillingness of chiefs or political officers to enforce them or to levy substantial fines on those found guilty of violations,” Dr. P. S. Selwyn-Clarke, both lauded and maligned as medical officer of health, highlighted some of the contradictions and challenges at the core of colonial health policy.⁹⁸ Europeans and Africans alike often resented the work of the medical officer of health and his staff of inspectors who seemed not to care about the impact their work had on residents’ daily lives.⁹⁹ Governors were wary of medical interventions because of their cost and the risk of local rebellion; public health officials often chose to do things “on the cheap” by focusing on the city’s white population.¹⁰⁰ But this restrained action generated its own form of critique. By both criticizing African practices as “unhealthy” within emerging conceptions of international technocratic standards while also refusing to invest in urban development or medical education, colonial officials created an impossible double bind for Accra residents. This dilemma highlighted the inconsistencies and inefficiencies of a segmented colonial bureaucracy and generated public complaint and condemnation, both in the pages of the newspaper and in the debates of the Accra Town Council.

At the root of this contestation lay a persistent racism that infected Western medical research and practice. Like other technocratic fields, practitioners and scholars alike have long assumed that the biomedical revolution that gave rise to modern conceptions of medicine and public health was scientifically “neutral” and disconnected from social and racial ideologies that dominated the nineteenth and early twentieth centuries. However, as Echenberg argues, “Even though bacteriology in the wake of Robert Cox’s model of the germ theory clearly adopted a ‘civilizing mission’ to root out diseases, its vocabulary could also incorporate nonwhites as causative agents of disease and as the contributors to the spread of infections.”¹⁰¹ In evaluating practices and applying rules governing medicine and public health, medical officers and inspectors exercised significant class and racial prejudice.¹⁰² British officers were “quick to list the African domestic behaviors responsible for incubating contagious diseases, encouraging vermin, and harboring malarial mosquito larvae,” Newell notes, often pointing to their inability to pay for imported commodities like soap as a sign of their danger to public health.¹⁰³ These attitudes were embedded in the rhetoric and practice of medicine and public health and, consequently, in the urban planning models that they inspired. As Vaughan and many others have noted, tropical medicine spawned a new way of thinking about African cities and their inhabitants, helping to translate British ideas about town planning into new colonial and imperial realities and inspiring new obsessions with “proximity” in physical and social space.¹⁰⁴

And yet, medical interventions in Accra could not fully separate African and European residents and did not fundamentally transform the town’s health.¹⁰⁵ As Patterson notes,

The MOH and his African inspectors did not erect impressive hospitals or provide injections to heal the sick; instead, they poked around people’s compounds, looking for mosquito larvae, unauthorized buildings, excess lodgers, or the sick; they issued a steady stream of summonses and fines for those who relieve themselves in a place other than the filthy public latrines, sold food on the streets without an expensive cover, or dumped garbage in a handy gutter rather than a distant and already overflowing dustbin. In short, the MOH and his men badgered people in many ways without any obvious benefit to anyone except those who collected the fines or got jobs as inspectors.¹⁰⁶

Regardless of the rhetoric, these realities highlighted struggles over more than just health. Chiefs, sanitary inspectors, traders, medical officers—not to mention African political representatives, lawyers, doctors, and newspaper editors—and other colonial officials all struggled over power, land, and resources through debates about the meaning of “public health” in the town.¹⁰⁷

HEALTH INFRASTRUCTURE IN THE GOLD COAST

Patterns of investment in health infrastructure generally reflected the rhetoric from the Colonial Office, even as local conditions shaped the realities of daily practice. When observers from the Liverpool School of Tropical Medicine visited Accra in 1900, they noted that investment was only noticeable in the European community of Christiansborg.¹⁰⁸ Four years later, little had changed. Francis Hart noted that “apart from a hundred pounds or so a year for Accra absolutely no financial provision is made for the protection and preservation of the public health, the Government doctors, who are nominally the health officers of the towns in which they are stationed, not being provided with the funds, which will enable them to keep the communities entrusted to their care sweet and clean.”¹⁰⁹ Hart noted that the medical service, and its principal medical officer, Dr. Henderson, CMG, were “exceptionally efficient.” Government doctors, however, seemed to spend much of their time and energy in private practice where they charge exorbitant prices that prevent individuals from seeking care.¹¹⁰ And yet, these observations reflect a growth from early hospitals established in 1882 and 1883 in abandoned bungalows with limited staff. As Dr. J. Desmond McCarthy noted, any moderately ill European preferred to be sent back to Britain rather than pursue treatment at the colonial hospital.¹¹¹ Despite this underfunding, the number of African patients seeking treatment did increase steadily through the late nineteenth century and justified an expansion. Jonathan Roberts argues that the increases likely represented the increasing authority of the colonial state over the health of African residents—Africans employed in the colonial service sought treatment at the hospital in order to document illness, merchants and elites sought treatment as a way to signal status and wealth, and individuals who were injured in accidents or were in custody may have been taken to the hospital by the police. However, Roberts argues, Accra residents also likely saw the hospital as yet another addition to the plurality of therapeutics available in the city, particularly for more serious trauma cases.¹¹² The presence of early African doctors like Dr. J. F. Easmon and Dr. Benjamin William Quartey-Papafio also likely increased the willingness of African residents to trust the colonial hospital as a source of treatment and undercut the possible spread of rumors about nefarious activities associated with colonial medicine, which did circulate in other parts of the continent in which medical systems were dominated by white medical professionals.¹¹³

The establishment of professional centers of training in London and Liverpool, however, marked a shift in colonial patterns of investment. By 1904 there were six government hospitals in Axim, Elmina, Cape Coast, Accra, Ada, Keta, and Kumasi, as well as dispensaries at Sekondi, Tarkwa, Saltpond, and Akuse. At three hospitals—Axim, Cape Coast, and Accra—there were special services for Europeans as well as dedicated nurses. In Accra there was a dedicated building for contagious diseases as well as a lunatic asylum. In all, 1,305 patients were treated at various hospitals in 1902; 2,109 patients were treated in 1900.¹¹⁴ Medical services continued to expand through the early twentieth century—in 1916 a new European hospital was built at Ridge—and yet, government officials continued to complain about the colony’s inadequate medical care. Doctors complained about sanitary conditions, overcrowding, and poor maintenance. The construction of the new Gold Coast Hospital at Korle Bu in 1923, however, marked a major new form of investment. The hospital became the major medical and surgical center for the entire country. In 1927, Korle Bu served 206 inpatients and 11,283 outpatients. By 1938, they were serving 292 inpatients and 17,903 outpatients. These more general medical services were complimented by a new venereal disease clinic (1920) and maternity and children’s hospitals like the Princess Marie Louise (1926), which were widely popular in the city and made a significant impact on high infant mortality rates in the city. In 1925, infant and maternity clinics of various sorts were serving 13,438 patients. By 1937 the number had risen to 21,253.¹¹⁵ Expenditures for health constituted a quarter or more of the total Town Council budget through at least the 1930s.¹¹⁶

These increases in investment, however, also reflected an increasing European control over the health of the town and subjected doctors and government officials alike to public criticisms. Critics, like the physician writing into the Gold Coast Independent as CER, acknowledged that “all the business of the physician is more especially the care of the sick with reference to the cure of disease or where that is beyond his power as is too frequently the case.”¹¹⁷ The challenges of diagnosis and treatment led physicians to focus on medical questions related to disease, reducing the patient to an object of scientific curiosity. And yet, they argued, the physician also had responsibilities to the general public health:

These duties become more numerous and important as the density of population increases, so that in a large town as Accra he finds himself “nolens volens,”¹¹⁸ in almost daily contact with legally constituted authorities in the shape of ‘a mock municipality,’ sanitary department, road department and whatnot, and is not infrequently summoned before the courts. Moreover, the physician who has been placed at the head of these institutions invariably forgets that he becomes an adviser to the government as well as to the public at large; consequently his responsibility so far as it affects the public, corresponds to a degree, the position which she takes and the advice which he gives in regard to public health matters; this is true whether his attitude on these subjects be active or passive; for his silence will be taken to mean that there is no necessity for action or change.¹¹⁹

Whereas doctors were focused on the physical health of their patients, these commentators argued that an improvement in mortality rates required direct investments in the development of the entire community. Instead, investment seemed to have resulted in a number of conflicting and overlapping institutions of authority with no clear and coordinated plan of action—“a practitioner finds it difficult to know who is actually responsible.”¹²⁰ As this physician noted, the broader group of professionals supporting public health included a range of practitioners including local healers. Coordination and cooperation, rather than bureaucratic expansion, seemed like a more effective path forward—a sentiment that was echoed in the calls for education and community engagement by ATC members around issues of sanitation.

CULTURAL CONCEPTIONS OF HEALTH AND DISEASE

European narratives about the “unhealthiness of the coast” oversimplified the competing definitions and understandings of health within Accra’s diverse population. Despite long histories of interaction along the coast, there was little hybridity in Accra’s health cultures. Roberts argues that the difference between Western and African approaches were “largely incommensurable.”¹²¹ Among African residents, illness was largely understood as “the struggle between the body, society, and the supernatural forces that surrounded them.”¹²² A “sick” person was one who could not fulfill the responsibilities of their social role and, as a result, African patients often put off treatment until their illness was significantly advanced or they were disabled in some way.¹²³ Europeans, however, arrived at the coast with an understanding of health as the result of miasmas, and later bacteria, which could be treated with medicine and privileged early intervention—a position that was further strengthened with advances in medical research that inspired a new form of confidence in the efficacy of Western medicine in the tropics that often defied lived realities.¹²⁴

Individual patients often combined multiple forms of treatment or chose between a range of possible treatment options as part of what Roberts calls “therapeutic pluralism.”¹²⁵ Patients were often cautious and pragmatic, but African healing cultures were also highly adaptable and responsive, and local healers often served as an “interpreter of shared values.”¹²⁶ The healers that Kilson interviewed in the 1960s and 1970s were “enterprising older Ga men” who would have been born, come of age, and trained during this period. Kilson was struck by their “diverse social background and experiences”: “Some spoke only Ga; others spoke and wrote English fluently. Some were members of Christian churches; others adhered to traditional religious cults, and one was a Muslim. Earlier in their lives they had pursued various occupations including those of school teacher, cloth designer, soldier, Christian evangelist, and fisherman.”¹²⁷ While these healers experienced different degrees of socioeconomic success, they all eagerly embraced the opportunity to learn and apply new information and treatments that might aid their patients. Despite stereotypes of the “fetish” priest, these Ga healers were often keen observers who recommended social, psychological, or physical interventions that effectively addressed underlying problems, even if patients ascribed their issues to supernatural causes.¹²⁸ African-born physicians also complicated overgeneralized and racialized assumptions British officials had about African understandings of health, embracing the efficacy of Western medical practices and theories and often being openly critical of African healing traditions.¹²⁹ Boundaries, in other words, were often not as simple as either discourses at the time or scholarly interpretations made it seem, and Africans were much more responsive to the introduction of new scientific knowledge.¹³⁰

These different approaches to health were complicated by obviously uneven investment in health infrastructure and health standards within European and African communities in Accra.¹³¹ Early commentators highlighted inequalities that were exacerbated and laid bare during outbreaks of smallpox and influenza in the early twentieth century.¹³² As late as 1935, Councillor Akilagpa Sawyerr noted that lepers were found begging in public markets on a regular basis and that regulations were not adequately enforced to protect the public.¹³³ Colonial officials regularly disputed accusations about double standards and disinvestment, driven in part by a belief that African health would inevitably improve through an investment in European health.¹³⁴ But there were also more tangible investments in health infrastructure, education, and research.¹³⁵ The new hospitals represented distinctly new kinds of experiences that removed patients from the network of family and friends who formed their therapeutic management group and put themselves in the exclusive care of Western medical experts. The physical and social conditions of the hospital—its construction and organization, the process of patient intake and treatment—reduced individuals to autonomous patients and “abstracted, medicalized bodies” who were transformed “from a colonial subject into a medical subject.”¹³⁶ This never amounted to the kind of “biopower” described by Foucault, but colonial health interventions were consequential in their intrusion into the daily lives of residents. Rules and regulations did result in various kinds of punishment but did not necessarily change practice and weren’t necessarily rooted in reality. But these rules did change the ways in which African bodies and health practices were classified within emerging technocratic fields, which had both immediate and long-term effects for local communities.

RATS AND DISEASE: THE BUBONIC PLAGUE

The plague outbreak in 1908 was arguably the first major test of new colonial and public health strategies in the Gold Coast. In early twentieth-century Accra, medical officers of health like Mrs. M. S. Deacon (1901–1904) pursued numerous public health initiatives that included the preparation of educational materials for schools and the operation of a thirty-man “scavenging crew” that sought to eliminate various forms of “nuisance” in the city.¹³⁷ But, as complaints from townspeople, visitors, and British officials alike attest, these programs had done little to change the shape of the city or the practices of its residents. The kinds of significant interventions that health reformers envisioned were deemed largely impossible in Accra, where local populations and political leaders fiercely resisted changes to the spatial layout of the city and maintained a significant degree of autonomy in its social, economic, and cultural spheres. As we shall see, justifications and strategies for plague prevention overlapped in significant ways with antimalaria campaigns, but the epidemic nature of the disease generated new kinds of urgency both in terms of intervention and investment. When rats and livestock began dying and individuals began falling sick in late 1907, rumors quickly spread among residents that the illness was the result of a “poisoning.”¹³⁸ British officials, however, recognized the signs of plague and requested “expert” assistance from Dr. William John Ritchie Simpson. Simpson was a professional adviser to the government, a professor of hygiene at King’s College London, and a cofounder (with Sir Patrick Manson) of the London School of Tropical Medicine. But Simpson was also a self-made expert on plague control, having worked on India’s plague outbreak in 1896 and followed the disease as it spread throughout the British Empire in the late nineteenth and early twentieth centuries.¹³⁹

Simpson represented an interesting bridge between older miasma theories and new breakthroughs in bacteriology and immunology. Medical research offered few insights into the prevention, treatment, and cure for plague in the early twentieth century, and Echenberg argues that “public health officials trying to cope with outbreaks between 1894 and 1901 were hardly better equipped than their pre-germ theory predecessors had been either to establish causation, or more important, to treat plague patients.”¹⁴⁰ Simpson’s own Treatise on Plague, originally published in 1905, reinforced statements by the British India Plague Commission (of which Simpson was a leading member) that identified the source of plague as “unsanitary conditions of overcrowded human habitations” and pointing to highly unpopular strategies like demolition and construction of overcrowded and infected neighborhoods as the primary effective strategy for halting the spread of the disease.¹⁴¹ By the time plague arrived in the Gold Coast in 1907–1908, however, researchers had recently identified the flea as the primary transmission vector for the bacteria Yersinia pestis. Simpson thus arrived in the Gold Coast armed with the most recent medical knowledge, older models of European public health measures, and racist and colonialist stereotypes about non-Western peoples. Like many other medical practitioners, Simpson continued to evoke the dangers of human-to-human transmission and miasma explanations of causation through his plague control measures. Despite being widely embraced as a field manual for the colonial service, the strategies outlined in his Treatise on Plague, which focused on cost savings and expediency, largely ignored the sociocultural issues that such measures would undoubtedly provoke in communities like Accra.¹⁴² Importantly, however, Simpson saw plague measures as an important means through which officials could achieve larger planning goals. Whereas the manual began with “how to” suggestions for plague mitigation—rat kills, fumigation, inoculation clinics—it quickly transitions to more comprehensive strategies for surveying new towns and constructing buildings with appropriate sanitary infrastructure.¹⁴³

And yet, given the dangers that plague posed to both European and African residents and the “serious inconvenience” that quarantine had caused for trade in the colony,¹⁴⁴ Simpson’s arrival was initially welcomed by many who hoped to limit the spread of the disease. Rumors abounded about the origins of the disease and the cause of its spread. The Gold Coast Leader published a detailed summary of some of the public discussions and concerns circulating in the early days of the outbreak:

The Accras, as is well known, are great travellers, most of whom find employment down the coast; and some are known to have been engaged on Railway lines being laid in the Portuguese Colony, where we understand coolies also are employed, and it is probable these have brought the disease from India or China from whom the Accra workmen may have caught it, and that is has thus found its way to Accra. This disease is also said to have visited the French Colony not long ago, but whether German Kratchi, the French Colony, or Benguela is responsible for the introduction of the plague to Accra, it has visited the place and raised the mortality of Accra—ever greater than that of any other town in the Colony—to an alarming proportion, and done much havoc for days before the authorities were aware of its presence. Anyone who knows Accra is aware of two facts namely that funerals are there, a matter of every day occurrence, ranging from two at the lowest to as many as twelve in a day and averaging 6 or 7 a day in Accra town alone, exclusive of Christiansborg; and that as a rule the Accras have more confidence in fetishmen, native medicines, and charms than in European practice, as they never go near the Hospital if they can help it, and only do so as a last resort, seldom appearing to the European Practitioner til native medicines and the fetishmen have signally failed after having been well fleeced by them. We have no information as to the date of the first appearance in Accra, but it was already prevalent and doing its fell work as reported by passengers from Accra by the ‘Burutu’ when they left Accra on the 9th instant.¹⁴⁵

In drawing connections between the relative mobility and cosmopolitanism of Accra residents and the appearance of plague elsewhere in the world, the Fante editors of the Leader were simultaneously expressing an outsider’s assessment of Accra life and connecting the city to networks of imperial labor and trade. Accra’s connection to other parts of the world, both through its role as a port city and trade hub and through its residents’ migration to other parts of the continent, put its people—and, as a result, the rest of the Gold Coast—at risk. However, the newspaper’s editors also argued that the city’s social and cultural practices might help to spread plague. Large crowds gathered at funerals and suspicion of Western medicine could make it difficult to control the epidemic. Danger, it seemed, came from both home and abroad.

Accra was undoubtedly the epicenter of this particular outbreak. However, on arrival Simpson quickly began a tour of the colony to assess the conditions and evaluate the extent of the spread. As he traveled, he spoke to public assemblies, sharing knowledge about the disease, including detailed descriptions of the high mortality rate and the suffering of victims. Containment of the disease required careful quarantine that limited the active connection between rural and urban areas that defined economic, social, and cultural life throughout southern Ghana. Speaking to community leaders in Cape Coast, Simpson stressed the importance of inoculating foreign traders and limiting the movement of carriers and kola buyers coming from infected regions. Individual actions also mattered. Upon the prompting of J. Mensah Sarbah, Simpson recommended a number of key actions that could prevent the spread:

1)Every room, yard and surroundings of a house must be swept daily.

2)All rat holes must be filled up; white wash the inside of houses instead of the outside.

3)All house refuse, and town or village sweepings must be collected outside the town or village, and there burnt daily. Pigs ought not to be allowed to roam about.

4)Rats propagate plague by their leavings, urine, or spittal getting into uncovered food; people must therefore cover up all food. Fleas from rats also spread the plague, a relentless war must be waged against rats, and the more they are killed the lesser the risk of an outbreak.

5)The outskirts of town or village must be kept clean; windows of rooms should be opened for free ventilation.

6)Strict isolation, away from town or village of any one attacked.

Since the smell of fish attracted rats, Professor Simpson recommended that smoking, curing, and keeping of herrings and highly seasoned fish should be in reserved spots outside the town.¹⁴⁶

Many of the recommendations echoed a broader sentiment that the plague was at least partly the result of poor sanitation—namely, the “bad air” and poor water supply in cities like Accra and Cape Coast—which reflected the persistence of older understandings of disease and contagion.¹⁴⁷ But even in relation to rats, these recommendations seemed to misread scientific research about the flea vector and emphasize cleanliness rather than rapid and widespread inoculation.¹⁴⁸ Importantly, however, community leaders also used these sessions as opportunities to make claims to better resources and infrastructural investments. The Tufuhene called for the erection of “public urinals suitable for the tropics” and invited Simpson to return to Cape Coast to inspect the town and make recommendations to government and commercial leaders.¹⁴⁹ As one commentator wrote in the Leader, “What matter, if men, women and children die, not of the plague, but from exposure and hunger. ‘The man on the spot’ has spoken and his word is enough; if any one dare remonstrate, he is put down as an interfering semi-educated nuisance, and he who seeks to serve the public by using the knowledge he received in school is branded a usurper.”¹⁵⁰ In focusing so much energy, attention, and investment on plague cases and deaths, colonial strategies seem to validate “the official on the spot” while simultaneously putting into sharper relief the lack of support for broader community health in non-emergency times and generating new forms of public critique in cities along the coast.

Figure 2.1. Street Scenes, 1955. Source: Photographic Archive, Information Services Office, Ministry of Information, Accra R/2200/8.

Intervention was particularly intense in Accra as a site of widespread outbreak. Before Simpson’s arrival, acting governor Major H. Bryan called on Dr. Quartey-Papafio to help coordinate a campaign to fight the disease, marshaling Ga leaders to collaborate and support government efforts to fight the disease. Despite having been excluded from the colonial medical service on racial grounds, Quartey-Papafio largely agreed with government strategies centered on Western medical research and established public health practices.¹⁵¹ Ga leaders, however, were more skeptical of the possible strategies deployed in fighting the plague, even if they were in general agreement about the urgency of intervention. In January 1908 Bryan formed a Sanitary Committee, which was empowered to “inspect any dwelling suspected to harbor plague, to demolish any house deemed infected, and to quarantine anyone who had contact with the disease.”¹⁵² These new measures effectively sidelined the chiefs in planning or implementing public health measures and created new punishments (jail or fines) for anyone who obstructed or interfered with the work of the committee or its representatives: this created an unprecedented centralization of authority under the guise of protecting the public health from imminent danger.¹⁵³ The Sanitary Committee immediately began work fumigating infected houses and attempting to demolish abandoned or dilapidated structures but were immediately threatened with legal action by property owners—a form of resistance that echoed ongoing challenges around urban planning and sanitation reform in Accra.¹⁵⁴ Unable to make direct interventions in the physical space and structures of the city, the Sanitary Committee quickly changed strategies, isolating patients and transporting them out of heavily populated areas via armed guard. Held in leg irons with mentally ill patients in the asylum in Victoriaborg, patients and their families were unsurprisingly outraged by the treatment they received. Kojo Ababio, the chief of James Town, gave the Sanitary Committee a piece of open land at Korle Gonno, which served as a quarantine site for those who had been in contact with sick patients. Ababio’s actions, however, reflected more than a mere desire to support public health. Chiefs in Ussher Town protested that Ababio had used the situation to make a claim for the land at Korle Gonno—a contestation that continued to reverberate throughout the epidemic and beyond.¹⁵⁵

Simpson arrived in February armed with a two-pronged approach: widespread vaccination and demolition. Simpson’s plan to demolish the old quarters of the city was met with immediate resistance, despite Quartey-Papafio’s support as a son of Ussher Town. The Sanitary Committee agreed that a portion of Ussher Town should be evacuated, and the committee held a meeting with the Ga Manche in which the chiefs and people exhibited “unfriendly distrust.”¹⁵⁶ As Roberts recounts, “When Quartey-Papafio led the Sanitary Committee into the neighborhood to destroy infected houses, the residents stoned him and forced his team to retreat.”¹⁵⁷ Colonial officials’ theories about the role of “fetish priests” in the uprising seemed to ignore other forms of discontent connected to the public health initiatives, including the ongoing contestation over land at Korle Gonno.¹⁵⁸ While Simpson backed off from some of his most aggressive plans, the committee made clear that “what was then being asked of them might afterwards have to be forcibly carried out, if the disease any more got worse.”¹⁵⁹ When residents who were asked to aid in the construction of temporary housing were slow to provide assistance, the Ga Manche himself had to threaten to charge the chiefs and people for the cost of using prison labor.¹⁶⁰

The mass vaccination campaign found a much more receptive audience in Accra. British and Ga leaders alike, including the governor and his wife, the colonial secretary, and the Ga chiefs, received their vaccines at a public event to highlight their safety and encourage public participation.¹⁶¹ By the end of the campaign, nearly all of Accra’s population had received a dose of Haffkine’s prophylactic. While Simpson and other colonial leaders viewed the successful vaccination as a triumph of Western medicine, Ga residents likely embraced vaccination because of its similarities to ritual scarification, which sought to protect the body from spiritual forces, or variolation, a long-standing practice among local healers that introduced small amounts of contagion directly into the skin of patients in order to generate immune response and protect against infection.¹⁶² Importantly, however, vaccination also cost residents little in comparison to the demolition exercises.

In the tightly knit Ga community, residents who witnessed their neighbors’ houses marked for demolition or their belongings burned would have been understandably skeptical of the plague-fighting strategies. Their concerns were also rooted in a much deeper suspicion about Simpson’s plans to use demolition to pave the way for a new reordering of city space through segregation.¹⁶³ In advocating for quarantine and segregation as a strategy for plague prevention, Simpson was drawing on strategies that predated germ theory by centuries.¹⁶⁴ Segregation was a familiar concept in Accra. In 1901, Governor Matthew Nathan had declared his intention to segregate white populations from their Ga neighbors due to concerns over sanitation and health: inspired, in part, by new studies about the mosquito vector for malaria that viewed African neighborhoods as “native reservoirs” of disease.¹⁶⁵ Nathan built new colonial offices and bungalows near the Danish fort of Christiansborg and the new European community of Victoriaborg, a significant distance from the old Ga town, surrounded by open land and scenic vistas, free of perceived contagion and separated by a buffer or cordon sanitaire. Importantly, this move also redirected investments in sanitary infrastructure and public works away from the old Ga quarters of Kinka, Nleshi, and Osu and toward new European communities.¹⁶⁶ In doing so, Nathan and others were inspired by changes in the medical understandings of disease that had accelerated by the end of the nineteenth century.¹⁶⁷ These strategies sought to avoid disease, but they also sought to “segregate the governors from the governed” and to secure more amenable vistas to support the morale of European officers.¹⁶⁸ Buffer zones constituted a “line of hygiene” that was one of the “boundaries of rule” in colonies like the Gold Coast, which reinforced the ways that emerging practices of public health were deployed as a “special form of governance” that could regulate the circulation of objects and people that were considered different and, thus increasingly, dangerous.¹⁶⁹ But distance could not completely eliminate interaction and movement. European officials, merchants, and missionaries challenged rigid residential segregation models and continued to live in and engage African communities to fulfill their responsibilities, and African residents regularly moved between these different areas for work and trade.¹⁷⁰ The experience of the segregated city in Accra, in other words, more closely followed the model of many West African cities, which had distinct areas for foreigners who settled for trade or other activities but still engaged in the life of the town.¹⁷¹ When Simpson arrived in Accra, he was impressed by Nathan’s work to segregate the city and pushed Governor Rodger to further reinforce the distance between European communities and African quarters that he judged to be congested and unsanitary.¹⁷²

By the time the plague was contained in December 1908, the Gold Coast had recorded 344 cases with 300 deaths; in Accra, 250 Africans died, and no Europeans were infected.¹⁷³ Despite the varied success of these strategies, Simpson leveraged his experience and professional credentials to push for further reforms to the town’s infrastructure, spatial organization, and sanitation. Simpson’s report described Accra as an “exceptionally healthy site” that was in “deplorable sanitary condition.” Congestion, poor housing, narrow streets, and disordered neighborhoods created opportunities for rats to hide and were breeding places for mosquitoes. Drainage was terrible, markets were filthy, and the water supply was deficient. Importantly, Simpson noted that the Accra Town Council had failed in its sanitary responsibilities—there was insufficient staff and the medical officer of health and other councillors were too busy to properly attend to sanitary matters.¹⁷⁴

Even in the aftermath of the plague, memories of the sickness and death it caused continued to motivate officials to reform sanitation and health services, guided by Simpson’s report. In the years immediately following the epidemic, the British government made new investments in water, sewage, housing, mosquito control, and infrastructural development and increased funding for the Public Works Department.¹⁷⁵ The process of reconstruction began in 1908 with compensation for landowners and a surveying of the town. And then a plan for the reconstruction of the port area of James Town and Ussher Town was drafted that called for wider boulevards and roads.¹⁷⁶ The government formed the Accra Improvement Committee in 1908 to consult with the governor on strategies to improve the town.¹⁷⁷ The government constructed new streets, hospitals, and permanent housing projects in Korle Gonno and Adabraka. The health branch was established in 1909 as a direct result of the plague epidemic, which institutionalized public health as a key component of governance.¹⁷⁸ But this energy and investment was short-lived. As a result of the costs associated with the plague, the Accra Town Council faced increasing pressure to collect revenue.¹⁷⁹ Ten years later, British observers noted that the towns between Accra and Winneba “are now in a much worse condition than they were before Professor Simpson visited them in 1908,” and the Accra Town Council was regularly criticized for its perceived failures in providing for the sanitation of the town.¹⁸⁰ Segregation and slum clearance activities, which were accelerated during the plague further reinforced inequalities in sanitary investment, made congestion and squalor worse, and reinforced government calls for even more demolition.¹⁸¹ While Simpson’s specific recommendations for Accra may not have been implemented with a great deal of lasting success, his broader strategies influenced policy within the Gold Coast and across the British Empire as a new model for town planning, motivated by fears of contagion and rooted in the principles of segregation.¹⁸²

WHITE MAN’S HUMBUG: MOSQUITOES

While the urgency of the plague epidemic prompted prompt action and concentrated intervention, plague mitigation strategies and public health policy in Accra emerged in conversation with much older attempts to address the threat of endemic tropical diseases. The “fevers” that had long decimated European populations in the “white man’s grave” presented significant challenges to British officials seeking to consolidate and extend colonial authority in the Gold Coast. In the 1890s new tropical disease experts like Patrick Manson and Ronald Ross established the importance of the mosquito vector in propagating a wide range of tropical diseases, from elephantiasis and dengue fever to malaria and yellow fever. Like the plague, these fevers presented enormous health risks for European residents and, being conveyed through an insect, it presented similar kinds of challenges for those seeking to eliminate the threat. In attempting to prevent the disease, public health officials drew on emerging theories and models of urban planning that flourished in the late nineteenth century: if you could not cure the disease, you could mitigate the threat by attacking it at the source—waging a war on mosquitoes through the reconfiguration of city space and urban living. Importantly, however, mortality rates for African residents with mosquito-borne diseases like yellow fever and malaria were significantly lower. Individuals were often infected in infancy and, while this did contribute to a high infant mortality rate in Accra and throughout the southern Gold Coast, those who did survive maintained some form of immunity that, in most cases, protected them from death or serious illness.

These differential disease experiences undermined the kind of social solidarity that characterized much of the public health concern associated with the plague. This obsession with mosquitoes, many Africans argued, was a “white man’s humbug,” even as they acknowledged the high death rates among Europeans resident on the coast.¹⁸³ Even more than the interventions associated with the plague, these tensions over spatial practice and disease through the war on mosquitoes shaped emerging forms, theories, and practices of urban life that cast African bodies as inherently diseased and justified new forms of intervention into urban residents’ daily lives. In doing so, colonial officials often blurred the boundaries between “sanitation”—often a highly cultural matter—and “medicine” under the broad umbrella of “public health.” By the early twentieth century, sanitary officials, medical officers, and town councillors focused extraordinary amounts of energy and resources on the elimination of mosquitoes and the mitigation of mosquito-borne diseases. These efforts were organized around three major approaches: residential segregation, larva inspections to prevent breeding in domestic water supplies, and interventions in the built and natural environment to prevent breeding in ponds, drains, puddles, and the Korle Lagoon.¹⁸⁴

Segregation was first proposed by Sierra Leonean physician and medical officer, Dr. J. F. Easmon, in 1893.¹⁸⁵ Particularly after the discovery of the mosquito vector, a wide range of medical experts advocated segregation as a way to protect Europeans from Aedes Aegypti (which spread yellow fever) and Anopheles (which spread malaria). Governors Maxwell (1895–1897) and Hodgson (1898–1900) refused to implement segregation strategies in Accra out of concern that it would provoke strong resistance among African residents. However, in 1901 Governor Matthew Nathan embraced segregation as an official government policy, building bungalows in newly developed European residential areas in Victoriaborg and Ridge, separated by a buffer zone a half mile east of the African sections of town.¹⁸⁶ Nathan argued that African bodies and homes were “native reservoirs” of disease that must be separated from that of European officials, who did not have the same kinds of immunities that resulted from adaptation to tropical climates. As he noted to Ronald Ross, “There are many times as many Europeans here as in any other West African colony, and that, though I don’t undervalue sanitation for natives, I fear they themselves do. Improvement in the health of Europeans is absolutely the first desideration for general improvement in these colonies.”¹⁸⁷ Public health, it seems, was actually about protecting European health.

While Nathan waited for construction to begin on the new European neighborhoods, he also sought to clean up the city, reactivating dormant portions of the Towns Police and Health Ordinances of 1878 and 1892, which “compelled house owners to clean unsightly premises and provided the government with direct authority to appropriate private property for street widening and drainage.” He also expanded the powers of the governor further through the Towns Amendment Ordinance of 1901, which “allowed the governor wide powers to expropriate private property where needed for any public purpose.”¹⁸⁸ Nathan and his successor, John Rodger (1904–1910), used these new powers to condemn and demolish buildings in African neighborhoods, paving way for a sanitary cordon or buffer zone that would surround European residential districts.¹⁸⁹

These policies provoked resistance from a number of quarters. Officials initially refused to compensate householders who were evicted, prompting protest from both individual residents and African organizations like the Aborigines Rights Protection Society. For elite Africans, segregation seemed to exacerbate racial tensions that had been growing throughout the late nineteenth and early twentieth centuries, undermine the class and social solidarity they often expected from European officers, and limit their access to the benefits and opportunities associated with colonial development.¹⁹⁰ But European residents also bristled under the new segregation scheme, which created false separations between European officials who were allowed to work in the city during the day but were expected to return to their homes the newly constructed residential districts at night.¹⁹¹ In practice, many merchants, missionaries, and officials continued to live in the old town, continuing centuries of social and spatial culture, while Africans moved back and forth to the new official districts for work. Complete separation was impossible. When Hugh Clifford became governor of the Gold Coast in 1912 he quickly eliminated the formal practice of segregation and actively resisted the formal imposition of a “quarter-mile rule” for residential segregation in British West African cities; he argued that “even if complete segregation of European habitations on the Gold Coast could be affected at moderate cost, the European dwelling in them would not thereby be rendered immune even from mosquito borne disease. No European in this country can exist without his staff of native servants, who cannot live at a distance of at least a quarter mile from his house. Europeans are required by the exigencies of their public duty to come into daily contact with natives of all ages, and most Europeans have from time to time to make tours through the country, during which anything resembling segregation from the native population is a sheer impossibility.”¹⁹² But, importantly, he asserted that the policies also provoked active resistance from African residents who were being asked to fund public works from which they would receive no obvious benefit. Instead, segregation seemed to further exacerbate the imbalance in investment and enforcement through policies that were informed more by racial stereotypes than actual scientific evidence.

Mosquitoes and mosquito-borne diseases, however, remained a persistent problem. In 1913, the Gold Coast Nation reported that a “Wesleyan Sister” had died from fever in coastal towns and used this death to renew calls for addressing mosquito problems in Cape Coast and Accra. The city’s leadership was disgraced by “unsatisfactory drainage of the capital” and the “drains, pools, and swamps of Accra and its swarms of mosquito.”¹⁹³ In publicly calling for greater intervention through these cases, African newspaper editors and other African elites contributed to a growing conversation about the public threat of mosquitoes, even if that threat was primarily seen as one centered on European residents. The threat of endemic disease and the failures of other health interventions to significantly alleviate the risk associated with mosquito-borne diseases justified increasing levels of intrusion by government into the private spaces of African residents in Accra. As early as 1901, sanitary inspectors organized through the Health Department were empowered to check compounds for larvae. Amendments to the Towns Ordinance in 1904 further empowered the ATC to “carry on the war to death against the noxious mosquito” and again in the 1911 Destruction of Mosquitoes Bill.¹⁹⁴ This 1911 bill crystallized long-standing practices and expanded the authority of the inspectors over an unprecedented swath of public and private spaces. The medical officer of health or their appointees were granted the authority to enter any property between 6 a.m. and 6 p.m. to inspect for larvae, and owners and occupiers of “premises” were subject to prosecution and fine if inspectors found larvae or otherwise unprotected water sources on their property.¹⁹⁵ Vague guidelines in the bill, however, led to arbitrary and capricious enforcement. Sanitary officers were “known to rudely invade the privacy of people and search about among their belongings as if they were suspected of having done something wrong,” causing offense to householders.¹⁹⁶ Community members questioned the respectability and qualifications of individuals appointed to positions as sanitary inspectors and other public health positions by the MOH as “scavenger[s] or . . . common laborer[s],” particularly when their authority was backed by the sympathy and power of the courts.¹⁹⁷

These inspections constituted “one of the most frequent contacts between rulers and ruled in Accra,” and African larvae inspectors were extremely unpopular.¹⁹⁸ Residents questioned whether the inspections were even effective, particularly as puddles and drains in public spaces remained, and rules were rarely enforced in European residential areas until the ordinance was extended to cover those areas in 1930.¹⁹⁹ As Newell notes, the materials found in typical African compounds were less likely to collect water in significant quantities compared to the garbage produced by imported European goods.²⁰⁰ And yet, over one hundred thousand inspections were conducted every year in Kinka, Nleshi, and Osu. Every year, sanitary authorities reported detailed numbers—how much brush was cleared, how many bottles were collected, how many puddles or drains were filled or treated.²⁰¹ It’s unclear whether the inspections were effective, particularly given the lack of enforcement in European quarters and, as we’ll see, the government’s inability to address the Korle Lagoon. Rumors circulated that the monies collected through fines were used to pay the inspectors’ salaries or contribute to the upkeep of the Town Council, encouraging additional prosecutions.²⁰²

These rumors were rooted in Accra residents’ deep suspicion about the effectiveness of inspectors, viewing sanitation as “nothing but an instrument of oppression and device for affording opportunity for a number of Government officials to lord it as tyrants over them.”²⁰³ The constant flux of policies and plans raised questions about the efficacy of colonial strategies and the science behind their claims. “Nuisances,” it seemed, were a particularly “urban” phenomenon, and commentators wondered whether this was a real concern for the broader public or a particular investment in European health.²⁰⁴ In the 1920s, the Town Council hired special “mosquito brigades,” a new class of sanitary inspectors who operated like a quasi-police force responsible for monitoring the habits of residents and whose work was rewarded with relatively lucrative salaries and opportunities for advancement within the colonial service.²⁰⁵ These brigades were reviled for intruding into “women’s spaces,” destroying personal property unnecessarily, and violating sacred objects.²⁰⁶ Inspectors contaminated water used for cooking and drinking by using ladles in multiple vessels without proper cleaning.²⁰⁷

African town councillors brought their constituencies’ concerns to ATC meetings, noting that “in many instances the officers did not understand the language of the people and consequently their instructions could not be intelligently followed, with the inevitable results that [women in the house] were often committed for nuisances or such like offences.”²⁰⁸ Summonses, Kitson Mills argued, seemed to be issued “indiscriminately” against offenders.²⁰⁹ Akilagpa Sawyerr asked “whether some steps should not be taken to ameliorate the condition of the people brought before the District Magistrate every week for sanitary offenses.”²¹⁰ In response, the medical officer of health insisted that he had received no such complaints. But the constant stream of prosecutions and the various derogatory nicknames that residents gave inspectors and the courts in Accra and other districts reinforced these complaints. The district magistrate in Accra saw so many residents brought up for sanitary offences related to mosquito larvae that women in the city called in the loloi court. These realities were certainly not unique to Accra—techniques and strategies related to mosquito mitigation and public health expanded throughout the colony and across British West Africa. The chief commissioner of the Northern Territories noted that people in Tamale referred to the MOH and his staff as “summa summa” (“summons summons”).²¹¹ In Lagos, African sanitary inspectors were called wolé wolé in Yoruba and were greatly feared.²¹²

As observers noted, high rates of crime in urban areas were often less the result of actual crime and more the consequence of ineffective sanitary inspection strategies.²¹³ Town councillors and newspaper editors alike called for more extensive public education—punishment served only to criminalize the practices of African residents and did little to actually change behavior. As Akilagpa Sawyerr noted, “Sanitary Inspectors should make health suggestions to the people so as to dispel their ignorance instead of dragging them before the district magistrate every time.”²¹⁴ The goal, it seemed, was not actually to correct unsanitary habits but to maintain the constant stream of prosecutions and fines.²¹⁵ In resisting these calls to critically reflect on their practices, medical experts highlighted that the point was not really to “improve the situation” after all.²¹⁶ By 1926, an Accra editorialist noted that “education may have been lacking, but coercion was not; thousands of householders were fined every year.”²¹⁷ Nearly twenty years later, “Buyer” wrote to the editor of the Gold Coast Leader described the one hundred people being prosecuted for having larvae in their compounds at district commissioner’s court on June 15, 1942: “The worse of it was that the poor people who can scarcely earn one-penny for their living were all fined on the average one pound each. These poor women had each, one empty kerosene tin for water every morning, but as soon as they bring the water into their houses there appeared the Sanitary Inspectors who at once issued summonses against them.”²¹⁸ These prosecutions were not advancing public health, these commentators argued.²¹⁹ They were criminalizing the most mundane and essential details of everyday life, transforming women (and men) cooking and cleaning in the compound into criminals who violated the safety and security of the public.

YELLOW JACK: “THE YELLOW FEVER BOGEY” AND EUROPEAN DEATH

While malaria arguably received outsized attention from medical researchers, yellow fever provoked fear among colonial officials. The Ae. Aegypti mosquito, which carried yellow fever, caused a disproportionate number of deaths among Europeans in the Gold Coast and prompted what Patterson describes as “draconian measures” to mitigate its threat.²²⁰ Health officials regularly reported the clinical details of all documented yellow fever cases back to the Colonial Office, individual British officers were instructed to put screens on their windows and sleep under mosquito nets, and various levels of government imposed segregation and larval control measures as part of broader mosquito control strategies. When a yellow fever outbreak (twenty-four reported cases) was discovered in Sekondi and Accra, as well as in other West African colonies, in 1910–1911, the Colonial Office quickly dispatched a Yellow Fever Commission led by Sir Rupert Boyce to West Africa. Boyce, a pathologist and one of the founders of the Liverpool School of Tropical Medicine, had become a yellow fever specialist, having led government investigations in the West Indies in 1909. Boyce quickly established rigid quarantines, evacuated Europeans from infected areas, and waged a vigorous campaign against the Ae. Aegypti larvae by fumigating official buildings and European bungalows with sulfur. Of the twenty-four reported cases, seventeen were European. Sixteen Europeans and three Africans died from the disease.²²¹

Recurrent yellow fever outbreaks in 1913 and 1915 highlighted that conditions had not significantly improved since Simpson’s visit—widely viewed by British officials and leading African figures alike as a watershed moment in the history of public health in the Gold Coast.²²² For Accra residents, however, the government’s approach to yellow fever also further highlighted the inequalities of access and resources related to public health and raised questions about the true intent of these initiatives and the legitimacy of the science that informed them. Some cases of yellow fever resulted in quite mild symptoms that could be difficult to identify, so the Yellow Fever Commission advocated “all cases of fever should be carefully observed and classified in order that so far as possible, such mild cases of yellow fever may not pass unrecognized.”²²³ In the absence of an effective clinical test that would allow researchers to identify yellow fever cases, yellow fever remained a threat and “an offense to the comity of nations.”²²⁴

These realities, however, also presented alternative possible responses. In 1911, prominent African physicians F. V. Nanka-Bruce and C. E. Reindorf published a series of articles in the Gold Coast Leader arguing that official positions that excluded African physicians further endangered the public: “As medical men, although not officially entrusted with prophylactic duties much good may be done by us in the promotion of hygiene, because all sections of the [community] can approach us and do approach us in such times of distress for the obvious reason that we are black. Up to the time of writing we have not as yet received any official notification of the above mentioned outbreak excepting of course the yellow jack at James Fort.”²²⁵ The physicians argued that involving private African practitioners would allow them to better support public health initiatives, care for their patients, and learn from the latest scientific and medical research. But these articles also provided important perspectives on African reception to healthcare. As they noted, the Dispensary “offers better opportunity of discovering low forms of infection amongst natives than the absurd practice of sticking thermometers in the mouths of the apparently healthy . . . especially when rejected cases are not followed up or isolated.”²²⁶ These practices violated African understandings of health and raised suspicions among women and children who “began to make fun of the ‘whiteman’s juju.’”²²⁷ But it also actively undermined the professional qualifications of these trained physicians. Sending out inspectors of nuisance with limited training to oversee vaccination clinics was an affront when qualified physicians were available in the same town and who later had to treat vaccinated patients who developed infections from improper vaccination. The insistence of “official” control undermined the health of everyone when underqualified individuals confused symptoms or provided improper treatment. A lack of clear authority and organization within the medical and sanitary departments further complicated matters. Things had not improved significantly by 1913, when a misdiagnosis of Mr. J. E. Acquah led to what editors of the Gold Coast Nation called “yellow fever panic.” Lack of clear guidelines led to a waste of funds and enormous inconvenience; medical officers, they argued, should “hold themselves in check when tempted to go to undesirable lengths in reporting cases that come under official notice.” Moreover, these “professional errors” appeared to follow a pattern of overreaction, which was dangerous to African residents who were “sacrificed” due to medical mistakes and fear-informed judgment.²²⁸ What the governor applauded as “prompt measures adopted by the Sanitary Department [that] has caused the disease to be stamped out before it has succeeded in claiming more than a very few isolated victims” was interpreted very differently by those who were less susceptible to the disease but aggressively targeted by prevention efforts.²²⁹

Larval control measures were extremely unpopular among Africans. Some of those complaints about “mosquito propaganda” echoed the broader concern about the unequal standards, overreach of sanitary officials, excessive prosecution of poor residents, and the effectiveness of mosquito control measures like segregation—a “policy of coercion evidently founded upon a plague bogey in which the people have no faith.”²³⁰ In 1913 African Legislative Council representative Hutton-Mills voiced the frustration of a wide range of his constituents when he argued that “the recurrence of yellow fever evidently shows that there is fault somewhere and clearly the fault lies on some body or person and is not due to lack of funds. With the increase of the European Medical Staff—I emphasize the word ‘European’—Accra, as the capital of the Colony should not be allowed to remain in its present disgraceful condition any longer, nor should the Europeans be taken away from the town and new quarters provided for them elsewhere from the revenue obtained from the natives.”²³¹ Quarantines for yellow fever certainly disincentivized Africans to report the disease, but popular African opposition was also rooted in a skepticism about the dangers of yellow fever.²³² In the midst of the 1913 outbreak the Gold Coast Nation published an article calling for reverse segregation—removing the remaining Europeans from the African town “on the grounds that they were carriers of the disease.”²³³

Even as general health improved, investment in health and medicine continued to increase in the interwar period, inspired in part by both the growth of the European population and ongoing fears of yellow fever.²³⁴ Yellow fever outbreaks garnered interventional attention. The Rockefeller Foundation sent a team to visit West Africa in 1920 and followed with a larger group five years later. But it was new vaccine developments that finally ended the threat of the endemic disease. In 1930 the discovery of a vaccine for yellow fever made it possible for researchers to conduct their work. By the late 1930s, mass vaccination was possible, ending the “yellow fever menace.”²³⁵

“THE LAGOON IS A MOSQUITO PROBLEM”: MALARIA AS A UNIVERSAL DISEASE

If yellow fever only really presented a serious risk to European residents, malaria was considered a more universal disease that called for a universal remedy. As the homeopathic doctor John William Hayward noted in an address to the Africa Trade Section of the Liverpool Chamber of Commerce, “Malaria and malarial fevers are of the same nature and require much the same treatment wherever they occur, whether in Africa, India or America. In each region they own the same cause: put on the same general characters of intermittent, remittent, or continued, run the same general course, and require much the same remedial measures.”²³⁶ For Hayward, this reinforced the importance of training for physicians who would treat malaria, but it also pointed to a broader attitude in scientific communities about the treatment of diseases deemed to be “universal”—universal treatments did not require local knowledge. Hayward, who had never been to the Gold Coast, felt just as qualified to speak on the conditions there as anyone else.²³⁷

While yellow fever and plague generated hysteria among public health officials, Patterson argues that “malaria is, and has been for centuries, Ghana’s most devastating disease.”²³⁸ Transmitted by the female anopheles mosquito, malaria is the result of infection from one of four types of protozoa, all of which are present in Ghana. Because treatment was similar for all four, however, physicians and clinicians rarely tested for type. Many infants in the Gold Coast were infected soon after birth due to the prevalence of mosquitoes: as a result, there were high infant death rates in cities like Accra. However, children who did survive into adulthood would have some degree of resistance which largely protected them from death or extreme illness.

Europeans who had not built up the same kind of resistance were not similarly protected. British doctors had been using quinine to treat malaria by the mid-nineteenth century, but it was not widely used as a prophylactic. Nineteenth-century tropical service understood malarial fevers as the product of “poisonous vapors” that resulted when strong sunlight or heavy rains reached “decaying vegetable matter.”²³⁹ Ronald Ross’s 1898 discovery of the mosquito vector “not only revolutionized the study of tropical diseases, but endowed ‘tropical sanitation’ with scientific status as a means of malaria prevention.”²⁴⁰ Colonial officials were required to screen their houses and sleep under mosquito nets, but Ross argued that the government should adopt a more comprehensive strategy: (1) treatment, (2) prophylaxis, (3) control of mosquito larvae, and (4) control of adult anophelines.²⁴¹ Inspired in large part by the work of Dr. Walter Reed and Dr. W. C. Gorgas in Cuba, Ross argued that effective management of malaria required extensive investment in drainage and larvicide. But colonial officials, who were reluctant to spend too much money in West African colonies adopted the more cautious approach advocated by Patrick Manson, which emphasized individual hygienic precautions like mosquito proofing and preventive quinine treatments. Officials were certainly correct that it would be nearly impossible to destroy all mosquito breeding places in tropical areas; but, as Ross pointed out, the more cautious approach of the Colonial Office would provide protection for Europeans but leave the masses completely unprotected.²⁴² Segregation and uneven investment, instead, followed a broader pattern within public health strategies that defined the twentieth century.²⁴³

Malaria, like plague, defined the careers of tropical medicine specialists. Patrick Manson became the medical adviser to the Colonial Office in 1897 and became the head of the new London School for Tropical Medicine in 1899.²⁴⁴ Ross launched a major medical expedition to West Africa in 1899, which raised his profile throughout the region as the “distinguished and gallant Major.”²⁴⁵ Liverpool and London merchants likewise invested heavily in research to prevent and treat malaria in the late nineteenth and early twentieth centuries. But this new research on “blood-based diseases” often reinforced British stereotypes about a “homogenous and bad-blooded ‘native,’” justifying segregation and other spurious public health policies on racial grounds and directly shaping the politics and practice of town planning in West Africa²⁴⁶—what Newell calls the “haemo-political turn in imperialist rhetoric,” in which epidemiological evidence seemed to justify racial discrimination in colonial policy.²⁴⁷ These new forms of scientific research transformed African bodies and nearly every part of the daily life of residents in cities like Accra—cooking, cleaning, bathing, going to the toilet, disposing of waste—into a threat that required regulation and mitigation.²⁴⁸

Ross and other tropical medicine specialists like Dr. M. Logan Taylor consulted with colonial officials and provided “proper” training for sanitary officials on how best to drain or fill puddles and potholes that might provide breeding spaces for anopheles mosquitoes. Government living quarters were mosquito-proofed and the Accra Town Council hired a thirty-man scavenging crew supervised by Mrs. Deacon, one of Ross’s protégés. The Town Improvement Committee sought to advance “proper methods of individual hygienic protection” in the name of public health.²⁴⁹ The new strategies that Nathan advocated, however, were almost immediately criticized by African political leaders in towns throughout the Gold Coast as an attempt to introduce new forms of racialization and transform the colony into “the Land of Fines.”²⁵⁰ Colonial officials and medical researchers were also disheartened by early efforts, which had limited success in eliminating mosquitoes and thus required constant treatment.²⁵¹ New strategies—the introduction of “millions” (cyprinodont) fish, and new medications and treatments, such as homeopathy—began appearing in Gold Coast newspapers.²⁵² And yet, as early as 1901, the death rate among Europeans had already begun to fall. In 1903 Governor Rodger attributed the 50 percent reduction in European death rates to the public health efforts of his predecessor Nathan. However, Roberts and others argue that it was unlikely any of the public health strategies associated with mosquito control were responsible for these improvements. Rather, the widespread availability and use of quinine as both a treatment and a prophylactic and the standardization of quinine doses was more likely responsible for the improved mortality rates.²⁵³

Uneven results from malaria prevention efforts often did little to dissuade colonial officials as to the effectiveness of “professional” recommendations. A visitor to Accra in 1913 “came to Accra to experience much trouble from mosquitoes. During my stay . . . I never enjoyed a sound sleep.” The visitor’s experience highlighted through first hand experience the contradictions of colonial policy. As he argued, “Those posts seem to have increased tremendously in spite of all the action of the famous Mosquito Brigade. A fruitless expenditure of energy, eh? And of money too, eh?”²⁵⁴ Other African residents readily critiqued the “liberties” that Town Council officers took with such mundane objects as swish collected for building, and they protested the seemingly constant expansion of the category of “nuisance,” through which town councillors sought to regulate daily life in the city.²⁵⁵

Accra residents did not protest the elimination of mosquitoes per se, but they did readily recognize that the methods and justifications for antimalarial and antilarval strategies often did not line up in obvious ways. For Accra residents and Gold Coast intellectuals, mosquito campaigns raised questions about just governance, taxation, and representation. As we saw in chapter 1, colonial officials often readily dismissed African residents’ and town councillors’ petitions and proposals for infrastructure that called for modern public services. They were, however, much more responsive to a “mosquito point of view.”²⁵⁶ Effectively eliminating mosquitoes required the reconfiguring of public spaces and the maintenance of infrastructure—responsibilities that produced their own politics and required negotiations between the colonial government, the Town Council, and Ga spiritual and political leaders. But colonial officials and town councillors alike also used the “mosquito problem”²⁵⁷ to justify regulations that allowed sanitary inspectors and other Town Council representatives increasing authority to intervene in private, domestic spaces of all town residents, backed by the power of the courts.

These tensions and contradictions were perhaps best embodied by the ongoing struggle to address the “mosquito problem” in the Korle Lagoon. Colonial officials had long been suspicious of the lagoon as a “reservoir of miasmatic gases” that caused the deadly tropical fevers that killed so many European officials. As early as 1877 colonial medical reports blamed contamination in the lagoon on local Ga residents. Ross’s discovery of the mosquito vector transformed discourses about the lagoon; while it was now reviled as a mosquito breeding ground, Accra residents continued to be blamed for the condition of the site.²⁵⁸ For Ga people in Jamestown and Ussher Town, the Korle Lagoon, which bisected the city, was not only a source of fresh water and food but also a site of spiritual significance.²⁵⁹ Colonial technocrats, however, saw an opportunity. As Accra grew in importance as a port city during the cocoa boom, colonial officials launched a plan in 1919 to dredge the lagoon and transform it into a deep-water harbor. However, the project quickly ran into problems as the rights to the land and its proceeds were contested—a fight that dated back to Kojo Ababio’s “donation” of land in Korle Gonno in the midst of the plague epidemic. The case was tied up in colonial courts for years as subchiefs in Ussher Town and the priests of Korle fought over who had rights to land and fees in the lagoon. The contractor ultimately abandoned the project.²⁶⁰

Despite these failures, medical officers continued to push the government to address problems with mosquito breeding in the lagoon throughout the 1920s. The marshy shores of the lagoon provided a particular threat to antimalarial efforts. Government engineers and public health officials implemented a number of different solutions to improve conditions in the lagoon, building channels and gates and oiling the lagoon waters; however, the channels soon silted up, the gates washed away, and the oil could not quite reach the marshy edges of the lagoon.²⁶¹ In large part due to the persistent advocacy of Principal Medical Officer Selwyn-Clarke, who viewed the lagoon as the source of a “plague of mosquitoes,”²⁶² the Gold Coast government finally secured funding from the Colonial Office to begin work on the lagoon in 1929. “There can be no question of the lagoon being completely filled in,” Selwyn-Clarke noted, acknowledging the importance of the waterway to the surrounding Ga community. But at the same time Selwyn-Clarke felt that “there can be no doubt that a proportion of the ill-health of the town of Accra results from the presence of marshes chiefly along the eastern margins of the lagoon from the bund on the south of Agbogbloshie, Adabraka, and Kokomlemle to the north.”²⁶³

In preparing the estimates for the project, the acting director of public works argued that reengineering the lagoon was “essentially a mosquito problem” but that engineers would need to also consider how to balance concerns about the smells emanating from the sewage that was discharged into the lagoon from the city’s main water drains. Straightening the banks and deepening the bed of the lagoon would require a delicate balance between health and sanitation, disease and sensibility, sickness and smell.²⁶⁴ In “reclaiming” the lagoon, British officials sought to address both of these challenges simultaneously, taming the dangers of the lagoon through technical and mechanical intervention and the application of engineering and scientific research, turning it into an “artificial lake with level or gently sloping banks free from pools and pot holes and not subject to erosion.”²⁶⁵ Secretary of State for the Colonies Sidney Webb granted the Gold Coast government £195,000 to remediate this “serious menace to the health of Accra” and asked for regular updates on the project.²⁶⁶ Work began, and engineers built a causeway over the sandbar, but—as with the engineering works installed in 1919, these quickly filled with sand and could not be maintained. As colonial officials struggled to manage the financial challenges of the global depression, the reclamation project was eventually abandoned. Looking back ten years later, government officials acknowledged the futility of their efforts.²⁶⁷

By the 1940s Korle Lagoon was once again considered an infamous mosquito breeding ground.²⁶⁸ The construction of a major Anglo-American air base in Accra during World War II once again renewed interest in Korle’s mosquito problem. The British and American scientists who constituted the Inter-Allied Malaria Control Group considered Africans living in the city as a “reservoir of disease that could be cleansed with the help of chemical pesticides.”²⁶⁹ These scientists used Ga residents as experiment subjects, housed in test cabins overnight to attract mosquitoes, as they compiled the Accra Anopheline Index and tested new strategies for addressing the city’s mosquito problem.²⁷⁰ Military authorities were highly critical of previous civilian efforts, arguing that, by the 1940s “malaria control in any sense of the word simply did not exist. Oiling was haphazard, larva inspection had become perfunctory, and there was profuse breeding in the Korle Bu Lagoon, the Klotey Lagoon near Christiansborg, and in small bodies of water all over the city. The colonial medical department cannot even give intelligent advice.”²⁷¹ In response, these new scientists doused the lagoon with larvacides and engaged in a widespread spraying campaign throughout the city—a first in Accra. American reports on the campaign noted that “the application of larvicide . . . was strongly resented by the local native population who associated a high religious significance to these lagoons . . . [but the] natives [were] placated through negotiation by British authorities with the African chiefs.”²⁷² Roberts argues that the reports highlight both the residents’ resistance to the use of chemicals and concern about colonial encroachment on sacred spaces; the report also describes how government officials used indirect rule to curry favor with local chiefs to disenfranchise religious authorities and undermine local politics in the city.²⁷³ Importantly, however, the reports also highlight a shift in public health strategy. If the government had resisted the deployment of larvacides for decades out of fear of local discontent, by the 1940s scientific research trumped any local concerns as long as funding and manpower were available.

CONCLUSION

Despite lofty rhetoric, the reality of public health interventions in Accra rarely lived up to the hype from colonial officers. Concentrated efforts at intervention, as seen in the plague epidemic of 1908 were rare—more like parenthetical moments than sustained processes of hegemony.²⁷⁴ As Roberts argues, “The governors to come would show little interest in massive sanitary projects so long as the white population was relatively free of disease, and there were men like Simpson to put out brush fires like the plague of 1908.”²⁷⁵ But we must also be careful not to take for granted the power of the British colonial state or the predominance of Western medicine in the health and healing of Africans. As recent studies of indigenous medicine and therapeutic pluralism have shown, biopower was always incomplete. That would have been plainly obvious to townspeople who lived with and suffered from the consequences of inadequate infrastructure and incomplete projects.²⁷⁶ These failures were widely debated in newspapers throughout the first half of the twentieth century, and the reports of African town councillors about complaints from their constituents suggest they were also widely discussed and debated in the streets of Accra.

Public health and medical departments largely remained in the “partial paralysis” that Governor Hugh Clifford observed in the 1910s, caught between ever-proliferating public health regulations, the demands and protests of the public, and the realities of insufficient resources.²⁷⁷ In 1915 the editors of the Eastern Star published an indictment condemning the condition of the town and the failure of its Town Council.²⁷⁸ In 1922 African observers noted the “mess at the dispensary” of the acting director of medical and sanitary services and the “conditions obtaining at present at the lunatic asylum,” which were “anything but satisfactory.”²⁷⁹ While the arrival of development-minded Governor Gordon Guggisberg led to more investment in hospitals and a greater focus on African health, these developments did not necessarily translate into more substantive changes in the structures of investment or the prejudices that underlay policy.²⁸⁰ Under Guggisberg, Roberts notes, “The health branch intervened more and more in the daily life of the inhabitants of Accra”²⁸¹ through infrastructure, inspections, and fines. Controlled by British colonial government and the “official” representatives of the Accra Town Council, public health strategies often exacerbated inequalities and justified greater racial segregation without appreciable benefits in actual public health.²⁸² Health and hygiene were not “just metaphors and rhetoric . . . for cleansing and purifying, but were the actual modes and tools of management for colonialism and nationalism.”²⁸³ Investments in African health were an investment in the future development and wealth of the colony, not an inherent good.²⁸⁴

As Roberts has argued, even if the memories of mosquito inspectors, loloi courts, and segregation have faded, the impact of all this is marked on the landscape of a city in which high levels of inequality are embedded in both spatial organization and infrastructural provision. But importantly, these early encounters also shaped the prevailing practices, theories, and models of public health and the role of Africans within them. Colonial public health strategies often reclassified African relationships to urban space and transformed African bodies and spaces into sites of disease and contagion that must be regulated and managed. As Vaughan argues, biomedical interventions created subjects and objects simultaneously, producing a concept of “the African” that made sense to colonial administrators and erased class differences in the minds of Europeans.²⁸⁵ These new constructions of “otherness” were embedded in emerging national, imperial, and international scientific infrastructures.²⁸⁶ The consolidation of colonial rule in places like the Gold Coast coincided with radical changes across scientific disciplines. As Helen Tilley argues, organizations like the Rockefeller Foundation and the League of Nations shaped medical developments in colonies like the Gold Coast in the interwar period, and international scientific congresses connected British colonial officers with other scientists around the world in ways that gave weight to their belief in the universality of their scientific research, despite obvious contradictions and challenges on the ground.²⁸⁷ Scientific concepts often reinforced the priorities and goals of colonial governance and economics, even if said concepts did not lead to actual improvements in public health.²⁸⁸

As numerous scholars of medicine and health in colonial Africa have now demonstrated, Africans were certainly “active agents in the production, application, and appropriation of scientific knowledge,” using medical and scientific research to advance their own agendas and advocate for their own health.²⁸⁹ However, the increasing professionalization and standardization of scientific practice within imperial and international circles had significant consequences for individuals in cities like Accra. Certainly, British technocrats who created and implemented these policies failed to fully understand the dynamism of African cities. And they were never able to successfully control residents’ daily lives in a way that would fully appease European racial ecologies and racialized medicine. And many Africans embraced these policies and the ideologies that underlay them. Even Dr. P. S. Selwyn-Clarke, the once-derided medical officer of health who was criticized for his aggressive approach to public health, was praised upon his departure from the Gold Coast. Newspaper reports argued, “At one time, we did not see eye to eye with Dr. Selwyn-Clarke but eventually what was considered by an ultra-conservative people to be a ruthless and inconsiderate overthrow of their accepted order of things was nothing but an overzealousness on his part for the work for which he came out.”²⁹⁰ But in reducing African practices to “dirt” and “disease,” set in opposition to the “cleanliness” and “health” of Western medical and hygiene practices, public health officials, medical doctors, and other technocrats and officials reduced complex African cultural realities and criminalized long-standing practices, often based on prejudice.²⁹¹

While the archives are not full of reports of open rebellion, the consistent failure of public health strategies is a testimony, in part, to the quiet resistance of Accra’s population: they ignored rules and laws when they were deemed impractical or expensive, thus “playing the game” only when they were forced to.²⁹² While British officials and elite Africans often interpreted this as a disregard for public health, it might just as well been seen as opposition to ineffective or incoherent policies. This was not resistance for its own sake. It was a response by residents to the realities facing their communities. Biomedical interventions failed because they failed to consider the social, political, and cultural context of health. But they were consequential all the same. Per the mandate of the Accra Town Council, sanitation and health remained at the center of everything, foundational to the categorization and regulation of urban life and urban space. Public health increasingly justified town planning, from segregation and slum clearance to suburban development and infrastructure provision.