This chapter reviews the history of medicine in what were the Belgian colony of Congo and the administered territories of Ruanda-Urundi (now Rwanda and Burundi). A problem that many of the chapters in this book tackle, if sometimes indirectly, is what medicine is and who defines it. This question, while already difficult in the context of heterogenous communities in Belgium, is often the central problematic in studies of medicine in the colonies. The disciplinary lens of the scholar often delimits what medicine is. For example, ethnological recordings from the late nineteenth and early twentieth century on indigenous medicine and magic undertaken by men such as Reverends Joseph Van Wing and Karl Laman are often the reserve of scholars focused on anthropological and phenomenological analyses of human experience. Clinical records, as well as administrative records, newspaper reports and official correspondence are mined as more traditional historical data. Works of individuals such as John Janzen and Jan Vansina and, more recently Nancy Rose Hunt, have destabilised such divisions.² Further new methodologies such as the histoire croisée approach also suggest ways to encompass both the historicity and the culturally embedded nature of the object under study, as well as the cultural biases of the researcher.³ Nonetheless, questions of interpretive frameworks, girded by often-unstated disagreements on what constitutes medicine, still vex the history of medicine in the colony. This tension is heightened when scholars of colonial medicine are in dialogue with more Europe-focused scholars of medicine. As observed by Waltraud Ernst, the history of science and medicine in the colony requires different historiographical and conceptual vantage points than ‘Europe-based academics’ to capture the indigenous perspective in the colonial exchange.⁴ Further, because this collection is about Belgian medicine, we focus less here on indigenous medicine, particularly as we do not want to create facile comparisons between the changes in the medical domain occurring in Europe and those in the colony. In other words, to stay within the general theme of the collection (history of Belgian medicine), and to avoid reproducing Eurocentric assumptions about what counts as legitimate medicine to African populations, we limit our discussion to Western medicine, expanding beyond the political economical perspective to address some of the wider issues springing from such involvement, and leave the reader with further readings relating to issues of Congolese, Rwandan and Burundian medical practices. Some of these readings indicate how a shared history of a Belgian and African medicine in the colony has been written, but much more can still be done. This reflects in part the relatively light scholarship in Belgian colonial history in comparison to research in French and British Africa.

A history of medicine in the colony was, not too long ago, only the story of colonial medicine. But colonial medicine was and is often presumed to be many things: Western medicine, medicine of the state, missionary medicine, tropical medicine, public health, notions of hygiene and various imported concepts of disease and health. It is sometimes narrowly defined as the medical services administered by the colonial state, in this case Belgium. Under such a narrow definition, university research projects, missionary hospitals and private European medical care including that of major industries and the like are excluded. The discussion that follows includes medicine that is not specifically administered by the colonial government, in other words the more expansive domain of Western medicine in the Congo and Ruanda-Urundi, as they accompanied the imposition of Belgian colonial rule even if they were often not part of the colonial state. Thus, the following discussion presents what are often uncoordinated efforts by various actors to provide their versions of Western medicine in the Congo and Ruanda-Urundi. These actors had motivations and methods that sometimes overlapped, competed or even clashed. While the Belgian colonial state sometimes attempted to coordinate such efforts, it never truly controlled the heterogenous elements trying to ‘heal’ or ‘sanitise’ the region.

We also must keep in mind that no matter how inclusively we want to define colonial medicine, or even if we speak generally of European medicine, it was the medicine of a tiny minority. The vast majority of medicine practised in the Belgian Congo and Ruanda-Urundi would fall under the realm of what is now called traditional medicine, but what was at the time called ‘sorcery’, ‘witchcraft’, ‘superstition’, ‘empiricism’, ‘quackery’, ‘fetishism’ and the like. Some of the conflicts between popular medicine and state-approved medicine parallel those in the story of the professionalisation of medicine in Belgium, but certainly in degree if not kind, the differences here were much more substantial and wildly incommensurate on the political, social, economic and cultural level.

We have few studies tracing how these West and Central African medical practices were influenced in an epistemological sense by the importation of Western medicine distinct from colonialism more generally. We also know that there was a wilful dismissal of indigenous medical practices by Western medical practitioners. In this limited space, we cannot do justice to the complexities and issues in this domain, although we will briefly touch on ‘where’ indigenous medicine lies in relation to Western medicine. We also observe again that except for the research of a few individuals such as Maryinez Lyons, Nancy Rose Hunt and Jean-Luc Vellut, even Belgian colonial medicine is an underdeveloped field.

All cultures, including those of Central and West Africa, had thriving medical traditions before the arrival of the Europeans.⁵ With the arrival of Europeans, most of this medicine was dismissively lumped into superstitions, witch doctors, fetishes and idols. While a great deal of work has been done in recovering the complexity of indigenous medical practices of the colonial and pre-colonial period, historians of medicine (particularly those who work primarily in the European context) sometimes reproduce in their analysis the historical relegation of such medical practices into the realm of culture. As such, one can imagine that real ‘medicine’ entered a healthcare vacuum. This is grossly incorrect. However, what we can say is that, as Vellut observed, it is really only in the field of medicine and healthcare that there exists ‘so strict a division between the worlds of the colonized and the colonizers’.⁶ Indigenous medicine continued to thrive and was little directly influenced by colonial medicine post-1885. To be clear, it would be strongly influenced by the changes wrought by colonialism writ large, but not by any direct competition with European medicine per se. For example, both the erosion of traditional political authority by new colonial administrations and the juridical abolition of trial by poison ordeal would reconfigure the possibilities for the exercise of traditional medicine.⁷ As Nancy Hunt also reveals in her study of the Congo, a nuanced cultural history can be reconstructed from examining anxieties surrounding what are, in the West, squarely medical topics such as depopulation and infertility, through examination of ‘therapeutic insurgency’ from the Congolese as a response to a repressive biopolitics imposed by a ‘nervous state’.⁸

This chapter focuses on both what is common and what is quite peculiar about the Belgian case in the history of medicine in the colonial context. Belgium was an imperial nation, but this fact was sometimes unnoticed during the colonial era and still is by many Belgians.⁹ This in itself is part of the peculiarity of Belgian colonialism, and shaped Belgian colonial medicine. Political, economic and church interests vested in the Belgian colonies were in some instances freer to shape the colony as they saw fit, outside the interference of a general metropolitan public. The downside of such disinterest, however, included fewer resources from the metropole and a lack of checks on colonial abuses.

As noted in the opening pages of this book (see the Introduction), medical practice and discourse are implicated in identity formation, whether citizen or subject, gender or race. As other chapters in this book have demonstrated, in the metropole they interlinked questions of citizenship and the ‘right’ to health with notions of gender and class. One can debate whether colonial medicine exacerbated this differentiation, or simply followed the dictates of the state. As Shula Marks noted over twenty ago, biomedicine in the colonies ‘played a major role in creating and reproducing racial and gendered discourses of difference’ (see also Chapter 1, pp. 40–7).¹⁰ The Belgian colonies were no exceptions to this general observation. In the Belgian Congo, one could even argue that such discourses of differences were more prevalent than in most other colonial situations. For example, while we have the stereotype of the Frenchman in Indochina or Algeria or Guinea proclaiming of his colonies, ‘C’est la France!’ we think a similar image, under a similar rhetorical imagining, cannot be conjured between Belgium and Ruanda-Urundi/the Belgian Congo. Colonial policies indicate that Rwandans, Burundians and Congolese were not meant to be assimilated as Belgians. Certainly this was true before the Second World War, but even the debut of indigenous identification cards in 1948 still explicitly delimited the non-Belgianness of its carriers: Africans were either colonial subjects or Belgians of colonial status. These lands would never become ‘Greater Belgium’, even if there existed some propaganda by pro-colonialists agitating for the Congo as Belgium’s tenth province.¹¹

The ever-contentious question of the colonial relationship confounds further an understanding of medicine’s role in creating the citizen-subject. In other words, ‘state’ medicine could operate under similar justifications in Belgium or in the Congo, but the dynamic between the state and the subject was fundamentally different. Further, as illustrated in the opening quote, the conceptual gulf between state and subject as to what constituted medicine was also considerably greater. Even the term ‘subject’ attributed to the Congolese must be approached carefully. Congolese under Belgian rule were never citizens,¹² and it was often a stretch to view them as subjects. They were, most commonly, treated as objects. It is generally accepted that among ‘colonial medicines’, Belgium’s version swung towards the more authoritarian and totalitarian end of the spectrum. Congolese, as medical consumers, were often coerced or cajoled rather than persuaded or served.

Belgian colonialism can be roughly divided into three stages: exploration and consolidation (1870–1908), expansion (1909–40) and relinquishment of control (1940–62).¹³ The earliest stage coincides with the establishment of Leopold II’s Congo Free State (CFS) (1885–1908), while expansion occurred during the period when Belgium took the CFS (and what was German Ruanda-Urundi in 1916) and implemented a territory-wide health administration. The period from 1940 onwards represented a sea change in the attitudes of both coloniser and colonised through all colonies in the globe as the assumptions of colonialism became increasingly untenable. In this period, colonial powers had to adjust both their message and their methods to justify control of entire other peoples. In some instances, colonising powers attempted to reestablish power after the disruptions of the Second World War, with widely varying success. Even those successful at maintaining their colonies, such as Belgium, were forced at minimum to appear to be ‘preparing’ their colonies for independence in the post-war epoch.

The beginnings of state medicine under the CFS

Western medicine in the Belgian colonies would ultimately be represented by four main activities: a state-organised medical service, missionary medicine, industrial medicine and research organisations and activities. The administrative structure of the CFS, recognised by the 1885 Treaty of Berlin, was a hasty conversion of a semi-private organisational presence on the ground, the Association Internationale du Congo.¹⁴ These agents were multinational; the colonisation of the Congo forcibly a multinational and military enterprise due to Belgium’s lack of direct colonial experience and insufficient resources at the moment of the creation of the CFS.¹⁵ The CFS itself was not in fact a Belgian colony, but the personal fiefdom of Belgium’s controversial monarch Leopold II. His treatment of this territory (almost eighty times larger than Belgium itself) as a personal domain to be ruthlessly commercially exploited led to some of the most notorious abuses of indigenous populations of the age of high colonialism (in a historical period where abuses were many and shocking). From 1885 until the end of the First World War, the state adopted measures drawn from the model of public health in Europe (sanitary cordons, lazarets, quarantines and so forth) but quickly realised that they were unsuited to the health situation in Central Africa.

State medicine, as introduced in the nineteenth century, overlapped considerably with military medicine. Medical doctors often served as integral parts of initial exploratory expeditions, mainly to ensure the health of expeditionary forces.¹⁶ This reflects the fact that the history of medicine in the Congo, written from the perspective of Belgium, is a history of military conquest and commercial exploitation. When the CFS became the Belgian Congo, the structuring of the medical staff was still modelled on the military administration. Indeed, the health service was patterned on the military, with the grades of doctors corresponding to those of the notorious Force Publique.¹⁷

Not surprisingly, little was invested in medicine. In 1888, the health budget represented 2.24 per cent of the regular budget and dropped by 1906 to 1.9 per cent.¹⁸ This was offset in part by special funding Leopold reserved for research on sleeping sickness, which was decimating the local populations.¹⁹ The first two hospitals serving black populations were created to tackle the negative financial impact of sick workers on the two major railway projects in the region. In 1897, the Société du Chemin de fer des Cataractes created an indigenous hospital in Matadi and in 1903 the Compagnie des Chemins de fer du Congo supérieur created a hospital for workers in Stanleyville.²⁰ This also reflects the limited mandate of medicine, and the underlying rationale for healthcare provision. Health was not a public good but a commercial or military good – it was provided to improve military control and economic exploitation, thus only to those populations directly related to these aims.

Independent of the colonial state, missionaries and industrial concerns also developed substantial medical activities. Catholic and Protestant missions were significant Western medical care providers. Both were present from the founding of the CFS, although initially, Protestants outnumbered Catholics. The Catholics in large part participated through agreements signed with the Belgian State to be auxiliaries in the Native Medical Services (SAMI), or through agreements with the private industrial sector (e.g. the Sisters of St Marie of Namur were contracted to work with the Huileries du Congo belge). The Protestant denominations, many of whom were active in medical care, existed in uneasy, informal cooperation with the colonial state from the arrival of Henry Morton Stanley at Stanley Falls in 1877. Orders such as the British Baptist Missionary Society, the American Baptist Missionary Society and the Swedish Mission Society staffed their missions with accredited doctors and created hospitals and clinics throughout the territory.²¹

International agitation over the human tragedy of Leopold’s CFS led to its annexation by Belgium in 1908. This did not fundamentally change the medical system, even if a department of health services was created in 1909 and a chief physician, Dr Heiberg, was appointed in 1911. Many services were simply carried over, and many agents of the CFS converted to agents of the Belgian Congo. In two years, the number of doctors doubled, reaching fifty-nine, still an insignificant number in a country with a population between ten and thirty million.²² When the CFS was annexed by the Belgian state, state-supported discrimination against Protestant organisations continued, despite their presence being technically protected under the stipulation of religious freedom in the 1885 Berlin Act, which had created the CFS. In truth, the CFS and Belgium colonial state could more accurately be characterised as begrudgingly tolerating rather than protecting the Protestant presence in the region.²³ However, Belgium recognised the important contribution of the medical services provided by the Protestant Church. In fact, in Ruanda-Urundi, Protestant societies such as the Church Missionary Society or the Seventh-Day Adventists could only obtain entry into the mandated territories by creating modern hospitals.²⁴

Expansion

Under the CFS, many doctors continued to be career soldiers, who seemed more willing to emigrate, on both the Belgian and Italian sides.²⁵ This trend would continue as the health services expanded. The health service also had a significant number of career military doctors placed at the disposal of the colony by the metropolitan army, and young graduates performing military service in the regions administered by Belgium.²⁶ In the interwar period, on average 42 per cent of doctors in Ruanda were doctors performing their military service through the colonial medical service. In total approximately 20 per cent of career military doctors served in the colonial medical service.²⁷

The lack of investment in health characterises the entire period of the CFS, and lasted until the First World War. The expansion of the medical service, ostensibly to reach the entire indigenous population, was part of a wider global trend. The 1919 flu epidemic, which decimated populations across the globe, did not leave the Congo untouched. An estimated 4 per cent of the indigenous population succumbed to the murderous disease, as many as four hundred thousand individuals.²⁸ The shock of this wave of mortality may have also served to spur more organised and widespread action against epidemics. This change in policy can also be explained by other spreading epidemics – most notably sleeping sickness – and by the acceleration of economic exploitation in the colony, visible through the multiplication of major infrastructure projects and the development of the mining sector, all activities that were very labour-intensive. It became necessary to ‘undertake a systematic, organised conquest of tropical environments’ to allow ‘penetration of industrial capitalism and its production methods’ including ensuring a healthy workforce.²⁹ In French West Africa, medical assistance to the natives was launched in 1905, while the British colonial medical services grew out of the medical departments run by the Colonial Office at the turn of the century.³⁰ In the Belgian Congo, a native medical service (Service d’Assistance Médicale Indigène or SAMI) was launched in 1911. However, unlike the native medical services of Britain and France, its remit was much more limited, initially to the treatment of sleeping sickness, and later expanding to other communicable diseases.³¹

The medical services continued to have staffing shortages even as it tried to expand in the period of consolidation, for various reasons. In the Congo, state doctors were subordinate not only to administrative authorities, but also to Catholic Church authorities.³² Further, state medical service was public health focused, with limited clinical practice and few chances to stay connected to an adjacent booming tropical medicine research network. Ambitious doctors desiring to finish their careers in the university or private practice would have few opportunities for advancement in the Congo. Low status, the conditions of life and the anti-liberal approach to medicine in the colony ultimately made recruitment difficult.³³ Thus the state frequently turned to foreigners, perpetuating the policy of the CFS.³⁴ The health service included a significant number of physicians from Italy (which had early on developed a naval medicine and worked at the forefront of the antimalarial fight).³⁵ However, during the interwar period, a nationalistic mood in Belgium translated to efforts to ‘nationalise’ staff in its colonies: regulations proliferated that adjusted the status of foreign physicians with temporary and limited term contracts, with a slightly higher salary but no right to a pension.³⁶

In 1929, the colonial secretary Henri Jaspar noted in the House of Representatives that there were only 127 physicians in the Belgian Congo, roughly one doctor for every 94,500 Congolese. Shortly after, the Université de Bruxelles conducted a comparative survey, and noted that Cameroon in 1930 had one physician per 55,500 inhabitants, compared with one doctor per 350,000 inhabitants in the Belgian-administered Rwanda. This was perceived as a challenging gap, partially explained by the fact that the two territories had different population policies (economic exploitation versus settlement), and Cameroon had a higher Western population (which was always targeted as a priority by medical activity). As a comparison, the survey launched by the Université de Bruxelles reported on the basis of the statistics of the Bureau International Du Travail in Geneva that there was at that time one doctor per 2,344 inhabitants in Belgium, one per 832 in England and one per 1,509 in France.³⁷

Rwanda, Burundi and the Belgian Congo followed the same basic administrative structure for their medical services, with an inspector general, several districts with medical officers, hospitals in the major colonial enclaves and lazarets run by religious orders. Under the orders of the médecin en chef, based in the capital, were the provincial doctors.³⁸ Secondary posts were entrusted to doctors of first and second class, who depended directly on local authorities to fulfil their mandates.³⁹ Medical assistants remained subordinate to Western staff. They were prohibited from performing certain medical procedures, except under the supervision of the Europeans. Their assignments were also decided by European staff. But European medical staff were ultimately too expensive and too sparse to ensure all the medical activity. African auxiliaries were imperative. The wages of the lowest paid European doctor were still six times higher than that of the highest-ranking medical African in the late 1920s; exactly the same ratio as Iliffe observed in British East Africa at the same time.⁴⁰ African employees, almost exclusively male, would remain socially, economically and technically subordinate to European staff. The Belgian Congo experimented with training programmes and schools for nurses and native auxiliaries from its creation in 1908, but largely failed in its efforts into the 1930s.⁴¹ Indeed, the nursing schools created by Protestant missions initially met with more success. The state also attempted to train midwives and birth attendants, but like its nurse training schools, met with little success until the late 1950s, on the eve of independence.⁴²

Sleeping sickness became the major problem of the colonial medical service. Its rapid spread, devastating effect on the populations of the region and the lack of real understanding of the disease or effective prophylaxis led to extensive efforts by the Belgian colonial government to experiment with various control methods. Sleeping sickness would spur early scientific research missions, experimental coercive public health measures and the implementation of a semi-military medical grid. Medical authorities of the CFS, and later the Belgian Congo, set up special itinerant missions to combat sleeping sickness. These units were responsible for regularly monitoring populations, detecting and isolating the ill. This eventually expanded to mobile teams that canvassed entire regions, village by village, screening and treating often unwilling native populations (Figure 3.1).

Figure 3.1 Health worker Ruyters visits patient, Beni, 1937 (Province of Costermansville).

Both the British and the Belgian medical services strove for mass, decentralised medical treatment for sleeping sickness. However, the Belgian administration preferred to go to the patient and force him to submit to treatment, while the British expanded medical services through widespread dispensaries run by African nurses, encouraging local populations to receive treatment through their communities. They also developed several programmes to target the vector, the tsetse fly. Germany, with its strong expertise in laboratory medicine, focused on diagnosis. Ultimately, the three colonial powers wrestling with sleeping sickness – Germany, Britain and Belgium – each approached its eradication in different ways. While the German East African solution was based on the microbiological model using widespread laboratory screening, British Uganda focused on an entymological solution and eradication of the tsetse fly and Belgium focused largely on policing and restricting human population movements.⁴³ The hubris of various African colonial governments around the treatment of sleeping sickness has been recently well documented by Guillaume Lachenal in his study of the development and use of the experimental drug Lomadine.⁴⁴

In regions controlled by Belgium, systematic screening and treatment missions of sleeping sickness patients by mobile teams began in the interwar period (Schwetz in Kwango and Rodhain in Uele) between 1918 and 1920, in a context of concern over the widespread depopulation of the region.⁴⁵ The sleeping sickness campaigns would become the major public health and medical research intervention in the region. Europeans could not fail to notice that the Congolese who had the greatest interaction with European enclaves (workers, soldiers, catechists and African religious converts) were succumbing in alarming numbers to a variety of epidemics, sleeping sickness being the most noticeable. A state hospital construction programme was launched in 1921 for indigenous populations, followed by a new organisation of the medical service in 1922, which became autonomous and directly dependent on the governor general. The health service was organised in a network of fixed health facilities, supplemented by special missions against trypanosomiasis. The first efforts at medical surveillance would take place in Kwango in 1923–24, in a manner that ‘seemed more a police operation than a public health operation’.⁴⁶ Kwango would also become a foil to later efforts at medical surveillance.

Major endemic and epidemic diseases were the focus of the interwar period. Parastatal organisations were formed in the interwar period, mostly focused on vertical programmes screening and treating specific diseases in circumscribed areas. These vertical programmes were the forerunners of today’s public–private partnerships in global health. One of the first such programmes was the Queen Elizabeth Funds for Native Medical Assistance (Fonds Reine Elisabeth pour l’assistance médicale indigène or FOREAMI), created through a funding partnership between the Belgian state and the personal funds of Belgian Queen Elisabeth in 1930. The goal of FOREAMI, a semi-autonomous medical organisation, was to completely rehabilitate a delimited area by an organised comprehensive medical service. Its budget was substantial: the annual income of this capital accounted for more than 10 per cent of the total budget of health services.⁴⁷

The Bas-Congo was selected as FOREAMI’s first area of action, due to its proximity to major European enclaves, the relatively developed routes of transportation and the importance of the Congolese workers in this region, who were being decimated by sleeping sickness.⁴⁸ The sector was divided into subsectors run by doctors. Each subsector comprised a series of circles with a population of twenty-five to thirty thousand individuals, assigned a (European) doctor and a health worker and supported by African auxiliaries (nurses, nurse assistants, messengers, drivers, mechanics, etc.). At the circle level, a mix of SAMI, AMIB (also referred to as SADAMI/Service auxiliaire de l’Assistance Médicale Indigène) and FOREAMI doctors and health workers carry out mobile screening tours, accompanied by African auxiliaries. FOREAMI intended to fully canvas selected regions and ‘turn around’ the health situation, then defer medical responsibility to the colonial health service. This would not be as straightforward as assumed. FOREAMI’s initial activities in the Lower Congo affected around 600,000 people, involving 26 doctors, 23 health workers, 4 medical officers, 40 missionary nurses and nearly 500 Congolese auxiliaries. Expansion of the FOREAMI model was planned for Kwango and eventually other territories. Between 1932 and 1935 FOREAMI was also active in the Ruandan territory of Tanganika-Ruzizi. Here it was focused solely on sleeping sickness, following what its director referred to as a purely ‘nosological’ programme rather than the integral programme of Bas-Congo.⁴⁹ The attempt to move into the Kwango in 1935 with a concomitant decrease in activity in the Bas-Congo was aborted, in part due to the perceived primitive conditions in the Kwango, but also due to a recrudescence of epidemics in the Bas-Congo. Budget cuts, resistant ‘native mentalities’ and geopolitical events ultimately delayed further expansion of the FOREAMI until after the Second World War.⁵⁰

In many ways, the medical model of FOREAMI was new, even as it built upon the experience and frustrations of Belgian medical officials in effectively reaching a wider population. It put into practice a new approach to the SAMI that grew from previous mobile sleeping sickness treatment units, namely a relatively thorough medical census of a region carried out methodically by mobile teams.⁵¹ Doctors working in the Congo and Ruanda-Urundi were aware of the specificity of their health system. For Janssens, mobile teams practising a full medical population census constituted one of the most striking and original features of the Congolese health organisation.⁵² A similar system existed since 1916 in French Equatorial and Western Africa, led by Dr Eugène Jamot, but it was a largely vertical programme targeting only sleeping sickness.⁵³ The originality of FOREAMI lay in its objectives: not only to eradicate all diseases in a specific area but also to improve public health.

While FOREAMI was broader in its ambitions than SAMI, it was limited in its geographic reach. Other programmes, targeting specific diseases, could be highly invasive but likely had little effect on overall population morbidity and mortality. For example, nearly five million Congolese were examined each year on the eve of the Second World War for diseases such as yaws and leprosy.⁵⁴ It should be noted that both diseases, while aesthetically unpleasing, were not terribly mortal. Vellut considered such medical grids as ‘totalitarian fantasies that crossed the history of the relationship between colonial bureaucracies and African peasantries’, adding that they sought in fact to ‘guarantee a complete mastery over the transition between two models of health, that inherited by the Old Regime which was more or less degraded or impacted depending on regions, and that which corresponded to the demands of a new era. They were transitioning from a primitive colonial regime to an advanced colonial economy’ and the response to these growing demands.⁵⁵ FOREAMI was inspired by this new philosophy.

The medical services continued to have a military character in the interwar period, as young physicians coming out of universities could perform compulsory military service (one to three years) in the territories under Belgian colonial administration, either in the service of the state, the Fondation médicale de l’Université de Louvain (FOMULAC) or national missions.⁵⁶ Further, the significant proportion of career military doctors was also partly due to the fact that lieutenant doctors could get ahead by working a few years in the colonial service.⁵⁷ Ultimately, all the chief medical officers of the colony of the interwar period had worked in the health services of the colonial troops during the First World War, encouraging the continued military character of Belgian state medicine. The rigid, authoritarian bias of colonial social medicine would compromise its efficacy, because it was ultimately maladapted to the struggle in conditions of rural poverty, despite the fact that the authorities ‘had the intention to practice a “constructive imperialism”’.⁵⁸

As the colonial medical services expanded, it attempted to bring religious and charitable health providers under its loose direction through a constellation designated the Charitable Native Medical Services (Assistance Médicale Indigène Bénévole or AMIB, also later referred to in reports as SADAMI – see above). The AMIB, a unique configuration of public and private medical services in the Belgian Congo, was created after the governor general observed in 1920 the lack of coordination among the various charitable medical organisations working in the Congo. Its creation was in part an effort to co-opt the medical capacity of the Protestant medical missions, which represented an important contribution to Western medicine in the region, and a continuation of the historical legacy of the 1906 Concordat between the Vatican and Leopold II for Catholic missionary services in the CFS.⁵⁹ Through the AMIB, the government supplied drugs and equipment and supplemented funding for salaries and expenses to missions. In exchange, these missionaries provided services for the colonial health services, including basic medical care in rural areas and collection/reporting of medical statistics.

After completing a basic course at the School of Tropical Medicine, missionaries were charged with prophylaxis and treatment of specific endemic and epidemic diseases (particularly sleeping sickness). Moreover, Protestant societies, like some Catholic societies, also committed some doctors, nurses and health workers to the goals of the state, including the work of FOREAMI. The AMIB, and the heavy and extended formal involvement of religious orders in state medicine, was a uniquely Belgian phenomenon. This was in part a reflection of the heavy and sometimes controversial involvement of Catholics more generally in colonial governance (see Chapter 2, pp. 72–3).⁶⁰

Both Catholic and Protestant missions, for their part, realised the value of medical care to their proselytisation efforts. Medical care could draw indigenous populations. Protestant missions in particular easily framed the provision of medicine within their more general mission of caring for the afflicted. Thus, medical care was often provided with a heavy dose of religious ministering. For example, patient families could be required to attend prayer services while the patient was being treated, and patients’ ministrations could be simultaneously spiritual and physical, as, for example, when prayer services were conducted in recovery wards.⁶¹ Baby clinics and milk distribution could take place immediately after church services, or ‘rewards’ for regular infant consultations would be given on Christmas Eve (Figure 3.2). Ultimately, medical provision increased the visibility and attractiveness of the missions’ work.⁶²

Figure 3.2 Leopoldville. Milk depot and baby clinic, n.d.

It could be argued that the unique atmosphere at missionary dispensaries made their offer of Western medicine more attractive than that of a secular health centre. The integration of Christian symbolic gestures into medical activities (blessing of the sick, sign of the cross, prayers) and the social support available in missions may have aligned their practices more closely with Congolese therapeutic systems, which largely recognised disease as signs of individual and community imbalance most effectively treated by including the entire social body. Congolese medicine involved the ritual action of many members of the community beyond the immediately afflicted. Therefore, missionaries could be perceived, like their peers elsewhere in Africa, as healers with mystic abilities, because they combined ritual prayer with medical care. The similarity between the two created church distrust of native medicine because missionaries were aware that it linked health and sacred action.

Dispensaries, antenatal care and baby clinics, maternity hospitals and hospitals, leper houses, nurseries, homes for disabled and elderly people, labour occupational medicine, surgery, lazarets for sleeping sickness patients, tuberculosis or sanatoriums for incurable patients, camps for infectious patients, insane asylums and Goutte de lait⁶³ were some components of the missionary health services. Christian networks of villages and outposts run by African evangelists provided rural bases for the organisation of vaccination or medical screening campaigns. Thus, similar to Europe a century earlier, priests, nuns, ministers and deaconesses were key to expanding new sorts of health services to rural areas and dispersed populations (see Chapter 2, pp. 68–71).

Indeed, missionary societies largely practised what Dr Schweitzer has called a ‘sentimental medicine’,⁶⁴ in contrast to the ‘combat medicine’ disseminated by government mobile health teams that adopted an army-inspired organisation to align, order, sort and treat the masses. A variety of Protestant missions (largely foreign) and Roman Catholic orders (almost exclusively Belgian) would ultimately provide medical care in the region. Women’s congregations were predominant in healthcare on the Roman Catholic side, as nuns provided care in most colonial hospitals and clinics (see Chapter 1, p. 40). Catholic fathers also ran some lazarets and dispensaries. The Protestant medical teams were more internationally mixed, and were composed of licensed doctors, nurses and lay staff mainly of British, American, Swedish and South African origin. Broadly speaking, Catholics worked in the domain of palliative care while Protestants provided more acute medical services. For instance, before the Second World War, Protestant missions in the Congo performed a substantial number of surgeries annual, and Catholic missions none.⁶⁵

However, as in many other fields, Roman Catholics and Protestants were often fiercely competitive with each other in their offer of medical care. Indeed, in part to avoid conflict, colonial authorities limited the presence of several health centres in the same region. Spiritual influence (and first arrival) at times de facto determined who would be assigned to what geographic region. A relatively sophisticated Protestant medical apparatus arrived early in the region, independent of colonial control. Catholics, however, were formally and extensively involved in the colonial state medical apparatus, although the church would attempt with middling success to provide medical services linked more tightly with Catholic missions beginning in the interwar period. This included luring licensed doctors to work in Catholic missions and sending mission staff for accreditation in nursing and tropical medicine in Belgium. Protestant missions quickly experimented with local schooling of African auxiliaries in medicine, successfully opening a state-recognised medical auxiliary school in 1932.⁶⁶ The rancorous competition between the two religious groups led to several instances of accusations, denouncements and legal proceedings relating to medical practice, among other issues.

Parallel to the establishment of colonial state and missionary care provision, the private sector would also launch medical programmes for the industrial workforce. A dual medical system worked in parallel: that of the government, on the one hand, and that of religious missions or trading and agro-industrial companies, on the other. Even while it was still in its formative stages in 1905, the Union Minière du Haut Katanga (UMHK) assessed the risk of sleeping sickness in Katanga during a prospecting mission. In 1914, it appointed a doctor to organise a medical service that, with the help of the colonial government and the Comité spécial du Katanga,⁶⁷ included in its remit displacement of villages (from locations deemed unhealthy), deforestation and monitoring of population movements and the establishment of disease screening and healthcare facilities. This accompanied an explosion in labour recruitment, with the union’s mining workforce increasing from 2,500 African workers in 1914 to 12,000 in 1920, with an average mortality of almost 12 per cent. The union would develop a comprehensive pyramidal medical structure for early detection, isolation and prevention of diseases through medical action at all levels. It instituted a sprawling health apparatus to assure the health of the workforce through dispensaries in mines, factories and camps, hospitals with several hundred beds in the various operating sites and a central hospital well equipped with all modern medical technology. This policy yielded impressive results, as morbidity would drop from 3.85 per cent in 1926 to 0.91 per cent in 1955, and mortality per thousand workers from 37.8 in 1920 to 3.55 in 1959.⁶⁸

The union’s comprehensive health policy would become the archetype for large-scale enterprises in the Belgian Congo. Other major companies followed suite, such as the Compagnie du Kasaï, the Forminière (particularly active in the fight against sleeping sickness), the Huileries du Congo belge, the Kilo-Moto gold mines, the Minière des Grands Lacs, Symétain, Otraco, etc. Such occupational medicine was dictated by both the economic imperatives of a healthy workforce and by legislation on labour protection requiring a medical check for those entering into the service of any private company. The colonial government also demanded that large companies invest in the campaigns against endemic diseases, vaccinations and curative care for populations neighbouring these worksites.⁶⁹

Rather late, in the 1920s, Belgian universities became involved with the other heterogenous sectors involved in healthcare in the Congo. The Catholic University of Leuven partnered with the Jesuit Catholic order in Kisantu province to create the Medical Foundation of Leuven University (la Fondation médicale de l’Université de Louvain or FOMULAC)⁷⁰ in 1926. Intended as both a research and medical foundation, it had three main goals: research on tropical medicine, medical provision through hospital service and training of African nurses and medical assistants. It worked in Kisantu in 1925, Katana in Kivu province in 1929 (after a government request) and Kalenda in the Kasai in the 1950s. The colonial state treated FOMULAC much like other parastatal and religious organisations: it requested that the organisation assist in the work of FOREAMI for the rural sector of Kisantu, where a FOMULAC hospital and nurse training school were constructed in 1928. It also requested that FOMULAC take over the hospital complex constructed by the government after the Second World War (through the FBEI, discussed later). Similar to FOMULAC, in 1936 the Free University of Brussels created the Medical and Scientific Centre of the Free University of Brussels (Centre scientifique et médical de l’Université Libre de Bruxelles or CEMUBAC) to carry out combined scientific research and medical care provisioning, focusing on tuberculosis.⁷¹

The model of CEMUBAC revealed the ties between university health research and the private sector, as it collaborated with the Lomami and Lualaba Company (a subsidiary of the Compagnie du Congo pour le commerce et l’industrie, a holding owned by the Société générale), while FOMULAC worked more on a university–government partnership model (Figure 3.3). Collaboration between Belgian metropolitan universities and European health actors in the Congo would continue after the Second World War, with increasing numbers of universities involved, including the University of Liège and the University of Ghent.⁷² These links between metropolitan universities, European public health actors and private industry have in some cases endured through independence, civil war, dictatorship and into the current fragile state of the Democratic Republic of Congo.

Figure 3.3 Lomami Recruitment Mission (MOI) for the UMHK, 1930. The doctor carefully examines each native at the preparation camp and thus establishes his robustness index (index of Pignet).

Even as state, charitable and industrial medical services expanded in this period, the exposure different Congolese populations had to Western medicine would remain wildly uneven, with many Congolese never seeing a Western doctor. Most Congolese who received Western medicine were those central to colonial enclaves: military, workers, prisoners, religious converts and, to a lesser extent and at a later period, colonial functionaries. It should be observed that, with the partial exception of religious converts, these categories were largely male and of working age. Women, children and elderly people were thus exposed to Western medicine to a much lesser degree, often as ‘dependants’ of their male counterpart. Such populations were often separated from their original communities and had to adhere to a new model of social life, including a different medical domain. Soldiers or mine workers and their families were automatically exposed to preventive and curative measures dictated by the standards of Western medicine. Even after death, their bodies remained embedded in this other medical logic, as, for example, all of the deceased at Lubumbashi hospital (of the UMHK) were systematically autopsied for medical research until at least 1918.⁷³ The people attending the missions entered for their part a Christian space and were enclosed in a net of educational, religious, sanitary, economic and social activities aimed at separating them from their ‘pagan’ past and creating a good Christian. Converted mothers were strongly urged to attend baby clinics and abandon former childcare practices, while the sick had no choice but to get treatment in a missionary dispensary as consultation with traditional healers was perceived as a return to ‘paganism’.

The Second World War and the end of Belgian colonialism

After the disruptions and devastations of the Second World War, all colonial powers, including Belgian, reached a crisis point. The recently created United Nations was openly hostile to the assumptions of colonialism. In this context, reform was necessary. Belgium launched a ten-year plan (Plan décennal) intended to forward both the economic and social development of the Congo. The social aspect had a strong medical component: it aimed to improve living standards and prevent rural depopulation, as indigenous well-being became perceived as ‘the best guarantee to ensure and keep the friendship of the Congolese population’,⁷⁴ preventing impoverished populations from establishing ‘a dangerous revolutionary potential’.⁷⁵ State medical and health budgets and activities thus exploded after the war. At first glance, it may seem paradoxical to align such activities with the increasing likelihood of colonial independence, but in fact, such interest was in part inspired by a concern to appease an increasingly vocal indigenous elite about the benefits of the colonial relationship. The comprehensive medical networks developed during the interwar period in limited regions of the Congo by FOREAMI were applied to entire populations, both urban and rural. In 1947, the Fund for Indigenous Well-Being (Fonds du bien-être indigène or FBEI) was set up to ensure social investments in the rural areas of the Congo. Its funding came ‘from the reimbursement by Belgium of the expenses of sovereignty assumed on its behalf by the Congo during the war 1940–1945’.⁷⁶ This capital was increased thereafter by grants from the National Lottery and the Colonial Lottery. The FBEI financed the construction and equipping of medical and surgical centres and rural hospitals, maternity wards, infant clinics, medical schools and sanatoriums as part of the ten-year development plan. The fund also financed programmes for leprosy, tuberculosis screening and disinfestation.

A medical school in Congo would be created at the very late date of 1954, on the eve of independence, when a private partnership between the Jesuits of the Lower Congo and the Catholic University of Leuven created the Faculty of Medicine of Lovanium. Lovanium’s first two doctors would not graduate until the independence of the Congo, in 1961. The colonial state for its part did not open a Faculty of Medicine until 1956, within the University of the Belgian Congo and Ruanda-Urundi in Elisabethville.

Nonetheless, the ten-year plan and the creation of the Congolese universities could not stop the direction of history. The Second World War had broken the illusion of European superiority and power. The thinness of the ‘white line’ that kept subjected populations in check had been made apparent for both imperialists and colonised populations.⁷⁷ The rise of communism and the Cold War further weakened the position of pro-colonialism. In 1960, the Belgian Congo became the independent Republic of Congo; Ruanda-Urundi followed suit to become the independent countries of Rwanda and Burundi in 1961–62.

For much of the population, and for a majority of afflictions, medical authorities would ultimately have little interaction with the sick. Indeed, similar to French or Belgian farmers of the nineteenth century, colonised populations continued to use both traditional and Western medicine ‘to satisfy their physical well-being, as well their social well-being’, in the words of Jean-Marie Bouron, utilising a medical pluralism that still marks the therapeutic regime in the region.⁷⁸ In short, African patients did not consider that Western doctors held the monopoly in remedies for physical and mental problems.

Conclusion

In many ways, Belgian colonial medicine was very much typical of its time. The state medical system was strongly influenced by other colonialisms. The colonial administration made explicit comparisons and research into how its peers were running their medical administrations. France was particularly influential. But the British colonies, protectorates and mandates also offered some models that occasionally inspired practitioners and administrators.

The colonisation of Central Africa in the late nineteenth century coincided with the birth of tropical medicine as a recognised medical research speciality. Medical research expeditions in some senses grew out of geographical exploratory expeditions. While early research expeditions were largely foreign organised, as the Belgian colonial medical service grew, so too did its research capacities. The first medical laboratory in the CFS was set up in 1899 in Leopoldville. Not surprisingly, many research expeditions were focused on sleeping sickness, including the well-known 1903–05 Dutton Todd Christy expedition conducted by the Liverpool School of Tropical Medicine. Medical officers could serve as part of wider imperial networks of scientific research, particularly in relation to sleeping sickness.⁷⁹ However, the majority of medical doctors in the Congo were ancillary to these networks, working in difficult conditions in the bush, often in a public health surveillance role, with limited autonomy and low status. Colonial possessions enabled tropical medicine. They provided the resources, the rationale and the legitimacy for tropical medical research. African bodies were important source materials for such research.⁸⁰

Certain other global trends in colonial medicine are repeated in Belgian Africa. Services dedicated to indigenous populations beyond colonial enclaves were created (sometimes only at first on paper) in Africa, South East Asia and Latin America in the first decade of the twentieth century, so-called native health services or assistances médicales indigènes. In the Congo, this would be called the SAMI, but its remit was much narrower than that of other contemporary medical services for indigenous populations. Further, as in other colonies, private charitable and religious institutions provided medical care, although this phenomenon was comparatively more pronounced and more enduring in the Congo. Professionalisation in the interwar period in Europe was also followed by pushes to professionalise medical staff in colonies around the globe, with more stringent accreditation and training requirements and the phasing out of lay health workers in state institutions. Again, in the Congo, this was done to a lesser extent. The use of certain metrics, such as under-five mortality, would come into vogue in the interwar period as a synecdoche for both the health of the general population and the effectiveness of the civilising mission of the coloniser.

The Belgian case is also marked with several distinct peculiarities. The Belgian colonial endeavour began through the ambitions of the Belgian King Leopold II and would become influenced by his excesses. When Belgium acquired the CFS, the blueprint for medical care laid down during Leopold’s abusive personal fiefdom continued in some fashion. For example, the military doctors who oversaw care of the Europeans working in the exploitative CFS became the ‘civilian doctors’ overseeing care of Europeans working in the ostensibly more enlightened Belgian Congo. The conservation of an entire cadre of men (and they were all men initially) complicit in a violent, oppressive system offers an interesting historical lens to view how care evolved in the 1910s and 1920s. As Belgians in the metropole had little say in Leopold’s endeavours in Africa, so too did most continue to have little interest in a Belgian colonialism, unlike in neighbouring countries such as France and the Netherlands, where large swaths of the population had a vested interest in overseas ventures that extended beyond economic gain.⁸¹ The metropole’s indifference is one of the striking distinctions of Belgian colonialism, as are its more restrictive immigration and emigration policies.⁸² Further, as Vellut has argued, the state was essentially hamstrung by a very strong industrial coalition that confined, if not dictated, its functioning.⁸³

Medical training for indigenous personnel, usually planned in conjunction with the creation of a native medical service in colonies globally,⁸⁴ was largely aborted in the Congo. While many colonies had difficulty creating such a cadre of workers, Belgium’s efforts were particularly ineffective. This was in part due to the thinness of resources from the metropole, but was also strongly influenced by the Catholic monopoly on primary school education in the region. Such education, critics argued, emphasised moral and social training rather than technical or administrative skills.⁸⁵ Further, as in most colonies in the world, colonial officials in the Congo and Ruanda-Urundi repeatedly expressed their fear of educated Africans wishing to emancipate themselves from European tutorship, and who would be disconnected from local people. Like France’s Instituts Pasteur, parastatal research institutes tightly connected to the metropole, such as Lovanium, began providing specialised education to so-called évolués, but this would be after the Second World War.⁸⁶ Thus, unlike in colonies such as Algeria or Indochina, such training would not be offered until what would be labelled the period of ‘decolonisation’. Was this development at this late date an effort at ‘catch-up’ by Belgium to what other colonial powers offered, or was it also an effort to meet the growing vocal demands of indigenous populations for education, a political voice and socio-economic opportunities? It was likely both.

As in other colonies around the globe, the Second World War heralded the beginning of the end of Belgian colonialism. Populations in both Ruanda-Urundi and the Belgian Congo began to agitate for independence in the 1950s. Medical care slowly passed into the hands of the évolués, and, indeed, medical doctors such as Gaston Diomi Ndongala and Pierre Canon would become prominent in the independence movement.⁸⁷

Belgian colonial medicine, in the end, left strong traces in the current field of international humanitarian aid. In some ways, the public–private cooperation for healthcare pioneered by movements such as FOREAMI and FOMULAC have become the template for providing care in current, so-called fragile states. In such fragile states, because a robust political administration is lacking, public services are arranged through public–private partnerships that are largely independent of political processes. Bureaucratic and administrative authority was always weak in the Congo, arguably more so than in many other colonies.⁸⁸ The indifference of the general metropole to the colony in the pre-Second World War era likely further weakened such authority. In addition, the disproportionate power of the Catholic Church subtracted from the administrative legitimacy of the colonial state. As Vellut observed, the power bloc of colonial companies and the administrators of the colonial state (and we would include the Catholic Church in this formulation), excluded effective political control.⁸⁹ We could even, provocatively, call the Belgian Congo a hybrid of a colonial state and the modern fragile state.

The Belgian Congo’s answer to the call for a population-level health service was thus fundamentally different than that of other colonies. The colonial bloc would forcibly partner with private industries and charitable groups to achieve wider health action, bypassing the lack of political will. This is currently how international humanitarian organisations often approach provision of care in instable regions. Further, vertical programmes such as the massive campaigns for sleeping sickness that begin in the first and second decade of the twentieth century could be seen as templates for later programmes such the hookworm eradication programmes of the 1930s and the mass vaccination programmes against smallpox in the 1950s. Belgium, starting a bit ‘behind the curve’ as a colonial power, had to innovate solutions for health problems in a colony that was poor in resources and political will.