Medicine and Health in the Modern Middle East and North Africa (Arab Studies Journal, Fall 2019)

In his exploration of the interconnectedness of medicine, statecraft, and empire, Omar Dewachi intervenes in narratives that dismiss contemporary Iraq as “ungovernable” by placing the trajectory of medical infrastructure into a specific colonial context. The author’s description of the decrepit state of Iraqi health care in the wake of war and sanctions, as laid out in his preface, introduction, final body chapter on Iraqi doctors in contemporary Britain, and conclusion, is deeply moving. He illustrates how, as one Iraqi patient chain-smoking in Beirut declares, “Life in Iraq is a tragedy” (Dewachi, 2). Dewachi’s skills as a historically sensitive ethnographer are put to good use in answering the haunting question that drives his analysis: how did a medical system heralded as a success until the1980s deteriorate into its current state of crumbling hospitals and outbursts of targeted violence against doctors?

By reconstructing “the making and unmaking of Iraq’s healthcare system,” Dewachi presents the history of medicine in Iraq as a microcosm of broader state-building processes and modes of governance (Dewachi, xiii). He traces how decades of war and sanctions have dismantled both the medical system and the state. For Dewachi, the “making” of Iraqi medicine began in earnest during World War I, when the British entered Mesopotamia through the Persian Gulf port at Basra in 1914. Drawing on British records and accounts from medical officers, he describes the occupation of Mesopotamia from the perspective of the diseases and harsh environment that took a deadly toll on British Indian troops and served as a justification for post-war colonial intervention. In the mandate period, Iraq was a site of political and medical experimentation. As in other Middle Eastern mandates, the European administration systematically denigrated earlier Ottoman efforts to modernize education and medicine. Dewachi’s discussion of how Ottoman-trained doctors converged on mandatory Iraq and interacted with British medical officers is particularly fascinating. A promising direction for future research would be to incorporate late Ottoman sources regarding medical training and practices into studies of public health in the Mandate period and beyond. In addition to British Medicine and Health in the Modern Middle East and North Africa imperial records, Dewachi draws on autobiographies of Iraqi doctors to study colonial medical education and the fierce debates over the political and social role of the Iraqi “citizen-doctor” (Dewachi, 85).

In the oil-fueled development period of the 1950s, state engineering of economic growth and modernization resulted in rural to urban migration, increasing contempt of urban elites for peasants’ poor health habits, and a growing cohort of Iraqi doctors who were a central component of Iraq’s middle professional class. Densely populated urban ghettoes and unfinished or inadequate development plans exacerbated disease. The period of the Iran-Iraq war, ironically, witnessed certain improvements in public health, such as a reduction in infant and maternal mortality rates and improved rural medical care, alongside the wartime devastation. Dewachi terms this tension the “paradox of war and statecraft in Iraq” (Dewachi, 129). He argues that the wartime obsession with productivity resulted in pronatal state policies, even as other development states were promoting family planning in the same period. His final chapter shifts the ethnographic gaze to Britain, where Dewachi illustrates the enduring influence of British mandatory medical patronage and the destructive impact of decades of sanctions and war on the Iraqi medical infrastructure through the struggles of the large population of Iraqi doctors who have relocated to Britain. Many of his interlocutors are disillusioned by their status as “second-class doctors” or are considering “finding alternative career paths in Britain” (Dewachi, 167). Dewachi, himself an Iraqi-trained medical doctor, stops short of explaining his own decision to reinvent himself as a historical anthropologist after his escape from Iraq in 1998. His unique blend of local professional expertise, ethnographic work, and historical insights have resulted in an invaluable contribution to medical and state histories.

Ambitious in its scope and elegant in its organization, Khaled Fahmy’s In Quest of Justice is a significant intervention in the fields of legal and medical history in modern Egypt and the Middle East. By interweaving law and forensic medicine, Fahmy takes on several prominent debates in Middle East studies. Underlying his project is a firm belief in the methodological power of archival-based research to complicate and even transform assumptions about the Islamic world. The targets of his interventions comprise: Talal Asad’s work on the secular, which he critiques for dismissing the incremental steps of how law changed over time; Islamist legal historiography, which, Fahmy contends, constructs an identitarian binary between Western and Islamic law rather than grappling with the “historical evolution” of shari‘a (Fahmy, 30); and legal histories of the Egyptian state, which he argues have mistakenly privileged European, rather than Ottoman, imperial contexts. Throughout the text, Fahmy weaves together broader historiographical interventions with the fruits of his labor in the Egyptian National Archives. He emphasizes the significance of the siyasa court records, which he claims upheld fiqhi principles through the integration of modern medicine and bureaucracy. To explore scientific and medical knowledge and practice, Fahmy also draws from the records of medical and public hygienic institutions, particularly the Qaşr al-‘Aynī Medical School and Hospital.

Fahmy organizes his five body chapters around the senses of sight, sound, smell, taste, and touch. In the first chapter, he challenges a narrative in which the introduction of modern medicine in khedival Egypt “is typically analyzed in terms of enlightenment versus superstition or vision versus blindness,” and argues that non-elite Egyptians’ interactions with new practices of quarantine and dissection were shaped more by the realities of an encroaching militarization than by any Islamic reluctance to embrace scientific progress (Fahmy, 42). The second chapter examines the interactions between shari‘a and siyasa courts in terms of their different— but complementary—reliance on audible, spoken statements and silent, written evidence. Chapter 3 explores the contagionist-localist debate over disease transmission by reconfiguring nineteenth-century Cairo according to sources and experiences of smells. The fourth chapter on taste traces the transference of the responsibilities of the market inspector, or muhtasib, to the sanitary police and forensic laboratories. In the final chapter, Fahmy presents the displacement of official violence with forensic evidence and bureaucratic procedures as an evolution of the role of touch in enforcing law and constructing sovereignty.

While generally effective as a means of thematically unifying his arguments, this use of the senses as “heuristic devices” works better in some instances than in others (Fahmy, 37). A problem with his proposed shift from an “ocular-centric” urban history of a Cairo divided into two cities along class lines to an “olfactory tale of one city,” for example, is that it limits the idea of miasma to emissions that humans could detect with their noses. Miasmatic theory was the idea that one could become ill through exposure Medicine and Health in the Modern Middle East and North Africa to air that had been contaminated by poisonous vapors given off by decomposing organic matter, and it was, indeed, often identified by putrid smells. But one of the reasons that miasma-driven explanations endured into the late nineteenth century (and arguably persists in other localist explanations up to the present) was the flexibility of this concept. In localities suffering from disease, the absence of bad odors did not prevent miasmatic explanations. Fahmy acknowledges the “imprecise nature” and “shifting definitions” of miasmas but settles on smell as the driving diagnostic technique (Fahmy, 154). This minor critique does not detract from the dynamism of Fahmy’s methodological innovations, which allow him to trace how a range of historical actors drew on forensic medicine for legal evidence over the course of the nineteenth century.

France established Tunisia as a protectorate in 1881, and Richard C. Parks places Tunis squarely within its context as deeply connected to—but also distinct from—French Algeria, where Jews had been naturalized en masse in 1870. The Tunisian Jewish community had longstanding internal divisions that were unique to this port city. In the late seventeenth century, significant numbers of Livornese Jews settled in Tunis. This new Jewish community, known locally as “Grana” Jews, differentiated themselves from the long-established Twansa, or “indigenous,” Jewish community by maintaining a Judeo-Italian vernacular and separate synagogues, cemeteries, and markets. But Parks argues that French military intervention marked a distinct rupture in Tunisian Jewish alliances, as “a new colonial identity forged in the crucible of imperial expansionism was created,” resulting in novel forms of Jewish communal collaboration (Parks, 13). Moreover, inflicted with demographic and political anxieties over the large Italian population in Tunisia and emerging indigenous nationalist movements, the French administration naturalized only select Tunisian Jews. Such strategic demographic engineering had the added bonus, from the French perspective, of weakening anti-colonial nationalist movements by fostering divisions between Muslims and Jews in Tunis.

Parks’ periodization is focused on the early decades of the twentieth century, when both the physical structure and the human bodies of Tunis’ Jewish quarter, or hara, were targeted for modern transformation. French scientific and medical movements of the late nineteenth century, which Parks tells us were epitomized by the peculiarly optimistic Lamarckian view that undesirable genetic traits could be dismantled over the course of a single lifetime, form the ideological backdrop of early twentieth-century urban Tunis. He draws on research in the Tunisian national archives, the French diplomatic archives, the archives of the city of Paris, the archives of the Pasteur Institute in Tunis, and the Alliance Israélite Universelle in Paris. Parks also uses memoirs and literature to broaden the range of voices and perspectives in his narrative, notably framing each chapter with a quote from Albert Memmi.

Parks’ main argument pivots around the idea of Jewish regeneration “through the authority of science and medicine,” and his case studies primarily focus on how discourses of hygiene and health shaped plans for and material changes to urban space and Tunisian Jewish minds and bodies (Parks, 20). In the introductory chapter, he establishes the historical background of nineteenth-century genetic and racial science and places French attitudes towards Tunisian Jews in the context of ambiguous racial, national, and religious categories of Jews in France. His second and third chapters describe the modernization of Jewish space in French colonial Tunis. Through an analysis of the colonial bureaucratic structure and laws, Parks demonstrates how public health and hygiene were operationalized in reorganizing Tunis’s neighborhoods along ethnic and religious lines. While areas that the French administration deemed as Arab-Muslim remained underdeveloped in the name of preserving authenticity, colonial projects destroyed and reconstructed the hara in the name of regeneration and modernization. Parks’ comparison of the Jewish Ghettoes of Paris and Tunis is particularly effective in terms of demonstrating both the importance of metropolitan politics in shaping colonial spaces and how different social, economic, and legal settings resulted in contrasting applications of modern science and hygiene. He also adds nuance to our understanding of how French colonial assimiliationist and associationist debates played out across different population groups in North Africa.

Having established how Jewish identity coalesced in Tunis’ urban spaces and regenerationist discourses in the early twentieth century, Parks explores the emergence of new political movements in the community, particularly the rivalry between the Alliance Israélite Universelle and Zionist organizations. Activists in both groups competed over who could best shape young Medicine and Health in the Modern Middle East and North Africa Jewish minds and bodies into modern subjects. Although Parks frames the chapter in terms of regeneration of the Jewish body and mind, he dwells on the well-trodden historiographical ground of the identity politics of rival Jewish political ideologies at the expense of more fully developing his medical discussion. In his last chapter, Parks presents Jewish women—or rather, “their reproductive powers”—as the “lynchpin” of colonial regeneration (Parks, 116-117). Here he engages with the rich literature in the history of medicine that recounts how women’s and children’s health became male-dominated scientific fields starting in the early modern period, displacing women from long-established roles as midwives and healers. Muslim women in Tunis, Parks tells us, were excluded from colonial maternity reforms, while Jewish women became targets of state intervention in the medicalization of childbirth and hygienic motherhood. Significantly, Parks complicates this story by highlighting how Jewish women maintained an active role in determining birthing practices and child care; a group of prominent Jewish women even successfully opposed a 1905 proposal that would have assigned maternity assistance allocation to a committee of Jewish men.

All three books are engaged in broader discussions of practices, institutions, and discourses that comprise colonial medicine, and to what extent the Middle East region participated in and influenced this global imperial trend. Focusing on the role of the state in medical and public health projects in colonial settings, each study investigates how biomedicine was operationalized as a form of power over colonized bodies, a means of claiming Western cultural superiority, an ideological justification for European intervention, and a discourse with which to describe racial difference and the health ramifications of distinct environments and disease burdens. Parks explicitly frames hygiene and sanitation as elements of French colonial medicine. He illustrates the interconnectedness of metropole and colony in terms of how elite French Jews, colonial officials, and local Jews in Tunis understood race, religious identity, and urban space. Dewachi’s text also is structured around an engagement with colonial medicine; his starting point corresponds with the rupture caused by British intervention in Iraqi medicine, and he brings his story full circle by presenting Iraqi doctors in Britain today as a manifestation of the lingering consequences of empire.

But Fahmy asserts that medicine in Khedival Egypt was fundamentally different from “colonial” medicine, stating that “the racial matrix that typically informs this model in such places as the colonial cities of French North Africa and the British Raj was missing in Cairo” (Fahmy, 170). He argues that because Cairo’s sanitation was divided according to class rather than race, it was not the colonial medicine practiced in the more explicitly racialized spaces of colonial India and North Africa. In British India, “this anxiety about the health and security of the empire was based not only on the belief that India was a distinctly diseased environment but also that Indians were an inherently diseased people” (Fahmy, 171). The ruling elites in khedival Egypt, in contrast, Fahmy tells us, believed in the improvability of common Egyptians’ habits and health, and constructed policies around that belief. As a result, he concludes that “[t]he elegant sovereignty-discipline- governability triangle that Foucault identified for Europe seems to be equally applicable in khedival Egypt, where, unlike in India, medicine could not be described as colonial” (Fahmy, 173).

The problem with this conclusion is that it posits too clear of a division between categories of race and class in constructing nineteenth-century paradigms of sanitation, environment, and disease. Notions of race, spatially segregated socio-economic classes, disease occurrence, and sanitation needs were mutually constitutive. Assumptions of racial, cultural, and physiological differences drove European empire, but such differences were themselves envisioned and articulated to meet the ideological requirements of an inherently exploitative global system. Discourses of colonial hygiene and sanitation were inconsistent because colonial officials relied on stereotypes of diseased natives to distinguish the colonized from the colonizers, but they simultaneously justified imperial interventions and urban planning through an ideology of the universal potential for improvement of body and environment. The notion of the diseased native developed concomitantly to segregationist urban planning and racially tinged scientific research over the course of the nineteenth century. Moreover, if we take seriously Fahmy’s assertion that we should locate khedival Egypt in an Ottoman imperial context, the class-based bifurcation of Cairo has the potential to expand our notions of the colonial city and colonial medicine. While designed to ensure the strength of the Egyptian military, colonial medicine in Cairo also enforced the bifurcation of the city according to class, and thus facilitated Cairo’s transformation “from a mere provincial capital into a powerful center within the Ottoman Empire” (Fahmy, 273). In this sense, Fahmy’s Medicine and Health in the Modern Middle East and North Africa health-sensitive perspective can broaden our understanding of colonial medicine as a means of enforcing more than just a racialized subservience to the metropole. The tenets of modern sanitation developed to a large extent to enforce the distinctions that served the interests of the ruling elites, who defined subject populations according to their (presumed) need for medical and scientific salvation.

Finally, all three texts take on the question of what constituted modernity in the Middle East: which specific practices, institutions, and ways of thinking signified historical ruptures in the nineteenth and twentieth centuries? How did the transformation of health into public health with the forceful entry of the state into unprecedented concerns for the body and the body politic fundamentally alter the mechanisms of governance and the relationship between states and populations? Histories of medicine, health, and disease emerge in these texts as pathways to reconfigure the “modern” in the Middle East around the experiences of non-elites. Fahmy is committed to highlighting the choices of ordinary Egyptians who employed medical and legal innovations “in quest of justice.” Parks traces how the notion of regeneration provided the ideological grounds for elite Jews, French colonial officials, and local communities to reshape the embodied lives of Tunisian Jews. Dewachi shows us that war and sanctions in Iraq have dismantled the basic medical infrastructure relied upon by Iraqi patients and doctors who have not been privileged enough to leave. By bringing to the forefront such transformations of the everyday, this provocative body of work greatly sharpens our understanding of how modern institutions, scientific practices, and ways of understanding populations and the human body fundamentally reconfigured life for non-elite populations in the Middle East.