The First International Leprosy Conference, Berlin, 1897: the politics of segregation

Primeira Conferência Internacional sobre Lepra, Berlim, 1897: a política segregacionista

ANALISYS

The First International Leprosy Conference, Berlin, 1897: the politics of segregation

Primeira Conferência Internacional sobre Lepra, Berlim, 1897: a política segregacionista

Shubhada S. Pandya

Flat 11, 'Shanti Kuteer' Netaji Subhash Road Mumbai 400 020 India, [e-mail]

ABSTRACT

The present paper examines the first attempts to internationalise the problem of leprosy, a subject hitherto overlooked by historians of imperialism and disease. The last decade of the nineteenth century saw many in the 'civilised countries' of the imperialist West gripped by a paranoia about an invasion of leprosy via germ-laden immigrants and returning expatriates who had acquired the infection in leprosy-endemic colonial possessions. Such alarmists clamoured for the adoption of vigorous leper segregation policies in such colonies. But the contagiousness of leprosy did not go unquestioned by other westerners. The convocation in Berlin of the first international meeting on leprosy revealed the interplay of differing and sometimes incompatible views about the containment of leprosy by segregation. The roles of officials from several countries, as well as the roles of five protagonists (Albert Ashmead, Jules Goldschmidt, Edvard Ehlers, Armauer Hansen, and Phineas Abraham) in the shaping of the Berlin Conference are here examined.

Keywords: leprosy, Berlin Conference, Armauer Hansen, segregation, India.

RESUMO

Esse artigo analisa as primeiras tentativas de internacionalização do problema da lepra, assunto até hoje pouco considerado pelos historiadores do imperialismo e da saúde. A última década do século XIX viu muitas pessoas dos 'países civilizados' no Ocidente imperialista viverem o medo de uma invasão de lepra via imigrantes cheios de germes e expatriados que adquiriam a infecção nas possessões coloniais em que a lepra era endêmica. Tais alarmistas clamavam pela adoção de uma forte política segregacionista para os leprosos em suas colônias. Mas a capacidade de contágio da lepra não era um tema inquestionável para outros ocidentais. A convocação em Berlim do primeiro encontro internacional sobre lepra revelou a existência de visões diferentes e algumas vezes incompatíveis em relação ao combate à lepra através da segregação. O papel das instituições oficiais de diversos países e, principalmente os diferentes papéis de cinco protagonistas (Albert Ashmead, Jules Goldschmidt, Edvard Ehlers, Armauer Hansen, e Phineas Abraham) da Conferência de Berlim são aqui examinados.

Palavras-chave: lepra, Conferência de Berlim, Armauer Hansen, segregação, Índia.

The sharp interest in the late nineteenth century western world in leprosy was partly due to a belief in the salutary effect of leper segregation in ridding medieval Europe of the disease. As some historians have pointed out, the West's 're-discovery' of leprosy in the late nineteenth century was the flourishing imperial enterprise and the alarming presence of the disease in the conquered territories in Asia, Africa and elsewhere. In keeping with the global dimensions of imperialism, and as a consequence of the advances in bacteriology, attempts to internationalise the leprosy question were to be expected. Precedents were available in the International Sanitary Conferences convened to discus the containment of cholera — a major disease threat to the commercial interests of the ruling powers. International conferences on scientific aspects of specific diseases had also become an annual feature of the medical scene in Europe and America in the West. As in the case of cholera quarantine and contagion, so in leprosy, segregation/isolation of tainted individuals would be expected to feature at the centre of the international polemics. These ramifications have not yet been examined by leprosy historians, whose pre-occupations have tended to be with disease policy and perceptions in individual endemic countries, e.g. Norway (Irgens, 1973), Colombia (Obregón, 2002) and regions and countries under the imperial yoke, e.g. Africa (Vaughan, 1991, pp 77-99), Hawaii (Gussow, 1993) and India (Kakar, 1996). This paper, using primary and secondary sources, traces the role and interests of various persons embodying various forces that shaped the First International Leprosy Conference in Berlin in 1897.

A spectre haunted large parts of the Western world in the last decade of the nineteenth century — the spectre of the most 'loathsome' of diseases, leprosy, lapping on European and American shores. At the high point of Western imperialism, great anxiety was felt about the likely importation of the dread disease endemic in the colonies, into 'civilised countries'. The paranoia was the more ironic, because only a few decades earlier endemic leprosy had been viewed as evidence of civilisational backwardness, — implicitly this was a category not applicable to the West. For example in 1862, an authoritative medical journal in England opined that the countries of Asia continued to be infested by leprosy, ''to a greater or less extent, generally speaking, in proportion to the physical and moral degradation of their people'' (BMJ, 12.6.1862). The smugness of the 1860s was rapidly overtaken by panic in 1889, in the wake of the widely publicised Father Damien incident. That European priest had succumbed to leprosy after associating with the lepers in the settlement on the Hawaiian island of Molokai. Thereafter, it became painfully clear to imperialists that physically and morally degraded indigenous peoples could endanger Western well-being. The power of the Damien episode in the public sphere lay in its potential for sentimentalisation, the perceived legitimisation of the contagionist doctrine, the opportunity to reinforce the West's sense of moral superiority and, what Zachary Gussow (1989) has called the 're-tainting' of leprosy by Christian evangelism. The traditional Protestant-Catholic rivalries were temporarily papered over in the sensationalisation of this episode by the Western press. Contrary to what has been claimed by other historians, the place of the discovery of the leprosy germ in 1873 in this scenario is questionable (Worboys, 1993, p. 512).

In his incisive analysis of lepra-phobia in nineteenth century white America, Gussow argues that one of its inspirations was racism. In a country that was undergoing a demographic transformation by immigration, the entrants were particularly feared and stigmatised by white Americans, as it was the case of the Chinese, who according to the 1882 legislation were prohibited to immigrate into the United States (Gussow, 1989, p. 116). A particularly emotive allegation in the United States was that germ-laden Chinese 'coolie' labour had carried the disease into the pristine Hawaiian Islands, a territory deeply important to American commercial interests. Gussow, (1989, pp 132-3) also argues that on the other hand leprosy-endemic Norway, also a source of immigration, did not excite such prejudice: ''Norwegian leprosy never generated horror and alarm simply because Norwegians were never perceived as a 'loathsome' people whose germs were considered culturally and biologically anathema to Anglo-Saxon civilisation'' .

As the most important possession of the largest colonial power of the day and, to quote the Prince of Wales, ''the chief seat of the disease'' (Times of India, 8.7.1889), India, in the years 1889-90, was targeted by both domestic and expatriate British alarmists as the fount of infection. ''One must see leprosy in its virulence [cried an English cleric] Are Europeans liable to leprosy? — Is England in danger? I answer yes. Europeans and their descendants freely exposed to the disease take the malady just as readily as others.... One more loud and warning cry, England! beware!'' (Wright, 1889). Others spread the word that there was an ongoing ''dreadful revival'' of the disease in India (Mackenzie, 1889). Demands were made in newspaper editorials in the English-language press in India to the colonial authorities to 'segregate and segregate' lepers. The pressure on the colonial government to play a more interventionist role in leprosy slowly eased over the next few years, following the visit of a three-member Leprosy Commission to India in 1890-91, whose brief was to investigate all aspects of the disease in the country, including its mode of spread. The members of the Commission, who were staunchly literal-minded about the definition of 'contagion' (transmission by skin to skin contact), concluded that though leprosy was scientifically an 'infectious' disease caused by a bacillus, it could not be deemed 'contagious'. (Report of the Leprosy Commission, 1893, p. 289). They also rejected the hereditary hypothesis. Their final report discouraged the adoption of systematic leper segregation as a public health measure, and saw no reason to interdict marriages between lepers. At the same time, quizzically, they commented favourably on institutionalisation of leper beggars, leper tradesmen and those sufferers who volunteered for it (Report, 1893, p. 290). The Government of India, not at all unhappy at the prospect of being honourably absolved of the expense and trouble of carrying out mandatory systematic isolation of thousands of lepers, chose to accept the Commission's recommendations. The leprosy panic of 1889 gradually ebbed; it was only in 1897 that all-India legislation on the lines recommended by the Commission was finalised. (It was enacted early in 1898.)

The above overview gives the range of opinions and policies on the leprosy question when the First International Leprosy Conference was convened in Berlin in October 1897, almost a quarter of a century after the discovery of Bacillus leprae. This paper, utilising unpublished correspondence and other material, investigates the genesis of the Conference. Focusing on five protagonists — a Frenchman, an Anglo-Saxon American, a Norwegian, a Dane, and a Briton — it also examines the interplay of conflicting national priorities and self-interest reflected in the form and content of that meeting.

Dramatis personae in order of appearance

Jules Goldschmidt of Paris was for 26 years the superintendent of the leper asylum at Funchal in the Portuguese islands of Madeira. In 1894, he surveyed the world leprosy scene and expressed deep misgivings about the possibility of controlling the disease in Asia. It would be absurd, he concluded, to even conjecture a diminution of leprosy in China, where the disease found ''too mighty an ally in stagnating civilization'' and neglect of every hygienic measure. Coolies had borne the pestilence wherever they had gone, and he declared that America was fully justified in excluding the Chinese from the privilege of immigration, since ''the coolie will never accept modern civilisation'' (Goldschmidt, 1894, pp. 197, 198, 199). Goldschmidt was equally pessimistic about India, which ''next to China, exported the greatest number of cases to countries enjoying immunity'', and he predicted that it was in Hindostan that the ''contest'' with leprosy would encounter its greatest difficulties. It was essential, said he, that all lepers and their families, if not confined within leprosy hospitals, should yet be restricted to their villages and be denied opportunities for social intercourse with the public at large. He additionally recommended ''an abundant dietary, with a certain quantity of alcoholic beverage,'' which afforded the best protection against the disease, but he doubted whether the prescription could be carried out among the 'Buddhist Hindoos'. In this gloomy scenario, Goldschmidt marked the silver lining was provided by Norway and said he was sure the disease would soon become extinct in that country thanks to the segregation measures adopted. But, he warned, the West would only be fully secure if restraints imposed on lepers within disease-endemic countries were supplemented by ''a stern denial of entry to all diseased subjects, and surveillance of all suspected individuals,'' by countries to which immigrants flocked (italics added).

Albert Ashmead (1850-1911) of New York and Philadelphia was of impeccable Anglo-Saxon lineage, his Gloucestershire ancestors being among the early settlers in seventeenth century Pennsylvania. A crucial event in his professional life was a three-year sojourn in Japan, which he felt provided him with the authority to dogmatise about the international leprosy danger. He presented his credentials on the matter in the following words: ''Dr. Ashmead has made an extensive study of leprosy, having had extensive opportunities of studying that disease in the Far East, and is internationally regarded as an authority on the subject . He was one of the founders of the Berlin Leper Conference of 1897'' (Ashmead entry in National Cyclopaedia of American Biography). An exception to Gussow's case that Anglo-Saxon America was racially selective in its lepra-phobia, Ashmead considered bacillus leprae lodged in Norwegian bodies to be as dangerous to the United States as those in Asian: ''We Americans are interested, not in our own leprosy, for we have none, we are interested in the Leprosy of Norway, Japan, China, Hawaii [we must] prevent the disease from being brought by emigration '' (Ashmead, 1897-1898, pp. 399-400). In 1883, he settled in New York, pugnaciously promoting his proposition that American freedom from leprosy necessitated a cordon sanitaire.

By 1895, Goldschmidt and Ashmead had discovered each other, and despite their differing perceptions about the threat from Norwegian leprosy, they shared a common pre-occupation. ''[T]he prophylaxis of this foul disease occupies my mind very much,'' Goldschmidt wrote, gratified that his American friend also believed that leprosy spread ''by direct contact from man to man'' (Goldschmidt to Ashmead, 26.12.1895). To his sympathiser, Goldschmidt unveiled his pet plan for an ''International Committee for the suppression of this plague''. All governments concerned, ''[and] very few only are not concerned,'' were to be solicited to convoke a 'Congress' to frame stringent prophylactic measures against leprosy which were to be carried out by all ''civilised nations'' (Goldschmidt to Ashmead, 26.12.1895). The prospect of stamping out leprosy by government edict was eminently attractive to both men, but it was obvious to them from the start that the support and involvement of Armauer Hansen was indispensable to the success of their scheme. ''A Leprosy Congress without Hansen would be a play of Hamlet with the Prince of Denmark left out,'' Ashmead told a correspondent later (Ashmead to Falcao, 6.9.1896).

Gerhard Armauer Hansen (1841-1912) of Bergen, the most famous Norwegian leprologist of the day, was his country's Chief Leprosy Officer from 1875 till his death. His high scientific stature was due to his discovery of the bacillus as early as 1873. However, it was his stewardship of Norway's apparently highly effective leprosy control policy based on leper segregation, which earned his views worldwide attention and respect. The crux of the Norwegian strategy was the ''mixed segregation law'' enacted in 1885, applicable to all lepers, and envisaging domestic prophylactic measures as well as compulsory institutionalisation evaluated on a case-by-case basis (Vogelsang, 1978, pp. 295-7). The act compelled a sufferer to remove himself/herself into an asylum if health inspectors found that he/she was negligent in following the prescribed domestic sanitary measures such as using separate rooms, beds, bedding, clothing, and eating utensils. As a consequence of the enactment, the number of lepers forced to enter asylums increased over the years, though at no time in the nineteenth century were all sufferers institutionalised.

Replying to criticism at home that the measure was too harsh, Hansen defended himself by laying out his philosophy for action as a public health man. His free use of words such as 'power', 'rights', 'obligations' and 'force', demonstrated that he viewed leper segregation in authoritarian terms. ''Who has the right, the single individual or the community?'' The diseased had obligations, he asserted, ''the most important being not to contaminate the healthy.'' It was quite simply a question of power: There were two alternatives, either the healthy must evacuate, or the lepers must be put outside the community and be isolated. For the greater good, the leper was duty-bound to endure the disadvantages of isolation. If he did not display the requisite concern for his healthy fellows, ''then there is no other alternative than to use force'' (Vogelsang, 1978, pp. 296-7). Those who refused to follow his advice were incorrigibly 'stupid', according to Hansen (Hansen to Ashmead, 1.11.1896). These passages show that claims by historians of a harmonious, humanitarian and problem-free blending of research and public health in the tackling of Norway's leprosy problem are exaggerated. Shows of force and manipulation of public opinion were resorted to.

In July 1896, Hansen responded favourably to Ashmead-Goldschmidt overtures. He reported that Norway's health authorities were agreeable to holding the meeting in Bergen, ''the headquarters of the story of leprosy,'' if they had a prior assurance that the invitation would be accepted by leprologists of other countries. Hansen expected the world to come to Bergen as pupil in search of enlightenment: ''we [Norway] hardly had (sic) anything to learn from foreigners while we are capable of giving good information,'' he said (Hansen to Ashmead, 9.7.1896).

Edvard Ehlers (1863-1937), dermatologist of Copenhagen, an investigator who, in the early 1890s, journeyed to the Danish territory of Iceland, to study the reasons for the decline of leprosy there. His report, in the form of an essay, earned him a prize from the National Leprosy Fund in London (which was established following the death of Damien). He concluded that ''absolute want of cleanliness plus Armauer Hansen's bacillus'' provided the 'true paradise' for leprosy; and he attributed its decline to the presence of four — albeit 'ancient' and 'miserable' — isolation asylums, combined with slowly advancing 'civilisation' on the island (Ehlers, 1895, pp. 185-6).

Phineas Abraham(1847-1921), a prominent dermatologist of London, was acquainted with leprosy due to his birth in Jamaica. He took the diploma of the Royal College of Surgeons in Ireland and was for some years the curator of the College's museums in Dublin. His higher education was at St. Bartholomew's Hospital in London. In 1886, he decided to specialise in diseases of the skin and pursued his interest in leprosy. In 1889, Abraham was selected Medical Secretary of Britain's National Leprosy Fund and edited the Journal of the Leprosy Investigation Committee, which appeared during the peak of the leprosy scare of 1889-90. Though inclined towards the contagionist doctrine, the prevailing paranoia made him hesitate to express himself forcefully: ''the British public,'' he explained, ''is rather liable to an occasional emotional outburst'' (Abraham, 1889-1890, p. 119). He highlighted that there were a ''great many doubtful points'' with regard to the etiology as also the desirability and utility of preventive measures such as segregation. On the alarmists' allegation about the revival of leprosy in India, he remarked pointedly that ''[t]he question whether leprosy be really increasing in our colonies is by no means easy to answer definitely.''

Competing schemes

Goldschmidt seized on the gathering at the International Congress of Dermatology, held in London in August 1896, to canvass his 'International Congress for Considering the Entire Suppression of Leprosy'. In his communication to the delegates he harped on ''the danger of a new pandemic of leprosy on the European continent.'' Hastily absolving Norway, the so-called 'classical leper academy' of Europe, of culpability as a disease disseminator [because it was interfering 'intelligently' in the disease], Goldschmidt's (1896, p. 865) accusing finger pointed at unnamed, but easily identified, governments and populations (those of India, for one) which were inactive and apathetic in the face of the rampaging scourge.

Fortified by Hansen's apparent acquiescence, Ashmead had meanwhile constituted a 'Provisional Committee', comprising Hansen, Goldschmidt and himself to publicise the scheme among influential leprologists and petition governments to send delegates to a Congress to be convened at Bergen by the Norwegian government. ''Mankind,'' he declared grandly, ''at no time of history has fought for a greater object'' (Ashmead, 1896, p. 387). The powerful were also addressed: Queen Victoria did not escape Ashmead's overtures. After all, the head of the largest empire with the largest leper population could not but be sympathetic to so 'momentous' an undertaking. He spelled out the main task of the Congress: to form a 'Permanent Committee' of officials from each 'civilised' country, to supervise anti-leprosy measures world-wide. He was very clear about the measures that he envisaged to be satisfactory:

The suppression and prevention of leprosy can only be accomplished by smothering it by means of [leper] isolation. We want to obtain enforced and complete isolation by the consent of governments; we want the necessary measures to be taken, everywhere, rigorously, and that the principle of isolation may pass into practice, with all its consequences, all the duties and efforts it may entail (Ashmead, 22.1.1897).

For reasons not difficult to discern, Ashmead did not address the Government of India. In his alarmist eye, its obstinate laissez-faireism about leprosy segregation had placed it beyond the pale. Instead, he indicted the Indian authorities of gross negligence. The non-segregation of lepers in a country ruled by Great Britain was, he said, a terrible instance of misgovernment. ''There are 200,000 lepers in India, and it is the pest (sic) place of the whole Orient for this and several other diseases... cholera, plague etc. ... As long as such medical misrule is permitted to exist by the civilised world, just so long will efforts to prevent the spread of such diseases be comparatively futile '' (Ashmead, 1897, p. 55).

Not content with pouring scorn on the Government of India, Ashmead turned his attention to a concern nearer home, viz., establishing an American cordon sanitaire against leprosy. He drafted a model emigration law specifically directed at Scandinavian immigration. In brief, its provisions were:

Emigrants from Norway and Sweden to be examined for leprosy by the Medical Officer attached to the United States Consulate, at the point of embarkation; lepers detected to be off-loaded; emigrants from 'leprous families' to be 'disinfected', permitted to settle only in designated American States, and kept under surveillance by the State health authorities for seven years. During this period they were not to be allowed to cross State boundaries. Emigrants with leprosy, who escaped detection in their home country and entered the United States, were to be immediately repatriated (Ashmead, 1896-1897, p. 69).

Ashmead's invitation received expressions of sympathy from a few important leprologists such as Albert Neisser of Breslau and Oscar von Petersen of Moscow; and three governments agreed to send delegates. But by September 1896, Hansen was expressing his dissatisfaction at Ashmead's presumptuously announcement that the Congress would meet under the sponsorship (i.e., funding) of the Norwegian government. ''Norway was a poor country,'' Hansen pointed out, and could only help other countries with 'good advice'. Moreover, he was doubtful as to the 'good work' a permanent Committee of officials could do (Hansen to Ashmead, 18.9.1896). A retraction from Ashmead about Norwegian government sponsorship was demanded, and a hint was dropped that he, Hansen, might opt out of the scheme altogether (Hansen to Ashmead, 4.9.1896). Hansen was probably irked by the American's blatant attempt to implicate leprosy in the issue of Norwegian immigration. The final inducement to Hansen to withdraw from the Goldschmidt-Ashmead scheme was soon provided by a rival plan.

As the brain behind the scheme, Goldschmidt in his turn elaborated on the format of the 'Congress'. It was to be composed of official delegates only; there were not to be scientific discussions on the bacteriology, pathology and treatment of leprosy, the object being simply and solely to determine the measures to suppress endemic leprosy, and prevent its export to untainted countries. As such, the question of curing leprosy could only be secondary (Goldschmidt to Ashmead, 9.8.1896).

Unknown to Goldschmidt, Edvard Ehlers was also pursuing a personal agenda at London in 1896, namely the formation of an international 'league against leprosy' on the pattern of that existing for tuberculosis. He claimed that he had drawn 'unanimous' support for this from ''the most renowned European leprologists'' assembled there (Ehlers to Ashmead, 18.9.1896). He envisaged an 'International Leprosy Conference' to discus all aspects of leprosy, scientific and administrative. With the rival claims of Ehlers and Goldschmidt, leprologists were presented with two proposals for an international meeting. Ehlers possessed some powerful advantages over his competitors Goldschmidt-Ashmead. The repute of his study of Icelandic leprosy gained him a respectful ear from his peers, while Goldschmidt probably, and Ashmead certainly, had no investigative reputation to speak of. Ehlers was also energetic, while abjuring Ashmead-style polemics, which not a few, including some American leprologists, found unacceptable (BMJ, 25.9.1897; Dyer, 1897). Not the least, he shared a long and cordial friendship with fellow Scandinavian, Armauer Hansen.

Aside from personalities, the respective schemes also were antithetical on all points. Ehlers envisaged a 'Conference of Leprologists', with scientific discussions and debates featuring prominently. His rivals envisaged a 'Congress' of official delegates representing countries', where scientists could at best hope to be tolerated. Stirring up governments was not, maintained Ehlers, the way forward. While governments could be invited to send delegates to the 'Conference', these were to be appointed ad hoc with no special or permanent role. The Goldschmidt-Ashmead 'Congress' on the other hand, was a means to politicise leprosy segregation by bringing it under supra-national authority. Lastly, given that Norway saw itself only as a mentor on leprosy control, Ehlers' 'Conference' was more likely to issue non-binding recommendations on the subject of segregation, rather than edicts. Ehlers easily consolidated his position by obtaining, with the support of German dermatologists, the sponsorship of the Imperial German government for a Conference at Berlin. In a few weeks he announced triumphantly to Goldschmidt: ''it is a Conference at Berlin, it is not a Congress at Bogotá, or at Bergen or at London'' (Ehlers to Goldschmidt, 18.11.1896, English translation).

The First International Leprosy Conference

Invitations to the Leprosy Conference to be held in October 1897 at Berlin went out over the signatures of an 'Organising Committee' comprising Edvard Ehlers (as General Secretary), Robert Koch, Armauer Hansen and the influential German dermatologist Oscar Lassar. Referring to the growing public anxiety about leprosy, the invitation said the Conference would have scientific discussions and provide guidance along 'correct lines' on the subject of leprosy prevention (Einladung und Programm, 1897). Almost 180 leprologists, dermatologists and scientists attended on the invitation of the Organising Committee, while thirty delegates from various countries were present on the invitation of the Imperial German government. Hansen and Ehlers were deputed by their respective governments. Ashmead's hope of representing his government was not fulfilled. He did not attend, contenting himself with proposing a 'Resolution' to be adopted on the formation of an 'International Leprosy Committee'. The Resolution was quietly dropped by the gathering without discussion (Dyer, 1897, p. 364). Goldschmidt, who attended, spoke in moderate tones on the importance of a united front to control the disease. The Government of India did not send a representative, a fact widely commented on, without surprise. Neither did the British government. Both relied on the persuasive powers of the dermatologist Phineas Abraham to defend their stand:

The venerable pathologist Rudolf Virchow was unanimously acclaimed as President, which was more than a gesture of respect for the discoverer of the Lepra Cell. It symbolised the Conference's ethos, viz., the victory of the proponents of bacterial etiology over the doubters and nay-sayers. The father of cellular pathology had been for most of his professional life a notable critic of the causal role awarded to germs by germ theory votaries. In 1877, he had remarked sarcastically: ''because one or other contagious illness is caused by bacteria, immediately all contagion is bacterial'' (Virchow in Rather, 1958, p. 145). In the early days of the debates on causation, he had defended the doctrine of localism (Pandya, 1998), but eventually yielded — rather ponderously — to the evidence of bacteriology: '' Armauer Hansen discovered the leprosy bacillus. I will not asset that the grounds for embracing the present view [of infectious transmission] are absolutely convincing, but I am positive that this view is much to be preferred '' (Virchow in Rather, 1958, pp. 232-3). As if to stress that this was a Conference, not a Congress, the organising committee for scientific discussion set ample time aside. The large number of pathologists and bacteriologists attending concluded that, despite failure to cultivate the germ in vitro and in vivo, there was compelling evidence to implicate Hansen's bacillus leprae as the etiologic agent of the disease.

In the discussion on 'The Prevention of Leprosy' too, Hansen was the central figure. The greatest interest centred on his address on the subject of the management of leprosy in Norway. The architect of the apparently successful mixed 'obligatory and facultative' model of segregation, was confident and frank, maintaining that the obligatory component of the 'mixed' model was superior and responsible for the good results: ''I believe'', he said, ''that the results of isolation rules as practiced in Norway, are the result of isolation Where there are many lepers, isolation at home is insufficient, and institutional care must be given to the isolated'' (Hansen, 1897, p. 165). He also disclosed his strategy of manipulation of Norwegian public opinion away from domestic prophylactic measures by lepers, towards compulsory segregation of sufferers in institutions.

I travel all over the country, where lepers live. Our lectures on the rules of cleanliness and isolation of lepers are not accepted. Lepers never accept that he (sic) can be dangerous for his fellow men, and naturally does not want his freedom to be restricted; hence I see to it that healthy persons attend our lectures. The healthy persons listen [it] is important that they do not want contact with the lepers. If I achieve that then my goal is reached. In Norway we have achieved that a leper who wants a servant does not 'find one. (Abraham, 1897; Hansen, 1897).

Hansen said he was proud to report that as a result of such efforts, Norway had more lepers living in institutions than outside, and ventured to predict that in the beginning of the new [twentieth] century, leprosy would have 'entirely disappeared' from Norway. If only the measures that had worked and were continuing to work so well in Norway could be put into universal practice, the disease would be quickly eradicated, Hansen concluded, to loud applause (Bombay Gazette, 8.11.1897).

He therefore proposed the following 'Resolutions' before the Conference:

a) Leprosy can be prevented through isolation.

b) The system of compulsory registration, control and isolation as practiced in Norway is recommended.

c) In each country the sanitary authorities must be allowed to make regulations according to their 'particular social conditions', with the permission of their governments (Hansen, 1897, vol. 2, p. 165).

Ehlers' resolution on the establishment of an International Leprosy Society was favourably received, and a high-power Committee, presided over by Virchow, was formed to study its feasibility (Dyer, 1897, pp. 363-4). The result of this initiative is unknown; however, a more tangible result was the decision to bring out a periodical Lepra Bibliotheca Internationalis, which appeared from 1900, ceasing publication in 1915 probably as a result of the First World War.

The acclamation that greeted Hansen's firm espousal of segregation did not by any means exhaust the discussion. The influential French dermatologist Ernest Besnier (1831-1909), representing the French Academy of Medicine, denied that segregation was necessary to control leprosy. The disease was contagious, he acknowledged, but in France it was feebly so. The lepers there were not a menace, and he saw no need for legal restraints on them. No hard harm comes from treating them in general hospitals. Notification and simple 'precautions' by lepers' families were sufficient prophylaxis, according to him (Lancet, 23.10.1897).

India

India, with the largest leprosy problem, was inevitably the 'absent presence' at Berlin. Despite not having sent official delegates, the colonial and British governments had an able apologist in Phineas Abraham, who pointed out the disadvantages of forcible segregation. No fewer than sixteen legislative acts had been passed to contain leprosy in the British Empire, but the results were doubtful, he said. In South Africa, attempts to banish leprosy patients to an island had led to concealment of the disease by the sufferers and their relatives. Abraham was shrewd enough not to baldly question the contagionist doctrine, but he did make bold to urge that knowledge on etiology being 'far from complete', it was unjustifiable to 'dogmatically' base conclusions and policies on it (Abraham, 1897, vol. 2, p. 180). He cited the Indian Leprosy Commission (of 1890-91) to refute allegations that leprosy was spreading unchecked in India and that little had been attempted by the colonial government in the way of systematic management of lepers. ''Voluntary isolation'', as recommended by the Commission, was being carried out, ''as far as practicable'', maintained Abraham. On this point also he tread carefully — too frequently invoking the notoriously anti-contagionist and anti-segregationist Indian Commission in front of a gathering composed of avowed contagionists might weaken his case.

On the issue of the 'practicality' of leper isolation in India, however, he was willing to expound, and feelingly. His discourse smacked of the 'civilising mission', but there was a novel twist to an old litany. British colonialists, official and non-official, were wont to disparage Indian society for its supposed 'apathy' and 'indifference' towards suffering lepers, who had no recourse but to either 'passively endure' their affliction (Carter, 1876, p. 80) or be thrown ''to the charity of unfeeling India'' (Jackson, 1910, p. 239). Abraham's case, on the contrary, was that Indians were so obstinately fond of their leper friends and relatives, that they frustrated the government's efforts at compulsory segregation: ''[W]here lepers are numerous, and their friends even more numerous, and not desirous of being separated from them, [hence] harsh measures of isolation and segregation become impossible '' (Abraham, 1897, p. 180). In other words, it was Indians incorrigibility that prevented an otherwise willing colonial government from going in for wholesale compulsory segregation.

In 1896, plague was imported into India from Hong Kong and quickly became epidemic. The severe socio-political backlash from Indian society against the forcible search-and-isolate measures unleashed by the colonial authorities provided Abraham with the rhetorical wherewithal (Catanach, 1989). If the colonial government was having serious political difficulties in enforcing 'simple sanitary precautions' on Indians in the case of so deadly a disease as plague, how much more difficult might it not be to insist on rigorous measures (of compulsory leper segregation) in the case of so slow and insidiously progressive a disease as leprosy? It proved that 'social and political' constraints in various countries rendered leper segregation as a universal and uniform system a ''manifest impossibility,'' he said.

In contrast to his eloquence on Indian wrong-headedness, Abraham's reference to the crux of the matter, namely 'ways and means' in leper segregation was indeed brief: ''The segregation and maintenance of upwards of 100,000 souls is a large undertaking.'' The mention glossed over the fact that the economics of segregation had always been an important consideration in the India government's less than energetic response to leprosy prevention. For example, in a 'Leper Bill' drafted in 1889 in response to post-Damien segregationist clamour, the responsibility for establishing and maintaining leper asylums was placed on already cash-strapped Local Bodies and Municipalities, and not with the provincial and central governments. As argued earlier, the Government of India's ready acceptance of the Leprosy Commission's anti-segregationist recommendations was based on reluctance to spend. In any case, the plain fact was that in 1897, Indian leprosy lost the status of 'imperial danger' awarded it by alarmists in 1889. Leprosy suppression was therefore a non-issue in the eyes of the colonial government. The absence of India representation at Berlin was itself symptomatic of this. In plague the authorities had a new 'imperial danger', a far more potent one than leprosy, to contain which they deployed their considerable financial and coercive resources.

Assessment

What effect did the dissenting opinions have on Hansen's proposed 'Resolution'? Besnier's amendment that isolation was appropriate only where leprosy was 'largely spread' or focalised was accepted. The British attempt to politicise the leper segregation issue, on the basis of its difficulties in India, failed: the word 'politics' found no mention in the Conference's 'Final Statement'. However, failure in 1897 did not deter the British from claiming a victory. The Royal College of Physicians of London, with a long history of conservatism on the issue of leper segregation, falsely claimed to the Colonial Office in 1898 that the Berlin Conference had indeed recommended that 'careful consideration of social and political conditions' be given in formulating leprosy prevention policy (Royal College of Physicians, 1898).

While the rout of Goldschmidt-Ashmead at Berlin was thorough, a feature of their proposals that came to be incorporated into future conferences was the sending of official delegates, albeit without investing them with executive powers. Though the attempt to internationalise leprosy control came to nought in1897, a proposal to prevent and deny entry of 'alien' lepers by countries was approved at the Third International Leprosy Conference at Strasbourg in 1923 (Resume, 1926). Nevertheless, the first Conference set the tone: the medical lobby, not officials, dominated deliberations. As such, resolutions endorsing leper segregation, which emerged regularly from such conferences till the 1950s, remained permissive rather than obligatory.

Acknowledgements:

Research for this paper was made possible by a 'Wood Institute Resident Research Fellowship', 1998, at the College of Physicians of Philadelphia (Ashmead Papers); a Travel Grant from the Wellcome Trust, London, 1997; and copies of a few documents obtained through the courtesy of the Librarian, Bergen State Archives. I thank Dr. Katie Modi for translating the German references.

BIBLIOGRAPHIC REFERENCES

Manuscripts and periodicals

Ashmead, A. S. Handwritten entry for National Cyclopedia of American biography, New York.

Ashmead, A. S. 6.9.1896 to Falcao,

Ashmead, A. S. 22.1.1897 'A Berlin!', Circular addressed 'To all leprologists'.

Ashmead, A.S. 1897 Suppression and prevention of leprosy (pamphlet), p. 55.

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Publication Dates

• Publication in this collection
  08 Mar 2004
• Date of issue
  2003

History

• Received
  Sept 2002
• Accepted
  June 2003