P.

Boomgaard The development of colonial health care in Java; An exploratory introduction In: Bijdragen tot de Taal-, Land- en Volkenkunde 149 (1993), no: 1, Leiden, 77-93

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PETER BOOMGAARD

THE DEVELOPMENT OF COLONIAL HEALTH CARE IN JAVA; AN EXPLORATORY INTRODUCTION

Introduction
The history of health, disease and medical care in Indonesia bcfore independence is a sadly neglected field, bolh in absolute and relative terms. In absolute terms because the number of recent books and articles on this topic is minimal, and in relative terms because the history of 'colonial medicine' in other areas, particularly those with a British colonial past, has received much more attention over the last decade or so. This sorry state of affairs cannot be attributed to a lack of unpublished or printed primary and secondary sources. Particularly the colonial medical services produced vast numbers of monographs and articles on health care, medical research and training in the then Netherlands Indies.1 In addition to these publications, there is a wealth of descriptions of individual 'tropical' diseases, 'medical topographies', and studies of local or regional indigenous health practices ('folk-medicine'). As research on these topics in the archives of Indonesia and the Netherlands has hardly even begun, it is impossible to give an idea of the quantities involved, but potential researchers can be assured of an abundant harvest. Reading through the few available recent studies, one is struck by the fact that Dutch authors in particular have opted for - to borrow a phrase - the custodial approach.2 They describe the organization of the colonial medical services, the various 'campaigns' launched by these services, the training of

1 2

For a recent overview of this literature see Mesters (1991). his felicitous term has been taken from MacLeod (1988:2).

PETER BOOMGAARD (1946) majored in economie and social history and wrote a dissertation focused on nineteenth-century Java. He taught history at the Erasmus University (Rotterdam) and the Free University (Amsterdam), and held a research position at the Royal Tropical Institute (Amsterdam). He is director of the Royal Institute of Linguistics and Anthropology (KITLV), and editor of the series Changing Economy in Indonesia. Recent publications include Children of the Colonial State; Population, Growth and Economie Development in Java, 1795-1880 (1989) and Population Trends 1795-1942 (1991, with A.J.

Gooszen).

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Dutch and local physicians, and the results of tropical medical research.3 Little attention is given to what could be called the social history of health, disease and medical care in a colonial setting, in which the perception of a 'disease environment' and the development of medical care are not an objective reality or a neutral force respectively. It is clear that there is room for both approaches. A comprehensive history of the colonial medical services in Indonesia would be most welcome, and is, in fact, long overdue. The social historical approach is bound to benefit from such an overview. At the same time, one hopes that the historian who might undcrtake the task of writing the 'institutional' history will be influenccd by the concerns of the social historian of colonial medicine. It is to these concerns that this article is addressed. It focuses on a restricted number of issues, such as the confrontation between 'Western' and 'traditional' medicine, the ambivalent role of Western medicine as both a 'tooi of Empire' and a prime example of 'benevolent rule', and the persistcnce of colonial and indigenous traditions and problems. Given the present state of our knowledge, the reader would be well advised to expect more questions than answcrs from this short essay.

Background Up to the 1960s, convenonal wisdom had it that the introduction of Western medicine in tropical countries led to lower morbidity and mortality rates. If we limit ourselves to Java, there is, indeed, evidence of a gradually improving life expectancy at birth between 1800 and 1940 (Boomgaard and Gooszen 1991:48-66). Although other factors clearly contributed to this improvement, there is not much doubt that Western medicine was of some importance. Modern orthodoxy, however, though not denying recent improvements due to Western medicine, emphasizes the arrival of Western diseases prior to Western medicine, implying that European doctors at best made up for the havoc wrought by disease-carrying European sailors and soldiers (MacLeod 1988:8; Arnold 1989:4-6). This is evidently true for Central and South America in the 16th century, Australia and Oceania in the 18th and 19th centuries, and Africa in the 19th and 20th centuries (for example, Crosby 1986:195-216). One hesitates to apply this statement without qualification to Asia, however. Europe and Asia had been connected by maritime and overland trade routes from way before the age of Europe's maritime expansion in the
3

A good illustration of this can be found in ihe collection of essays published by Luyendijk-Elshout (1989).

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16th and 17th centuries, and there is sufficient evidence for a 'microbial unification' of the two continents from the 14th century onward (Le Roy Ladurie 1973; McNeill 1979). Syphilis, in all probability just imported in Europe from America, seems to have been the only 'new' disease to accompany European maritime expansion in Asia (Crosby 1972:122-164; Qutel 1986:9-17). Only under exceptional circumstances does syphilis attain epidemie proporons, and there is no evidence that I am aware of that it led to permanently higher overall death rates. Generally speaking, therefore, Asia escaped the fate of a dramatically increasing death rate upon (intensified) European contact suffcred by the above-mentioned areas. However, one can argue that the spread of some epidemics, such as cholera - itself of Asian origin - the Hongkong plague - ditto - and the 1918 influenza pandemic, was facilitated and accelerated by improved maritime transport in the 19th and 20th centuries, due to the ever-increasing imperial and commercial expansion of the European powers. One could also argue that the rapid spread of malaria - not as such a European import - in 19lh- and 20th-century Asia was caused largely by European irrigation projects and the expansion of plantation agriculture. Although in this case the cure - quinine - followcd the spread of the disease fairly closely, it is a debatable point whether it was sufficiently effective prior to the 1940s (Amold 1989:10). These consideraons regarding Asia as a whole are also relevant for Java. Java has participated in international commerce since the 5th century AD at the latest, and one is, therefore, inclincd to assume that by the 16th century it had become part of the 'civilized disease pool'. Nevertheless, one cannot ignore the fact that Java was hit by at least four severe, supra-local epidemics - or combinations of famincs and epidemics - aftcr the arrival of the Dutch in relatively large numbers, namely in 1624/7, 1644/5, 1664/5, and 1674/7, apart from a number of local erop failures and epidemics.4 The big famines and epidemics secm to have been largely the rcsult of droughts, floods and war - I have left the purcly war-induced faminc of 1618/9 out of consideration - although one should not, without further research, dismiss the possibility that rcccntly introduccd diseases aggravated erop failures. In the 18lh century we encounter several local malaria and smallpox epidemics and local famines, as in the 17th century. Owing to canal construction in the environs of Batavia, however, the malaria epidemics in and around the city increased in virulcnce, with peaks in 1733/38, 1745/55, and 1763/67. The 'putrid fever' of which there were some epidemics in
4 Daghregister 1624:47, 68, 83, 90; 1625:133, 146, 148; 1664:117, 249, 470; 1665:80, 149; 1674:241, 308; 1675:90, 105, 137, 183; 1676:50, 68, 144, 192, 208; 1677:282, 338, 438; De Jonge 1862/95, V:42, 100, 278; VII:110; Babad 1941:178; Raffles 1830, 0:259; De Graaf 1958:131; De Graaf 1962:29, 77; Meilink-Roelofsz 1962:292; Reid 1988:60-61.

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Batavia, such as the one in 1770, may have been typhoid fever, possibly a new disease in Java. The only epidemics of more than local importance - at least as far as I know - occurred during the periods 1745/6 and 1757/60. The first of these is badly documented, but it seems safe to assume that almost continuous warfare after 1740 and the drought of 1746 had something to do with it. During the years 1756/60, West Java and the western parts of Central Java were hit by a mysterious 'plague', which probably took the lives of some 100 to 150,000 people, or 10 to 15% of the population of the area concerned. This epidemie also followed in the wake of a war and concomitant erop failures, although it should be mentioned that West Java itself had not been part of the war theatre.5 As a rule, therefore, wars and erop failures owing to droughts or floods, sometimes in combination, go a long way in explaining 17th- and I8thcentury 'epidemie' mortality peaks. European influence, however, was seen to play a role in the spread of malaria, albeit only locally. As the present state of our knowledge regarding the nature of the epidemics mentioned leaves much to be desired, a final verdict will have to be postponed. We are better informed on disease patterns in the 19v and 20th centurics. In the 19th century, we observe several local and regional and fewer supra-local cholera, malaria and smallpox epidemics and one major epidemie of typhoid fever. In the 20th century, smallpox has all but disappeared and cholera and typhoid have become much less important. In their stead came influenza one major epidemie - and the plague (Boomgaard 1987; Gardiner and Oey 1987). Influenza came from Europe and typhoid may have had the same origin, but all the other epidemics arrived from other Asian countries. It seems reasonable to assume, however, that the rapid spread of these diseases was a funcon of intensificd maritime links, as such a European 'product'. A more important discovery seems to be that in Java epidemics and famines, taken together, no matter how devastating their effects may have been locally, did not on average contribute more than 10 to 15% to total mortality, if measured over a longer period (Boomgaard 1987:50; Gardiner and Oey 1987:71). Although such an esmate cannot be projected backwards to the 18th and 17th centuries without further evidence, we may safely assume that even during that period, epidemics and famine contributed less to total mortality than endemic diseases. Unfortunately, our knowledge of endemic disease patterns is even less satisfactory. Before and around 1800, dysentery was probably one of the biggest killers, and it remained important in later years. However, it is not
Plakaatboek VI, P {^Plakaal or edict) 14.9.1753; VII, P 30.12.1758; VIII, P 24.7.1770; De Jonge 1862/95, X:317, 323; Noble 1762:89-90; Raffles 1830, II: Appendix A; Semmelink 1885:339-389; De Haan 1910/2:522-530; Schoute 1929:237, 294; Malleret 1968:33; Boomgaard 1987:49, 61; Boomgaard 1989:119-120.
5

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clear how much the image we have of this is distorted by the fact that most of our information comes from urban areas, particularly in the earlier periods. In the 19th century, the spread of endemic malaria may have increased, but from the 1920s onward it seems to have declined. Finally, tuberculosis is increasingly mentioned in the 20th century, although it is not clear whether this reflects a true increase or an improvement in diagnosis and reporng. Concerning these endemic diseases it can be said, again, that they were not European imports, but that their spread may have been facilitated by Western influence. It is also clear that between 1800 and 1940 mortality decreased, which implies that the expansion of European medicine, among other factors, more than counterbalanced the spread of certain diseases. In the 19th century, European medicine was not able to offer much more than smallpox vaccinations and quinine. After the spate of medical discoveries in the late 19th century, however, European medicine had much more to offer, and this, in combinaon wilh hygine measures, the provision of clean water, mosquito extermina'on (in the fight against malaria), and higher per capita food consumption, went a long way in explaining rising levels of life expectancy at birlh.6

The meeting between 'Western' and 'Oriental' medicine During the 17th and 18th centuries, the VOC (Dutch East India Company) sent some medical doctors and many surgeons to Asia. Doctors (medicinae doctores) were university graduates with a largely theoretical training and a relatively high status. Surgeons had a lower status, lower pay, and a much more practical, artisanal training, focused on the treatment of fractures and wounds. In the course of the 18th century, the status, income, and training of these two groups of medical professionals in the Netherlands began to converge, a process that ended in a complete merger in the 19th century. In Asia, the VOC surgeons were allowed to practise as medical doctors from the outset.7 Apparently, employment by the VOC was unattractive for medical doctors. Asia, therefore, mostly became acquainted with Dutch medicine through the activities of VOC surgeons, who seem to have been fairly popular with Asian rulers. In 1656, a high 'mandarin' of the ruler of Tonkin requested the services of a good surgeon from the Governor-General. Around the same time, the ruler of Quinam (Annam) detained chief surgeon Dirk Jorisz van Leyden, who had drifted ashore after being shipwrecked. In 1672,
6

Boomgaard 1987; Gardiner and Oey 1987; Boomgaard and Van Zanden 1990:49-51, 131-132. 7 Schoute 1929:27, 106; Van Andel 1981; Frijhoff 1983; Van Lieburg 1983.

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the VOC chief surgeon Daniel Brockebourde was loaned to the Siamese (Thai) court to serve as the king's physician. His mestizo son and two grandsons also served as personal physicians to several Siamese rulers. The ruler of Arakan (Burma) in 1663 asked the local VOC Resident if he could 'keep' surgeon Nicolaes Bouckens, who had applied for leave of absence in Batavia. In the 1660s, the surgeon Gelmer Vosburg stood in high esteem with the Nawab of Bengal, whom he had cured of some painful afflictions. The Nawab's successor was treated by a VOC chief surgeon, Jacob Valkenier. In 1663, another surgeon, Jacob Frederick Bertsch, could be found at the court of the Moghul in Delhi, where, in 1680, we encounter chief surgeon Jacques du Pree, and after his fall from grace - not for a medical but a political mistake - surgeon Jacob van den Bergh. Indonesian rulers were also interested in the services of VOC medics. In 1638, the Sultan of Banten had a Dutch surgeon treat one of his wives. In 1669, the ruler of Sukadana likewise sent to the Governor-General for a VOC surgeon for the treatment of his Ratu Agung. The Susuhunan of Mataram and his little son were both treated by the surgeon of a VOC ship riding at anchor near the coast in the coastal town of Tegal in 1677. Finally, Raja Arung Palaka of Bone (Makasar), suffering from a swelling on or in his nose, was attended to by Dutch surgeons.8 Given these data, I am inclined to disagree with David Arnold, who stated that, prior to 1800, European physicians only rarely offered their services to local rulers (Arnold 1989:11). Although the pre-modern surgeon has often been ridiculed as a glorified barber, with whom he originally shared the same guild, it may well be that the VOC surgeons, often well versed in anatomy and not burdened by too many theoretical preconceptions as they were, served these Asian rulers better than the medical doctors could have done. At the same time, it cannot be ruled out that the rulers saw the European surgeon primarily as just another kind of magician, with the likes of whom many an Asian court was well stocked at that time. Given the fact that in the 17th century astrological considerations had not yet taken their leave of the medical profession (Van Andel 1981:34-40), this was a pardonable mistake. Europeans were also interested in Oriental medicine. Well-known examples of (amateur) scho.lars, employed by the VOC, who published their findings on medical matters in the Indies were Bontius (Jacob Bondt, 1592-1631) with his De Medicina Indorum, and Rumphius (Georg Everhard Rumpf, 1628-1702) with his Amboinsch Kruidboek (Herbarium Amboinense). Daghregister 1656/7:49; 1661:240, 435; 1663:6, 165, 425, 664; 1667:233; 1669:427; 1677:274; 1680:231, 758, 824; Tavernier 1692, 11:537; Ten Brummelhuis 1987:43.
8

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My impression is that European medical professionals assumed, as a rule, that every ailment typical for a certain region could be cured by drugs from that region: God, who had sent the disease, would also provide the cure. They acknowledged the expertise of indigenous healers in these matters. European surgeons and doctors were less impressed with the knowledge of local healers of the anatomy of the human body. Derision was reserved for the magico-religious aspects of indigenous medical practices, such as the use of incantations, amulets, and imitative and sympathetic magie. 9 In other words, the European doctors and surgeons, although themselves certainly not entirely free from 'magical' influences in the earlier years, objected predominantly to the non-secular aspects of Oriental medicine. I have used the term 'Oriental medicine' for want of a better one. Medicine as practised in the Archipelago in the pre-modern period has hardly been the object of serious recent research. From the glimpses one occasionally gets from the sources, these practices do not seem to have differed much from the better documented 19th- and 20th-century healing methods, which are usually referred to as 'folk-medicine' or 'traditional medicine'. Allhough traditional Indonesian medicine has been a fairly popular research topic over the past decades, a comprehensive historical study covering the last century and a half is still sadly lacking, the abundance of sources notwithstanding. One can easily suggest a number of ques'ons that need to be answered by the prospective researcher. The term 'traditional', for instance, may be convenient for some purposes (and for some regions), but is rather unsatisfactory if one is interested in the confrontation between 'traditional' and Western medicine.10 Traditional Indonesian medicine, obviously, included animistic and shamanistic elements, but, given the historical development of the region, one would also expect Ayurvedic (Indian), Chinese and Unani (Islamic) influences. Greiner, a physician who worked in the Archipelago in the 1850s and 60s, emphasized the 'Arabian' character of medical theory among the better educated Javanese (Greiner 1875:182/3). Particularly in the case of Arabic/Islamic medicine, there might be some common ground wilh Western medicine, given the tributary relationship of both to ancient Greek medicine.1' Although I am certainly not suggesting that there were no fundamental differences between Western and Indonesian medicine, there may be room for the hypothesis that, originally, they were not as far apart as has been

' On magical medicai practices, see, for example. Kleiweg de Zwaan 1914; Kreemer 1915:69-74. 10 For a similar approach, conceming the label 'traditional' for ja/nu (authentic Indonesian medicine), see Jordaan 1988. 11 For an overview of traditional Asian healing methods, see Kusumanto Setyonegoro 1983.

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thought, and that the 'microbial unification' of the Eurasian land mass perhaps was followed by a unification of medical theory and practice.

The growing gap and the attempts to bridge it In the 19th century, when professionalization of the medical establishment in Europe entailed an increasingly strong reacon against lay opinions, including folk-medicine in Europe itself, European doctors became more critical of indigenous medicine in Indonesia. Increasing attention to hygine and clean water (Corbin 1982; Luckin 1986), even before the great medical discoveries of the late 19lh century, and the by then complcted process of secularization, made for an increasing distance between European university graduates and Indonesian practitioners. Nevertheless, their basic attitudes towards the aetiology of diseases were quite similar: Europeans believed that a great many diseases were causcd by invisible miasmata (bad vapours), while Indonesians held invisible evil 'spirits' responsible.12 The tendency to grow apart was reinforced when, in the late 19th century, the 'microbial revolution' (Koch, Pasteur) turned medicine, up to then more a craft than anything else, into a science. Although not all European doctors in the Indies were immedialely converted to the germ theory of diseasc13, the belief in miasmata was on its way out, whereas belief in evil spirits was not. Indonesian healers, who, by virtue of their greater knowlcdge of local drugs and hcrbs, had up to then been viewed by many European doctors as slightly disreputable colleagues, were now regarded increasingly as deceitful magicians, or at least as superstitious quacks (cf. Arnold 1989:7). It is probably no coincidence that around the same time Indonesian medicine and healers became the object of systematic anthropological research. During most of the 19th century, the medical literature on Indonesia, mostly Java, had consisted of case-studies of patients, descriptions of specific 'tropical' diseases, particularly epidemics, and 'medical topographies'.14 At the end of the century, we can observe a rathcr sudden upsurge in dctailcd studies of indigenous medical belicfs and practices, written by missionaries, doctors and clhnologists, which pcaked
12

On miasma see Corbin 1982; on evil spirils Wiselius 1872; Willeen 1887; Kruijt 1906; Nieuwenhuis 1911; Kleiweg de Zwaan 1914; Sangkanningrat et al. 1927; Van Hien 1933/4. 13 When the German physician H. Breitenstein published his memoirs in 1900, he was still a supporter of the miasma theory. Koch's visit to Java, in 1899, had not changed this (Breitenstein 1900:94-95). 14 Case-studies and descriptions of diseases in the various volumes of Geneeskundig Tijdschrift van Nederlandse hl ndi (from 1854 onward). 'Medical topographies' were a fashion of the 1840s and 50s: for example, Bensen on Banten, Bleeker on Batavia, Muller on Semarang, and Broekmeijer on Pasuruan; for references see Repertorium, seclion 'Gezondheidstoestand en Ziekten'.

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between 1900 and 1925. By 1915, the time was ripe for the first more or less comprehensive overview (Kreemer).15 With the growing distance between Western and Indonesian medicine, the latter became an appropriate subject of anthropological, not medical research. The notion of 'traditional' medicine was bom. It had to be studied carefully if one ever wanted to encourage acceptance of Western medicine. It is one of the ironies of history that precisely during the period of the great medical revolution in Europe (1860s-1880s), the European and Eurasian lay population of Java was drawn increasingly into the sphere of influence of indigenous medicine. Eurasian ladies, such as 'Njonja' (= modern Indonesian nyonya, 'Mrs.') van Blokland, and 'Njonja' van Gent, wrote books - in Malay! - on Javanese drugs and healing practices for a lay public, which were apparently so well received that they went through at least three or more editions. 16 After 1900, their place was taken by the enormously popular books - in Dutch - by Mrs. Kloppenburg, which also went through many editions (Kloppenburg-Versteegh 1907, 1911). Later, European doctors employed in Indonesia would testify that during the early decades of the century the European and Eurasian populalion relied more on these books and on indigenous healers than on European physicians (W0ller 1940:92; Eerland 1970:5). In part, this can be attributed to a shortage of European doctors. However, to many families who had residcd in Indonesia for generations, European medicine was as alien as Europe itself.17 Small wonder, then, that the indigenous population of Java was equally hesitant to avail itself of the services of European physicians (for example, Breitenstein 1900:105; Vermeer 1939; Wellcr 1940:92). Various factors may have contributed to this attitude. In the first place, around 1900, European medicine did not have all that much to offer, smallpox vaccination, quinine, and castor oil apart. Secondly, economie factors should be considered. European doctors and hospitals were often located far away, and fees and medicine were expensive. Thirdly, one should not undcrestimate psychological obstacles, such as the fact that the patint had to leave his or
15 For example, Vorderman 1894; Simon 1902; Romer 1908; Kreemer 1908; Winkler 1909; Kleiweg de Zwaan 1910; Van Ossenbruggen 1911; Schreiber 1911; Kleiweg de Zwaan 1913; Van Ossenbruggen 1916; Maijer 1918; De Kat Angelino 1919/21; Elshout 1923; Bouvy 1924; Winkler 1925; Nieuwenhuis 1929; Weck 1937. " Van Gent-Detelle 1883 (5th edition); Van Blokland 1899 (3rd edition). It is not always realized that at the end of the 19th century the majority of the Europeans and Eurasians in Java often spoke better Malay than Dutch. This was to change with the arrival of large numbers of Europeans after the turn of the century. 17 Arnold (1989:11-12) suggests that, at least in the British colonial world, the reliance of Europeans in the colonies on European medicine increased in the 19th century, whereas my data suggest that in Indonesia this process took place much later.

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her village and family, and had to confide in an alien, a belanda (Dutch) moreover, who was probably perceived as part of the state apparatus. Finally, if a Javanese suspected that an evil spirit was involved, a visit to the local dukun (Javanese healer-herbalist-exorcist, often female) was called for, not one to a European doctor. Of these factors, the first one was to change fundamentally after 1900. Particularly the very effecve anti-yaws 'campaigns' must have left a lasting impression, which may go a long way in explaining the popularity of 'shots' of whatever kind with the Javanese in later years (Vermeer 1939:6061; Peverelli 1942:12), which has survived down to the present day. Other elements also contributed to the increased acceptance of Western medicine, such as the growing decentralizaon of medical facilities, the increasing 'Javanization' of medical personnel (cf. Arnold 1989:20), and continuing urbanization, resulting in a quicker adoption of Western attitudes in general (Verdoorn 1941:14-18). In the meantime, European medicine, particularly insofar as it was in the hands of the government, had shifted its focus from curative to preventive methods. Most physicians regarded the attempts to 'convert' the Javanese to Western notions of hygine as the most important, but also the most difficult part of their task. To a population that regarded evil spirits as the main causative agents of illness, the link between good health on the one hand and boiled water and latrines on the other was not easily explained. Originally, some people seem to have opted for attempts to formulate the desired preventive measures in terms of actions against spirits in order to secure the cooperation of the Javanese population (Stoll 1903:304; Kohlbrugge 1907:84-85). Fairly soon, however, a three-pronged course of action was adopted: intensive propaganda 'campaigns' and health education, avoidance where possible of measures which would be offensive to the sensibilities of the population, and the use of force - as in the case of the plague - if necessary (Verdoorn 1941:18; Hydrick 1944; Boomgaard 1986:73-75). On the eve of the war in the Pacific, it could be said that some progress had been made, both in terms of acceptance of Western medicine and of reduced morbidity and mortality. It was also clear, however, that further progress would be severely hindered by the low Standard of living of the Javanese population and the restricted budget of the health services.

Medicine and Empire To state that Western medicine facilitated the expansion of the European colonial empires in Asia (and Africa) is to labour the obvious. In the case of Java, where the Dutch had already establishcd their rule before the heyday of

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'tropical' or 'colonial' medicine, this is less obvious, though it certainly applies to the so-called Outer Provinces (all the areas outside Java). Here, Western medicine was evidently a tooi of empire. Although Java had been colonized without the benifit of modern medical science, therefore, Western medicine was nevertheless introduced as part of the alien power structure. The first European physicians to be encountered by the Javanese were VOC employees, and in the 19th century almost all European medical personnel belonged to the Military Medical Service

{Militaire Geneeskundige Dienst, MGD). The Javanese smallpox

vaccinators, with whom even the population of the remotest villages came into contact, were government employees. In the 20lh century, a separate Civil Medical Service {Burgerlijke Geneeskundige Dienst, BGD) was detached from the MGD (1911), to be renamed Public Health Service {Dienst voor de Volks Gezondheid, DVG) in 1925. After 1900, the number of private practitioners increased, as did the number of hospitals run by missionaries and planter associations. Although they did not form part of government, they were certainly 'tools' in the broader colonizing effort. The Public Health Service was almost a state within the state. It launched campaigns against endcmic (hookworm, malaria, yaws) and epidemie diseases (for example, the plague), being invested with powers which went far beyond those of doctors in Europe. In addition, it was charged with the implementation of quarantine measures, the management of public hospitals and outpatient clinics, intensive hygine schemes, medical and nutritional research, the training of doctors, dentists, nurses, midwives and vaccinators, the production of vaccines, and the collection of all kinds of statistics.18 This kind of medical state intervention was unheard of in Asian countries before the 19th century, but it was equally alien to the European situation of that period. This was neither Western nor Oriental, therefore, but was a phenomenon sui generis, bcing truly colonial in nature. The same applies to the predominant role of hospitals, outpatient clinics and, later on, health centres in colonial Indonesia; this was not a Western or an Oriental feature either (Schoute 1929:330-331; Schoute 1935:15). It seems likely that the 'governmental' nature of colonial medicine, particularly in its more coercive aspects, was ill-calculated to engender confidence in 'Western' medicine. This was already apparent in the early 19th century, when villagers sometimes fled to the mountains and the forests when the vaccinators were on their way. It was feared that vaccination was really an attempt on the part of the colonial government to cast a spell upon those being vaccinated, in order to make them join the army (Boomgaard 1989). In the 20th century, it was in particular the Plague Service, with its spleen punctures and its burning down of entire plaguestricken villages, which arouscd suspicion of European medical actions, as
For parallels in the British empire, see Arnold (1989:12-19).

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was pointed out by Indonesian nationalists of that period (Abeyasekere 1986:10). Doctors who set sail for the Indies doubtless had the same variety of motives as those who go to developing countries today: they were idealists (Eerland 1970:21), saw it as a moral duty (Vermeer 1939:22), or were simply looking for adventure (W0ller 1940:20, 93; Mooij 1978). If they saw a connection between medicine and empire, it was empire as a tooi of medical science, not the other way around.

Epilogue To what extent is the past still visible in the present? One of the sadly conspicuous features of Java's present health situation is the persistence of (relatively) high rates of infant and maternal mortality. It was precisely this aspect of indigenous Javanese 'health care' which, between the 1840s and 1940s, almost invariably elicited the most caustic cricism. Until far into the present century, doctors described indigenous child delivery practices, with the assistance of a traditional birth altendant (midwife), in the most lurid terms, culminating in Van Buuren's 570 short case histories, published in 1909. Although the first attcmpts to train young Javanese women in the Western obstctrical tradition for a professional career as midwives date back to 1850, not much changcd during the above-menoned period.19 A detailed description and analysis of the problems surrounding childbirth and the relative lack of success in solving thcm, over a period of a century and a half, would provide excellent material for a scholarly study.20 Here one would encounter, in a nutshcll, almost the entire range of obstacles which confronted attcmpts to improve the heallh of the Javanese population. To name but a few of these factors: the lack of hygine and the 'magical' notions of the indigenous midwife on the one hand, and the lack of funds to train a sufficient number of 'modem' midwives and to pay them an adequate salary on the other. Of course, today's problems are but a shadow of the horrors of the prewar period, but it is ncvertheless remarkable that perinatal and maternal care are still, relatively spcaking, underdevcloped. The olher 'survivals' to be mentioned are typically 'colonial' ones, in the sense that they are ncithcr typically Western nor Oriental. I am referring to the governmental nature of pre-war health care, often combined with an emphasis on hospitals, outpatient clinics and health centres. Particularly the style of the family-planning campaign - although not a direct heritage of the

" Epp 1845; Bosch 1851:26; Harloff 1852:386-389; Greiner 1875:183; Kreemer 1882; Van Buuren 1898; Van Buuren 1909; Van Buuren 1910; Vermeer 1939:17; W0llci 1940:92; Verdoorn 1941. 20 An interesting attempt in ihis direction is Niehof 1992.

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colonial period - smacks of the intensive pre-war rural hygine programmes (cf. Huil 1987). The ambivalent position of nurses in health centres (Sciortino 1992) also dates back to the colonial period. The nurse was a colonial 'invention' in Java, connected with the prominent role of outpatient clinics (for example, Vermeer 1939:56-57), wilh functions that reflected the peculiarities of local circumstances. Here, again, we are confronted with a phenomenon that is neither purely Western nor Oriental. Some typical features of colonial health care, therefore, did not disappear when the colonial rclationship between Indonesia and the Netherlands was terminated. They are by now firmly embeddcd as structural elements of present-day Indonesian medical care and family planning. A more thorough study of this colonial hcritage, though certainly interesting in its own right, might thus be of more than purely hislorical rclcvance.

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