My thanks to Michael Worboys for the good things he has to say about Epidemics and History: Disease, Power and Imperialism in paragraph two of his long review: "Overall the volume is a remarkable achievement" etc. However the comments he makes in paragraph one and from paragraphs three to eleven invite a response. I am framing this response in a way which I hope will help inform the historical profession as a whole about recent developments in cultural-medical history.

As is well known, the first major contribution to the history of disease written by a non-medical person was William McNeill's Plagues and Peoples, published in 1976. Although mildly Eurocentric (as most historical studies published in Europe and America were back then), Plagues and Peoples was a major advance on the self- congratulatory, well-intentioned antiquarian studies written by retired medical doctors before 1976. It was studies of the latter sort, rather than studies in the history of science (as Worboys claims), from which historians had to break free before an independent sub-discipline, known as the history of medicine, could take off and be recognized by the historical profession as intellectually respectable.

In his review, Worboys said that "Epidemics and Disease [sic] is based on assumptions which most social historians of medicine will be uncomfortable with." (my emp. his para 3). Indeed yes, with the passage of time the discipline of history moves on and develops new forms. I should point out here that back in the early 1980s when social history seemed to be at the cutting edge of the discipline, I wrote a Social History of Western Europe 1450-1720 from a West African perspective. The book went into a second printing and a Swedish (!) translation, and so was reasonably successful. However all that was more than fifteen years ago. As far as I can tell from reading the principal historical journals and the Times Literary Supplement, new style "cultural history" buttressed by insights from anthropology and comparative literature (following Edward Said) is now one of the most innovative and exciting forms of written history. Even though some journals still include the term "social history" in their title, social history as originally conceived of by late lamented masters (such as E. P. Thompson), has grown rather long in the teeth and has had nothing much new to say for some time. This being the case it is rather amusing to see Worboys (a self-professed practitioner of the social history of medicine) jumping to the defense (if that is what he is doing) of the post-modernist hero, M. Foucault ( his para. 8).

Worboys (para. 3) is troubled by my use of "disease constructs", a conceptual tool which my unconscious mind probably picked up from my readings in historical anthropology and comparative literature. Worboys claims that that I define "disease constructs" as "the culturally filtered, false, even delusional, perceptions of disease that were developed by the agents of imperialism." I confess that a disease construct is "culturally filtered", but I fear that the rest of Worboys' definition of Watts-style disease constructs is his own invention. It must be stressed that each Watts-style construct is disease specific, and specific in time and place. I first use this conceptual tool in my discussion of "leprosy" in medieval Western Europe. In this context, only by the wildest stretch of imagination can one talk about the use of perceptions of disease by "agents of Imperialism" as those last three words are commonly understood today. In short, I fail to comprehend Worboys' definition of a Watts' disease construct.

Worboys goes on to say (para. three) that Watts "continues to work a clear distinction between `the real world of objective fact (p.139) and culturally mediated perceptions.'" I have read and re-read my page 139, but have failed to locate the accusatory phrase "the real world of objective fact" anywhere on that page. Where I do use the phrase (my page 124) the full sentence reads: "In the real world of objective fact, the sexual authoritarianism that began to flower in the mid-eighteenth century (greatly assisted by the anti-masturbation scare) led in the next century to the near demise of literature about actual human reproductive processes." This sentence clearly has nothing to do with the reality or non-reality of any particular disease. It is interesting to note here that in his magisterial study of contagion, Peter Baldwin specifically quotes my conclusion about the 18th century medicalized fear of masturbation which, together with other factors, "combined to render prostitution one of the few traversable avenues of male sexual release." [Peter Baldwin, Contagion and the State in Europe, 1830-1930 (Cambridge U. P. 1999), 424].

Worboys claims ( para. 3) that I have "a decidedly presentist approach to medical knowledge." This allegation presumably relates to my decision, when writing the book, to establish the nature of the specific disease/diseases each chapter is about. Thus in Chapter 6, when writing about yellow fever and malaria, I discuss the understandings of those diseases set forth by medical scientists at the Cairo Conference on Tropical Medicine held in 1928. Nineteen-twenty-eight is some 69 years before Epidemics and History went to press (i.e. hardly "the present"). Similarly, in Chapter 2, Leprosy, I give extensive coverage to medical doctors' ideas about the disease in the 1890s and 1920s. Perhaps by "presentist approach" Worboys means anything which discusses the germ theory established by Pasteur and Koch more than a century ago? Ian Hocking, writing in general terms about differences between scientists and social constructionists (The Social Construction of What?, Harvard U. P., 1999) stresses the remarkable stability of scientific knowledge since the time of Newton. In a cultural-medical history of the epidemic diseases I deal with, I assume it is legitimate to posit a somewhat similar stability of knowledge since the time of Koch. To label this assumption "presentist' is to assign medical history to the tender mercies of the antiquarians, a position from which some of us (including Michael Worboys in his substantial essays -my page 384) have long been struggling to rescue the sub-discipline.

Worboys (para 3) is also troubled by my use of the trendy terms "power", "imperialism" and "Development". In the recently published issue of Past & Present no. 165 (Nov. 1999), the great medievalist, Richard Southern, is quoted (page 221) as saying that an essential requirement for the writing of history "is experience of menthe third quality is compassion for the sufferings, ambitions and delusions of both the oppressed and the oppressors." Worboys is, I understand, a long-term denizen of a north of England university, whereas I have spent seventeen of the last twenty years living in the Non-West (in Nigeria and in Egypt). As an historian, I am by definition interested in sorting out possible connections between the past actions of colonial masters and the actions of successor indigenous regimes which, very often, are largely staffed by descendants of earlier collaborators with the white invaders. In short, I am interested in the consequences of past actions. Worboys (in his north of England university) does not seem to realize the extent of the cultural impact (to say nothing of the disease impact on non-immunes) which even a few well-armed colonialists could make on an indigenous culture. May I recommend that in the absence of lived experience, he read some of the recently published accounts of the Harrowing of the North of England by William the Conqueror and his handful of followers? Here certainly is an example of how the few completely transformed the lives of the many.

Worboys (para 3) is also troubled by my use of the concept "Ideology of Order" which I apply solely to my discussions of bubonic plague. Peter Baldwin clearly understands what I mean when he states: "Watts calls the quarantinist policies first elaborated in Italy against the plague the 'Ideology of Order', an authoritarian set of interventions that disrupted the everyday lives of citizens." (Baldwin, Contagion, 30). Worboys thus seems to have lost the thread of the argument when writing: "The notion that public health programmes were driven, across centuries and continents, by an 'Ideology of Order" begs more questions than it answers." True enough, but the "notion" is Worboys' own creation not mine.

Similarly. I find it difficult to believe that Worboys read my chapter on leprosy with any understanding. When discussing the European Middle Ages, my thesis was that many (perhaps most) alleged lepers were in fact normally put-together people, people who did not have the shriveled hands and feet nowadays associated with a proper leper. However these "lepers" happened to have enemies who found it was possible to get rid of them by having them committed to a leprosarium. Thus, Worboys' long discussion about Hansen's bacillus is entirely irrelevant to my discussion of medieval leprosy. As I go on to show in the second part of that chapter, in the late 19th century, the leprosy paradigm which was cobbled together by curious readings of medieval evidence was selectively used by some imperial regimes in some places, but not in others. To expect to find a clear pattern in such matters is to ignore modern understandings of history which see it as a formless mixture of contingencies, accidents, inconsistencies etc.

At this point it would be appropriate for me to point out that a good half of each chapter in Epidemics and History is NOT about European colonial impacts on the Non-West but instead is about one or other European society and the differing perceptions of each particular disease by those who ruled and those who were ruled. This is not apparent from Worboys' review (para. 2). Indeed some of Worboys' phrases lead me to wonder if he was reviewing two or three books at the same time and got mixed up about which author said what. Thus in his comments on my chapter on bubonic plague (para. 5) he says that I conclude "with a discussion of the disease in American and British empires after 1850." In fact, the second half of the chapter deals with Egypt under the Mamluks, the Ottomans and Muhammad Ali, ending in 1844. Egypt was not part of the British or the American empires at that time: the British shelling of Alexandria and conquest of Egypt did not take place until 1882.

Still on the topic of the bubonic plague, Worboys takes me to task for not coming to definite conclusions about "the patterns and determinants of control measures" and for not coming to definite conclusions about how they fit into E. Ackerknecht's typologies (formulated in the l940s). On these particular issues Worboys should turn to Peter Baldwin's 580 page book on contagion. There he will find that although Baldwin specifically set himself the task of testing Ackerknecht's typologies, in the end he found he could not come up with definitive answers about whether they were appropriate or not.

In his discussion of my readings of cholera, and of yellow fever and malaria, and my Afterword, Worboys fails to understand the extent to which colonial medical doctors and medical scientists were not free agents. Instead they were pawns in the great game of power politics being played out by the ruling elites in the metropole. In the case of cholera and quarantine policies in India, and the sea lanes leading from India to West Europe, further research in the recently re-opened India Office (at the British Library) has convincingly shown that as of 1867, when dealing with an outbreak of cholera among 3 million pilgrims at the Hardwar Fair, the officiating sanitary officer with the government of India, James McNabb Cuningham, zealously established cordons and emergency isolation hospitals to block the movement of pilgrims, who he suspected of harboring the disease in their guts, from the great cities of the North. Then in mid-1868, on the eve of the opening of the Suez Canal, Cuningham was persuaded by those in Authority in London to adopt a new cholera ideology which was l80 degrees at variance with policies he himself had used in 1867. This radical alteration in policy and ideology (cholera now seen as a locally generated disease, not brought in by human intercourse, hence there was no need for the quarantine of shipping from Bombay) was a political decision, based on commercial considerations, which had nothing to do with the medical finding of north German or pre-1869 British scientists (my paper on this forthcoming) . And as for S. R. Christophers (para. 10) and his call for segregation in West Africa based on his claim that black African children harbored the malaria parasite but that white children and white adults did not harbor the disease, in Epidemics and History (p.263) I point out that that Christophers' own contemporary, Dr. William MacGregor, Governor of Lagos, publicly and repeatedly stated that the rapid expansion of malaria-blighted regions was not due to racial characteristics of blacks, but was instead largely due to the behavioural patterns and Development policies of white invaders-such as himself. MacGregor's statements did not go down well with Authority back home in England who saw to it that he was transferred to Newfoundland-where there was no malaria. But Authority saw to it that Christophers, the Social Darwinist, was sent to India where in one capacity or another he remained in charge of the investment-friendly British malaria programme until 1932. [for an update, see my paper in Past & Present no. 165 (Nov. 1999), 141-181].

Worboys (para 3) sees my use of the word "Development" as "anachronistic". He obviously did not understand why I always used the capital letter "D" and why I defined my understanding of this conceptual tool at the first possible opportunity (my pp. xiii-xiv). In common with Peter Baldwin (who in Contagion coined quite a few words I had not seen used before), I accept that English (on both sides of the Atlantic) is a living language, rather than a fossil preserved by some learned Academy. My use of the capital "D" was a signal that I was using the word Development in a special way. Taking the broad view appropriate to what Worboys terms "big-picture" history, I---as a denizen of a still imperialized Non-Western country----fail to see any essential difference between the Development processes Columbus and Co. had in mind (golden treasure to pay for the liberation of Jerusalem, slaves to work European-owned primary product plantations, personal wealth, and personal status enhancement) and the processes put in motion in the long-19th century Age of European Imperialism, and the processes being managed by the agencies of Globalization today-the multi-nationals, the World Trade Organization, the I.M.F, the World Bank. In all instances, wealth, power, longevity and glory ended up in the possession of the few.

May 2000