Introduction for Disorder and Diagnosis

INTRODUCTION

HEALTH AND POWER

IN THE SUMMER OF 1899, the British civil surgeon Atmaram Sadashiva Grandin Jayakar knew cholera was coming to Muscat. But when he tried to alert the local authorities, no one would heed his warnings. Jayakar, stationed as a British imperial representative in the coastal city since 1873, pleaded with Sultan Faysal bin Turki (r. 1888–1913) to take precautionary measures against the cholera epidemic raging in Karachi.¹ Not only did Faysal’s government fail “to wake up to the danger,” but the sultan even suspended quarantine arrangements for several weeks.² This total absence of surveillance, Jayakar believed, allowed for infected passengers arriving by mail steamer to pass effortlessly into the local community, triggering an epidemic that progressed “gradually and insidiously.”³ Adding to Jayakar’s frustration was the fact that, even as residents started developing the dreaded symptoms of diarrhea, vomiting, thirst, restlessness, and leg cramps, authorities “doubted and denied” the epidemic.⁴ Local people, for their part, also proved reluctant to seek help as they and their family members fell ill. Jayakar himself learned of the epidemic only indirectly when, in September 1899, news of a twelve-year-old boy’s sudden death due to “vomiting and purging” led him to “suspect the probability of the appearance of cholera.”⁵

Cholera finally subsided in the twin ports of Muscat and Muttrah by January 1900, but it continued to devastate Oman, especially the interior region nestled between the Hajar mountain range and the deserts of central Arabia.⁶ Local politics obstructed Jayakar’s ability to surveil cholera’s advancement beyond the “almost circular range of hills” that framed Muscat’s “picturesque appearance from the sea” (fig. 0.1).⁷ Nevertheless, from his coastal enclave, Jayakar learned that Oman suffered “enormous mortality.”⁸ Agricultural life in the interior region flourished thanks to an expansive network of engineered water channels, known locally as aflāj (sing. falaj), that pulled precious water down from the mountains.⁹ In the time of cholera, this combination of interconnected water systems and human mobility proved deadly. The bacterium Vibrio cholerae that causes cholera disseminates through food or water that is contaminated with fecal matter. For people who develop severe symptoms, the course of illness is rapid and devastating. Dehydration from diarrhea and vomiting can lead within hours to kidney failure, coma, and death. The breathtaking speed at which cholera ravaged previously healthy bodies only intensified the terror of its symptoms.¹⁰ In early October 1899, a caravan returning inland from Muttrah had introduced cholera in the village of Surur, “which lies on the highway to the Sharkiyeh or Eastern District of Oman.” As Jayakar reported, “the suddenness of the invasion and the alarming rate of mortality there caused the people to be almost panic-stricken and to flee in all directions,” carrying the infection with them.¹¹ By November, letters dispatched from Oman to the Sultan of Zanzibar, Hamud bin Mohammad, contained updates on the dire situation: “Everything is lifeless . . . The people of Oman are afflicted by the epidemic, smallpox, the famine, and the rising cost of living. Every crisis is greater than its sister!”¹²

FIGURE 0.1. View of Muscat in the early twentieth century.SOURCE: Theodore Thomson, Report by Dr. Theodore Thomson on the Sanitary Requirements of Certain Places in or near the Persian Gulf, &., Printed for the use of the Foreign Office, October 1906. London School of Hygiene & Tropical Medicine Library & Archives Service.

We can imagine how in 1899 and 1900, as the water channels streamed down from the mountains, Vibrio cholerae also flowed through Oman’s communities. Jayakar was attuned to scientific advancements that posited connections between cholera epidemics and shared water supplies. He also demonstrated a nuanced understanding of local water infrastructures. He identified patterns of “washing the dead quite close to the aqueducts” as “the determining cause” of cholera’s intensity in Oman. “When a dead body is removed to one of these aqueducts for washing,” he wrote, “a breach is made in the masonry of the aqueduct quite close to the place where the body is, and the water allowed to run over it, some of which evidently runs by the side of the aqueduct and eventually pollutes it. Cholera germs in abundance had thus an easy access to the water supply of most of the places and gave rise to those sudden and violent explosions.”¹³ Jayakar reported that cholera claimed 12,231 lives in Oman.¹⁴ He estimated that 10,000 people lived in Muscat and 15,000 in Muttrah at the turn of the century; in other words, Jayakar calculated that the total number of deaths from cholera was comparable to the entire population of one of the main coastal cities.¹⁵

Reflecting British imperial classifications of the region’s people, Jayakar cataloged cholera mortality and morbidity from a “racial point of view.”¹⁶ But even though he categorized the population as Baluchi, Arab, African, Persian, and Indian, Jayakar ultimately placed more emphasis on social class and wealth, rather than ethnicity, to explain how the epidemic developed.¹⁷ He carefully documented patterns of cleanliness, medical and prophylactic practices, and the degree of willingness to seek out medical care across different communities. For example, he observed that the Baluchis suffered “the greatest incidence of attacks” because “their habitations are mostly in the filthiest localities and themselves most regardless of the commonest rules of personal hygiene.” The Indian community, in contrast, enjoyed “almost absolute immunity” from cholera, Jayakar reported, thanks to the geography of their housing, the relative affluence of their living situation, and their willingness to seek out Jayakar’s medical care.¹⁸ Finally, morbidity was starkly gendered; Jayakar noted that in some communities “women were suffering more than men” at a rate of nearly double the number of cholera attacks because “the duty of nursing the sick generally devolved on the fairer sex.”¹⁹ From Jayakar’s perspective, official neglect, usage of dangerous water, poor sanitation, gendered caregiving, and reluctance to seek medical help characterized the local response to Oman’s cholera crisis of 1899–1900.

But, in addition to its devastating loss of life, the epidemic shifted Sultan Faysal’s understanding of the relationship between health and politics. Just as cholera was retreating from the coastal cities, simultaneous outbreaks of plague and influenza struck Muscat and Muttrah.²⁰ Facing this renewed epidemiological onslaught, the sultan supported disinfection and inoculation, built hospital sheds, and hired a medical practitioner and assistant who had plague experience from Bombay.²¹ Faysal’s unprecedented willingness to take measures against plague in the aftermath of the cholera epidemic constituted a remarkable transformation. The sultan, despite persistent skepticism among residents and subjects, had recognized public health as a responsibility of sovereignty and an instrument of governance.

Jayakar’s description of the devastating cholera epidemic in Oman at the turn of the twentieth century opens a door to the questions that this book seeks to examine. Jayakar, an official British doctor, begged the sultan to take measures that would allay the spread of epidemic by placing restrictions on the movement of people. Local people, in turn, resisted or ignored those efforts, and the sultan came to interpret refusal to participate in sanitary measures as a challenge to his sovereign power. State formation, medicine, and public health became interwoven during this age of imperial competition and the consolidation of local rulers in nascent monarchical states. Imperial and local actors diagnosed new sources of political and epidemiological disorder in Arabia and responded by inserting novel forms of state power into daily life. How did the encounters between people seeking health and people bestowing—or inflicting—public health practices upon others transform the Arabian littoral of the Persian Gulf in the modern era? Jayakar’s observations included stark differences in mortality across racial and religious communities, and between men and women, depending on their exposure to disease, their labor as caregivers, and their willingness to seek medical help. How were medical interventions experienced differently by men and women and by the various communities around the region?

FIGURE 0.2. The Arabian Peninsula, Persian Gulf, and surrounding areas in the twenty-first century. Map by Maggie Lehane, University of Wisconsin Cartography Lab.

From the late nineteenth century, the intensification of the British imperial presence in the Gulf corresponded with a growing microbiological understanding of contagion among the global scientific community. In emerging as a threat to more valued white and wealthy bodies, nonelite people and the diseases that they had the potential to carry assumed greater visibility in historical records. Thanks to this confluence of biological, social, and political factors, astonishingly resilient and resourceful historical characters emerge out of the crevices of accounts of disease and medicine.

Disorder and Diagnosis is a social and political history of how medicine, disease, and public health transformed the Arabian littoral of the Persian Gulf from the late nineteenth century until the 1973 oil boom. By integrating the biological, environmental, and political aspects of health to highlight the role of nonelites in state formation, the following chapters challenge the predominant assumption that oil, Islam, imperial officials, and autocratic monarchies were most central to the production of the modern Gulf. Rather, this was a transformation shaped by everyday people. In 1862, steamships linked Gulf ports to Bombay and Karachi, and thus initiated a new era of accelerated connectivity and British imperial integration. In the late nineteenth and early twentieth centuries, quarantine stations and hospitals incorporated the bodies of Gulf residents into an unprecedented medical infrastructure that was built on existing networks of transregional mobilities. The search for oil in the first half of the twentieth century and its aggressive exploitation in the aftermath of World War II expanded the focus of colonial medical interventions from the coast into the hinterland, and from white and elite bodies to indigenous and itinerant laborers. And, in the 1960s and 1970s, the transition of the Gulf’s Arabian littoral from British spheres of influence to formally sovereign states accelerated the transformation of peripatetic populations into increasingly rigid categories of citizens and noncitizens.

Over this longue durée, an array of medical projects—quarantines, hospitals, childbirth, vaccinations, nursing, and folk medicine—illustrates how the Gulf and its Arabian hinterland served as a buffer zone between “diseased” Asia, the Ottoman Empire, and white Europe; as an object of development; and as a space of scientific translation. Mobile, multiethnic, and multiconfessional residents of regions that would become Kuwait, Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, and Oman accepted, modified, or rebelled against top-down medical institutions. From the mid-nineteenth century, the relationship between ideas of contagion and contamination and racial and spatial segregation were institutionalized on a global scale. In the Gulf, the paradigm of health as a colonial and civilizing mission and, consequently, as a method of cultural erasure mediated interactions between local populations and doctors as well as imperial and state officials. From this increasing entanglement of public health, governance, and everyday life, new venues of interaction and negotiation between states and populations emerged.

Beyond National Borders and Chronologies

This book places overlooked historical actors at the center of the development of the modern Gulf and Arabia. It also positions the Arabian littoral of the Persian Gulf as a nexus of global circulations of people and pathogens. Along with urban spaces, illicit and licit trade, and fluid legal systems, modern public health and medicine emerged through the intersecting behaviors and beliefs of a range of actors. Disorder and Diagnosis explores the tension between the Gulf and its Arabian hinterland as a coherent epidemiological and medical space and as a disorderly crossroads of imperial and local political projects and imaginaries.²² Previous scholarship has constructed histories around ways that the flows of pathogens transcend state and national borders and shape emerging political frontiers.²³ Building on such insights, this book emphasizes movement to demonstrate the importance of considering the Persian Gulf and Arabian Peninsula as an epidemiological region in the prenational period, and even well into the twentieth century. The modern state, with its claims to control space and time as part of a presumed natural and logical ordering, aims to deprive individuals of the ability to imagine alternatives by removing, or making unthinkable, any space not tied to a single temporal and spatial national identity.²⁴ By privileging mobility and connectivities, Disorder and Diagnosis moves beyond the stark spatial and conceptual limitations of the national frame and locates alternative historical imaginaries amid the fluctuating contours of regional configurations.

As well as insisting on the permeability of national borders, this book also overturns predominant chronologies of Gulf development. Emphasizing how Gulf societies steered their own course as they navigated their way into oil-funded modernity challenges the long-standing assumption that this region’s history has moved in a separate, stagnant time scale.²⁵ In the late nineteenth and early twentieth centuries, British imperial officials and American missionaries fostered the belief that the people of this region existed outside of prevailing definitions of modern progress. In the context of health and disease, they expressed such sentiments by describing local medicine as mired in unscientific traditions and resistant to, or incapable of, change or development in conversation with other medical systems. A second assertion of regional inertia occurred when the post–World War II oil state (echoed by its ideological interlocuters) declared itself the exclusive provisioner of progress, modernity, and social welfare. Centralized state medicine planned by foreign experts and staffed by noncitizen workers was projected to supersede the demand for local curative practices.

Resulting from such extensive erasure and denial of the dynamism of bottom-up local histories, discussions of the Gulf and the Arabian Peninsula have been subjected to a persistent exceptionalism.²⁶ Narratives of the region produced by contemporary states and social scientists alike have embraced deterministic paradigms positing that oil wealth resulted in authoritarian regimes and passive citizens, privileging global economic forces over local politics.²⁷ Meanwhile, specialists in other areas of the Middle East and Arab world have overlooked the mutually constitutive connectivities and shared experiences between the modern Gulf and the wider region. National accounts wholeheartedly promote a narrative in which the predominantly Arab states of the modern Gulf are supposed to have leaped from a period of darkness and relative isolation before the discovery of oil and arrived with dazzling speed in well-financed and tightly controlled global cities characterized by commoditized affluence.

Much Gulf historiography, spanning nineteenth-century British dominance and the current age of American hegemony, focuses on describing a series of skirmishes, treaties, and agreements and locates the driving force of historical change in negotiations between regional elites and global superpowers. More recently, however, scholars have explored local archives and read sources “against the grain” with the important aim of recovering historical voices that have been left out of this elite and imperial-centered political narrative by focusing on urban histories and the lasting effects of imperialism.²⁸ A related body of scholarship seeks to integrate the Gulf into the Indian Ocean world, looking at how individuals, institutions, and economies operated under the imperial radar and complicating assumptions regarding the omnipresence of British authority.²⁹

While oceanic history is central to the Gulf experience, much of the extant scholarship depicts this world of trade and mobility largely (though not exclusively) as the purview of men.³⁰ Until we consider how women fit into this milieu of fluid connectivity between land and water, we risk erasing a large part of the region’s history. The intersections of the politics of health, childbirth, motherhood, and gendered medical labor particularly show women to be productive and creative agents. Moreover, while trailblazing work has considered the interplay of religion, politics, women, and gender in the region, the lens of health allows us to shift our focus toward questions of reproduction and political economy.³¹ While there is a real methodological challenge in uncovering women’s contributions, histories of health reveal dense archival discussions of women’s lives and thus offer an opportunity to fill this void. The chapters on hospitals, childbirth, experiments, and nurses emphasize women’s experiences as patients, mothers, and workers in the framework of a politics of health. Working beyond and between national frames of time and space allows such stories to shift toward the foreground of Gulf modernity.

Between Politics of Health and Theories of Power

The devastation of epidemic makes visible the politics of everyday life. Histories of the Gulf and Arabia have focused on the political and economic dynamics between local elites, transregional merchant communities, British officials, and tribal challengers. But, as Jayakar’s estimates on cholera mortality in the 1899–1900 epidemic poignantly illustrate, disease was the overwhelmingly predominant cause of daily hardship and loss of life for local communities of the pre-oil period. Indeed, British imperial officials believed that the Gulf climate was so dangerous that the Government of India was reluctant to appoint significant numbers of Europeans as local agents in the Gulf until the twentieth century; as a British Indian, Jayakar’s own lengthy tenure in Muscat from 1873 to 1900 exemplifies that trend.³² Such fears were not unfounded. Disease took a hefty toll on European and local communities alike. Between 1800 and 1810, four British agents in Muscat died from climate-related causes.³³

Disorder and Diagnosis intersects with a range of historical studies seeking to make sense of the relationship between disease, state, and population. One way of taking stock of current trends in the history of medicine is to ask how different scholars have grappled with Michel Foucault’s assemblage of territory, security, discipline, and population.³⁴ Historians long have struggled to reconcile the inescapable reality of Foucault’s influence with disciplinary vexation over his methods. As Allan Megill put it: “The main complaint is perspectival and methodological. Foucault leaves unanswered, even unasked, questions that historians find essential; his generalizations are usually supported by insufficient warrants.”³⁵ Nevertheless, scholars productively have crafted sharp research questions in response to Foucault’s broad strokes. David Scott, for example, encourages researchers working on the colonial state to identify “the point or points of power’s application, the object or objects it aims at, and the means and instrumentalities it deploys in search of these targets, points and objects.”36 In approaching health as a lens onto the politics of everyday life, this book pursues a series of related questions: Which political rationalities and methods do state actors employ to manage a population and individuals simultaneously? How does the state apply power over territories and populations both conceptually and materially? Which mechanisms enable sovereigns to define the people and geographies they claim to govern? Which conditions of possibility prompted corporate agents to turn to epidemiological studies and medical experiments to render populations legible and more productive? How do institutions like quarantine stations, clinics, and hospitals encourage individuals to self-regulate or to find ways around such disciplining interventions? Finally, and most crucially for this study, how do the everyday practices of a range of people nuance or overturn doctrinaire categories of biological, social, and political personhood?

We can trace Foucault’s influence across recent studies of medicine in the modern Middle East in which scholars continue to interact with and push back against his claims in creative and innovative ways.³⁷ In her study of madness, modernity, and war in Lebanon, for example, Joelle M. Abi-Rached critically synthesizes how histories of mental health have interacted with Foucault’s framework. She notes the shift from a triumphalist postwar position on the continual progress and improvement of medicine to Foucault’s famous critique that “moral and hence psychological treatment was more insidious and perverse than the physical shackles used to restrain the insane, for it trained and turned the will against itself.”³⁸ The current historiographical wave aspires to a middle ground, managing, as Abi-Rached puts it, “to display through contextual specificities the multiple functions of asylums and the porousness of the institutional politics of mental illness that together involve different actors with diverse resources and interests.”³⁹ Similar trends may be observed in the history of medicine more broadly, in which concerns with overarching institutional power are mediated by the activities and choices of individuals as reconstructed by historians through close and critical readings of available archives.

Without claiming to have escaped the long shadow of the Foucauldian corpus, this book builds on such approaches to the history of medicine by offering a commitment to historical methodology as something of a restraining check on totalizing theories. It is unhelpful to elide the fact that institutions, often with the support of debilitating state violence and astonishing influxes of wealth, have transformed the lives of people in the Gulf and the Arabian Peninsula on a massive scale from the mid-nineteenth century to the present. But, as often as not, grandiose theory crumbles when we work to construct meaning from quotidian choices and actions rather than from sweeping generalizations. “States and municipalities,” as Helen Tilley writes, “have never had a monopoly over cultures of care.”⁴⁰ Individuals—and even entire categories of people—who have been expunged from master narratives emerge as creative and active historical figures when they choose, as we will see, to abscond from quarantine, give birth at home, or seek hospital treatment.

Empire, state building, and modern medicine are projects that share an impulse to diagnose disorders and prescribe solutions. Such dynamics of health and power—and their remarkable limitations—are the central concern of this book. The idea of health systems, medical imaginaries, and scientific practice in this region that existed “before” the introduction of biomedicine is integrated into the chapters as appropriate; however, my narrative rejects the rigidness of a before-and-after timeline.⁴¹ First, the assumption of indigenous medicine as it was practiced “before” and “after” external influence presumes a homogeneous and unchanging medical system, depriving the region of its own vibrant health histories. Second, the convergence of the state, public health, and medical institutions as an experience of modernity constitutes a key venue through which the Gulf and Arabian Peninsula were integrated into global processes. Third, the nature of my sources shapes the content of my discussion. I integrate British imperial records, American missionary writings, Islamic scholarly opinions, scientific studies of the health conditions of local people, local newspapers, and Arabic-language histories of health and al-ṭibb al-shaʿbī (folk medicine). This interweaving of a wide range of archival genres allows this book to foreground the influence and experiences of populations who might otherwise remain absent from the historical record.

The Chapters Ahead

Quarantine stations and hospitals demonstrate two distinct examples of how British imperial visions of modern medicine and local imaginaries of health and mobility intersected. In the late nineteenth century, quarantine stations materialized Britain’s efforts to fend off its Gulf rivals. Chapter 1, “Contagion,” positions the Gulf in the global networks of disease, empire, accelerated communications, and scrutinized contagions of the late nineteenth and early twentieth centuries. Quarantine stations allowed state actors to wield sovereignty and to construct new classifications of the population in the name of sanitation. The chapter turns to the scale of local life to reconstruct experiences of disease and notions of contagion leading up to the imposition of imperial quarantines. Then, a tour of the quarantine stations that knitted Gulf ports together reveals how this imperial infrastructure’s unprecedented claims over Gulf bodies integrated categories of race, class, and gender into a sprawling sanitary infrastructure. But the limitations of the imperial sanitary imaginary were evident in the persistent disorder that the lens of social history exposes. Even as imperial intermediaries at the local level embraced quarantine, the reluctance of travelers to interrupt their journeys rendered the stations so porous that they proved ineffective as a means of blocking the spread of disease.

From quarantine stations that forcibly fixed travelers in space and time, I turn to medical institutions that drew in health-seeking patients from around the region. Chapter 2, “Hospitals,” reconstructs how communities in Manama, Muscat, and Kuwait made use of American missionary and British Agency hospitals in the early twentieth century. It traces how hospitals produced new forms of gendered personhood, in which medical care was delineated between spaces for men and women, and between male and female medical professionals. An emergent competitive medical marketplace created pressure on local elites to integrate health services into their broader projects of governance. In stark contrast to the quarantine stations, hospitals emerged as a top-down medical infrastructure that eventually enjoyed popular local buy-in. The nascent hospital infrastructure prompted local rulers, American missionaries, and imperial officials to scramble to meet the evolving medical expectations of everyday people. The British Empire, operating on the cheap, depended on intermediary actors such as American missionaries and Indian doctors, like Jayakar, to invest time, money, and concern in the ailments of local people. At the same time, hospital projects would have failed had they not achieved bottom-up popularity. Local people expressed their enthusiasm with their feet, traveling far to access hospital care.

Yet local people’s embrace of hospitals remained strategic and selective. Their behavior did not align neatly with doctors’ normative vision of patients who obediently accepted scientific diagnosis. Despite the growing popularity of hospitals, childbirth, a critical event in women’s lives, remained beyond the control of women missionary doctors throughout the early twentieth century. Chapter 3, “Childbirth,” counterbalances the focus on the rise of institutionalized medicine and public health as driven by male elites and missionary doctors. In defiance of women missionaries’ efforts, local women resisted the medicalization of childbirth and persisted in giving birth at home under the care of midwives and women relatives. This chapter makes women’s worlds visible in the face of a historiography that has overwhelmingly characterized the rhythms of oceanic mobility and national development as masculine experiences. Taken together, quarantines, hospitals, and childbirth remind us of the nuance and contingency of empire and state building in everyday life by revealing how local people could alternately resist and tactically make use of medical infrastructures.

Motherhood as a category of health and an act of politics is also an important theme in Chapter 4, “Experiments.” In the post–World War II period, a new imperial structure achieved hegemony in the Gulf in the form of the oil industry’s corporate colonialism. To unpack how this emergent geopolitical alignment intersected with local experiences of health, I examine medical experiments carried out in eastern Arabia under the auspices of the Arabian American Oil Company (Aramco). Rather than assuming local passivity in the face of the postwar corporate onslaught, my intention is to stress that the emergence of health care as a central demand of popular movements in Arabia is just as important as the goals of company officials and university scientists for understanding how medicine developed. The racial segregation and extractive exploitation of the oil industry coincided with global decolonization and regional Arab solidarities. Popular and labor movements envisioned health care as a universal right that people could demand from their employer and their state. From the 1950s to the 1970s, amid these broader changes in the popular politics of health, Aramco funded a Harvard project to use the people of the region as a population on which to test experimental trachoma vaccines. In Aramco’s capitalist frame, the goal of medicine was to produce healthy bodies of laborers and sanitized environments for work. As a result of oil exploitation and state consolidation, public health expanded from the Gulf coasts into Arabia’s interior. The partnership between Harvard and Aramco constructed eastern Arabia as a space of medical experimentation contingent on the desire of local parents to seek care for their children’s infected eyes.

Chapter 5, “Nurses,” shifts the focus from women as health-seeking parents to women as noncitizen workers. In the 1960s, migrant Arab women nurses in Kuwait drew on pan-Arab solidarities to attempt to advance their professional claims. Over the course of postwar state building, noncitizen women performed the labor of birthing Kuwait’s medical system, a hallmark of the country’s welfare project. Interviews with nurses in the Kuwaiti press from this period show that these women actively positioned themselves as vanguard Arab modernizers. They drew on the discourses of Arab unity and modernist development to push back against patriarchal norms that constrained their professional and personal lives. Noncitizen Arab women nurses struggled to convince the Ministry of Health and the Kuwaiti public that they were essential professionals who deserved fair pay and decent working conditions. The chapter concludes with the post-1973 pivot away from the Arab world and toward South Asia as a source of health-care workers as the Ministry of Health, in step with other agencies, prioritized cheaper labor.

Finally, in chapter 6, the narrative springs forward to the late twentieth and early twenty-first centuries to explore how more than a century of imperial, corporate, and state Gulf medical modernization never fully supplanted local esteem for folk medicine. Instead, the demographic anxieties produced by autochthonous citizenship and exploitative labor practices created conditions that fostered nostalgia for the folk medicine of pre-oil Arabia. This chapter shifts methodologically to a socially situated textual analysis. It examines how two Arabic-language accounts of al-ṭibb al-shaʿbī (folk medicine) construct health history as a space of nostalgia for a pre-oil, nativist past. The resurgence of al-ṭibb al-shaʿbī overturns the idea of a teleological progression of medicine. This counternarrative of medicine is made possible by a resurgent interest in folk medicine that frames certain health practices as indigenous to the region’s Arab Muslim population. In this conceptualization, al-ṭibb al-shaʿbī is an immutable cultural artifact, a tool for delineating national inclusion, and a foil to biomedicine as an alienating and overly institutionalized experience.

The accelerated globalization of disease and the subsequent elaboration of medical knowledge and institutions transformed the relationship between imperial and local political elites and everyday people in the modern Gulf and Arabia. The periodization of the first five chapters of this book ends in a dynamic moment of transition from public health as a poorly funded and sporadically implemented manifestation of British imperialism and American missionary work to top-down development projects that targeted the bodies of oil workers and emerging citizen and noncitizen populations. Chapter 6, however, examines an alternative reading of the stories I unravel in the preceding case studies. Looking back from ideological narratives of medicine constructed by citizens in the late twentieth and early twenty-first centuries, these politicized accounts express nostalgia for pre-oil society in their attempt to reconstruct folk medicine as a yardstick of national belonging. By fashioning the history of folk medicine as a site of heritage, such narratives contribute to broader patterns of demarcating inclusions and exclusions among local populations in modern Arabia and the Gulf.

Across these chapters, my method has been to focus on striking and surprising archival fragments, encircling them with thick contextualization to reconstruct their social, political, and medical worlds. I identify the pursuit of health as an assemblage of motivations that guided collective, but largely uncoordinated, action.⁴² While the theme of health seeking as a form of politics unifies the narrative, I am attentive to how the concept of health itself is historically fluid. That is, I locate the politics of collective, uncoordinated action in changing medical infrastructures and social dynamics. People in Arabia adjusted their expectations of what constituted health in dialogue with state projects, missionary hospitals, and globalizing science. I seek to shift the focus of this region’s modern history away from the actions and schemes of ruling elites and corporate executives and toward the ambitions and activities of middling intermediaries and ordinary people. As the following chapters show, even when powerful actors, be they local, imperial, missionary, or corporate, aspired to use medical and health institutions as tools for demarcating and disciplining populations, the nimble creativity of everyday people complicated or even undermined those top-down visions. Rather than chronicling a teleological march toward modernity, I attempt to find a balance between aspirations of totalizing power and resurgent moments of unanticipated consequences, persistent disorder, and even chaos.

Notes

1. Atmaram Sadashiva Grandin Jayakar (1844–1911) earned a degree in medicine and surgery in India and then passed the Indian Medical Service exam at the Royal Victoria Hospital in Southampton, England. During his twenty-seven years in Muscat, he worked under twelve different political agents, spent a period as acting agent, and served as the personal physician to Sultan Turki bin Saʿid (r. 1871–1888). In addition to his medical writings, he produced studies of Omani proverbs and sent specimens of local wildlife to the British Museum, which resulted in some local species being named in his honor. Mark Hobbs, “A Polymath in Muscat,” Untold Lives (blog), British Library, 28 August 2014, https://blogs.bl.uk/untoldlives/2014/08/a-polymath-in-muscat.html. See also Charlie Sammut, “The Life of Dr Jayakar: A British Agency Surgeon in Muscat,” Anglo-Omani Society, 14 May 2020, https://www.ao-soc.org/news/aos/podcast-transcript-cs; Charlie Sammut, “Medicine and Politics at the Edge of Empire: Surgeon Lt Col Atmaram Sadashiva Grandin Jayakar,” Anglo-Omani Society, 18 May 2022, YouTube video, 1:00:52, https://www.youtube.com/watch?v=YRC8-j_MjWk.

2. India Office Records (hereafter IOR) V/23/77, no. 379, “Administration Report on the Persian Gulf Political Residency and Maskat Political Agency for 1899/1900,” 23.

3. IOR V/23/77, 23.

4. IOR V/23/77, 25.

5. IOR V/23/77, 23. Cholera, the hallmark pandemic calamity of the nineteenth century, was no stranger to Arabia and the Persian Gulf. Arabia’s Gulf coast was vulnerable to epidemic invasions by way of land communications with the Hijaz as well as by sea. The most common periodization of cholera pandemics is as follows: 1817–1824 (first), 1829–1851 (second), 1852–1859 (third), 1860–1875 (fourth), 1881–1895 (fifth), 1899–1923 (sixth), 1960– (seventh). See Christopher Hamlin, Cholera: The Biography (Oxford: Oxford University Press, 2009), 4.

6. Historically, Oman referred to the interior region, as distinct from the coast. For a succinct description of Oman’s geography, see Thomas F. McDow, Buying Time: Debt and Mobility in the Western Indian Ocean (Athens: Ohio University Press, 2018), 28–29.

7. IOR V/23/29, no. 138, “Report on the Administration of the Persian Gulf Political Residency and Muscat Political Agency for the Years 1876–77,” 96. British-backed coastal rulers had long been subject to resistance from the interior, where people viewed the sultanate as illegitimate due to its dependance on British imperial power. Expressions of opposition to the sultan had punctuated the years leading up to the cholera epidemic. In 1896, for example, a British agent penned a strikingly forthright assessment of the situation: “The authority of the Sultan is quite rotten beyond Muscat and Mattrah where our gunboats protect him. . . . Yet the fiction of keeping the Sultan’s rule is to us as useful as keeping off Foreign Powers from some 600 miles of coast. But how long can we keep the fiction going, when the Sultan is afraid to go 10 miles from his capital?” Quoted in Briton Cooper Busch, Britain and the Persian Gulf, 1894–1914 (Berkeley: University of California Press, 1967), 59–60.

8. IOR V/23/77, no. 379, “Administration Report on the Persian Gulf Political Residency,” 31.

9. J. C. Wilkinson, Water and Tribal Settlement in South-East Arabia: A Study of the Aflāj of Oman (Oxford: Oxford University Press, 1977).

10. “Cholera—Vibrio cholerae Infection,” Centers for Disease Control and Prevention, https://www.cdc.gov/cholera/general/index.html.

11. IOR V/23/77, no. 379, “Administration Report on the Persian Gulf Political Residency,” 31.

12. Sultan bin Mubarak bin Hamad al-Shaybani, Al-Tawaʿin fi al-Dhakira al-ʿUmaniyya (Muscat: Mahboub, 2021), 69–70. Following the 1856 death of Sultan Sayyid Saʿid al Bu-Saʿidi and the ensuing competition between his sons, in 1861 the British separated Zanzibar from Muscat and Oman. The British established a protectorate over Zanzibar in 1890.

13. IOR V/23/77, no. 379, “Administration Report on the Persian Gulf Political Residency,” 31.

14. In his encyclopedic Gazetteer of the Persian Gulf, Lorimer estimated that the population of the sultanate (excluding Dhofar) was around five hundred thousand at the beginning of the twentieth century, although Wilkinson believed that number was too high. See Wilkinson, Water and Tribal Settlement, 5. On Lorimer’s Gazetteer as an imperial project, see Nelida Fuccaro, “Knowledge at the Service of the British Empire: The Gazetteer of the Persian Gulf, Oman, and Central Arabia,” in Borders and the Changing Boundaries of Knowledge, ed. Inga Brandell, Marie Carlson, and Önver A. Çetrez, Transactions 22 (Istanbul: Swedish Research Institute in Istanbul, 2015), 17–34.

15. IOR V/23/77, no. 379, “Administration Report on the Persian Gulf Political Residency,” 25. Population estimates for Muscat and Muttrah in the nineteenth and early twentieth centuries fluctuate, but Jayakar’s numbers are close to other contemporary figures. For a helpful list of population estimates, see Willem Floor, Muscat: City, Society & Trade (Washington, DC: Mage Publishers, 2015), 69–70.

16. IOR V/23/77, no. 379, “Administration Report on the Persian Gulf Political Residency,” 26.

17. Oman had the largest Indian presence in the Gulf from the 1750s to the 1950s, concentrated in Muscat and Muttrah. James Onley, “Indian Communities in the Persian Gulf, c. 1500–1947,” in The Persian Gulf in Modern Times: People, Ports, and History, ed. Lawrence G. Potter (New York: Palgrave Macmillan, 2014), 242. See also Calvin H. Allen Jr., “The Indian Merchant Community of Masqat,” Bulletin of the School of Oriental and African Studies 44, no. 1 (1981): 39–53. On Oman’s Khoja, or Lawatiyya, community, see Marc Valeri, “High Visibility, Low Profile: The Shiʿa in Oman under Sultan Qaboos,” International Journal of Middle East Studies 42, no. 2 (2010): 251–268.

18. IOR V/23/77, no. 379, “Administration Report on the Persian Gulf Political Residency,” 26. By the end of the nineteenth century, Muscat’s Indians constituted a privileged class, enjoying extensive landholdings and, more often than not, status as protected subjects of the British Empire. The Indian community’s protected status was also expressed in relatively greater trust in Jayakar, possibly enhanced by the fact that he was also an Indian British subject.

19. IOR V/23/77, no. 379, “Administration Report on the Persian Gulf Political Residency,” 26.

20. The British reported that, “so far as is known with the exception of one or two suspicious cases reported, there was no spread of [plague] to the interior as was the case with cholera.” The water system described offers a likely explanation of this distinction between the interior’s greater susceptibility to cholera than plague. IOR V/23/77, no. 379, “Administration Report on the Persian Gulf Political Residency,” 20.

21. IOR V/23/77, 20. See also Robert Geran Landen, Oman since 1856: Disruptive Modernization in a Traditional Arab Society (Princeton, NJ: Princeton University Press, 1967), 154–155.

22. My regional framework is in dialogue with Lawrence G. Potter’s assertion that “what is needed is a new historical approach in which the unit of study is the Persian Gulf in its entirety.” Lawrence G. Potter, introduction to The Persian Gulf in History, ed. Lawrence G. Potter (New York: Palgrave Macmillan, 2009), 4. Potter’s work on the Gulf region has exemplified a regional approach. See also Lawrence G. Potter, ed., The Persian Gulf in Modern Times: People, Ports, and History (New York: Palgrave Macmillan, 2014); and Lawrence G. Potter, Society in the Persian Gulf: Before and after Oil (Doha: Georgetown University in Qatar, Center for International and Regional Studies, 2017). Another recent study that embraces a regional approach is Laleh Khalili, Sinews of War and Trade: Shipping and Capitalism in the Arabian Peninsula (London: Verso, 2020). Khalili usefully incorporates Aden and the Suez Canal into histories of Arabian ports in her examination of regional patterns of integration into global networks of capitalism.

23. In her study of the Ottoman experience of plague in the early modern Mediterranean, for example, Nükhet Varlık presents the Mediterranean world “as a unified disease zone, with shared epidemiological experiences, as well as a common heritage of medical traditions.” Nükhet Varlık, Plague and Empire in the Early Modern Mediterranean World: The Ottoman Experience, 1347–1600 (New York: Cambridge University Press, 2015), 3. For the interwar period, Samuel Dolbee demonstrates how ideas of disease, climate, and race played a constitutive role in consolidating borders between post-Ottoman states. Samuel Dolbee, “Borders, Disease, and Territoriality in the Post-Ottoman Middle East,” in Regimes of Mobility: Borders and State Formation in the Middle East, 1918–1946, ed. Jordi Tejel and Ramazan Hakki Öztan (Edinburgh: Edinburgh University Press, 2022), 205–227. Other work also takes up the Arabian Peninsula and Persian Gulf regions as interconnected spaces of disease. Sabri Ateş demonstrates how corpse traffic converged with nineteenth-century cholera epidemics along the Ottoman-Iranian frontier. Amir A. Afkhami offers an overview of how pandemic cholera shaped modern Iran. From the perspective of Arabia’s Red Sea Coast and in the contact zone of Ottoman and British imperial rivalries, Michael Christopher Low integrates the Ottoman experience into the globally significant history of environment, disease, and mobility surrounding the Hajj. Sabri Ateş, “Bones of Contention: Corpse Traffic and Ottoman-Iranian Rivalry in Nineteenth-Century Iraq,” Comparative Studies of South Asia, Africa, and the Middle East 30, no. 3 (2010): 512–532; Amir A. Afkhami, A Modern Contagion: Imperialism and Public Health in Iran’s Age of Cholera (Baltimore: Johns Hopkins University Press, 2019); Michael Christopher Low, Imperial Mecca: Ottoman Arabia and the Indian Ocean Hajj (New York: Columbia University Press, 2020).

24. Henri Lefebvre, The Production of Space, trans. Donald Nicholson-Smith (Oxford, UK: Blackwell, 1991), 23.

25. Here I draw from Johannes Fabian’s discussion of the denial of coevalness. Johannes Fabian, Time and the Other: How Anthropology Makes Its Object (New York: Columbia University Press, 1983), 37.

26. Nelida Fuccaro’s pioneering work on Bahrain laid the groundwork for a historical critique of Gulf exceptionalism. Nelida Fuccaro, Histories of City and State in the Persian Gulf: Manama since 1800 (Cambridge: Cambridge University Press, 2009). For a more recent discussion, see Ahmed Kanna, Amélie Le Renard, and Neha Vora, Beyond Exception: New Interpretations of the Arabian Peninsula (Ithaca, NY: Cornell University Press, 2020).

27. For a cogent critique of this trend, see Alex Boodrookas and Arang Keshavarzian, “The Forever Frontier of Urbanism: Historicizing Persian Gulf Cities,” International Journal of Urban and Regional Research 43, no. 1 (2019): 14–29.

28. Frederick F. Anscombe, The Ottoman Gulf: The Creation of Kuwait, Saudi Arabia, and Qatar (New York: Columbia University Press, 1997); Fuccaro, Histories of City and State; Farah Al-Nakib, Kuwait Transformed: A History of Oil and Urban Life (Stanford, CA: Stanford University Press, 2016); Omar H. AlShehabi, Contested Modernity: Sectarianism, Nationalism, and Colonialism in Bahrain (London: Oneworld Academic, 2019); Marc Owen Jones, Political Repression in Bahrain (New York: Cambridge University Press, 2020).

29. Matthew S. Hopper, Slaves of One Master: Globalization and Slavery in Arabia in the Age of Empire (New Haven, CT: Yale University Press, 2015); Johan Mathew, Margins of the Market: Trafficking and Capitalism across the Arabian Sea (Oakland: University of California Press, 2016); Fahad Ahmad Bishara, A Sea of Debt: Law and Economic Life in the Western Indian Ocean, 1780–1950 (Cambridge: Cambridge University Press, 2017). Bishara succinctly makes the case for an oceanic history of the Gulf in “The Many Voyages of Fateh Al-Khayr: Unfurling the Gulf in the Age of Oceanic History,” International Journal of Middle East Studies 52, no. 3 (2020): 397–412.

30. As Maryam Alsada asks, if “men are the established actors in pearl trade activities,” then “where were all the women?” Maryam Mohamed Abdulla Ebrahim Alsada, “The Lives of Girls and Women in Bahrain and Qatar: Dress, Marriage, Health and Education in the Pearl Fishing and Early Oil Era” (PhD diss., University College London, 2022), 8. Haya al-Mughni offers a similar observation in Women in Kuwait: The Politics of Gender, rev. ed. (London: Saqi Books, 2001), 44. For an important intervention that challenges the idea that women were not active participants in Indian Ocean mobilities, see Scott Reese, “The Myth of Immobility: Women and Travel in the British Imperial Indian Ocean,” Journal of World History 33, no. 2 (June 2022): 301–320.

31. Helen Mary Rizzo, Islam, Democracy, and the Status of Women: The Case of Kuwait (New York: Routledge, 2005); Khalid M. Al-Azri, Social and Gender Inequality in Oman: The Power of Religious and Political Tradition (New York: Routledge, 2013); Alessandra L. González, Islamic Feminism in Kuwait: The Politics and Paradoxes (New York: Palgrave Macmillan, 2013); Madawi Al-Rasheed, A Most Masculine State: Gender, Politics, and Religion in Saudi Arabia (Cambridge: Cambridge University Press, 2013); Meshal Al-Sabah, Gender and Politics in Kuwait: Women and Political Participation in the Gulf (London: I. B. Tauris, 2013).

32. James Onley, The Arabian Frontier of the British Raj: Merchants, Rulers, and the British in the Nineteenth-Century Gulf (Oxford: Oxford University Press, 2007), 66.

33. Onley, Arabian Frontier of the British Raj, 69.

34. Michel Foucault, Security, Territory, Population: Lectures at the Collège de France, 1977–78, ed. Michel Senellart, François Ewald, and Alessandro Fontana, trans. Graham Burchell (New York: Palgrave Macmillan, 2007).

35. Allan Megill, “The Reception of Foucault by Historians,” Journal of the History of Ideas 48, no. 1 (1987): 132.

36. David Scott, “Colonial Governmentality,” Social Text, no. 43 (1995): 193.

37. To cite some illustrative examples, Afsaneh Najmabadi is critical of “a reductive Foucauldian concept of ‘the techniques of domination’” in her excavation of plural subjectivities of sexuality in contemporary Iran. Afsaneh Najmabadi, Professing Selves: Transsexuality and Same-Sex Desire in Contemporary Iran (Durham, NC: Duke University Press, 2014), 2. Omar Dewachi’s notion of ungovernable life in Iraq interfaces with biopolitics and governmentality and finds “the entire state to be a margin in which the constellations of historically situated regimes of knowledge and power are continuously confronting their own limits.” Omar Dewachi, Ungovernable Life: Mandatory Medicine and Statecraft in Iraq (Stanford, CA: Stanford University Press, 2017), 176. Khaled Fahmy argues that in Egypt, the Ottoman government “never developed a policy that could be interpreted as signaling an understanding of what Foucault called ‘the problem of the population’”; instead, Fahmy emphasizes the role of everyday Egyptians in forging a distinctly modern relationship between law and medicine in the nineteenth century. Khaled Fahmy, In Quest of Justice: Islamic Law and Forensic Medicine in Modern Egypt (Oakland: University of California Press, 2018), 51.

38. Joelle M. Abi-Rached, ʿAṣfūriyyeh: A History of Madness, Modernity, and War in the Middle East (Cambridge: Massachusetts Institute of Technology Press, 2020), 15, 16.

39. Abi-Rached, ʿAṣfūriyyeh, 16–17.

40. Helen Tilley, “Medical Cultures, Therapeutic Properties, and Laws in Global History,” in “Therapeutic Properties: Global Medical Cultures, Knowledge, and Law,” ed. Helen Tilley, special issue, Osiris 36 (2021): 6.

41. By “biomedicine,” or scientific medicine, I mean medicine that seeks to apply the biological sciences to the diagnosis, treatment, and prevention of disease. For an overview of scientific medicine and public health from the nineteenth through the first half of the twentieth centuries, see Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present (London: Fontana Press, 1999), 304–461.

42. Here I take inspiration from Asef Bayat’s concept of social nonmovements. Asef Bayat, Life as Politics: How Ordinary People Change the Middle East (Stanford, CA: Stanford University Press, 2010, 2013).