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08 Feb

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Publié par benbraham  - Catégories :  #Deontologie

Tipasa : La responsabilité médicale en débat

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Les professionnels de la santé ont débattu jeudi   à Tipasa de la responsabilité médicale dans le but d'éclairer la corporation  sur la responsabilité civile et pénale des actes médicaux.      
Le représentant de l’Ordre des médecins à Tipasa, Mr Mustapha Benbraham,  indiquera à l’APS que cette rencontre est d’autant plus utile que la wilaya  de Tipasa a enregistré ces dernières années plusieurs cas de fautes professionnelles  et erreurs médicales qui ont fait l’objet de poursuites judiciaires.      
Il existe, explique-t-il un déficit, voire un vide, en la matière au niveau  de la corporation des médecins dont beaucoup ignorent la responsabilité civile,  pénale et administrative de leurs actes.      
La rencontre s'inscrit aussi, ajoute-t-il, dans le cadre du programme de  formation continue qui touche tous les aspects de l’exercice de l’acte médical  et qui est devenue une tradition ancrée dans la wilaya.       
Des communications ayant pour thèmes :   "médecine légale et responsabilité  civile" et "le certificat médical vu à travers ses bases juridiques,  administratives et déontologiques" ont été présentées à cette occasion. Des  thèmes qui ont été animés, pour le volet pénal par maître Benbraham  Fatima et Messahli Keltoum, chef de service de médecine légale du CHU de Blida,  alors que le Dr Brankia Abdelmadjid, membre du conseil régional de l’ordre de  Blida, a abordé dans son intervention les volets juridique et déontologique du  certificat médical.      
La rencontre a été organisée à l’initiative de l’Association des médecins  libéraux de Tipasa (AMLT) en collaboration avec la direction de la santé et  la section de wilaya du conseil de l’Ordre des médecins.

 

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William Gallois 09/02/2009 06:31

 
 
Social History of Medicine Advance Access published online on July 7, 2007
Local Responses to French Medical Imperialism in Late Nineteenth-Century Algeria
By : William Gallois

 Department of History, Roehampton University, Roehampton Lane, London SW15 5PU, UK.
E-mail: w.gallois@roehampton.ac.uk


 
 SummaryThis article offers the first account of the lives of Algerian-born doctors working in the French colonial medical service between 1870 and 1900. Their stories reveal the manner in which the idea of medical imperialism had collapsed in Algeria, as a result of maladministration, racial policies, competition between civil and military authorities, budgetary constraints and the rise of the colons. The article also indicates the way in which medicine became a locus of opposition to French rule. It shows how the first decades of the Third Republic were critical in terms of a shift from the earlier idea of medicine serving as an emblem of the mission civilisatrice to the ideological potential of medicine being seen in much more nuanced terms by both French settlers and Algerian locals. It is argued that the notion of cultural resistance to imperialism through medicine emerges in the 1870s and 1880s, thereby prefiguring the work of Fanon and the Front de Libération Nationale's later analysis of the ‘sickness’ of colonial Algerian society.
Keywords: Algeria; France; colonial medicine; nineteenth century; ethics; doctors; North Africa; Third Republic; Sahara; Tuggurth



 
Medicine was a key feature of colonial Algerian life for two reasons. First, doctors were initially relied upon to make safe an extremely dangerous and misunderstood environment, where far greater numbers of French soldiers died from disease than in battle. Second, medicine was chosen to serve as an emblem of the French mission civilisatrice because the healing of locals by French doctors was perceived to be critical in conveying France's offer of a gift of ‘civilisation and progress’. French medicine was perceived as embodying an enlightened narrative of progress and, as such, could be used as a form of historical reorientation of the Maghreb back towards forms of development which had been abandoned when the Romans left Africa. This Orientalist history stressed the stark difference of the northern and southern Mediterranean, ignoring potential commonalties of heritage, such as those present in the history of medicine.
In the 1830s and 1840s, military figures such as Bugeaud conceived extremely ambitious plans to establish national health-care systems in the colony.1 Such proposals were the subject of heated debate in both Algeria and the metropole, and medicine quickly moved from being an idea around which all imperial groupings could cohere to a central battleground in arguments about the future and purpose of the colony.2 This was entirely understandable since the deployment of medicine as a central part of the narrative justifying the conquest of Algeria also led to it serving as a focus for disputes over the value of the colony.
In practical terms, such tensions were apparent in the medical sphere in at least six ways. First, there was the difficulty of managing a coherent health service in an environment which was riven by disputes over power and authority, principally between the army and the colons, but also between factions of the army, between the colony and the metropole, and between different political groupings within French Algeria. Secondly, and partly as a result of regime changes in France, a culture of indecision and policy confusion and reversals came to characterise the early colony. Thirdly, as Marcovich has noted, French imperialism in the nineteenth century was rather better at conceiving of plans and ideas than it was at implementing them.3 Fourthly, and relatedly, administrative structures established in Algeria tended to be inefficient, corrupt and organised in a confusing fashion. A perennial complaint of critics of the colony was that while the Ottomans had administered Algeria with an elite force of a few thousand troops, the French habitually relied on an army of tens of thousands of soldiers and administrators.
Fifthly, as time wore on, greater budgetary constraints began to be placed on French Algeria: what had originally been envisaged as an enterprise which would benefit the French economy came to be seen as a huge drain on metropolitan resources. Sixthly, and finally, there had always been an unresolved tension between France's description of a civilising mission built on universalist ideals and the reality of the conquest being founded on a racist picture of the world. That racism was quickly developed, often by doctors, into a set of hierarchies which conceived of a social order headed by native French settlers and which proceeded sequentially through categories of other Europeans, Algerian Jews, Berbers (themselves often divided into sub-groups), Moors and, finally, Algerian Arabs. Race was the single most important preoccupation of writers in nineteenth-century Algeria, with a spectrum of opinion that ranged from, at its liberal extreme, the advocacy of the establishment of institutions which recognised the essential differences of race in a kind of benign apartheid, to a concerted body of French opinion which argued for the ‘extermination’ of Algerians or their expulsion from the new possession.4
Given the centrality of medicine to the French imperial project, it is not surprising that an excellent secondary literature has developed on Algeria's place in the history of colonial medicine.5 The ground-breaking work in the field, which revealed the scale of France's desire to medicalise Algerian society, was that of Turin, who offered a comparative study of three forms of cultural imperialism—medical, educational and religious—in the period between 1830 and 1880.6 Using published and unpublished primary sources, Turin was able to show that the civilising potential of medicine was seen to be so great between 1830 and 1870 that successive metropolitan and colonial regimes centred their reform programmes for Algeria around medicine, generally oblivious to both the inability of doctors and French medical science to sustain this heavy ideological burden. This article extends Turin's analysis to the final decades of the nineteenth century, when a medical reform programme—the training of Algerians as doctors in the colonial medical service—is seen to come up against structural flaws very similar to those identified by Turin for the period between 1830 and 1880.
More recent work in the history of colonial medicine in Algeria has followed a different, comparative path, with Marcovich's evaluation of French medical imperialism in Indochina and Algeria, Keller's study of psychiatry in the British and French empires, Lepetit's account of the interconnections between French scientific ‘missions’ and military ‘expeditions’, and Osborne's complementary essay on the revival of Hippocratic ideas in such ventures.7 Both Lepetit and Osborne stress the importance of new hygienist ideas in the French conceptualisation of a Mediterranean region in which France had a historical duty to intervene through military conquests which were supported by medical histories and forms of explanation. Such works also highlight the tendency of recent scholarship to identify the emblematic importance of Algeria in France's regional and global colonial thinking. This is apparent in analyses of the place of race in such thought, in which medical ideas evidently played a large role. Here Lorcin's work on Algeria can be usefully compared with Cohen's global account of the place of race in structuring French imperialism on a broader scale.8 The related issue of the role which racialised medical thinking played in nineteenth-century famines and genocide, explored by Davis, has also depended upon Algerian examples and, in particular, Ageron's massive body of scholarship.9
The work of Davis also brings to mind Marks' important essay ‘What is Colonial about Colonial Medicine?’ in which she stressed the important role historians of medicine could play in looking beyond mortality figures and other statistics to reveal stories of human suffering from imperial settings.10 In methodological terms, that approach tallied with more general features of the history of colonial medicine: the attendance by Arnold to subaltern perspectives on the colonial experience, the Foucauldian stress on medicine as ‘contested knowledge’, and Cooter's suggestion that the modern field of medical ethics be used as both a method and an object of study in the history of medicine.11
It is in this context that I want to look at the lives of five Algerian-born doctors working in the French colonial medical system in the last three decades of the nineteenth century. Through their stories, as told in the letters and reports found in their hitherto unstudied personnel files, they reveal the manner in which the idea of French medical imperialism collapsed in the early Third Republic. As I have suggested, irresolvable flaws and tensions already existed in colonial medical structures by this point. What I think is revealing about the stories of the tiny number of Algerian-born doctors working at that time was the manner in which medical imperialism moved from being a justification for conquest, through a period of confusion and failure, to become a central locus of hostility and resistance to France. In other words, what we find in the writings and stories of such men is a precursor to the ideas of Fanon and the Front de Libération Nationale which stressed the manner in which opposition to France should be based upon a recognition of the malign contribution of the colonial power to the health of the Algerian nation, taking the idea of medical imperialism full circle in reappropriating it as a form of opposition to France. Such study of scientific thought as a means of contesting imperial rule has also been explored by Clancy-Smith in a recent essay on the maintenance of scientific teaching in Algerian centres of Islamic learning.12 Her work and this essay mark a move in studies of nineteenth-century Algeria towards the articulation of Algerian voices, which evidently connects to the earlier mentioned approaches of Arnold, Andrews, Cunningham and Cooter.
The five doctors studied here were among the tiny group of Algerian medical students who graduated from the University of Algiers Medical School in the 1870s and 1880s. The majority of them spent at least part of their careers in Tuggurth, a Saharan outpost which lay at the very edge of France's empire in the late nineteenth century.
Abdel Kader ben Zahra In May 1884, the first of our subjects, Abdel Kader ben Zahra, wrote to the Governor General in Algiers to describe his profound disillusionment with his life as an Algerian-born representative of French civilisation as it was expressed through medicine:
I write, Monsieur Governor, as a man who holds only the position of health officer, but I hope you will realise the great effort it has taken me to reach even that rank. Out of a population of three million Algerian Arabs there are just four colonial doctors, two health officers and two other medical officials. Those appointed as doctors have qualifications no different to my own—simply secondary education without a bachelor's degree—but they had the great fortune to work under Governor Chanzy, who felt moved to alter their ranks from health officers to doctors. In those days, the authorities never missed the opportunity to encourage young Algerians who wished to study and to assimilate themselves with their French masters; to enter into the new life which France offered them. I would like to believe that such policies continue to this day and that your office will support the development of more Algerian doctors so as to encourage our country down the road of civilisation and progress. Today, however, with my health officer's diploma I find myself without resources or a route of advancement. I feel like a sea-going traveller who, when his ship reaches the middle of the ocean, is told that he must disembark for he will be taken no further. Because of this, Monsieur Governor, I feel that I would have preferred to have not travelled on that journey and instead stayed on my own shore, where I would have been content with my savage existence and not troubled by these brick walls and obstructions which now face me.13
Ben Zahra was part of a tiny vanguard of Algerians selected for the role of propagandising the benevolence of French imperialism through medicine, yet his account of his career reveals the manner in which this mission failed at the outset. How, then, did ben Zahra and his peers come to see their lives as representative of the French medical imperial idea as a form of betrayal?
In May 1884, an Algerian Senator, Le Leliène, had received a reply from the colony's Governor General to a letter he had written asking that a post as Médecin de Colonisation be found for his protégé, Abdel Kader ben Zahra. The Governor General wrote that ‘While he would have very much liked to have found such a post for ben Zahra, the senator needed to be aware that the regulations of 23 March 1883 allowed for officiers de santé to be appointed to such positions only when no fully-qualified doctors were available.’14 For this reason he was unable to help at that time. From this brief exchange we can see some of the central realities of the medical system for men like ben Zahra: they were trained as officiers de santé, rather than as doctors, so as to preserve a racial hierarchy in the medical profession; they depended on patronage to obtain any kind of position with the qualification they had earned; and there was a limited demand for medical graduates of Algerian origin. In a follow-up letter direct to the Governor General, ben Zahra pressed his case for a post as a médecin de colonisation in the Tell or, at the very least, a temporary position in Tuggurth, where two doctors had died in post in quick succession.
Ben Zahra's letters bluntly reveal an Algerian's view of the manner in which France had reneged on the promises of medical imperialism. They show the extent to which the French rhetorical propagandisation of that idea had infiltrated Algerian society and the gaps which had always existed between enthusiasm for the promotion of the idea and the much more testing reality of instantiating that idea in practice. Ben Zahra's sense of betrayal reflected a sense of this gap between the avowed beneficence of medical imperialism and the truth of the French offer to Algerians. We see a very similar sense of moral anger in Prochaska's recounting of the words of Khélid Kaid Layoun in 1900:
As part of the metropolitan French reform effort of the 1890s, now winding down, a group of senators on a fact-finding tour passed through Bône. Khélil addressed them on behalf of a group of ‘young Bône Muslims’. He described the situation of these Francophone young Algerian males such as himself, who favored Algerian assimilation to France but could not convert their French education into a job, who were less and less Algerian but prevented from becoming more and more French, who were in short ‘floundering in civilization’.15
A sense of ‘floundering in civilization’ was common to both ben Zahra and Layoun as part of that small experimental Algerian elite, on whom France could not really decide whether to bestow the name of Frenchman or not. What their lives reveal is the inapplicability of discussions about ‘assimilation’ and ‘association’ to nineteenth-century Algeria, for the realities of the colony, and most particularly French thinking about race, were such that there never was a truly ‘assimilationist’ moment in Algeria. The closest France came to this was through men like ben Zahra, and in his life we see the prizing of racial hierarchies over an assimilatory universalism.
Ben Zahra's description of his childhood and the efforts which he had undertaken to reach the position which he described in his earlier letter, give some idea of why his despair was so absolute. He wrote to the governor that he had only learned to read and write from the age of ten, when he had been recruited to the army, having previously never even seen a European. His training there had concentrated on military duties and gymnastics and it was only through good fortune in being selected for one of two scholarships to the Lycée d'Alger by Chanzy at the age of 13 that he had had the opportunity to become educated. There he worked extremely hard, in spite of the fact that some options, such as the study of Latin, were ruled out for him on account of his late start in education. At the age of 17 he won a bursary to the medical school in Algiers and was well aware that his career up until that point had been characterised both by a great deal of luck and a colossal drive to succeed when the opportunity arose.
Ben Zahra was eventually appointed in Tuggurth, almost certainly because it was a posting which other European doctors would not accept, no matter how ambitious they were, on the grounds of the colossal risk involved in being posted to such a place. Ben Zahra was well aware of these dangers, for on accepting the position in June 1884, he wrote to the Governor General to state that his desire to recognise all that the government had done for him deserved a practical expression of thanks.16 This was in spite of the fact of ‘the sanitary conditions of the territory there, its distance from all intellectual life, the premature deaths of Mohammed Mustapha and Djillali ben Fiah from illnesses contracted in post, and his huge desire to continue his studies so as to obtain a doctorate’. Achievement of the latter might have seemed to have placed him on an equal footing with French doctors.
Yet the realities of the harshness of the conditions in Tuggurth were much worse than ben Zahra had envisaged. On arriving there, he was still suffering from the after-effects of a ‘fièvre paluske’ which he had contracted whilst working in Oued Rhia. Both he and his wife were sick for most of the time they lived in Tuggurth; so much so that his wife was sent to recuperate on the coast. Ben Zahra's many local enemies complained that until he was dismissed in the summer of 1885 he himself had only lived in Tuggurth for four months out of 12, and that his loss would hardly be missed since there was also a military doctor stationed in the town.17 There is no doubt that ben Zahra was often on leave, but such requests seem always to have been based upon either his own or his wife's poor health. When working, it is clear that he approached his task as a colonial doctor with great vigour, choosing to take responsibility for questions of public health strategy and the regional administration of health-care services as well as his regular duties of running a small hospital and travelling around the district to attend to the sick. His personnel files include a number of letters denouncing his character from military figures, who argued that the local commune would be better served by having its tax burden reduced by 4,000 francs annually, rather than paying for a doctor like ben Zahra who was so rarely in residence. There are compelling reasons for thinking that it was as much ben Zahra's ambition as a doctor and a medical administrator which motivated such complaints from the army.
In fact, one of the chief complaints of local military commanders, as seen in a letter to the Governor General of 14 April 1884, was that ben Zahra was too active in his position, for the military objected to the fact that he was claiming back money for medicine which he had dispensed free of charge to locals. This objection in fact arose from a confusion regarding ben Zahra's status in the complicated medical administration of Algeria. If he were a médecin de colonisation appointed by the government in Algiers, and funded from the capital, then he would be entitled to act as he had, but the local soldiers argued that he was actually merely an officier de santé, who ought to have been treated like other ‘médecins communaux’, for ben Zahra's salary, and the costs incurred from his free prescription service, were borne by local taxpayers.18 This bind in which ben Zahra was placed was typical of the incoherence of the practice of medicine in Algeria, for in making what was essentially an intentional mistake and a cost-saving measure, the civil state had condemned his mission to failure.
It is certainly true that ben Zahra did not adapt to the ‘great heat’ of Tuggurth, which is unsurprising given his own sickness.19 Yet it was not just the temperature which he found oppressive, for he described life in the town as consisting of ‘terrible solitude, being far from family, friends and all relations with the civilised and intellectual world’ to which he had become accustomed in the very different world of the coastal cities.20 Another form of local tyranny came in the manner in which he was treated by the military authorities who governed the town. Ben Zahra described a relentless campaign of intimidation against himself as a potential rival source of authority in the town, whose Algerian birth might help him to act as a more effective mediator with the locals than would be the case with the French army. The army constantly attempted to make his life difficult, preventing him from undertaking his duties and crushing his sense of professional esteem in the most public and humiliating fashion possible, to the extent that he was publicly beaten in the course of his duties.21 He concluded his letter to the Governor General by writing that he very much wanted to make a living for himself and his wife which depended on the fruits of his labour, but that the fruit he had found in Tuggurth was unbelievably bitter.
In his letters to the Governor General he lamented the fact that he found himself caught up in a struggle between rival forms of administrative authority, which was at its most tense in towns such as Tuggurth, which lay on the edge of the ‘civilised’ portion of French Algeria, where the army was committed to preventing the encroachment of civil powers. As ben Zahra said in one of his letters, had not all his problems arisen ‘because of the fact that I am a civil servant?’.22 A typical example of being caught up in such struggles was revealed in regard to ben Zahra's access to the pharmacy. This institution was controlled by the local Bureau Arabe and the lieutenant in charge would frequently frustrate ben Zahra's work by refusing to allow him entry to the pharmacy, preventing him from having his own key to the building, and failing to re-order essential requirements for the town. Ben Zahra felt understandably emasculated for he was not able to fulfil one of his main roles in the town, which was the provision of ‘free care to all the sick, irrespective of their wealth’.
The assault on ben Zahra had been committed by a certain Commandant Schérer and in the former's account it had amounted to a concerted effort to diminish his authority in the town, for Schérer had chosen to attack him in front of the Agha and his entourage while a number of locals waited for ben Zahra's assistance at the pharmacy.23 After the attack Schérer had driven away ben Zahra's clients. He was convinced that the reason why Schérer had behaved in this fashion was because ben Zahra had delayed handing back the key to the pharmacy as he had had to travel some distance to a patient in need. Ben Zahra wrote to the Governor General to say that he felt so threatened by the actions of Schérer and other officers that he had taken to carrying a revolver with him at all times.24 Other forms of intimidation included the fact that Schérer and other officers delighted in releasing patients from the hospital before their discharge had been authorised by ben Zahra. Similarly, Schérer would refuse to countenance the release of patients whose discharge had been authorised by ben Zahra.25
As ben Zahra explained to the Governor General, ‘to work with the Arabs it is necessary to possess a certain amount of prestige’ and it was this which the army were determined to ensure was eliminated in his case.26 Army officers would routinely dump manure outside ben Zahra's house as a symbol of his status in the town, and refused to stop doing so in spite of ben Zahra's protest that this presented a danger to public health. The character of the animosity which the army felt towards a doctor, who was not only a representative of the civil government of Algiers but also of the Arab race, was made plain when Schérer announced to ben Zahra, ‘You delight in playing the big man [le grand seigneur] here, but it doesn't wash with me’.
Ben Zahra also described the great gap which existed between colonial medicine in theory and in practice, and the very limited will and capacity of the state to undertake systematic programmes of medical intervention and public health in the 1880s. In October 1884, he noted that he had written:
A report for the Commander at Biskra in which I set out the sanitary situation of the territory and a programme of hygienic and public health improvements which were needed as a means of rapidly improving the health of the region. As with most of my letters, all I heard was silence. It was reminiscent of the manner in which I was treated when I sent a demand for pox vaccines to be sent so as to combat an imminent public health disaster as a result of the spread of an epidemic from Oued Souf. On hearing nothing, I myself, at my expense, sent a telegraph to a pharmacist in Batna to request supplies.27
The last we read of ben Zahra from his personnel file comes in a letter written by a Dr Picardin in December 1885.28 The writer was a doctor based in Bouira who wrote to the Governor General to discuss the options open to them in terms of finding a replacement for a Dr Gensolles who had left his position. Picardin had recently lost both his wife and his 12 year-old daughter to diseases in Bouira, but he was determined to remain in the town and prevent ben Zahra, who was serving as Gensolles' replacement on a temporary basis, from being appointed on a full-time basis. Picardin acknowledged that it was extremely difficult to find a doctor who was willing to serve in the town, for many had refused ‘on hearing of the terrible manner in which Mayor Paoli and his councillors had treated Gensolles’. But he assured the Governor General that the atmosphere in the town was now much improved.
We know no more of why Picardin objected so violently to ben Zahra, nor indeed whether he continued to serve in Bouira, although the absence of further documentation does suggest that his medical career may well have ended just a few years after he had graduated. The suspicion must be that Picardin's fears regarding ben Zahra were similar to those which had seen him driven out of Tuggurth.
Mohammed ben Mustapha
Before being sent to Tuggurth, Mohammed ben Mustapha had served in Ouazgla where he also encountered medical competition and a challenge to his authority, although in his case it came from French missionaries rather than the army. In 1870—the early date suggests that he was among the first Algerian-trained doctors in the colonial medical service—he wrote to the Governor General to complain that Catholic missionaries were dispensing free drugs, ‘telling people that they were the true doctors and that he was a charlatan’.29 As ben Mustapha angrily observed, the reverse was in fact true, for while he possessed formal medical training, it was very unlikely that this was the case for the mission's ‘doctors’. What this story reveals is the often complex cast of competing authorities at work in Algerian medicine, especially outside the major cities, and the absence of a strong, central authority as a means of regulating these contests. While it was true that all policy disputes went through the office of the Governor General, as we see here, that office was primarily concerned with the collection of information rather than active intervention in such disagreements.
The only other significant event recorded in ben Mustapha's file was his premature death at the age of 32 in 1881. From his letters it is clear that he always understood that Tuggurth was a dirty, risky, insalubrious place, and when he fell ill he requested a transfer out of the town for he knew that his chances of recovery would be much higher on the coast. This request was refused, however, and he was told that he could not leave until a replacement doctor had been found.30 His obituary in the bilingual French-Arabic official newspaper Mobacher is blunt in its account of the manner in which the difficulty of his work and the dangers of the disease environment in which he toiled contributed to his early death, but it also cannot avoid claiming ben Mustapha as a heroic emblem of the idea of French medicine in Algeria. It states that:
He died at the young age of 32, taken by a cruel sickness which he had encountered in the course of his duties. On falling ill, ben Mustapha threw himself even deeper into his work, addressing not only his regular duties but also the underlying problems of public health in the town. It was at that moment that the efforts of work and repeated attacks of fevers started to diminish his once robust constitution. His health rapidly declined and on acquiring a chest infection he requested a transfer to the more clement coast, which would also have been closer to his family [...] he died murmuring one last thanks to France, the country which he had loved so sincerely.31
Dilali ben Fiah
As we have learned from the example of ben Zahra, Dilali ben Fiah was the second of his predecessors to die in post at Tuggurth. His story is especially interesting for the manner in which it exposed the great gap between the idea of medicine and the realities of the rationing of funds for health, particularly after 1871. The first we learn of ben Fiah is in April 1881, when the Director of the Medical School in Algiers wrote to the Governor General, saying that he was finally in a position to supply the central government with a replacement doctor so as to relieve ben Fiah from his posting in Tuggurth. The tone of the letter is angry, for the Director explained that the underlying reason for this delay was that in 1880 the Governor General's office had suspended funding for the annual bursary competition for indigènes, which had provided 12 bursaries for the locals to attend the school since 1862.32
A year later, in further correspondence between the Director and the Governor General, we learn that in fact no replacement had been found for ben Fiah. This was indicative of both an abandonment of a commitment to something like an assimilated health service and also revealing of just how racially structured such a system had been at its most idealistic moment. There were of course many doctors who could be sent to Tuggurth, but both the Director and the Governor General knew that only Algerian-born doctors would be desperate enough for their career advancement to agree to go there. The manner in which the Director appealed to the Governor General to re-commence funding of bursaries was thus a deeply practical one, for he described such funds as ‘the means which we have for the recruitment to indigenous posts in the south’.33
Much of the rest of ben Fiah's file concerns the means by which his salary was paid, for as in the case of ben Zahra, there was some confusion as to what proportion of his salary was to be provided locally and what should come from Algiers. The local General of the Division, who commanded the region, demanded further support from the office of the Governor General, for not only had the indigenous population of Biskra paid for ben Fiah through taxes, but a special sum had been raised locally to boost his income by 540 francs a year, taking it, including sums for accommodation and the maintenance of a horse, to 4,210 francs annually. This extra sum had been granted in recognition of ‘the exceptional situation of this doctor, who works in one of most advanced Saharan posts, where the climate is dangerously harsh at certain times of year, and where the difficulties of living and of finding suitable accommodation merited a higher wage’.34 The final documents in ben Fiah's file detail plans to move him from Tuggurth to Beni Mansour, but it was evident that he had contracted a fatal illness before he got there.35








   Boulouk Bachi




The career of Boulouk Bachi reveals a third potential source of tension for Algerian-born doctors working in the field of colonial medicine. While ben Zahra had clashed with the military authorities and ben Mustapha with missionaries, Bachi's problems arose from tensions with the local colons and their political leaders. Our knowledge of his early career does not suggest that he was a man who sought conflict with authority, for from his qualification as an officier de santé in 1868 to his appointment in Fondouk in 1886, he appears to have been regarded as a model employee. In 1869, he had undertaken military service, working in a military hospital at the time of the famine, while ten years later he was described as ‘one of the most devoted practitioners in the whole of the colonial medical corps’.36 An 1883 report suggested that he was a man who had good relations with his superiors, his juniors and with the central administration, while in 1885 he was promoted to the third class of the rank of officier de santé, which merited a pay increase to 4,000 francs a year.37
When he arrived in Fondouk in 1886, he was 38 and had been practising medicine for 18 years.38 He was married with five children and spoke Spanish and Arabic as well as French, so he was undoubtedly a great asset to the colonial medical service. Rather curiously, he was paid only 3,500 francs a year at this point, which suggests that the local authorities in Fondouk had ignored the promotion which he had been awarded by the central administration. It is evident from Bachi's file that he was aware that Fondouk was not a suitable posting for him, as he tried to resign from his post in January 1886, citing problems with the health of his family.39 In an earlier report, the mayor of the town had praised Bachi for most of his work, noting his intelligence, morality and judgement, but the prefect complained that his relations with the local authorities were poor and that he was neglecting his duties to such an extent that he would need to be replaced. A set of investigations of Bachi's work then seem to have taken place, for in the spring of 1886 we read a letter from an official sent to review Bachi's work for the Prefect. The writer concluded that ‘When he is in post, I am convinced that Bachi offers all the care his clients need, and that he is in fact devoted to such work, but the problem is that he is often absent.’40 At times this appeared to have been because Bachi was treating patients at some distance from the town—and there may be the insinuation that this was for extra income—but when the official visited, he had claimed to have been in Algiers nursing his sick wife. In response to such accusation, Bachi declared that almost all of his absences were indeed caused by visits to distant farms, and that those who accused him should be well aware that he fulfilled his obligations according to the decree of March 1883 which required him to offer free consultations at set times twice a week, either in his own residence or at the town hall. He went on to add that the problem in the locality was more with the office of the mayor than himself, since the mayor had refused to supply him with a list of indigènes in the department, which was critical for the management of his service.41
By the end of 1886, it is clear that the level of hostility directed towards Bachi had increased for the local prefect wrote to the Governor General accusing the doctor of negligence, writing that he did not respond to demands for meetings and asserting that the mayor of Fondouk had reported that he was disregarding a number of his duties.42 This made reference to the annual report on Bachi which had been written by the mayor in which he had claimed that ‘It was to be regretted that he is absent too often and the population was growing restless for they did not have confidence in his services and the fact that he was not attending to his duties.’43 Yet that report also contains indications that Bachi's problems with the local authorities may in fact have had little to do with questions of his absences from the town or his derogation of his duties, and much more to do with the question of whether the colons considered it appropriate for an Algerian-born doctor to become involved in questions of politics. In his note, the prefect in fact claims that Bachi was ‘a capable and active doctor’, and while he does note that he should be reproached for being absent too often, it seems that the underlying problem was that Bachi ‘had become involved with questions and people which were dividing the commune’. For this reason, ‘a change would be necessary’.44
More details of this involvement are revealed in a letter of December 1885 from the mayor of Fondouk to the Governor General, in which he complained that public officials were becoming much too involved in elections. With regard to Bachi, he alleged that ‘Our médecin de colonisation is mixed up in all the elections in a very public fashion, debating and discussing such things in public places such as cafés.’45 This leads one to ask whether the complaints directed at Bachi really referred to his absences or to his visibility on the local political scene. The mayor went on to say that ‘on the fourth of October he was seen openly campaigning against the candidacy of Bonheur and Pelletier, and was in many senses the cause of the failure of these candidates to be elected in Fondouk’.46 The last we read of Bachi comes in an 1887 report which again addressed the question of his neglect of patients and his over-involvement in local politics. It is unclear whether such allegations ended his medical career or whether there was some other reason as to why his personnel file ended so suddenly.47








   Mohammed ben Larbey




Our fifth doctor was evidently a man of great ambition, but his experiences show how difficult it had become to achieve such aspirations in the colonial medical service by the 1880s. Like the other cases we have looked at, ben Larbey's is a story of disappointment and awareness of the gap between the bright idea of medical imperialism with which his career had begun and the realities of life on the edges of empire in the colonial medical service. Ben Larbey was a great rarity for he had begun his medical studies in Paris, and on graduating as an officier de santé he had worked in Algeria for a number of years. By 1881, he was keen to continue his studies and to return to Paris so that he might gain a doctorate and become a fully-fledged doctor. He applied, through the military authorities of the interior, to Algiers for a grant of 5,000 francs, which would consist of 450 francs for a set of five exams, a similar sum for the printing of copies of his thesis, 3,600 francs living expenses for two years, and at least 500 francs for books, clothes and travel.48 Ben Larbey appeared to have believed that he had secured the support of his military commanders in this aim, but the letter from the officer concerned reveals otherwise:
In making this demand, the indigène in question invokes the favour which had already been granted in similar circumstances to a number of his fellow Muslims. Yet he is in error here, for there has in fact been only one Muslim, ben Mekkache, who has been funded in this fashion, at a cost of 4500 to 5000 francs, to study in Paris. This example was therefore unique and the considerable costs which it entailed have convinced the central administration that such a heavy burden on the budget will not be repeated.
The example of ben Larbey was then used by the military authorities as a means of making more general claims with regard to the value of training Algerians to become doctors:
Why should such a colossal sum be spent on the creation of indigenous pseudo-doctors, who, with their double qualifications, would lie in an awkward position vis-à-vis their French colleagues, and who would subsequently demand as of right positions in the medical service which there is no chance would become immediately available? While there might be some justification for according a few local doctors training slightly beyond their initial studies, what advantage would there be in encouraging them to obtain doctoral titles, which they might gain without having to demonstrate the skills necessary to earn them? Finally, moving beyond the question of the level of education appropriate to the indigènes, why should we offer something to Muslims which we have refused to offer to the French?49
The officer went on to say that it would be pointless to grant any money to ben Larbey, for that would only encourage his ambitions. He also noted that, in any case, the funds which were available for Muslim scholarships had already been allocated in 1881 for the purposes of legal training in advance of reforms to the system of Islamic justice. So the career of ben Larbey was indicative of the distinct limits which the colonial authorities placed on the careers of Algerian-born doctors, and the diminishing importance of the promotion of the idea of medical imperialism as the century wore on. Ben Larbey's own experiences as a medical practitioner were similarly illustrative of broader trends for he encountered yet another form of competition as an indigenous doctor; this time from a rival doctor who successfully lured a large proportion of his clientele away from him.
Ben Larbey worked in Bou Medja and it was clear that, like Bachi, he had considerable problems with the class of colons from the moment he began working in the town. In October 1876, the local prefect wrote to the Governor General to complain that ‘while his Muslim brothers go to him with all their medical needs, with trust in what they perceive to be his French methods, the reality is that his bearing shows, on the contrary, that he has no idea of how to act according to French social norms’.50 The colons ‘accepted his treatment only with repugnance’ and the writer claims that a pattern was forming, for similar complaints had been made about ben Larbey in Bourkika.51 Ben Larbey was evidently moved on, for the next we hear of him comes in a duplication of earlier complaints from the prefect of Oued Fooda, where we learn that ‘he inspired so little confidence amongst the inhabitants of the town that another officier de santé had managed to come into town and build up his own client base’.52 The prefect contended that this situation could not be allowed to continue, for the cost of these doctors was being funded by the colonial medical service, and the prefect hoped that ‘it might be possible to use M. Larbey in a more favourable location by sending him to a territory which was inhabited only by indigènes’.53
In fact, we learn that a more concrete proposal is made—that ben Larbey be sent to Tuggurth, which should come as no surpise. While it is unclear as to whether the populations of these towns had any genuine reasons for feeling aggrieved at ben Larbey, the evidence would seem to suggest otherwise and indicate that his career was simply blighted by his being an Algerian Muslim sent to work with racist colons. I feel confident in saying this because there is too great a disparity between the criticisms of ben Larbey and the factual record of his career. The complaints made against him related exclusively to his failure to relate to the French and to the norms of French colonial society, yet the reality was that ben Larbey was one of only two Algerian-born doctors who had actually lived in France, and who would therefore have been completely aware of such norms. Perhaps that was indeed his real problem, for while he may have been aware of the social norms of Paris, he was perhaps less able to adapt to the ‘French’ norms of colon society, which contained many who, by this point, had had no experience of French life, let alone of metropolitan existence.








   Conclusion




What the stories of ben Larbey and his peers reveal is the manner in which the idea and practice of medical imperialism, which had been central to the identity of the Algerian colony from its inception, collapsed in the first decades of the Third Republic. This was obviously intimately connected to what Ageron calls the ‘victory of the colons’ which accompanied the army's loss of control of governance in Algiers, but it could only be partly explained by such a political shift, particularly as many doctors worked in tribal areas still under the control of the army.54
Fanon was later to write that ‘Western medical science was introduced into Algeria at the same time as racism and humiliation. Given its part in a system of oppression it was always viewed ambivalently by locals.’55 In order to resist, he argued, the locals had needed to reject ‘the doctors, the teachers, the engineers, the paratroopers’.56 Yet ben Zahra's letter, with which this article began, reveals that for some Algerians there had been a moment of hope when they had believed in the benevolence of the offer of medical imperialism and the opportunities to train in that health-care system. Ben Zahra and his colleagues reveal a sense of the way in which Algerian doctors came to feel betrayed by France and, as such, they represent an important voice in the shift from ambivalence towards French medicine, to overt hostility towards its aims and goals. As my introduction suggested, a complex of factors surrounding questions of governance, competition, funding and race, had meant that the civilising role assigned to colonial medicine had never been as successful in practice as it had been designed to be in theory. Yet later colonial conquests which relied heavily on medical ideas, such as those of Tunisia, Morocco and West Africa, failed to recognise the inherent flaws in the design and implementation of the Algerian medical imperialist template from which they borrowed.57








   Notes




1 Bugeaud 1838.
2 For the French picture of the medical scene in Algiers on their arrival, see Salva 1832, Rozet 1833 and Trapani 1830, and for good examples of debates on medicine and the Algerian colonial project see Bertherand 1855, Bodichon 1851, Duvernois 1858 and the two anonymously authored pamphlets La France: doit-elle conserver Alger? 1835 and Réfutation de l'ouvrage de Sidy Hamdan 1834.
3 Marcovich in MacLeod and Lewis (eds) 1988, p. 103.
4 See Ferro 2003 and, especially, Le Cour Grandmaison 2005.
5 See Gallois 2007 for a more detailed consideration of the literature.
6 Turin 1971.
7 Marcovich in MacLeod and Lewis (eds) 1988, Keller 2001, Lepetit in Borguet et al. (eds) 1998, Osborne in Arnold (ed.) 1996.
8 Lorcin 1995, Cohen 1980.
9 Davis 2001, Ageron 1972 and 2005. See Gallois 2007 for a fuller list of Ageron works.
10 Marks 1997, p. 215.
11 Arnold 1993, Cunningham and Andrews 1997, Cooter 1995.
12 Clancy-Smith in Burke and Yaghoubian (eds) 2006.
13 Letter of 30 May 1884, Centre des Archives d'Outre-Mer [hereafter CAOM], box ALG 113 bis, file 1u/1.
14 Letter of 1 May 1884, CAOM, ALG 113 bis, file 1u/1.
15 Prochaska 1990, p. 233.
16 Letter of 20 June 1884, CAOM, ALG 113 bis, file 1u/1.
17 Letter from the General of the Division to the Gouverneur Général, 20 May 1885, CAOM, ALG 113 bis, file 1u/1.
18 Letter from the General of the Division to the Gouverneur Général, 4 May 1885, CAOM, ALG 113 bis, file 1u/1.
19 Letter from ben Zahra to local Commandant, August 1885, CAOM, ALG 113 bis, file 1u/1.
20 Letter from ben Zahra to the Gouverneur Général, 10 May 1885, CAOM, ALG 113 bis, file 1u/1.
21 Letter from ben Zahra to local Commandant, December 1884, CAOM, ALG 113 bis, file 1u/1.
22 Letter from ben Zahra to the Gouverneur Général, 10 May 1885, CAOM, ALG 113 bis, file 1u/1.
23 Letter from ben Zahra to local Commandant, December 1884, CAOM, ALG 113 bis, file 1u/1.
24 Ibid.
25 Ibid.
26 Ibid.
27 Letter from ben Zahra to the Gouverneur Général, 10 May 1885, CAOM, ALG 113 bis, file 1u/1.
28 Letter from Picardin to the Gouverneur Général, 7 December 1885, CAOM, ALG 113 bis, file 1u/1.
29 Letter from ben Mustapha to the Gouverneur Général, 1870, CAOM, ALG 113 bis, file 1u/139.
30 Letter from Gouverneur Général to ben Mustapha, 1881, CAOM, ALG 113 bis, file 1u/139.
31 Mobacher: journal officiel, 5 December 1881, p. 3.
32 Letter from the Director of the Algiers Medical School to the Gouverneur Général, 22 April 1881, CAOM, ALG 113 bis, file 1u/68.
33 Letter from the Director of the Algiers Medical School to the Gouverneur Général, 15 July 1882, CAOM, ALG 113 bis, file 1u/68.
34 Letter from the General of the Division to the Gouverneur Général, 7 July 1882, CAOM, ALG 113 bis, file 1u/68.
35 Letter from the General of the Division to the Gouverneur Général, 22 January 1883, CAOM, ALG 113 bis, file 1u/68.
36 Annual Personnel Report, 1879, CAOM, ALG 113 bis, file 1u/28.
37 Annual Personnel Report, 1885, CAOM, ALG 113 bis, file 1u/28.
38 Annual Personnel Report, 1886, CAOM, ALG 113 bis, file 1u/28.
39 Letter from Bachi to Gouverneur Général, 18 January 1886, CAOM, ALG 113 bis, file 1u/28.
40 Annual Personnel Report, 1886, CAOM, ALG 113 bis, file 1u/28.
41 Letter from Bachi to the Prefect of the département of Algiers, 2 March 1886, CAOM, ALG 113 bis, file 1u/28.
42 Letter from the Prefect to the Gouverneur Général, 18 December 1886, CAOM, ALG 113 bis, file 1u/28.
43 Annual Personnel Report, 1886, CAOM, ALG 113 bis, file 1u/28.
44 Ibid.
45 Letter from the mayor of Fondouk to the Gouverneur Général, 24 December 1885, CAOM, ALG 113 bis, file 1u/28.
46 Ibid.
47 Annual Personnel Report, 1887, CAOM, ALG 113 bis, file 1u/28.
48 Letter from the Chief of the 1st Bureau of the Interior to the Sécrétaire Général, July 1882, CAOM, ALG 113 bis, file 1u/138.
49 Ibid.
50 Letter from local commandant to the Gouverneur Général, 27 October 1876, CAOM, ALG 113 bis, file 1u/138.
51 Ibid.
52 Letter from local Prefect to the Gouverneur Général, 1876, CAOM, ALG 113 bis, file 1u/138.
53 Ibid.
54 Ageron 1972, p. 228.
55 Fanon 1960, p. 111.
56 Fanon 1960, p. 113.
57 Gallagher 1983, Micoleau-Sicault 2000, Bidwell 1973, Conklin 1997.








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