1

‘The Age of Universal Contagion’:

History, Disease and Globalization
Alison Bashford

Medicine at the Border explores the pressing issues of border control and
infectious disease in the nineteenth, twentieth and twenty-first centuries,
in the ‘age of universal contagion’.1 This book places world health in world
history, microbes and their management in globalization, and disease in
the history of international relations, bringing together leading scholars on
the history and politics of global health. Together, the authors show how
infectious disease has been central to the political, legal and commercial
history of nationalism, colonialism, and internationalism, as well as to the
twentieth-century invention of a newly imagined space for regulation
called ‘the world’.
This is a modern history of a world with markedly more health, and less
acute infectious morbidity and mortality than previous centuries, in some
places. It is also the history of a divided world, where the manifestly
unequal distribution of the benefits of modern medicine and public health
marks the division between North and South, West and East possibly more
starkly than any other factor. Thus, analysis of global health raises a history
of medicine, but it also raises a history of geopolitics. The geopolitical
aspect not only concerns the historical geography of disease itself, but also
that of disease management: the reduction and prevention of microbes and
illness is rarely the only outcome of disease control, even if it is an impor-
tant one. The chapters collected here squarely address the under-recognized
place of disease control in the history of national and international gover-
nance, and in the processes of globalization over the modern period.
Medicine at the Border goes some way towards developing what might be
called a world history of the geopolitics of disease prevention.
Infectious disease management often has spatial implications, and uses
spatial measures of prevention, reduction and eradication: this is as true in
the twenty-first century as it was in the nineteenth century. For this reason,
borders of many kinds, and in many places, so often recur in practice: quar-
antine lines and migration screening, once a stethoscope to the bare chest,
now fever scanning at airports; trade barriers against BSE; home isolation
1
A. Bashford (ed.), Medicine at the Border
© Palgrave Macmillan, a division of Macmillan Publishers Limited 2007
2 Medicine at the Border

for the suspected carrier of the SARS virus; targeted vaccination in social
and spatial circles around a remaining smallpox victim. There is a geopol-
itics to each of these. But to focus on what happens at these borders, is to
miss another scale of geopolitics and disease management altogether.
For the politics of disease control concerns the governance of this side and
crucially that side, of the border as well. As we shall see, infectious disease
control – and the relief and prevention of suffering – has not infrequently
been a rationale for all kinds of formal and informal intervention beyond a
local jurisdiction, beyond a sovereign state. Over and over again, the aspi-
ration to promote health and prevent disease has resulted in pre-emptive
activity beyond the border: European powers sought to intervene in
Ottoman rule to prevent the spread of cholera; the US military, followed by
the Rockefeller Foundation, embarked on major yellow fever eradication
campaigns in Cuba, Panama, Puerto Rico; quarantine lines in Africa offered
a clear and politically useful demarcation for new ‘international’ borders
between Sudan and Egypt, between Uganda, French Congo and Belgian
Congo.2 This kind of geopolitics of disease prevention continues in the
realm of health aid and development:3 for example, assistance with
HIV/AIDS treatment will be given there (in the form of aid) but not here (in
the form of state-funded treatment of refugees). And other kinds of aid
workers cross national and political borders defiantly, armed with ideas of
‘humanitarianism’ and ‘universalism’ along with vaccines and antibiotics:
they aim for, and try to practice within, a world ‘sans frontières’.
While once disease prevention and geopolitics were simply related, more
recently the former has become a vehicle for, and even an instrument of,
the latter. The intense twenty-first century manifestations of defensive
nationalism, disease and security on the one hand, and global flow, supra-
national surveillance technologies, actual and imminent world pandemics
on the other, suggest a need to think about the provenance of these con-
nections, their effects in the past, and to temper assessments of their
alleged novelty, while at the same time recognizing a world linked in time
and space in ways altogether new.
Part I of this book, and of this introduction, deals with the connections
between national histories and the emergence of international and world
health structures over the twentieth century. Authors interrogate the inter-
nationalization of world systems of epidemic management, of eradication
dreams, of colonization, decolonization and world health governance.
The impossibility (and therefore historical inaccuracy) of separating out
colonial and national histories in the genealogy of world health becomes
apparent. Part II discusses the issue of territorial health regulation, of
medico-legal border control and movement of people across national lines,
both historically and in the twenty-first century. In Part III, authors pursue
aspects of late twentieth and twenty-first century global disease and
security. They examine contemporary global epidemic surveillance and
 Alison Bashford 3

information networks, flows of information, microbes and fear, which

increasingly bypass the nation-state, but cannot do so altogether.

World health: national and colonial histories

Several historical lines merged to create ‘world health’ as a problem, a

project and a possibility in the twentieth century: colonial medicine,
national territorial defense imperatives, international convention and
agreement on both trade and disease, regionally-interested organizations.
The domain of health and disease regulation was by no means incidental
to the consolidation of nineteenth and twentieth-century territorial
nation-states and to the related phenomenon of international relations.
Historians have rightly detailed the quarantine and so-called ‘sanitary’
conferences of the mid to late nineteenth century, as the direct precursors
to the early twentieth-century international organizations of health,4 and
to the evolution of Westphalian systems in practice.5 The reverse has also
been argued: that a new internationalism created national public health
measures. ‘It is only against the background of medical internationalism’,
write Stern and Markel, ‘that we can begin to understand the elaboration
of the United States Public Health Service regulations on immigrants
inspection, quarantine, and vaccination in the early 20th century’.6
There was a string of international meetings from 1851, initially taking
up the question of cholera, and later plague and yellow fever. As Brown,
Cueto and Fee summarize in their chapter, in 1902 an International
Sanitary Office of the American Republics was established which became
the Pan American Sanitary Bureau. In Europe, the International Sanitary
Conference discussed the need for a permanent international body and the
Office international d’hygiène publique resulted, based in Paris (1907).
After World War I, the League of Nations created an Epidemic Commission
to deal with typhus fever in Eastern Europe,7 and in 1923 the Health
Organization of the League of Nations was established with four areas of
work: epidemiology; technical studies; study tours; and the ‘intelligence’
work of the Far Eastern Bureau at Singapore.8 Alongside the proliferation of
formal intergovernmental organizations for health entered philanthropic
organizations like the various renditions of the Red Cross, and private US
philanthropic organizations, most significantly the Rockefeller Foundation
with its International Health Board established in 1913.9 The World Health
Organization succeeded both the League of Nations Health Organization
and Rockefeller’s International Health Board after World War II.
Zylberman shows the centrality of cholera and the Mecca pilgrimage in
shaping the earliest international discussions and agreements over infec-
tious disease, and in establishing precedents for European powers’ sanitary
intervention into Ottoman-ruled territories and peoples. Zylberman ana-
lyzes the complicated relations between European powers and the Ottoman
4 Medicine at the Border

Empire, where the latter’s apparent failure to contain disease and to imple-
ment preventive measures was a risk to Europeans. This betrayed it as a
‘weak state’ and animated European public health officials to act. Zylberman
argues that this was ‘pre-emption’ based on the need for (health) security of
Europeans. On the one hand, European powers were increasingly subscrib-
ing to Westphalian principles of non-intervention. On the other, they
were in practice intervening through a range of colonial and occupying
structures, and through a discourse of ‘civilization’ whereby another state’s
incapacity to be ‘civilized’ in a ‘sanitary’ sense was a justification for
intervention.
The nineteenth-century sanitary conventions and the early twentieth-
century organizations are most often discussed as the predecessors of later
twentieth-century world health. But there is another line of development:
colonial medicine and tropical medicine. The study of the ‘diseases of
warm climates’ institutionalized into the discipline of tropical medicine in
the late nineteenth century at sites like the London School of Hygiene and
Tropical Medicine, the Pasteur Institutes in Paris and the French colonies,
and the Johns Hopkins Medical School. As many scholars have shown,
tropical medicine was institutionally, politically and intellectually about
the large and broad project of colonization,10 it was always implicated in
the (medicalized) question of geography and place. Originally concerned
with the health of Europeans and Anglo-Americans ‘elsewhere’, that is, in
colonial situations and in ‘the tropics’, the discipline gradually developed
research and clinical interests in indigenous people, locals, those who were
understood to belong to place by virtue of history, and of race, climate,
geography and constitution.11
This historical scholarship has focused largely on British and French trop-
ical medicine, yet as Alexandra Minna Stern points out, the US history of
tropical medicine and colonial medicine merits further attention.12 Stern
examines here the extraordinary success (at one level) of the US military-
sanitary campaign in Cuba, which in one year reduced yellow fever mor-
bidity to zero. As a result of that success a similar strategy was implemented
in the Panama region, during the building of the Canal between 1904 and
1914. Thereafter, the Rockefeller Foundation assumed real interest in and
much control over disease eradication programs across Latin America. The
connections in this story between commerce, international relations, US
military colonialism, and a philanthropic public health were tight indeed.
Stern shows at once an important US axis on which colonial medicine
turned, a clear argument for the racial systems which underpinned and
were perpetuated by these health campaigns, and a specific example of how
tropical medicine was one of the roots of international health.
The history of world health cannot be understood as anything but
merged formations of colonial, national, and ‘world’ politics, played out on
specific local ground. Stern’s case study shows how these public health
 Alison Bashford 5

campaigns were often simultaneously about the nation (US security and
commerce) about colonization and colonized people and places (Cuba,
Panama) and about emerging meanings of ‘international’ (Rockefeller’s
public health interventions across Latin America). Indeed the Rockefeller
Foundation, through its extraordinary level of funding and influence was a
hinging factor between colonial medicine and international health,
shaping, for example, both ‘colonial’ institutions like the London School of
Hygiene and Tropical Medicine and ‘international’ institutions like the
League’s Far Eastern Bureau in Singapore, and indeed the League of Nations
itself.13 Sanjoy Bhattacharya’s study of another eradication campaign, the
famous instance of the eradication of smallpox in India, shows again the
complicated interplay between the local, the national and the interna-
tional. Challenging received stories of the victorious prominence of WHO
personnel, Bhattacharya details the tense and complicated politics and
pragmatics of local implementation and of the Indian government’s invest-
ment in eradication. Rather like Patrick Zylberman’s analysis of the
problem of ‘intervention’ on the part of the European powers into
the Ottoman Empire, the smallpox eradication campaign was one which
constantly encountered tensions between the international body and the
sovereign authority and interests of the nation.
That Stern writes of the Panama Canal and Zylberman of the Suez Canal
suggests that national borders are not the only territorial demarcations at
work in this history of global health and disease control. This is not only
about nations, but also about the formation of geopolitical ‘regions’. These
were often regions of colonial influence, often less formally demarcated
than nations, but not exclusively so: Coker and Ingram’s discussion of
Europe as a contemporary health region is a case in point. Alongside the
development of ‘international’ institutions like the Paris Office or the
League of Nations Health Organization were expressly regional institutions,
such as the Pan American Health Organization as well as the League’s own
Far Eastern Bureau based in Singapore.14
A shifting lexicon is significant here. Brown, Cueto and Fee explore the
changes from ‘world health’ to ‘international health’ to ‘global health’,
focusing on the fortunes of WHO since 1948. Weaving together the politics
and pragmatics of the Organization and its leaders, as well as changing
understandings of ‘health’ from, for example, disease eradication to primary
health care, they show the use of the discourse of ‘global’ for a renewal of
WHO as an organization. Brown, Cueto and Fee’s chapter contributes to
what is currently a fairly thin historical scholarship on WHO, in contrast to
the rich historical work on the League’s organizations, and on the
International Health Board.15 Their work opens up further questions about
‘the international’ to be historically (and geographically) scrutinized. For
example, at the beginning of the twentieth century, ‘international’ often
signified Europe: the so-called ‘international’ health organizations (at least
6 Medicine at the Border

the early examples like the Paris Office and the League of Nations Health
Organization) were at core, in orientation, and in interest, regional Euro-
pean organizations. This is not to diminish their significance, and certainly
not suggested in ignorance of ventures like the Far Eastern Bureau, the
influence of non-European personnel, and the intermittent inclusion of the
Americas. Rather it is to suggest that the primary drive of the Health
Organization, like the League of Nations itself, was the reorganization of
Europe, and both internal and external European security (including colo-
nial possessions and mandated territories). The point is that European-based
organizations and meetings in this period could apply the label ‘interna-
tional’ in a sustained way, whereas American regional efforts were geograph-
ically marked as ‘Pan American’. It is salient that, as Brown, Cueto and Fee
show, the 1902 International Sanitary Office of the American Republics
became after World War I the Pan American Sanitary Bureau and then the
Pan American Health Organization. Likewise, Pacific-rim organizations
were marked geographically as ‘Pan Pacific’ (for example the Pan Pacific
Science Congresses). There is an opportunity here to apply historian Dipesh
Chakrabarty’s call to ‘provincialize Europe’ in our discussion of European
‘international’ health organizations, and to think about the history of
regionalization, as well as colonialism and nationalism, in the development
of a twentieth-century global health.16
If ‘international’ at the beginning of the twentieth century stood broadly
for ‘Europe’, by the decades of decolonization after World War II, ‘interna-
tional’ in the domain of health came to mean the health of ‘developing’
countries: largely infectious disease prevention and eradication programs in
the so-called third world.17 In a strange turn, it was at this point that ‘inter-
national’ health fully inherited tropical and colonial medicine; or to put it
another way, tropical medicine itself was decolonized. And yet numerous
scholars – not least Weir and Mykhalovskiy in their chapter on geopolitics
and public health surveillance – argue that later twentieth-century world
health administration has inherited this history of health and colonization,
and retains a strongly neo-colonial character. Obijifor Aginam suggests that
this colonial inheritance has created a world health culture oscillating
between ‘global neighbourhood’ and ‘universal otherhood’.18

National security: territory, migration and border regulation

The geopolitics of disease prevention has often operated through, and

linked, nationalism and the policing of sovereign territory. From the early
nineteenth century both maritime and land borders became closely regu-
lated places for the inspection of the goods of commercial exchange, as
well as vessels and animals. This is why, in many modernizing bureaucra-
cies, quarantine officials were typically located within the broader govern-
ment office and power of ‘customs’. But nineteenth-century quarantine law
 Alison Bashford 7

typically governed the movement and traffic of goods, animals and

humans. With the emergence of European nation-states and their colonial
extensions over the nineteenth century, and with increasingly bureaucra-
tized administrative government, disease was checked by border inspec-
tions of people – their bodies, their identity and their documents. The
documents of health, of being disease-free (or more likely coming from a
disease-free town or region) existed as a system prior to the widespread use
of identity documents (the passport or the visa, for example). Thus one of
the factors which made jurisdictional (increasingly meaning national)
borders meaningful was the checking of health documentation and of
people’s bodies for signs of infectious disease, and indeed, for signs of
disease prophylaxis – vaccination. These procedures made borders more
than abstract lines on maps, but a set of practices on the ground.
On a world basis (but, as we shall see with some most interesting ex-
ceptions), immigration law and public health law became connected in
the late nineteenth and early twentieth centuries. This was a regulatory
response to the phenomenon of mass movement, of circulating diasporic
labor, of migrants, pilgrims, and refugees. A considerable body of scholar-
ship details the health clauses – the ‘loathsome disease’ clauses as they were
often called – in immigration law of various jurisdictions.19 In Europe,
cholera and the Mecca pilgrimage constituted the ‘eastern question’ as a
‘health question’.20 In the US, Russian-Jewish migration embedded quaran-
tine screening in entry procedures,21 while on the west coast and elsewhere
in the nineteenth-century Pacific, Chinese indentured laborers and gold-
seekers were singled out for regulation. Chinese Exclusion Acts emerged
from the 1880s onwards, cementing ideas about, and joint regulation of,
race, disease, territory and nationalism. Ironically, in the 1950s and 60s,
decolonizing nations throughout South East Asia borrowed migration law
from the ‘colonial-settler’ nations, and wrote similar health clauses into
their new national statutes.22 Through the implementation of these powers,
national populations were literally shaped, territories were marked, and
inclusions and exclusions on all kinds of bodily criteria were implemented.
But policing national territory was rarely about complete exclusion,
historically or currently. Rather, in both quarantine and immigration
domains, it was usually about monitoring entry and selectively including.
Recently historians have shown the close connections between border
screening processes and precarious inclusion into territory and civic iden-
tity: a rich historiography of health and citizenship is emerging. Both
Fairchild and Shah have demonstrated this on either side of the US conti-
nent. Decades of migrant health screening at Ellis Island, New York, did
not rest on any sort of legitimate microbiological or epidemiological ratio-
nale, Fairchild argues. Rather, it performed a more complex function of
initiation into an industrial culture.23 On the west coast, Shah has shown
how initial exclusion of Chinese in the late nineteenth century, became a
8 Medicine at the Border

provisional incorporation of Chinese communities into the US civic body

by the 1920s and 30s, but one dependent on ‘standardizing Chinese
conduct and living spaces according to American hygienic norms’.24
In this book, several extensions to this scholarship are offered, as well as
new case studies which detail interesting exceptions to the ‘exclusion’
model. In a study of health screening in the United Kingdom and
Australia, Convery, Welshman and Bashford compare the quintessential
instance of national medico-legal border control (Australia) and, as it turns
out, one of the most exceptional instances (the UK). Elsewhere, Bashford
has elaborated the deep significance of quarantine and health clauses of
immigration restriction acts to the demarcation and defense of Australian
territory (as an island-continent), to Australian nationalism and spec-
ifically to the White Australia Policy. These had a very particular manifes-
tation and connection to nationalism in Australia, but, as she has argued,
the conflation of health and immigration border screening with the
element of racial exclusion was ‘rather more ordinary than extraordinary’
for the period (of the early to mid-twentieth century).25 Until recently, the
United Kingdom’s history was starkly different. Certainly in the UK, there
has been a long popular (and sometimes expert) linking of contagion,
race, disease and dreams of exclusion and cultural/racial homogeneity, but
this was not rendered into law and official policy in the way that was so
common elsewhere (not only Australia, but the US, Canada, New Zealand
for example). There has been minimal formal linking of health and immi-
gration powers in the UK. This highlights that in the world history of
‘medicine at the border’, it was the colony-nations of settlement and
importantly the destinations of the Chinese diaspora in the nineteenth
century which created the legacies of joint health and immigration law
and regulation. This history of UK ‘exceptionalism’ is an interesting rever-
sal of the more usual center-periphery dynamic of colonial/imperial
history. But as these authors show, and as Coker and Ingram demonstrate
in their chapter on more recent developments, the future may look very
different indeed. In the last few years, the UK government and opposition
have sought to bring the UK ‘into line’ as it were: they are flagging for
implementation what is known as ‘the Australian model’ of rigid pre-entry
screening for various infectious diseases.
A different exception to the dominant history of the exclusionary capacity
of border screening and territorial nationalism, is the case of France. In an
important study, Miriam Ticktin details a counter discourse to exclusion in
the French political and philosophical tradition of universalism and human-
itarianism, expressed in the history of ‘medical humanitarianism’. She
details the history of Médecins Sans Frontières (MSF) within this tradition,
and the reach of the idea of medical humanitarianism (as well as MSF per-
sonnel) into French government and law. Partly because of the character of
French colonialism which incorporated colonial land and people into
 Alison Bashford 9

France itself, and partly because of the philosophy and idea of ‘the univer-
sal’ (and therefore the diminution of territorial, sovereign or civic human
difference), the French government recognizes the right of sick people to
make a claim to be treated within France. If other national histories are
dominated by the idea that illness, defect, and disease render people ineli-
gible for, or unlikely to receive, entry, in France the reverse is the case. And
if in so many other contexts historically, a ‘public charge’ argument has
been written into immigration law (that is, if the person is likely to become
a cost to the community through health and welfare dependence they may
be refused entry or deported) the French case certainly represents the reverse
principle. But as Ticktin shows, there is a subsidiary history of colonial rela-
tions also at work in French medical humanitarianism. Rather like Shah’s
precariously included Chinese-US citizens,26 people residing in France on
grounds of their illness must remain ill, in order to literally stay: despite a
rhetoric of universalism, they must remain in a position of dependency in,
and on, the French state, never quite equal, never quite citizens.
While Convery, Welshman and Bashford compare the Australian and
UK systems of health screening, it is also worth thinking about the
French and British instances comparatively. In the French case, there is
legal principle for positive action: the law provides for entry on the
grounds of illness, on the principle of universal medical humanitarian-
ism. In the UK, there is no such pro-active law or regulation, but much
the same thing happens in practice. That is (at least for the moment)
people diagnosed with, for instance, tuberculosis on entry are not
excluded and made to undertake treatment in their country of origin at
their own cost (as in the Australian case), but may indeed enter the UK,
and will be followed up at their local destination, by their local health
service. What adds a further layer to these histories of illness, exclusion
and inclusion is the current phenomenon of so-called ‘health tourism’,
wherein some nations are more open than others, to this particular kind
of border crossing: certain kinds of (monied) sick people are temporarily
admitted. Indeed scholarship on the current phenomenon, which is eco-
nomic in nature, and turns on complicated and not necessarily one-way
axes of North-South, East-West, could profit from being historicized in
terms of nineteenth-century colonial ‘health tourism’.27
Canada, like Australia, has strict screening policies and shares a not
dissimilar history of conflated health and race exclusions, although one far
less well known internationally. And yet both Canadian provincial and
federal law imposed versions of immigration restriction acts that incorpo-
rated various kinds of health criteria, which were race-based in implemen-
tation and intention. Here, Renisa Mawani looks at a recent turn in this
link between territorial policing and medical policing in Canada – the 2002
Immigration and Refugee Protection Act and the (new) provision for the
mandatory HIV testing of all immigrants. These measures, she argues, while
10 Medicine at the Border

determinedly race neutral, are nonetheless often race specific in effect.

Border security, she shows, is problematically coming to be promoted as a
primary preventive health measure, as if it were comparable to domestic
distribution of health resources and preventive education campaigns.
Epidemiologist Richard Coker has argued against the efficacy of border
screening for disease prevention and management.28 Here, with geographer
Alan Ingram, he explores disease and migration regulation in the European
Union and in the UK. In a field which often prioritizes the spread of acute
disease, in particular SARS and imminent bird flu, Coker and Ingram insist
on the need to keep scholarly watch on the politics of management of
chronic infectious diseases – HIV/AIDS, tuberculosis and malaria. Like
Mawani, Coker and Ingram draw attention to dubious (in public health
terms) distinctions drawn between medical humanitarianism as part of
foreign policy and the avoidance of medical humanitarianism as part of
domestic health policy. The former is politically expedient ‘good’ aid, while
the latter is politically inexpedient health funding of ‘foreigners’ as asylum
claimants or as intending migrants. There is, then, a strange disjunction
between promoting health aid elsewhere and the increasing refusal to treat
(for free) those people when they are in the UK. This is part of the long
history of the geopolitics of disease management, about people being
considered properly in their place, or improperly out of place.

Globalization: deterritorialized health?

Chapters in Part III of this book place these histories of global geographies of
disease and disease management, of borders, nationalism, and international-
ism, in the present. This section deals directly with new formations of secu-
rity, international relations and public health, which are nonetheless
derivative of this history. By the 1990s, as Brown, Cueto and Fee show, the
nomenclature of ‘global’ health began reliably to replace ‘international’
health in the context of ‘new and re-emerging diseases’ and of economic
globalization. This usage of ‘global’ has intensified after the experience of
SARS, anthrax bioterrorism, and threats of avian flu. In other words, micro-
bial threats became ‘global’ when they have impacted, actually or potentially,
on the ‘first world’, and in particular on the US.
Scholarship on globalization typically draws a distinction between ‘inter-
national’ (where the administrative and legal unit of the nation is always
present) and ‘supranational’, ‘transnational’ or ‘global’ (where organiza-
tions or systems do not rely on or refer to the nation as a basic defining
unit). Globalization is, by one definition: ‘the acceleration and intensifica-
tion of mechanisms, processes, and activities that are allegedly promoting
interdependence and perhaps, ultimately, global political and economic
integration’.29 Global economic forces, it is argued, undermine the inde-
pendent capacities of the sovereign nation-state, and the territorial basis of
 Alison Bashford 11

the Westphalian system is threatened because ‘social space is no longer

mapped in terms of territorial places, territorial distances and territorial
borders’.30 Instant communication, daily global mass movement, financial
cyber-transactions that are ‘placeless’, have, over the last decade created a
radically new world that is ‘supraterritorial’ or, as is often claimed, ‘deterri-
torialized’. Other commentators and scholars understand ‘globalization’ as
economic and cultural ‘westernization’.
Globalization, disease and its management are related in several ways.
First, the transborder nature of microbes and disease, has been, without
question, augmented with the frequency of travel. Second, there has been
considerable use of supranational, fully global technologies and networks
to track disease outbreak, as Weir and Mykhalovskiy discuss. Third, the
deep investment in the ‘development’ idea of international health and
world health, whereby the third world is developed in line with first world
sanitary and health conditions as a way to secure disease-free regions, rep-
resents the ‘westernization’ dimension of globalization, for all its benefits
in terms of morbidity and mortality. This latter aspect recalls, of course,
Zylberman’s argument on civilization and sanitary pre-emption.
For these reasons and more, historians of public health need to further
enter scholarly discussion on globalization. They need to complete the
third side of a scholarly triangle. On one side, there is a considerable litera-
ture on globalization, disease and health in the contemporary world.31 On
a second, there is increasing scholarly interest in thinking about globaliza-
tion historically, a recent extension of both imperial historiography and
world historiography.32 But the connecting side of the triangle is under-
developed: the historical study of disease and its management as part of the
historical process of globalization. Again, while there is some historical
discussion which picks up the idea of globalization and disease (especially
in world historiography)33 there is less on the idea of supranational disease
management, ‘supranational’ public health, as it were.34 The histories of
‘international hygiene’, ‘international health’, and ‘world health’ are cer-
tainly an aspect of a strictly international history (that is a history of inter-
national relations and ‘internationalism’),35 but they are also important
sites to examine the emergence of ideas about the ‘world’ in world health,
or ‘the globe’ in globalization.36
Globalization scholars often insist on the diminution of geography and
territorial borders, but most authors in this collection argue for their
ongoing significance. On the one hand, we learn from chapters in Part II of
the long legacy of national border control for public health which the
twenty-first century inherits. And we also see that, if anything, this histor-
ical legacy of territorial medico-legal border control is recently consolidat-
ing. On the other hand, however, the last two decades have indeed offered
‘deterritorialized’ methods of surveillance, methods not based on national
territorial security, or on the (literal) ground of border surveillance. Weir
12 Medicine at the Border

and Mykhalovskiy study closely GPHIN, the Global Public Health

Intelligence Network. Radically shifting from the ‘world health’ tradition
and history of sharing nationally-secured epidemiological information,
GPHIN has used global news/information/internet sources to pick up the
possibility of disease outbreak: it deploys the supranational ‘network’ of the
internet, rather than the geographical line of governmental border surveil-
lance. But Weir and Mykhalovskiy conclude (as indeed did GPHIN person-
nel) that this information gained supranationally, was then ineffectual
unless it could be verified by an authorized international body, the WHO.
Originally bypassing the nation-state, and the conventional international
order, GPHIN found that it could not do so altogether.
World health has been centrally about information flow and exchange,
from its origins in the nineteenth-century sanitary conferences and in the
knowledge-machines of imperial infrastructure. ‘Epidemiological intelli-
gence’ as it was often called was, in many ways, the first imperative of the
various early international organizations for health and for the prevention
of infectious disease. Yet media and communication exchange is not only
about the sharing of epidemiological knowledge between experts, but also
the proffering of advice from experts to ‘the people’ about how a disease
should be prevented or minimized.
Two chapters on SARS highlight the persistence of the national and local
in a supposedly globalizing world, and the significance of perceptions of
security and safety, risk and danger, generated by strategic and sometimes
accidental coalitions of national and international agencies, local and global
media. In a sharp cultural study of SARS in Toronto, Strange explores the
intense public relations/international relations efforts to re-package the city
as clean and safe. The representation of Toronto was a deeply commercial
question, in that the city had traded for years on its reputation as both clean
and safe, and found itself momentarily a dangerous place and a ‘pariah
state’, as well as fully ‘exoticized’ in its sudden link with the ‘epicentre’,
China and Hong Kong.37 Strange shows how the historic linking of Chinese
diasporic communities with disease returned to shape the cultural response
to SARS in North America. But this story was not a straightforward repeti-
tion of past Chinese discriminations and exclusions, for Toronto had also
long packaged and traded itself as a multicultural city, an ethnically ‘diverse’
city. And so, as Strange details, the city’s PR managers – professional semi-
oticians – found themselves with an odd and difficult representational
problem. How to manage competing perceptions of safety and risk, the
exotic and the secure, in this moment of intense global surveillance?
While migrants and refugees have historically been the problematized
population in terms of global infectious disease, SARS problematized the
tourist and the business traveler. One of the important facets of the SARS
episode in 2003 was that it crystallized for those few months, and onto the
everyday tourist and traveler, many of the spatial techniques of prevention
 Alison Bashford 13

and surveillance used more diffusely and permanently on migrants and

refugees all over the globe. Claire Hooker details how the fascinating epi-
demic unfolded and offers an analysis of how authorities mobilized both
‘old-fashioned’ public health models (whereby the ‘dangerous’ were iso-
lated in the quarantine tradition), and newer risk-based models (where ‘at
risk’ groups were acted upon). On the one hand, authorities looked to the
past and borrowed clumsily from old coercive quarantine controls. On the
other, these prompted a future-looking ‘preparedness planning’ mentality,
where health risk-minimization measures dovetailed with newly rigid
national security measures. Hooker explores how health professionals have
taken on the ‘new normal’ of constant bio-preparedness. Evident in each of
these chapters is SARS as an epidemic of fear, in which the perception of
security becomes as important as actual security.
The 2003 timing of SARS, as the follow-up to the 2001 attacks on the US
and anthrax and smallpox scares in 2001/02, meant, of course, that terror-
ism, bioterrorism and epidemic disease became conflated. This occurred
both intuitively at popular levels, but also deliberately at expert and insti-
tutional levels, especially but not only in the US. As Fider argues, public
health and ‘homeland’ security are increasingly twinned, as geopolitical
and geo-epidemiological issues. The newly intense bio-preparedness
imperative threatens to dominate public health priorities, both nationally
and globally. Yet the link to ‘terrorism’ of current ‘bioterrorism’, while cer-
tainly intense at the moment, is less novel than is often claimed.38 We
learn from chapters in this book that these concerns are often only appar-
ently new, and are better conceptualized as recent manifestations of pre-
existing clusters of modern concerns to do with territoriality, security and
communicable disease. If European intervention into Ottoman territory to
regulate the Mecca pilgrimage was ‘pre-emption’ as Zylberman argues, it
was also ‘bio-preparedness’. And we see from Stern’s work that programs
for health security have, often enough, squarely involved the military.
Current policy emphasis on ‘homeland’ (that is territorial) security, needs
to be understood as the latest expression of an enduring link between
disease and national defense.

Conclusion

The chapters in this book detail various historically specific but returning
logics and measures through which security from disease has been
sought: programs of movement restriction and quarantine at local,
national and global levels; programs of eradication by disinfection and
vaccination; ‘pre-emptive’ public health action, including the implemen-
tation of primary health; the conflation of migration barriers and health
barriers; surveillance of people and of information flow. Jointly, the chap-
ters both draw and qualify a historical shift from absolute measures (of
14 Medicine at the Border

quarantine) to relative measures (of surveillance), from territory-oriented

policing to network-oriented technologies, from old cordon sanitaires on
sites of commercial exchange to a world where trade barriers double as
lines of hygiene.39 Inescapable is a sense of the intertwining of the
national, the colonial, the international and the global in public health
of the modern period. The national was the colonial, the colonial was
already, the global. These spaces of regulation and movement did not
emerge in a neat sequence, but as overlapping modern social and political
formations. The interconnections between commerce, colonialism (mil-
itary and cultural), national self-interest and a deeply politicized public
health reveal the long past of current organizational, funding and discur-
sive links between aid, development, foreign policy and disease manage-
ment. This is both a historical and a historiographical point, suggesting
the need further to link previously disparate literatures.
‘Nothing can bring back the hygienic shields of colonial boundaries. The
age of globalization is the age of universal contagion’, write Hardt and Negri
in their now famous book Empire.40 Yet these collected chapters suggest a
rather more complicated historical connection between colonialism, hygiene
barriers, globalization and (what is missing in their formula) nationalism. In
fact, we can profitably rearrange these elements. The age of colonization is
better understood as the (first) ‘age of universal contagion’.41 We can see that
nineteenth-century colonial boundaries were minimal compared to the exclu-
sionary and segregative capacity of twentieth-century national boundaries.
And in fact it was lack of regulation, the absence of ‘hygienic shields’ which
most characterized the colonial world flow of people, goods, and disease. It
was rather more the ‘age of nationalism’ which embedded ‘hygienic shields’
into border regulation. Further, the ‘age of globalization’ – the world post-
HIV/AIDS, post-multidrug resistant TB, West Nile Virus and SARS – might be
‘global’ in terms of disease spread, but is also characterized by increasingly
intense regulation at national borders. Medicine at the national border,
indeed, is not really being ‘brought back’, it is spreading and deepening from
places where it never went away. As SARS revealed, and as pandemic influenza
may, medico-legal border control both haunts and challenges the trend
towards transnational globalization.

Notes
1 M. Hardt and A. Negri, Empire (Cambridge Mass: Harvard University Press, 2001),
p. 136.
2 H. Bell, Frontiers of Medicine in the Anglo-Egyptian Sudan, 1899–1940 (Oxford:
Clarendon Press, 1999), p. 4.
3 See F. Cooper and R. Packard (eds) International Development and the Social
Sciences: essays on the history and politics of knowledge (Berkeley: University of
California Press, 1997).
4 N. Goodman, International Health Organizations and their Work (New York:
Churchill Livingstone, 1971); N. Howard-Jones, International Public Health
between the two world wars: the organizational problems (Geneva: World Health
 Alison Bashford 15

Organization, 1978); W.F. Bynam, ‘Policing Hearts of Darkness: Aspects of the

International Sanitary Conferences’, History and Philosophy of the Life Sciences, 15
(1993): 421–34; J. Siddiqi, World Health and World Politics: the World Health
Organization and the UN System (Columbus: University of South Carolina Press,
1995); K. Lee, Historical Dictionary of the World Health Organization (London: The
Scarecrow Press, 1998); A.M. Stern and H. Markel, ‘International Efforts to
Control Infectious Diseases, 1851 to the Present’ Journal of the American Medical
Association, 292 (2004): 1474–9.
5 D.P. Fidler, International Law and Infectious Diseases (Oxford: Clarendon Press,
1999).
6 Stern and Markel, ‘International Efforts to Control Infectious Diseases’, 1476.
7 P. Weindling, Epidemics and Genocide in Eastern Europe (Oxford: Oxford
University Press, 2000); I. Löwy and P. Zylberman, ‘Medicine as a Social
Instrument: Rockefeller Foundation, 1913–45’, Studies in the History and
Philosophy of the Biological and Biomedical Sciences, 31 (2000): 365–79.
8 M.D. Dubin, ‘The League of Nations Health Organization’ in P. Weindling
(ed.) International Health Organizations and Movements, 1918–1939 (Cambridge:
Cambridge University Press, 1995) pp. 56–80; L. Wilkinson, ‘Burgeoning
Visions of Global Public Health: The Rockefeller Foundation, The London
School of Hygiene and Tropical Medicine, and the “Hookworm Connection”’,
Studies in the History and Philosophy of Biological and Biomedical Sciences,
31 (2000): 397–407; L. Manderson, ‘Wireless Wars in the Eastern Arena’ in
P. Weindling (ed.) International Health Organizations and Movements
(Cambridge: Cambridge University Press, 1995).
9 J. Farley, To Cast Out Disease: A History of the International Health Division of the
Rockefeller Foundation (New York: Oxford University Press, 2003); J. Gillespie,
‘The Rockefeller Foundation and Colonial Medicine in the Pacific’ in L. Bryder
and D. Dow (ed.) New Countries, Old Medicine (Auckland: Auckland University
Press, 1995); M. Cueto (ed.) The Missionaries of Health (Bloomington: Indiana
University Press, 1994); C.J. Shepherd, ‘Imperial Science: The Rockefeller
Foundation and Agricultural Science in Peru, 1940–1960’, Science as Culture, 14
(2005): 113–37.
10 See for example, M. Worboys, ‘Manson, Ross and colonial medical policy: tropical
medicine in London and Liverpool, 1899–1914’ in R. Macleod and M. Lewis (eds)
Disease, Medicine and Empire: Perspectives on Western Medicine and the Experience of
European Expansion (London: Routledge, 1988); A. Marcovich, ‘French colonial
medicine and colonial rule: Algeria and Indochina’ in Macleod and Lewis (eds)
Disease, Medicine and Empire; A.M. Moulin, ‘Tropical without the Tropics: The
Turning-Point of Pastorian Medicine in North Africa’ in D. Arnold (ed.), Warm
Climates and Western Medicine (Amsterdam: Rodopi, 1996), pp. 160–80; A. Bashford,
‘“Is White Australia Possible?” race, colonialism and tropical medicine in the early
twentieth century’, Ethnic and Racial Studies, 23 (2000): 112–35; D.M. Haynes,
Imperial Medicine: Patrick Manson and the Conquest of Tropical Disease (Philadelphia:
University of Pennsylvania Press, 2001).
11 See M. Harrison, Climates and Constitutions (Oxford: Oxford University Press,
1999); W. Anderson, Cultivation of Whiteness: Science, Health and Racial Destiny in
Australia (Melbourne: Melbourne University Press, 2002).
12 But see D. Armus (ed.) Disease and the History of Modern Latin America: from Malaria
to AIDS (Durham and London: Duke University Press, 2003); W. Anderson,
‘“Where every prospect pleases and only man is vile”: laboratory medicine as colo-
nial discourse’ in V. Rafael (ed.) Discrepant Histories: Translocal Essays on Filipino
Cultures (Philadelphia: Temple University Press, 1995).
16 Medicine at the Border

13 For the former, see R. Acheson and P. Poole, ‘The London School of Hygiene and
Tropical Medicine: A child of many parents’, Medical History, 35 (1991): 385–408;
D. Fisher, ‘Rockefeller Philanthropy and the British Empire: The Creation of the
London School of Hygiene and Tropical Medicine’, History of Education, 7 (1978):
129–43.
14 Manderson, ‘Wireless Wars in the Eastern Arena’.
15 But see see Stern and Markel, ‘International Efforts’; R. Hankins, ‘The World
Health Organization and Immunology Research and Training, 1961–1974’,
Medical History, 45 (2001): 243–66.
16 D. Chakrabarty, Provincialising Europe: postcolonial thought and historical difference
(Princeton: Princeton University Press, 2000).
17 See S. Amrith, A New Utopia: International Health and the End of Empire in Asia
(London: Palgrave, 2006).
18 U. Baxi, ‘Global Neighbourhood and Universal Otherhood’ cited in O. Aginam,
‘The Nineteenth-century Colonial Fingerprints on Public Health Diplomacy: A
Postcolonial View’, Law, Social Justice and Global Development Journal, 1 (2003);
See also N.B. King ‘Security, Disease, Commerce: Ideologies of Post-Colonial
Global Health’ Social Studies of Sciences, 32 (2002): 763–89; N.B. King, ‘The Scale
Politics of Emerging Diseases’, Osiris, 19 (2004): 62–76.
19 N. Shah, Contagious Divides: Epidemics and Race in San Francisco’s Chinatown
(Berkeley: University of California Press, 2001); A.L. Fairchild, Science at the
Borders: Immigrant Medical Inspection and the Shaping of the Modern Industrial Labor
Force (Baltimore: Johns Hopkins University Press, 2003); A. Bashford, Imperial
Hygiene: a critical history of colonialism, nationalism and public health (London:
Palgrave, 2004), ch. 6.
20 See P. Zylberman in this volume; M. Harrison, ‘Cholera theory and sanitary
policy’ in his Public Health in British India: Anglo-Indian Preventive Medicine,
1859–1914 (Cambridge: Cambridge University Press, 1994).
21 H. Markel, ‘“Knocking out the Cholera”: Cholera, Class and Quarantines in New
York City, 1892’, Bulletin of the History of Medicine, 69 (1995): 420–57.
22 Andreas Schloenharrdt details these Acts, but does not make this point in,
‘Exclusion of Infected Persons under Immigration Laws in Asia’. Paper presented
to the Infectious Diseases and Human Flows in Asia workshop, University of
Hong Kong, June 2005.
23 Fairchild, Science at the Borders, passim.
24 Shah, Contagious Divides, p. 204.
25 Bashford, Imperial Hygiene.
26 Shah, Contagious Divides.
27 For the latter, see for example, H. Deacon, ‘The Politics of Medical Topography:
seeking healthiness at the Cape during the nineteenth century’ in R. Wrigley
and G. Revill (eds) Pathologies of Travel (Amsterdam: Rodopi, 2000) pp. 279–98;
L. Bryder, ‘“A Health Resort for Consumptives”: Tuberculosis and Immigration
to New Zealand, 1880–1914’, Medical History, 40 (1996): 453–71.
28 R. Coker, ‘Compulsory screening of immigrants for tuberculosis and HIV: is not
based on adequate evidence, and has practical and ethical problems’, British
Medical Journal, 328 (2004): 298–300; R. Coker, Migration, public health and com-
pulsory screening for TB and HIV (London: Institute for Public Policy Research,
2003).
29 M. Griffiths and T. O’Callaghan, International Relations: the key concepts (London:
Routledge, 2002), pp. 126–7.
 Alison Bashford 17

30 J.A. Scholte, Globalization (London: Palgrave, 2000), p. 16.

31 For example, K. Lee, K. Buse, S. Fustukian (eds) Health Policy in a Globalising World
(Cambridge: Cambridge University Press, 2002); G. Berlinguer, ‘Globalization
and Global Health’, International Journal of Health Services, 29 (1999): 579–95;
M.E. Wilson, ‘Travel and the Emergence of Infectious Diseases’, Emerging Infectious
Diseases, 1 (1995).
32 A.G. Hopkins, ‘The History of Globalization – and the Globalization of History?’
in Hopkins (ed.) Globalization in World History, Pimlico, 2002, pp. 11–46;
M. Geyer and C. Bright, ‘World History in a Global Age’, American Historical
Review, 100 (1994): 1034–60; B. Mazlich, ‘Comparing Global History to World
History’, Journal of Interdisciplinary History, 28 (1998): 385–95.
33 Le Roy Ladurie, ‘The Unification of the Globe by Disease’ in The Mind and
Method of the Historian (Chicago: University of Chicago Press, 1981); I. Catanach,
‘The “Globalization” of Disease? India and the Plague’, Journal of World History,
12 (2001): 131–53; S. Watts, Disease and Medicine in World History (London and
New York: Routledge, 2003); D. Igler, ‘Diseased Goods: Global Exchanges in the
Eastern Pacific Basin, 1770–1850’ American Historical Review, 109 (2004);
D. Arnold, ‘The Indian Ocean as a Disease Zone, 1500–1950’, South Asia, 14
(1991): 1–21.
34 But see R. Packard, P. Brown, H. Frumkin, R.K. Berkelman (eds) Emerging Illnesses:
Negotiating the public health agenda (Baltimore: Johns Hopkins University Press,
2004); K. Loughlin and V. Berridge, Global Health Governance: Historical
Dimensions of Global Governance (London: London School of Hygiene & Tropical
Medicine and World Health Organization, 2002).
35 See P. Finney (ed.), International History (London: Palgrave, 2005). The absence of
any discussion of international health organizations in this collection character-
izes the current lack of integration of these fields.
36 This idea is developed in A. Bashford, ‘Global biopolitics and the history of
world health’, History of the Human Sciences, 19 (2006): 67–88.
37 C. Loh and Civic Exchange (eds) At the Epicentre: Hong Kong and the SARS
Outbreak (Hong Kong: Hong Kong University Press, 2004).
38 See for example, E. Fee and T.M. Brown, ‘Pre-emptive Biopreparedness:
Can We Learn Anything from History?’, American Journal of Public Health,
91 (2001): 721–5; N. Yand and X. Wang, ‘Disease Prevention, Social Mobil-
ization and Spatial Politics: the Anti-Germ-Warfare Incident of 1952 and the
“Patriotic Health Campaign”’, Chinese Historical Review, 11 (2004): 155–82;
R. Rogaski, ‘Nature, Annihilation and Modernity: China’s Korean War
German-Warfare Experience Reconsidered’, Journal of Asian Studies, 61 (2002):
381–415; B. Balmer, Britain and Biological Warfare: Expert Advice and Science
Policy, 1930–1965 (London: Macmillan, 2001); S.H. Harris, Factories of Death:
Japanese Biological Warfare, 1932–45 and the American Cover-up (New York:
Routledge, 2002).
39 Thanks to Claire Hooker for discussion on these ideas.
40 Hardt and Negri, Empire, p. 136.
41 For example, A. Crosby, Ecological Imperialism: the biological expansion of Europe,
900–1900 (Cambridge: Cambridge University Press, 2004); K.F. Kiple and
S.V. Beck (eds) Biological Consequences of the European expansion, 1450–1800
(Ashgate, 1997); G.W. Lovell, ‘“The Heavy Shadows and Black Night”: Disease
and Depopulation in Colonial Spanish America’, Annals of the Association of
American Geographers, 82 (1992): 426–43.