MEDICAL MISSIONARIES AND THE EXPANSION OF THE COLONIAL STATE

Missions were laying the groundwork in the 1930s for what would become a huge part of Ghanaian health infrastructure and a network of health practitioners, clinics, and dispensaries that was necessary for international health campaigns to be possible from the 1950s onwards. In conceptual terms and in logistical ones, this period was critical for setting in motion international health policies in the twentieth century. It is in these battles for local and national supremacy that global health acquired the conditions in which it could function. Though the role of the Scottish Presbyterians declined after 1927 and the government’s relationship with missions became more diffuse, the close connection between development and religion in the Gold Coast remained significant. Much like networks of colonial science that informed international health, networks of colonial medical mission were influential for what would later emerge in global health.

In the 1920s mission and colonial efforts at development had led to the growth of maternal and child health care in the Gold Coast. Child welfare work was begun by the Scottish mission in January 1921 by Dr Jessie Beveridge, who, according to government reports, ‘opened a clinic and dispensary for the treatment of minor ailments of school children and infants at Christiansborg, Accra’. It was a roaring success and quickly led to the government ‘supplying drugs and paying the salary of an interpreter’. Amidst a death rate of 400 per 1,000 births in some areas, the clinic was seen as an oasis by the government, and between 1923 and 1924 the government extended its own efforts by setting up temporary infant welfare centres in Christiansborg and James Town under Dr Mary Magill and other female medical officers. By 1926 the government built the Princess Mary Louise Hospital for children, with a woman European medical officer, ‘African subordinate staff’, and two nurse midwives. In addition, a dispensary was set up to carry on Beveridge’s work and the medical officer was posted to Sekondi to begin a welfare centre and weekly clinic in Chama. In the first eight months of the 1926 financial year, the Princess Mary Louise Hospital had 8,444 attendances, the clinic at Christiansborg had 2,987, and the centre at Sekondi had 4,964.²

In public health too, when efforts extended beyond Accra, particularly into rural areas, missionaries were crucial.³ This was the case in maternal and child health, and the dissemination of hygiene messages particularly. For example, in the eastern Gold Coast, the British Togoland Report of 1924 to the League of Nations wrote that ‘the presence of a qualified woman doctor on the staff of the mission, concentrating on Infant Welfare, has been a benefit to some outlying districts beyond the regular scope of Government Medical Officers. In her dispensary at Amedjope, and at many villages on tour she has, by individual treatment and general instruction, and by the circulation of appropriate literature among the more intelligent people, secured the confidence of the community, and she is now endeavouring to bring about a necessary improvement in the health conditions of mothers and children and to check the heavy infant mortality’.⁴

Mission contacts could also be vital in sanitation and vaccination campaigns.⁵ In A.W. Wilkie’s diary he consistently notes his own inspection of sanitation and standards across the mission schools across the Gold Coast, and details the outbreak of yellow fever in August 1926. Although, as A.G. Fraser wrote, the separation of the government medical and education department meant that schools were under-utilised in their capacity to help hookworm campaigns and antenatal care, Wilkie shows how in the 1920s they were used as sites for vaccinations.⁶ Where missionary education was more sporadic, for example in the Northern Territories, the colonial government had far less information or capacity to extend. Wilkie describes the significance of travelling medical missionaries such as Helen Russell, surveying a range of outposts and clinics.⁷ Beyond maternal and child health work, missionary networks both medically trained or otherwise were critical for the state to be able to extend their health work into new areas.

Missionaries became such a key feature of Gold Coast colonial health that there were (unsuccessful) attempts by Guggisberg to hand over the entire maternal and child health-care system to the Presbyterians. Simultaneously with large expansions in colonial infant welfare work, in April 1926, government officials met with a Presbyterian committee ‘to consider the taking over by the Missions of the Welfare work in the large centres in the Gold Coast’ and ‘the transfer of all welfare work including the existing work in Accra and Sekondi’ to the missions. The conclusions were in favour of considerable cooperation:

It was the opinion of the Director of Medical and Sanitary Services of that period that such work could only be successful if carried out by the Missionary Societies … the success and development of the work can only be guaranteed if the original suggestion is adopted of asking the Missions to become responsible for all welfare work for women and children. The object of the Government is not primarily to secure economy but success … The recommendations were approved generally by the Governor who name the Scottish Mission as the Mission to be asked to initiate the scheme … A letter from the Colonial Secretary, of 14th April, was read conveying the thanks of the Governor to the members of the Committee and noting with pleasure the willingness of Mr Wilkie to refer the matter to headquarters; also asking, in the event of the Secretary of State approving the transfer, if the Scottish Mission is prepared to take over the present work at Sekondi, and to advise, in consultation with the Director of Medical and Sanitary Services, as to priority of further building at Sekondi or Akwapim … Council records its sense of the high honour conferred on the Mission by the request to undertake this responsible work for women and children.⁸

What came of these committee meetings and experiments has not been recorded. However, the Presbyterian Mission did not fully gain the monopoly over maternal and child health that Guggisberg seems to have been planning for it in 1926. When Guggisberg handed over to Slater who became governor in 1927, the stage was set for the expansion of maternal and child health in mission work – but from a wider set of practitioners. Not only did new governors and the lifting of the papal ban in the following five to ten years draw Roman Catholics in, they allowed back the Bremen and Basel missionaries, and they facilitated the emergence of the International Committee of the Red Cross as one of the top three largest actors in Gold Coast infant welfare, alongside government and mission.

At the same time as he was empowering the Presbyterian missions, Guggisberg had been restricting Catholic missions until convinced of their loyalty. Up to 1926 there was struggle and negotiation between Guggisberg and the Presbyterians on one side, and the Catholic missions on the other. In 1906 a White Fathers Catholic mission post in the Northern Territories of the Gold Coast had been founded by the ‘Vicarde Apostolique du Soudan’ (later Ouagadougou) but had since not developed independently.⁹ Tension grew in 1924 when the Gold Coast government decided to set up schools in the North with Protestant missions, which Leonide Barsalou noted would have been harmful to the already financially struggling Catholic mission. In order to stop this ‘invasion protestante’ the White Fathers attempted to expand their schools and missions in spite of a lack of finances and personnel. Immediately they encountered opposition from the government, who, according to Barsalou, were concerned that French missionaries might be spies in the service of the neighboring colony. Thus, the White Fathers appealed to Rome to separate them from the Haute Volta diocese and create an autonomous mission at Navrongo. The Gold Coast government responded immediately to this, offering to send £100 in a grant when it had been completed. In June 1927 the White Fathers Catholic mission became the ‘Prefecture Apostolique de Navrongo’. After this there were few conflicts with the government, who were described by the Catholics as assuring their liberty of conscience.¹⁰ It was only in non-religious training that the governor demanded ‘final control’. By 1930 the mission had expanded and put a medical dispensary in every mission station, which gave government employees free treatment. The Catholic mission had also been able to set up a special leprosy centre at Navrongo. Nevertheless, the Presbyterians still had power over the French missions. A.G. Fraser was deployed to inspect the Catholic mission schools – though he was very positive about the progress that was being made.¹¹

Yet there were limits to the power of the Presbyterians before 1927, too – actual experiences, effects, and interpretations of religious visions for development were varied and cut in directions that its architects could not always control. The upheaval of the government expulsion of the Basel Mission and its replacement with the Scottish caused considerable protest from African Christians in the colony. For example, the Scottish Presbyterians may have seamlessly replaced the Basel Mission in the eyes of the colonial government, but indigenous Abokabi Christians were far less amenable to such a sudden change enacted by the state, especially as it resulted from diplomatic issues external to the colony. Many towns and congregations of African Christians desperately wanted the Basel missionaries to return, as can be seen in several articles and letters in the African-run newspaper the Gold Coast Independent in the early 1920s. The Scottish were regularly denounced. In one article subtitled ‘The Essence of the Basel Mission Spirit and the Failure of the Scottish Mission Bluff’, the writer attacked the newcomers’ superficiality: ‘Whatever you do, you cannot vie with the Originators. In theirs, was no superficiality. And, most unfortunately, this keynote happens to underrun the whole system. Upwards of four years tutelage has failed to scottishfy our well seasoned mentality. If we keep intact our wind and limb, it is the Basel Mission Spirit that still sustains us; but what, when says its last as it surely must?’¹²

Another article suggested that ten thousand full communicants had ‘evinced great interest in the return of the Basel Missionaries’. While a later piece denounced any statistical claims without evidence and a letter from the congregation in Akropong defended the ‘rescue’ of the mission by the Scottish, there was a considerable amount of bitterness at the forced departure of the Basel missionaries.¹³ Furthermore, while missions often aimed to reformulate domestic structures and produce paragons of Christian motherhood through hygiene practices and the rituals of child and maternal health, these efforts were contested and challenged. Missions could not always structure their encounters or the way they were interpreted by local communities.¹⁴

In practice, amidst local tensions, missionaries often prioritised their own survival over reforming communities. In some instances, the simplifying categories that missionaries used to classify the non-Christian world were put aside in the lived experience of intimacy and exchange in the cultural encounters of the mission field.¹⁵ For example, in 1926 in the Scottish medical and educational mission at Abokabi on the Southern Gold Coast, Wilkie wrote in his diary of how the missionaries had to rely on help from the chief to force local African Christians into providing labour for sanitary improvements to the school, otherwise the mission would be ‘lost’. Negotiation with and reliance on traditional authority was sanitised in Guggisberg and Fraser’s heroic development narratives, but adaptability and shrewdness were vital to the survival of a mission. Wilkie’s diary shows that in practice missionaries prioritised their own long-term survival by negotiating with local traditional authorities, even if that meant using the power of the chieftaincy to bully local African Christians.¹⁶ Robert Rothberg has emphasised how Ugandan missions were reliant on chiefs in their early and fledgling stages in the nineteenth century, but even missions such as that of Abokabi, which had been running since 1854 under the Basel Mission, could be vulnerable to local community power.¹⁷

Though they remained influential, the close Scottish Presbyterian relations with the government began to decline after Guggisberg left in 1927. An ecumenical organisation, the Christian Council of the Gold Coast (ccgc), was formed in 1929 following the 1926 Le Zoute conference.¹⁸ The first joint secretary of the ccgc from 1929–31 was the Scottish Presbyterian mission leader – Wilkie. However, in the 1930s, the number of actors and groups in Gold Coast health care expanded and grew, especially empowering Catholic missions, the Basel Mission (for a short time), the Red Cross, and the Bremen mission. In the 1930s Catholic medical mission was being widely financed by the government and Sisters were empowered by the papacy to acquire formal medical training. Already there was a dispensary being set up at Kpandu in 1926 and extended to Djodje under the Sisters of Mercy.¹⁹ By 1934 grants were being given to Catholic medical missions at Kpandu, Oeikwe, Akim Swedru, Asankrangwa, and Djodji in the central, western, and eastern provinces of the colony.²⁰ In 1934 the mission in Djodje saw 6,560 children attend, in Eikwe it was 22,143, and in Kpandu it was 20,710.²¹ In 1931, the Basel Mission, restored to the Gold Coast from 1926, opened a hospital at Agogo near Kumasi – though in 1940 this was closed and the staff detained. The Basel Mission’s attempts to set up at Mampong and Juaso were blocked by the Scottish mission and the government, much to the chagrin of Agogo’s doctors.²² By the 1940s the Red Cross had gone from being a minor player to one of the largest actor in maternal and child health centres.²³

Along with government officers, the Red Cross dealt with 22,789 attendances in Accra and 19,702 in Kumasi. Moreover, a Red Cross Sister was in charge of the Kumasi weighing centre and domiciliary. Even at this point the government report stated that ‘a wide future would appear to lie before the (Red Cross) Society in the continuation and extension of this valuable side of their field activities’.²⁴ Last was the Bremen mission, which returned to the Gold Coast and set up an infant welfare clinic at Amedzope, where, in 1935, 2,363 children were attending.²⁵ With this work the government approved a scheme for twenty-eight midwives-in-training to have hostel.²⁶

Campaigns against leprosy, increasingly funded by the government, became the focus of possible interdenominational cohesion in the 1930s.²⁷ In the Gold Coast, the government had been interested in leprosy work since the 1910s, and in possibly working with Catholic missionaries in this regard.²⁸ In 1918 there was some consideration by the government’s principal medical officer of training the White Fathers around Navrongo in professional medical work because of their utility in describing the incidence of leprosy cases in the Northern Territories. In 1930, this sort of state support was furthered with Dr Seth-Smith who arrived from Lawra with medical supplies and trained the White Fathers in treating common illnesses.²⁹ As with child and maternal health, by the mid-1930s the government was considering giving missionaries control of all leprosy work, and in the early 1940s the director of Medical Services proposed that it all could be ‘safely entrusted to missionary societies’ – but this did not materialise. Some of the missionary societies would not consider the proposal until after the Second World War, and those that would wanted money that the Colonial Office would not provide. Though the new governor Alan Burns wanted to pay the missions, the secretary of state for the colonies rejected the suggestion, stating that overhaul of the Nigerian system was the priority. It was not until after the war that missionary leprosy work was properly institutionalised as part of a government and international organisational plan with Colonial Welfare and Development Act funding.³⁰

Figure 1.1

‘Kenneth Stacey Morris in the Northern Territories (early 1940s)’.

Overall, government relations by the 1940s were more diffuse across the missions; the close relationship of the Scottish Presbyterian mission and the colonial state had been completely disrupted and major rifts emerged in the 1950s. The Gold Coast colonial state’s relationship with the Scottish Presbyterians had some similarities with contemporaneous relations in Malawi, where, between the 1900s and the 1930s, the Scottish Presbyterians and the state had been closely aligned. According to John McCracken, by the 1920s, with their networks of schools and hospitals, the missions at Blantyre and Livingstonia had been ‘drawn into an intimate, though, at times, strained, relationship with the government’. Building on the work of Karen Fields on the Watchtower movement, McCracken argues that in Central Africa the early colonial state ‘had more than a passing resemblance to medieval European states, with the spiritual and material resources of the Church being used to bolster state authority’. However, by the 1940s and into the 1950s this had broken down, and new rifts had emerged in response to a wider reappraisal of relations with the state by the church. In Blantyre, the Scottish mission even became ‘genuinely self-governing’ by transferring financial responsibility to the synod and distancing themselves from the developmentalism of the colonial state. Instead, the Presbyterians focused on concerns about the spirituality of their parishioners which they feared had been abandoned for the sake of social improvement. Missions, though divided, generally went into open opposition regarding the creation of the Federation of Nyasaland and Rhodesia.³¹ As will be analysed further in the final section of this chapter, in the 1950s in the Gold Coast the Scottish Presbyterians also departed from their close role with the state, in favour of independent, synod-run missions. Often their efforts resulted in far less support from the emerging state voluntary sector than other medical missions received.³²

In the late 1940s and 1950s there was a proliferation of types of denomination that were backed by government and majorly collaborating in medical work, such as the sdas, the Methodists, and the Salvation Army.³³ A symbolic turning point was in 1948 when the Catholic Medical Mission Sisters built their hospital at Berekum.³⁴ This postwar expansion was related to the huge increase in Colonial Office provision for development which, in the ten years following 1945, provided £120 million (which was then raised to £140 million by the 1950 Colonial Welfare and Development Act).³⁵ The colonial state was beginning to create a new system and infrastructure of liberal, voluntary sector-run health care. While there were variations in how this was expressed, the overall outcome was an attempt to institutionalise a variety of types of medical mission within a system of hospitals, partly financed by the state. These could not necessarily be controlled by colonial officials, and nor could they effectively perceive the full breadth of medical mission, but they were very effective in consolidating a network of mission hospitals that would form the basis of a sustained voluntary sector that has survived even its partial nationalisation in the twenty-first century.

THE POSTWAR VOLUNTARY SECTOR

The emergence of the postwar voluntary sector in colonial Africa was a revolution in statecraft that is still being worked out in many African national contexts. As Ruth J. Prince and Hannah Brown have shown in their wide-ranging work, volunteerism in Africa is key to understanding states’ relationships with development, and with transnational and global partners such as ngos.³⁶ Moreover, the relation to formal needs such as state recognition and more diffuse identity concerns such as social obligations and gender norms all create structures in which the agency of individual volunteers is considerably constricted.³⁷ In the late colonial Gold Coast and early postcolonial Ghana, meanings of ‘the volunteer’ were consistently remade in dialogue with the expanding ‘voluntary sector’ which was an emerging part of the state.³⁸ Medical missions were central to this voluntary sector.

The process that defined the formal character of the 1950s voluntary sector began under Alan Burns, the governor of the Gold Coast in 1941 and then between 1942 and 1947. Burns was keen to promote gradual Christianisation through medical mission.³⁹ He wrote in his History of Nigeria (1929) that for a ‘real Christianity’ to be introduced into Africa, the work must be ‘slow and patient’. Vital to this steady pace, he claimed, were ‘medical missions to gain the confidence of the people, without which nothing will be accomplished’.⁴⁰ Burns quoted two of the main architects of the formal government-mission alliance in the 1920s British Empire: the missionary statesman J.H. Oldham and one of his mentors, Lord Frederick Lugard. From Oldham’s notable publication Christianity and the Race Problem, Burns further bolstered his complaint against Christian division, echoing Oldham’s claim that ‘unless the Christian Church can exhibit a brotherhood as real as that of Islam, we cannot be surprised if the latter is more successful in winning the allegiance of pagan people’.⁴¹

Burns linked this to his disappointment about the ‘friction that has existed in the past between the Government and the missionaries’ because of their interference in political and judicial matters. He cited Lugard’s issues with missions who were looking to the government for support when they were thrown out by a paramount chief. Burns’s message was that Christianity could flourish by focusing on building trust over the long term, especially through medical mission, with government assistance in ‘pagan areas’, and by avoiding the tensions resulting from government challenges to Islamic authority. Burns’s book linked to key debates around Oldham and mission-government cooperation, and it was successful, being republished in five editions, the last in 1955.⁴² Through this academic work, several gubernatorial terms, and a stint as the assistant under-secretary of state for the colonies in the early 1940s, Burns became a major contributor to the discussion of how mission would function until the end of colonialism.⁴³

As a result of his gradualist understanding of Christianity and colonialism, Burns was especially keen on hospitals, and blocked the dominance of ‘preventative health’. Given the missiological and imperial culture in which Burns debated and received his ideas, his main focus was on hospital building. These were bastions of modern medicine in which over a long, sustained, and protected period of time, missionaries could build trust with local communities and display order, expertise, cleanliness, and bodily difference in biomedical clothing and equipment. As Fraser had put it, the aim was ‘to know and be known by the people’.⁴⁴ Missions could also directly convert locals while they were ensconced in hospital beds, as Megan Vaughan argued: ‘a lengthy stay … provided a medical and spiritual training’, it was a kind of ‘rite of passage’.⁴⁵ In consequence, as Pascal Schmid details, Burns clashed with his head of medical services, James Balfour Kirk, leading to the latter’s early retirement in 1944. Balfour Kirk wanted to establish a ‘Policy of Preventative Medicine’ which would emphasise immunisation and sanitary improvement to lower the incidence of disease. Balfour Kirk wrote that the Gold Coast needed ‘a general clean up of the country by means of mass survey and treatment campaigns, combined with the provision of water supplies and other essential sanitary apparatus and improvements’.⁴⁶

As Deborah Neill has shown, tropical medicine specialists like Balfour Kirk were equipped by their ‘transnational epistemic communities’ to ‘influence policy making by collectively identifying problems and solutions … circumscribing the boundaries and delimiting the options’.⁴⁷ However, while Balfour Kirk might have been supported at the transnational level by imperial medical networks, at the national level, Burns reigned. Burns’s spread of options was rooted in the networks and organisations of knowledge production in British interwar mission which surrounded Oldham, not in those of imperial medicine. Just as medicine could shape missionary theology, here theological ideas were considerably shaping medicine. Burns also justified the focus on hospitals by arguing that ‘while there can be no doubt of the great importance of preventive medicine, public opinion will not be satisfied if those who are actually sick are neglected in keeping well those who have so far been fortunate in escaping illness’.

This he noted especially with regard to ‘primitive tribes’ and people with family in hospital, both of whom needed to be inspired with ‘belief in the good intentions of the Government’.⁴⁸

Burns was able to spend more on hospitals, and development generally, because of high cocoa prices and increased revenue from the landmark 1940 Colonial Welfare and Development Act. Based on high revenue of mineral exports such as gold (which in 1938 had fetched £484,200) and cocoa (which had gained £9,990,000 in 1937 for 236,000 tonnes), Burns initiated a policy throughout the 1940s of hospital building where possible.⁴⁹ He also collected around £800,000 annually in income tax, bringing total revenue to an average of £4,469,000 annually, as opposed to the £3,669,000 annual revenue before the war. In 1944 Burns proposed £924,000 to be spent on new district hospitals, £400,000 on a new central hospital in Kumasi, and £250,000 on a mental hospital. This was out of a total of £3,789,000 spent on development, including roads, housing, water, and electric lighting, as well as harbour and railway improvements and agricultural credits which totalled £1,400,000. Hospitals therefore comprised 30.33 per cent of development expenditure. To pay for this, Burns also defrayed £1,000,000 over five years from the Colonial Welfare and Development funds, which had risen significantly in 1940. The annual expenditure on development in 1935–36 to 1939–40 was around £2,690,000 annually; under Burns this rose to around £4,250,000 annually.⁵⁰ Burns set the terms of the huge medical mission expansion in the Gold Coast which started shortly after he left office in 1947. He ensured that for the next decade hospital construction was the priority.

Burns’s lack of funding for rural health projects, especially in the Northern Territories where there was a high incidence of preventable disease, frustrated rural health workers. The entomologist Kenneth Stacey Morris wrote in a letter to his mother from the Northern Territories in 1939 explaining how little his tsetse control would cost:

Our team working through a strip of Lawra district only, in six months covered 1,000 sq miles of country, visited 52 villages and towns, examined 15,000 people and found and treated over 500 cases of sleeping sickness … This is a team of semi or un-educated local native trained by Saunders and I, none of whom gets more than £3 per month, mostly getting £1 to 35/− − The whole team of about 15 people, for diagnosis and treatment, costs only £25 per month in salaries, and works perfectly without our supervision from one month to another.⁵¹

Morris complained that the annual costs of his team were what ‘some of the doctors will draw in allowances and perks, quite apart from salary, + quite certainly they don’t do as effective work [sic]’. His three teams, he ranted to his mother, would cost £900 with £500 in drugs and other expenses and ‘shall save up to 3,000 lives per year … Cheap as life may be rated out here, or when enclosed in a black skin. I don’t think the authorities could boggle at that’. The government concern for hospital provision and Christianisation clashed with Morris’s aims:

here sit I, responsible for all this, and capable of its vast expansion had I but the chance, listening to the echoes of our wonderful 20th century civilisation blowing each other to bits to the tune of God knows how many hundreds of millions of pounds, and wondering, with very real doubts, if I shall be allowed, kindly graciously permitted by our wonderful humanitarian system, to spend 10/− a time saving the lives of these poor wretches who have a thing enough time of it anyway − + yet keep smiling - And above all - have given up killing each other for some time now!⁵²

However, Morris did eventually get part of what he wanted. In December 1949 he was offered £100,000 a year for a national tsetse control unit, a considerable amount given that overall medical expenditure for the colony was only £1,161,250 in 1950.⁵³ Even upon this offer, Morris still felt the Gold Coast government’s focus on such official institutions fell far short of the mark, describing the administration as content with him becoming one of the ‘dull pompous cogs … [who] kid themselves that they are doing a man’s job’.⁵⁴

In the late 1930s and 1940s, African newspapers in the Gold Coast were also complaining bitterly about poor sanitation. The African Morning Post provided space for ‘Provincial Items’ which community spokespersons mostly used to highlight unsanitary conditions, changes in chieftaincy, and church building work. On 12 January 1939 a news report for Cape Coast demanded that the ‘attention of the local Medical Officer of Health’ be ‘called to the insanitary condition of the Castle Yard Latrine’ which served officials and prominent people using the post office and the court. This ‘pity’ the writer blamed on the latrine being used by the public, as a result of which it had become ‘very filthy’.⁵⁵ The following week the writer for Nkawkaw described how the latrines had become full and even ‘when they were in use they were found to be insufficient for the inhabitants of the town’. For this, they chastised the ‘indifference of the authorities concerned with the affairs of the town’ who indulged in ‘unnecessary litigation’, and the columnist advised the sanitary inspector to ask for the chief’s cooperation in helping improve the area.⁵⁶ This was the same for Kokofu, about which the author went into detail, explaining that ‘the sanitary conditions here leave much to be desired. Goat and sheep’s excrement abound in the streets, thus producing an unpleasant smell. This is detrimental to the health of the inhabitants. We strongly appeal to the Omanhene and M. O. H. in charge of the Bekwai district to solve the situation’.⁵⁷

There was more in the next day’s newspaper. On Wednesday the 18th the correspondent for Mepom wrote that the ‘sanitary conditions of this town leave much to be desired’, but this time the inhabitants themselves were blamed for ignoring the dictates of the chiefs: ‘Refuse is freely thrown on streets. The outskirts of the town are weedy, thereby mosquitoes are bred and poisonous reptiles sheltered. The inhabitants do not care to carry out the orders of the Odi. kro … This town needs special attention as there had once broken out yellow fever here’.⁵⁸ Across Gold Coast villages and market towns, the unsanitary conditions were proclaimed in a variety of appalling, illustrative examples.⁵⁹

In 1938 seven new dispensaries were opened in Abomosu, Attabubu, Prang, Yeji, Grube Fian, and Ketiu in order to reduce the incidence of disease such as yaws and malaria ‘in the poor and more remote areas’. The predominant aim for the subsequent years was to improve ‘conditions in the mining health areas … rural sanitation … congested slums … [and] the extension of health education’.⁶⁰ Village dispensaries were the focus because, as the Legislative Council stated, ‘we are fully aware that Government cannot build hospitals in every state’.⁶¹ Moreover, as one of the African chiefs, Nana Hima Dekyi XII, stated in the legislative debates in 1940, not only had the fees become too high for the poor to visit hospitals, the council itself had ‘no money’ to help.⁶² Moreover, there were ‘severe’ epidemics of cerebro-spinal meningitis and outbreaks of smallpox during the Second World War, and the training of dispensers and nurses that had been planned became impossible.⁶³ In 1941, R.S. Blay told the council that more than 70 per cent (and in some areas more than 90 per cent) of applicants had been rejected from the army because of poor health, particularly yaws and guinea worm, because there were few dispensers and government doctors’ fees were too high.⁶⁴ By 1943, Nana Nyarko VII, the representative of the Ewe-speaking people, was complaining that ‘the poorer parts of the country have little or no medical service … instead of having a few well-equipped hospitals at a few centres there should be many dispensaries all over the country, so that it should not be difficult for any one in need of medical aid to obtain same at the time he needs it … Too much is spent at great centres, and too little is spent in vast areas’.⁶⁵

Table 1.1

Gold Coast child and maternal health providers in 1942 and 1943.

In spite of all this, it was a hospital network where money was targeted in late colonial Gold Coast, and thus in early colonial Ghana. From 1944 onwards, hospital building had become the colony’s main aim, though it was not until 1950 that this became rapid; the pathway had been chosen. In 1944, £83,000 was provided by the Legislative Council for building two new hospitals, out of a total council expenditure of £5,055,764.⁶⁶ In 1946 a nurses’ training school and hospital were constructed for £46,000 using funds from the £3,500,000 allocated to the Gold Coast through the Colonial Welfare and Development Act. The only issue holding back more hospital development was staff shortages, so nurses’ colleges aimed at filling the gaps. In March 1945, there was a further large outbreak of smallpox and an epidemic of cerebrospinal meningitis which recorded 1,052 deaths and had to be contained by the army. Nevertheless, the Takoradi-Sekondi hospital was renovated and in the following year a ten-year plan was laid out for ‘building new hospitals and for major works in connection with existing ones’.⁶⁷ Moreover, £31,000 for a leprosy survey and £94,650 for constructing and initially staffing three leper colonies was allocated from the Colonial Welfare and Development Fund.⁶⁸

As the colonial government increased spending on medicine after 1947 largely it was funneled into previous state and mission infrastructure channels, formalising and institutionalising them. Of a total £10,964,604 spending in 1947–48, 599,597 was spent by the medical heads. In the following year, 1948–49, there was a further increase to £11,487,703 in total and £814,616 by the medical heads.⁶⁹ By 1950, medical heads expenditure had grown to £932,831, which amounted to an overall medical service expenditure of £1,161,250 with an extra £45,210 for tsetse control and £172,333 for rural water development.⁷⁰ By 1948 plans had been passed for extensions to the hospitals at Oda, Winneba, Ho, and Keta, as well as a new dispensary on the hospital grounds at Axim.⁷¹ By 1950, there were twenty-eight private and mission hospitals with 878 beds, and thirty-three government hospitals (twenty-seven of which had medical officers) with 1,572 beds. A further mission hospital was planned for Worawora in Southern Togoland. This was in addition to widespread clinic work by the missions and international organisations. In 1949 the International Red Cross Society had five weekly mobile clinic serving over forty towns and villages, and in 1950 they treated 60,000 patients in mobile and static clinics (suggesting some decline from the heights of their provision in the early 1940s, perhaps because of increased strains on resources during the Second World War). In 1949, two mission dispensaries were opened by Europeans and Americans in the Northern Territories.⁷² In 1950, the French-Canadian Catholics began the first maternity and child welfare clinic in Jirapa, a leprosy clinic was opened at Banda in the Gonja district, and a missionary maternity clinic was being built at Nakpanduri in the Mamprusi district.⁷³

While there was some innovation in health care, generally the trend was towards continuing the mission-state development consensus. In addition to the clinics, the medical field units – which formalised and unified government immunisation efforts particularly regarding yaws in the Northern Territories – had £56,190 set aside for them and were in operation by the end of the decade.⁷⁴ Much was now being spent on medical services, made possible through loans, rises in export taxes, London stocks, the Colonial Welfare and Development Fund, and the global post-1948 boom in cocoa prices.⁷⁵ Increased funding also resulted from Colonial Office change; as Joseph Hodge shows, between 1947 and 1951 there was the one and only ‘full blown Chamberlainite “colonial development offensive” … to serve the direct interests of the British national economy’.⁷⁶ However, in the Gold Coast these changes served to formally consolidate earlier local patterns of health service, not innovate fundamentally.

There was concerted government response to epidemics of yaws and smallpox from 1946, but this was nothing compared to the effort in hospital construction. In 1946 the government returned to large-scale vaccination campaigns of smallpox as they had done in Accra in the 1920s. By 1947 there was already a clear effect, with most cases confined to the Navrongo-Nangodi area; by 1948 a population of 3,962,692 had a high proportion of people vaccinated.⁷⁷

As across Africa, these campaigns in the Gold Coast were ‘a model for further public health efforts, including the who eradication campaign’.⁷⁸ Mass treatment of yaws also increased in the Dagomba region of the Northern Territories, in which twelve teams were able to treat 20,609 cases.⁷⁹ This work continued into the next year under the direction of trypanosomiasis staff and with the help of the French authorities over the northern border.⁸⁰ This benefitted from Colonial Welfare and Development fund money: yaws treatment gained £8,000 between 1948–49, to which the colonial government added £2,240.⁸¹ However, in spite of these renewed efforts, communicable diseases remained huge killers with little investment to stop them; cerebrospinal meningitis recorded 11,002 cases and 868 deaths in 1948 alone.⁸²

Table 1.2

Smallpox vaccinations, deaths, and cases in the Gold Coast between 1945 and 1948.

The culmination of the tying together of medical mission and government in the Gold Coast was the government report in 1951 and the Maude Commission in 1952, which together ensured that ‘voluntary agencies’ became institutionalised. The Report of the Commission of Enquiry into the Health Needs of the Gold Coast was a landmark document in colonial and mission health which produced a detailed survey of the colony’s medical provision. It followed on the heels of the government’s publication of a ‘Statement of Principles Regulating Financial Assistance to Voluntary Agencies Undertaking Medical Work’ in 1951. The statement of principles formally declared the desire to obtain ‘assistance of non-Government agencies, particularly the missionary organisations, in the expansion of health service, especially in the field of maternity and child welfare work’. Following this, the statement offered capital grants and contributions toward recurrent expenditure for hospitals under the administration of combined mission-government committees. The Maude Commission supported the statement wholeheartedly: ‘We are strongly in favour of a policy designed to elicit a fuller contribution from the missionary societies and other voluntary agencies … if the maximum advantage is to be taken of these agencies whose objects are charitable and not profit-making, it is worth while having, if necessary, a careful negotiation with each without attempting to force the arrangements into a single mould’.⁸³

The latter sentiment challenging the uniformity of a formal ‘non profit-making’ sector is noted to have emerged from ‘experience’ with such relations within the uk. Maude himself was one of the major proponents of voluntary-state partnership in the nhs; he was concerned about the effect of government power on voluntarism and had gained significant control during his time as the permanent secretary of the Ministry of Health in the war.⁸⁴ In his concluding Gold Coast development estimates, Maude made provision for £140,000 of grants to medical missions to be expended by the end of the year.⁸⁵ However, Maude was also arguing here that such a voluntary sector should not be in a ‘single mould’. Instead, he wanted to empower the diversity and independent energy of missions through formalising their role within increasingly nationalised health systems. In the government’s response to the report, they fully backed Maude’s recommendations.⁸⁶ In doing so they proclaimed the start of a decade of very high government spending on missions, in which twenty-four medical mission hospitals would be built.⁸⁷

In contrast to Burns, for Maude the defence of medical missionary agency was not only to bolster government efforts or missionary work, but also to ensure the survival of democracy in British societies – and of liberalism everywhere – through a vibrant culture of voluntarism. Maude’s hope was to ensure a culture of liberal voluntarism, around the missions in the Gold Coast, that would provide the lifeblood of a national health-care system which otherwise could be turned into an instrument of coercion by the government. Voluntary associational life was conceived by Maude as critical to ensuring the flourishing of modern society.⁸⁸ In his 1948 address to the British Hospitals Contributory Scheme Association on ‘The Place of Voluntary Effort in the National Health Service’, Maude argued that ‘voluntary effort (has) the enormous advantage of elasticity and freedom of action. In pioneering and experimental work there are risks which it is right and proper for voluntary agencies disbursing voluntary funds to take, but which a Minister and public Department as trustees of public fund would be perfectly justifiable in refusing’.⁸⁹

Moreover, Maude argued that this pioneering spirit could not only prevail in voluntary associations, but also challenge the overbearing power of the state:

It is almost a truism to say in these days that modern inventions – the development of instruments of physical coercion and perhaps even more instruments such as a government-controlled press … have vastly increased the scope and powers of the state … ‘You will always have a totalitarian State unless you do a great many energetic things to prevent it …’ [A]ny useful public activity carried on by voluntary workers (as Mr T. S. Eliot has recently put it, the fulfilment of a public need by a private enterprise) has a value as a counterpoise to these ever increasing activities of the State.⁹⁰

In the context of Europe shortly after the war with the Nazis, Maude set his argument for the flourishing of the voluntarist spirit amidst the threat of totalitarianism and the ‘physical coercion’ which seemed abundantly possible for a state to use against its citizens. For Maude, it was in combination with the equalising powers of an interventionist state that the ‘fulfilment of public need’ was possible.⁹¹ Thus, his work emphasised their combination: a formal voluntary sector which operated in the loose reigns of a nationalised system. The kind of organisations where this liberal, elastic, and private culture could take root were ‘the Churches, the Universities, professional bodies, Trade Unions, Friendly Societies and many others’. These had ‘a part to play in providing this counterpoise not less but rather more valuable because the nature of their work brings them into close contact and collaboration with the public services’.⁹²

As the Gold Coast colonial government stretched out health services beyond the South, their decisions were informed by this vision for a progressive and lively voluntarist liberal culture, with voluntary agencies like medical missions taking risks in coordination with more restricted public services and pioneering the frontiers of the state. In their statement on Maude’s recommendations, the Gold Coast government welcomed the endorsement of their policy and emphasised that ‘greater flexibility’ would be introduced into their financial arrangements with missionary societies and voluntary agencies.⁹³ This dovetailed well with the kind of voluntarism which John Stuart has argued that missionaries were trying to promote in late colonial Africa. It also fit well into the developmentalist visions already prominent within the Gold Coast, from Guggisberg and Fraser through to Burns.⁹⁴ The result was that Maude had been successful not only in encouraging the application of public funds to voluntary agencies, but also in convincing the colonial government that the national health system could be tailored to enable a liberal voluntarist state.

More widely, the emergence of the formal voluntary sector in Africa was linked to the visions for the success of postwar state welfarism. Given their lack of democratic accountability and their linkages with the ‘structural adjustment’ reforms of the 1980s, ngos and fbos have been viewed as aberrations of state health systems; however, they were actually a fixed part of these systems from the 1940s onwards. Michael Jennings has shown in his work on postwar Tanganyika that a public-private, state and non-state contract was produced through grants-in-aid provision. Nationalisation of the health-care system in the 1970s served to reinforce this formal position of voluntary agencies by ‘preventing “non-authorised” alternative actors from operating in the country’. The ‘ngoisation’ of African health care was, therefore, not a later product of neoliberalism but a long-term legacy reflecting ‘fragility, fragmentation and structural weakness’. As Susan Reynolds Whyte puts it, the projectified landscape of the global includes many vertical programmes but not many horizontal.⁹⁵ ngos did not create the problem, they exacerbated the issues attendant on a ‘franchise state’ that had so few resources that it needed to outsource much of its health care to non-profit actors in order to prove that it could provide for the welfare of its citizens.⁹⁶ As Jose Harris has argued, by 1950 there had been a general shift to seeing the voluntary sector as a means to the end of ‘controlling … the sphere of public provision’. William Beveridge in his 1948 report was concerned that the Labour government was rejecting voluntary sector provision, but in fact it was seen as a component in achieving state welfarism. As Emma Hunter has shown, the visions of the Beveridge Report were repeated in the Colonial Office Social Welfare Advisory Committee and shaped the emergence of state welfarism in East Africa. Within this were concepts of duty carried over into postcolonial Tanzania state-building.⁹⁷ Voluntarist ideas as well as formal structures were a part of the shift in state health-care provision to formally incorporate medical missions.

The growth of a contracted and formal voluntary sector was happening across a variety of contexts in postwar Sub-Saharan Africa. In francophone as well as anglophone Africa, the formal voluntary sector was produced on a large scale, with colonial offices funding medical missions extensively through grants-in-aid in the late 1940s and 1950s. Part of the shift to formalise the relationship with missions that had been growing for decades was caused by the creation of massive development funds from Colonial Offices. In Cameroon in the 1950s, medical missions were funded extensively by subventions (grants) from the fides (Fonds d’Investissement et de Développement Economique et Social), a central French imperial fund created in 1946.⁹⁸ Much of this was Baptist medical missionary work from America, alongside older Catholic work.⁹⁹ Certainly, the drive for development can be seen in earlier prewar initiatives, and this was often with voluntary agencies’ support. However, in the postwar era, development planning as a systematic, internationally centralised programme affected African health care differently. As with fides, from Britain the Colonial Welfare and Development Act (cwda) of 1940 ensured far greater provision than earlier grants. In both French and British development, the process was less piecemeal, less ad hoc, and more widely distributed to national infrastructure. Postwar funding also increasingly focused on large buildings, partly because it was too difficult to commit to recurrent expenditure. In Kenya, there were grants-in-aid to medical missions for maternity services in 1925, but generally funding for hospitals was not systematically given across East Africa until the 1950s.¹⁰⁰ In 1954, Zambia missions were receiving 50 per cent of their recurrent expenditure.¹⁰¹ From 1940, the Zimbabwean colonial government was funding many mission hospitals and by 1977 sixty-three of Zimbabwe’s mission hospitals were still funded by government grants-in-aid.¹⁰² Similarly, there were huge amounts of subventions given from fides to many missions in 1950s Senegal.¹⁰³ This was the case in a variety of other Sub-Saharan African contexts too (with the exception of northern Nigeria).

Crucially, while there was more formalised and systematic provision after the war, still a variety of local actors had significant power in the timing and type of voluntary sector that emerged – particularly medical missionaries. A key aim of the fides and cwda programmes was to ensure closely matched funding within colonial governments.¹⁰⁴ The postwar imperial welfarism was not defined simply by top-down control of central colonial offices but, as with the 1920s and 1930s, by local administrations and local political conflicts. Moreover, though there was connection with 1940s British welfarism, the African context was very different. In colonial Africa there was an assumed lack of government capacity to stretch beyond the centres of power and a long-term expectation about the vital place of missionaries in the colonial project, especially in rural areas. By contrast, 1950s British national health care increasingly detached from church support and the state was expected to assume wide responsibilities. In colonial Africa missions had a far greater say in how the voluntary sector emerged. In the colonial government in Tanganyika, missions felt threatened during the 1950s by new colonial objectives, and although the government could never have radically reformed health services, missions defended their corner. By 1952 links with certain forms of mission were increasingly formalised.¹⁰⁵

This pattern of state empowering picked up in the 1950s after Burns left; Charles Arden-Clarke, the governor of the Gold Coast from 1949 to 1957, was pro-medical mission and he consciously aimed to further embed a voluntarist culture. In the early 1950s, as a result of many pressures (such as changing international politics, the emergence of ngos, ecclesiastical devolution, and concerns about communism), missionaries and pro-mission colonial officials actively tried to cultivate a culture of Christian voluntarism through centralised Colonial Service organisations. John Stuart has shown how the first attempt at this was the Oversea Service, which aimed to ‘foster a sense of Christian fellowship’ amongst new colonial service recruits. Notably, at the opening conference for the Oversea Service in 1953, the Gold Coast governor Arden-Clarke contributed as a speaker.¹⁰⁶ Arden-Clarke’s father was a Church Missionary Society (cms) minister in India into the 1920s, and Arden-Clarke himself had originally considering going into church ministry. He wrote to his parents in 1922 about his younger brother becoming a missionary, which he wrote would ‘buck you up no end, because I’m sure you were very disappointed in me’.¹⁰⁷ In a letter to his father in 1922, Arden-Clarke argued that twelve male missionaries trained in simple medicine would be far better than twenty erecting a stall in the village market and becoming a ‘general nuisance’ trying to preach monogamy and the Passion of Christ. That way, ‘Christianity will be knocked out by Mahommedanism’, he wrote.¹⁰⁸ Under Arden-Clarke, medical mission hospitals were hugely financed and well staffed.¹⁰⁹

By the eve of decolonisation, missions were opening a plethora of medical institutions with government support and government itself was admitting its inability to set up sustained preventive health care. In 1955, the government stated that as mission medical work continued to expand this was ‘encouraged as a policy of Government … in so far as the funds available for financial assistance permit’. In the same report, government contributions were extensively listed: in 1954 the new Presbyterian hospital at Bawku had been completed, the Roman Catholic mission hospital at Navrongo was completed, and progress was being made on their hospital at Jirapa – both ‘with funds provided by Government’. In addition, the Maternity Hospital and Midwifery Training Centre at Mampong was opened in May and was being run by the English Church Mission. There were also grants to the Methodist Mission at Wenchi in Ashanti, the Basel Mission staff training at Agogo, the Salvation Army at Begoro, and several Roman Catholic missions in the Western and Eastern regions alongside Jirapa in the North.¹¹⁰ Finally, further plans were made for a hospital at Worawora run by the Evangelical Presbyterian Church. Extra funds were also given for pupil nurses hostels at the mission hospitals in Navrongo, Jirapa, and Mpraeso (Kwahu).¹¹¹ At the same time, the government was building their own hospitals, such as at Koforidua for which £25,000 was earmarked.¹¹² Alongside these ventures there was the admission that systematic preventative health care across the colony was now extremely difficult and had largely been dismissed: ‘during 1953, it was appreciated that the basic necessity of improved environment hygiene and the responsibilities of local authorities in this regard were inadequately recognised … It has to be recognised, however, that many local authorities set up under the recent re-organisations of local government are not yet in a sufficiently strong position to permit the establishment of appropriate health services within a co-ordinated framework of supervision by the Central Government’.¹¹³

Given the long-term sustained focus on large-scale institutional medical provision, the new local authority structure could not make up the shortfall easily. While campaigns in preventative health care were beneficial, they were not in a position to radically alter the infrastructure and administration already in place. In 1956, £475,075 was granted by government for hospitals, clinics, and dispensaries alone. This was spread across a variety of government and mission projects: for example, £2,000 was given to support the Salvation Army’s construction of a clinic at Boso.¹¹⁴ The rapid growth of mission hospitals and clinics continued.

THE BOUNDARIES AND BENEFICIARIES OF THE VOLUNTARY SECTOR: MEDICAL MISSIONS AT KWAHU AND SANDEMA

Government actual expenditure on medical services increased year on year in the early 1950s; it was £965,020 in 1950, £1,037,795 in 1951, and £1,607,545 in 1952. Missions were building hospitals and dispensaries abundantly. By 1958 the minister of health stated that the government paid the recurrent costs for the Catholic hospitals at Jirapa, Damongo, and Navrongo, the Basel Mission hospital at Bawku, the English Church mission at Mampong, and the Seventh-day Adventist church at Kwahu. The independent Ghanaian government also provided annual grants to the Worldwide Evangelization Crusade’s Leper Settlement at Kpandai, the Basel Mission Hospital at Agogo, and the Methodist Hospital at Wenchi. They also provided annual grants to the Salvation Army clinics at Begoro and Boso, and the Catholic clinics at Akim Swedru, Eikwe, Dzodze, and Nandom.¹¹⁵

Many new mission actors in the 1950s capitalised on government funding to set up flagship institutions and work in places beyond where state medical services could readily staff. The sdas set up a hospital for the first time in the Gold Coast at Kwahu in 1955 (and officially opened in 1957).¹¹⁶ Moreover, the British Salvation Army formed their first clinic at Begoro in 1952, leading later to seven others by 1982, and the Worldwide Evangelization Crusade built a Leper Colony at Kpandai in Northern Togoland in 1952.¹¹⁷ Old mission actors, by contrast, took the opportunity to expand. For example, in 1953 the Presbyterians at Dunkwa Hospital built a new site with £49,000 of government development funds, with an extra £26,000 earmarked for 1955–56.¹¹⁸ Unlike the government, who struggled to staff large institutions in the far-flung reaches of the colony (especially lacking medical officers and nursing Sisters to meet increased demand), missionary bodies were at a zenith of recruitment from Europe and America.¹¹⁹ However, there also many that chose not to capitalise on the money and those who were unable to gain any funding. Medical missions in this period were formalising but they remained complex, varied, and independent in many regards.

Figure 1.2

‘The dispensary at Nandom gives an average of 37,000 consultations each year. Here a White Sister chats with a mother who is waiting her turn in the queue with her baby’ (c.1950s)

Given issues with independence and their desire to bypass government interests, many missions also set up their own institutions without consulting the government and actively refused to participate. The Roman Catholic Medical Mission Sisters Hospital at Berekum declined government financial aid of around £21,800, which the government could not ‘force’ them to accept. In the same Legislative Assembly debate, the government declined to help Catholics at Foso set up a clinic and were not setting up their own health centre in the area.¹²⁰ In some cases, missions did not even inform government as to their aims; for example, in 1955 the minister of health declined to give a government subsidy to the Catholic hospital plan for Akrokerri because there was ‘no information … received of any intention on the part of the Catholic Mission to build a hospital at Akrokerri’; ‘if the Mission has this intention it is hoped that it will first seek Government approval to implement it … (and state) at the same time what financial assistance, if any, would be required from Government’.¹²¹ A similar issue occurred with regards to Roman Catholic aims to build a maternity hospital at Takyiman, for which no application for funds was received.¹²² In the same year, the Catholic White Fathers had the Gonja Development Company Hospital at Damongo purchased for them by the government.¹²³ The government then debated whether to buy them an ambulance.¹²⁴ This was not simply a denominational issue, but a question of particular congregations or groups who had specific aims and agendas at specific times. Moreover, some missions changed their minds when circumstances changed: the Catholic hospital at Berekum originally had been allocated £21,000 (part of which also was sequestered for the Anglican hospital at Mampong), but when funds were insufficient they were diverted and reconsidered.¹²⁵ At the end of the process, Berekum turned down the money offered, choosing to promote their own independence over gaining further financial or national political power. The concept of the ‘volunteer’ often suggests freedom and agency, but its implication in emerging statecraft in the Gold Coast ensured that its practice was bound up with government visions for health infrastructure and population management. Adopting such volunteer roles within a state-formalised voluntary sector could have significant downsides for the restriction of activity and identities, in which many Catholic missions did not want to engage.

By contrast, in 1955, the Seventh-day Adventists (sdas) successfully gained funding from the colonial government’s voluntary provision to build their first hospital in the Gold Coast. Their work was part of a general expansion of sda medicine across the world: in 1940 sda health-care assets amounted to $9,687,457.49 with 6,184 employees, but by 1956 they totalled $53,841,675.96 with 10,292 employees. In the Gold Coast the government built the hospital and the sdas staffed it. As planned under the Maude Commission’s voluntary sector suggestions, it was established by a combined committee.¹²⁶ Along with money from offerings for foreign mission from the Northern European Division (for Ghana in 1957 alone this totalled $30,802.33), the sdas also had doctors from their Skodsborg Sanitarium in Copenhagen who could train staff in specific skills such as physiotherapy.¹²⁷ In the first few years the sdas sent two European doctors and three European nurses, as well as employing many ‘national’ nurses and assistants.¹²⁸

Figure 1.3

‘Captain Jeffrey Roberts received new Ministry of Health ambulance for Salvation Army clinic’ (c.1960s).

The initial doctors at Kwahu were presented in sda newspapers as fired up by evangelistic zeal and a pioneering spirit. According to the British Advent Messenger, the second sda doctor at Kwahu had ‘cherished the ambition’ of becoming a medical missionary since being a ‘schoolboy’. He had committed to two-and-a-half years at Kwahu with his wife, and the paper called on all to pray for them to prosper in this difficult task far from their home in Derby, England.¹²⁹ Little was said about the people Peter was going to help; the focus was on where he had come from and how big a leap it was to uproot to Kwahu. The first sda doctor at Kwahu, Dr J.A. Hyde, lauded the medical work there in terms of both modernity and effective Christian care. For example, in the sda newspaper Northern Light in 1956, a column entitled ‘Progress in Our Mission Fields’ described how:

Dr. J. A. Hyde reported on one of West Africa’s newest institutions, the Kwahu Hospital, erected for us by the Gold Coast Government. In its first year it treated 28,844 out-patients and 557 in-patients. Every available space of the hospital has had to be used to try to house these. An indication of the regard in which the hospital is held was given by a recent visitor. On inquiring whether the institution was a mission hospital, and being told that it was, the visitor continued: ‘I knew it must be; I could tell it by the way you cared for your patients’.¹³⁰

In this account, alongside statistics of patient treatment and struggles at housing them, is an anecdote meant to encapsulate the effect of Christian care. According to the comment, the hospital both helped those inside the institution and proclaimed the meaning of that care to surrounding people.¹³¹

The sda’s interpretation of the formal voluntary sector fit in colonial government terms, but it was not determined by them. The sdas showed off their biomedical effectiveness to the who and to the government, and also directed attention toward community evangelism. According to the same Dr J. A. Hyde in 1958, the governor-general (who by that point was the Earl of Listowel) and the who advisor to Ghana both commented that the Kwahu hospital was the ‘best equipped and run hospital they had seen in Ghana’. The latter said this within the Ministry of Health in Ghana, apparently much to the chagrin of another representative – but Hyde declared that the Lord had ‘caused His name to be glorified in the councils of men’.¹³² For Hyde, sda success was imagined in terms of God’s name being lifted high in government. This was a specific theology, taken from passages across the Bible such as Psalm 22, in which God collaborates with His people to proclaim His power in the assemblies of men. As is often the case when analysing volunteer categories, it is the vulnerability and insecurity of those taking up ‘volunteer’ roles which mean that their identities and tasks become circumscribed to formal structures. By contrast, the sdas had an international network on which they could rely for imaginative and material support, ensuring they could carve out their own pathways through the government voluntarist edifice. For the sdas, they were concerned to appear effective in linking to national and international governance networks, but they conceived of these successes as stitched into much larger narratives about creation and their own corporate relationship with God. The sdas navigated through changes in political context, but this did not mean that they simply received ‘voluntarism’ unquestioningly. They had agency to push back at the restrictions placed on the concept of the ‘volunteer’ in state terms by renarrating it in their own.

In all this maneuvering between different categorisations of their medical work, the sdas were actually not particularly Janus-faced. They proclaimed their aims for their hospital in ways that were not particularly subtle. At both the opening of the hospital in 1957 and the graduation and expansion in 1962, the sda presented copies of The Ministry of Healing (1905) to the ministers of health. The publication details the evangelistic and redemptive motives of their medical mission.¹³³ The hope was that it would shape the government’s work and ‘bear testimony to the healing work of the Seventh-day Adventists’.¹³⁴ Thus, while they were pleased to be affirmed by government and who representatives in biomedical terms and to benefit from the patronage afforded to state voluntarists, the sdas were up front about their motives. Again, there was much agency for the sdas to negotiate what voluntarism meant in Kwahu partly because of the strength of their position. They were providing a high-level medical service in a remote place that was difficult to staff for the government and in ways that were emphasising the colony’s success internationally. Even more than this, the sdas had networks beyond the colony and international health, which meant that they were part of something much bigger in their own eyes. This was fed and encouraged by newspapers where they could self-promote but also bolster their own sense of corporate identity by reading the narratives of others.

Beyond giving out pamphlets, the sdas used their role in the Gold Coast formal voluntary sector to conduct intense evangelism and supernatural ministry within a government-built hospital. Any voluntarist images that the sdas promoted did not determine the internal culture of the mission hospital, where they prioritised evangelism and spiritual warfare. The real passion of the medical work at Kwahu was certainly not in secular biomedical terms. The idea that missions secularised as they increased their formal relations with government was not the case here. In several sda newspaper articles this is well illustrated. For example, in the Northern Light in 1957 an article was written emerging from a mission service in London where testimonies of God’s ministry were shared between Northern European leaders and guests. The writer, J.M. Bucy, an American sda and the wife of an sda pastor, describes how ‘during the model Sabbath school and mission service conducted by M. E. Lind, the Division Sabbath school secretary everyone actively participated in the review and the lesson study. Then came the gripping story of the deliverance from fetish worship. Miss Amy Horder, a nurse from our Kwahu Hospital in Ghana, told of a woman delivered from heathen worship and a serious physical condition through prayer and loving medical ministry. Truly a remarkable mission story with a happy ending!’¹³⁵

This picture of simultaneous spiritual and physical conversion epitomised the effect at which the hospital aimed. Moreover, this was no minor service – Miss Horder was presenting to the heads of sda mission. ‘Fetish’ and ‘heathen’ worship, which were reported to be healed through prayer, were as much the hallmarks of the hospital agenda as biomedical illnesses. Furthermore, in an article in the same year in Messenger, initially quoting Acts, the director of nursing at Kwahu, Lionel Acton-Hubbard, wrote that the hospital’s mission was:

‘to labour both for the health of the body and for the saving of the soul … healing all who are oppressed by Satan’ … ‘the medical missionary work is to bear the same relation to the work of the third Angel’s message that the arm and the hand bear to the body. Under the direction of the divine head they are to work unitedly in preparing the war for the coming of Christ’. The gospel ministry is needed to give permanence and stability to the medical missionary work; and the ministry needs the medical missionary work to demonstrate the practical working of the gospel – neither part of the work is complete without the other.¹³⁶

The article sets the hospital’s ministry in the spiritual battle which ‘prepared’ the coming of Christ, giving their medical mission eschatological significance. Though this was not completely different from other missions formulating roles within the colonial state, the emphasis on the supernatural within government-funded health care is striking.

The media produced from Kwahu Hospital was about building personal and social identities, as well as beneficial political ones. Isabel Hofmeyr has argued that missions created an international ‘“archive” of strategies for reading and interpretation’ across the world, allowing them to imagine themselves as if addressing a ‘vast international Protestant public’, whatever the reality.¹³⁷ Hofmeyr’s thesis rings true for the sda authors. With a limited readership and an isolated existence in rural Gold Coast, Acton-Hubbard was nonetheless constructing a sense of self on an imagined larger spatial and temporal plane by narrating his place in the hospital. These articles provided a platform for him to individuate and distinguish his role, and a way to try to shape his identities for himself and for others in dialogue with all the competing demands that the mission field placed on him. As Guido Ruggiero puts it in the case of Italian Renaissance self-fashioning, ‘family, friends, neighbours, fellow-citizens, and other social solidarities … each constructed in dialogue with a person a socially recognized personal identity for that individual. Identities based upon “consensus realities” could be quite different for the same person depending on the group that shared them’. The personal narratives that Acton-Hubbard was creating afford perspectives on how he related to colonial discourses, theology, the supernatural, other people, objects and institutions, and his alien position in the Gold Coast. They do not provide an authentic picture of what was really happening in the hospital, but of how subjectivities were fostered within the context of missionary medicine.¹³⁸

An sda article from 1956 on electricity, prayer, and preaching at Kwahu Hospital shows more detailed aspects of how medical missionaries imagined their roles and experiences. Acton-Hubbard recounts in his article ‘The Light Shines at Kwahu’ that he imagined one night how impressive the hospital must look to the outside, illuminated by electricity, and how much the locals must desire the ‘light’ of Jesus Christ. In consequence he gathered the ‘young people’ around the hospital, largely a group of male students, and set out to organise an event in the town in which they could proclaim the ‘Story of Redemption’. Having gained the chief’s permission (navigating these local politics was vital to the survival of a medical mission), Acton-Hubbard and his group prayed together and began eight weeks of preaching to assemblies of ‘the chief, the Queen mother … the elders … (and) about 80 nonbelievers’. The male students sang anthems and people came to hear them, sometimes before going to the hospital’s Sabbath service. Acton-Hubbard and his disciples were replaying the Acts of the Apostles in the wilderness with even a make-shift Pharisee from a local mission to battle:

Yes, Friends, the young people of the hospital are sharing the light that has been given to them and the Lord is adding His blessing. The students are holding several before and after meetings and are gaining interests. In the course of one meeting a catechist from another mission in another town intruded and asked awkward questions at the end of the meeting. He was given a hearing and his questions were answered to the obvious satisfaction of the chief, his elders, and the assembled company. Yes, a new day is dawning in Atibie, Kwahu. The Holy Spirit is in this work and I feel we are right as we reiterate the words of our Lord ‘Say not ye, there are yet four months and the cometh the Harvest? Behold I say unto you, lift up your eyes, and look on the fields: for they are white already to harvest’. John 4.35.

Having seen off the challenge of local politics in competing missions and powerful chiefs, Acton-Hubbard declared that the evangelism was charging forward with success. Not one mention of any actual medicine in the hospital can be found in his account; the point of the institution was a base for mission and the shining of spiritual (and literal) light. His declaration that the ‘Holy Spirit is in this work’, combined with quoting Christ, is a classic trope of Protestant testimony, in which the feelings and experiences of the believer’s relationship with God are set within the limits of scriptural authority.¹³⁹ For his own sense of destiny and with an audience of potential supporters in prayer and money, Acton-Hubbard was constructing a ‘socially recognized personal identity’ of the evangelist, out on the frontiers of the faith, in dialogue with the movement of the Holy Spirit and the local culture. This was an alternate ‘consensus reality’ to that of the sanitised medical director which Acton-Hubbard performed at hospital openings and graduations for government officials. The sda’s role within the formal voluntary sector was an identity affirmed publicly to the state and the who, but largely separate from Acton-Hubbard’s spiritual and evangelistic life personally.

As for their biomedical role, the sda spiritual agenda was bound up with the desire to administer medicine and produce physical healing. Pamela Klassen has argued that, for many early twentieth-century Canadian doctors, technology was imagined as a way of communicating divine love, power, and prestige. Liberal Protestants were prominent on hospital boards and teams of determining clinical practice, and they perceived the point of the needle as the channel of the Holy Spirit. While sacral texts disseminated ideas, new materials such as electricity, radio, and X-rays were seen ‘as both metaphorical and physical channels for healing’.¹⁴⁰ As with Acton-Hubbard’s epiphany when realising the powerful effect of the light from the hospital, Klassen argues that many Protestants blended ‘scientific and romantic discourses of experience … proclaim[ing] the salvific and therapeutic benefits of technological and medical progress as tools for staying alert to the workings of the spirit’.

In drawing everyone into medical aid, for Dr Hyde of the sda mission, general medicine itself expressed the complete work of Christ’s ministry in which all become one in Him. Alongside their healing work, Acton-Hubbard was also training what he referred to as ‘Lightbearers’ – that is, students who were charged with ‘going out Sabbath by Sabbath, distributing literature and tracts, holding compound meetings and of course giving Bible studies’. They were equipped with ‘visual aids, special tracts, source material, marked Bibles … [and] the coloured sign “Lightbearer”, suitably set off on each side with a flaming torch’. Yet, as well as being a team of roving preachers, the photo with the article shows that these were also nurses and medical auxiliaries, half of them dressed in white medical uniforms and hats.¹⁴¹ Acton-Hubbard wrote that a group of visiting ‘evangelistic students studying health and First Aid at Kwahu’ were ‘absorbed into the working of the hospital’. The students attended lectures on helping on the wards and outpatient departments, and even attended major operations. On Sabbath morning they prayed, praised, and sang, they also had Bible studies prepared by Dr Hyde. For example, Dr Hyde would share his thoughts on ‘the completeness of the work in God’s remnant people’, describing ‘most vividly the tragic results of over specialization’ as well as counselling the group ‘to look to the Master’ as their ‘guide in living and working’, reminding them that the ‘medical evangelist work has always been near to the hearts of Seventh Day Adventists’.¹⁴²

Not only was evangelism an outworking of the hospital ministry, hospital ministry was also used to train evangelists in the meaning of body and soul healing. Giving them physically demanding tasks within the hospital was not to teach them how to be doctors alone, but also to show them how to discipline their work as local evangelists. For example, appealing to the problems with ‘over specialisation’ in restricting a doctor’s capacity to help lots of people, Dr Hyde instructed the evangelists on how exactly they should live: looking to Christ and not narrowing intellectual tracks. In some sense there was no real split here between physical and metaphorical healing, because the healing of the body and soul were joined.

While the sda mission exposes the underlying complexities and variety of identities at work within the voluntarist sector structures, not all missions could navigate the tensions so deftly. A contrasting mission, who struggled to find their place as state volunteers and who began their medical missionary work in the 1950s, were the Pentecostals and Scottish Presbyterians at Sandema in the Northern Territories. Whereas the strength of the sdas ensured that they could evangelise locally and even innovate in remaking boundaries between medical authority and spiritual authority, the Scottish Presbyterians had little of the resourcing, personnel power, or state links that would make this possible. Notably given their role only a decade or so previously, by the 1950s the Scottish Presbyterians found themselves unable to benefit from the resources the voluntarist sector was affording to many medical missions. The category of the volunteer was not neutral or depoliticised in development, but bound up with national and international political changes that informed its shape and determined who it empowered.

The Scottish Presbyterian mission began with two Assemblies of God Pentecostals who pioneered mission work in the Northern Territories in the 1930s. In 1951 Reverend William Lloyd Shirer, who had been at odds with the Gold Coast colonial government for twenty years, took a job with them as a community development officer. Shirer and his wife Margaret had toured the hinterlands since 1930 and built an Assemblies of God station among the Dagomba. In 1950, British colonial policy shifted direction and the Northern Territories was included partially in the expansion of mass literacy and health care, reshaping missionary roles within the neglected region. With fluency in two African languages and a wide network of local contacts, Shirer became a prime target for government recruitment. Shrewdly he accepted the new offer to the Department of Social Welfare and Community Development, and Margaret was given a role as director of the Vernacular Literature Bureau.¹⁴³ With little evidence of why they made the switch from strictly ‘religious literacy’ to government education work, it has been suggested that debates over ‘social mission’ encouraged their move.¹⁴⁴ Perhaps as well, the Shirers exemplify the pure opportunism that mission sometimes required. Abruptly, they had gone from religious mavericks to hot property in the eyes of the state and it seems likely that the couple simply used this to the advantage of Protestant mission. As shown in their work with the Scottish Presbyterians, in addition to the Shirers’ new employment they continued to scout out opportunities for missions, using their knowledge and political clout to open the doors wide to incoming teams.¹⁴⁵

Through their government position, the Shirers facilitated the Scottish Presbyterian medical mission among the Builsa in the Northern Territories which ran from 1955 to 1972. As it was originally designed as a church planting mission and then adapted to suit the large medical needs of the local population, the project was desperately underfunded. It was mostly staffed by volunteers and unpaid Scottish nurses married to clergy. Nevertheless, with the Shirers’ advice and contacts, the mission drew in crowds of local people for the church and medicine, forged long-term relations with communities, built several buildings, became a focus for vaccination programmes, and set up an ad hoc but vital ambulance service to the local Catholic hospital. With only an empty government clinic arriving in the 1960s and a couple of Catholic priests in the adjacent area, for almost twenty years the Presbyterian group provided the sole biomedical care to a region of around 70,000 people.¹⁴⁶ As a result of the Shirers and alongside evangelism, ministry, and sustained church growth, the Presbyterians created the first elements of biomedical health infrastructure in the area.

The mix of government administration and church-funded mission work between these adroit Pentecostal ministers and Presbyterian medical workers typifies how fluid the boundaries continued to be between the sacred and the secular in health care on the eve of the Gold Coast’s decolonisation. Health care in Sandema was part of a large-scale increase in medical mission in the 1950s which spanned across the Gold Coast, including the North, and was backed by a great deal of government funding. There was a plethora of different forms of medical mission involved in this process, which together had nevertheless transitioned into a formal voluntary sector by the end of the 1940s. As a result of a blend of colonial policy making, government decisions, and missionaries’ aims, the expansion was defined by contractual relations to the state. At the same time, informal collaborations remained essential to the sustainability and effectiveness of the missions, especially in local relations with communities, government, chiefs, and other missions. There were limits to formal government control and informal relations remained significant to the growth of mission.

By contrast with the sda mission, the Scottish Presbyterian medical mission in Sandema in the Northern Territories had a stronger sense of themselves as volunteers, but could not fully benefit financially from the formalisation of the voluntary agency sector. In terms of their own self-identity, a form of voluntarism mattered far more to the Scottish medical mission at Sandema than it generally did to the sdas. All of the health workers and nurses at Sandema were literally unpaid until 1966 when they employed their first professional member of staff. Before that, the medical mission was informal and unsystematic; it was funded by the Scottish Foreign Mission board but only for the church ministry that it was setting up. It must be noted here that while the Northern Territories were included in the 1950s development agenda, this certainly was not such a radical alteration, since it still remained the neglected region of the colonial state. The medical work, which comprised a huge amount of the mission’s actual efforts, did not earn anything. It was supplied by individual nurses and ministers’ wives filling their suitcases with medical equipment and drugs on the way to the Gold Coast. They also personally fundraised on furloughs by travelling around Scotland in all weather conditions including thick snow, and at churches’ ‘bandage Sundays’, women’s guilds, and Sunday schools. In a letter to the partners of the mission, its leader Colin Forrester-Paton wrote that ‘30 or 40 … [come] every morning for treatment … government had to withdraw the African nurse from the existing Sandema Dispensary … Mrs Duncan originally planned to do something for mothers and their children but as soon as it became known that she was a nurse, people began flocking to her’.¹⁴⁷

Louise Duncan was the wife of Robert Duncan, the minister attached to the mission, and had almost no knowledge of the Gold Coast or Africa at all when she arrived in 1956. Unlike the Forrester-Patons who had Oxford degrees, the Duncans were working-class Glaswegians with Robert being the first to attain higher education in his family. Using local networks and connections, Colin Forrester-Paton attempted to get funding from the government under their expansion of medicine in the Northern Territories, but was never successful. He wrote in 1957 that the government offered ‘to provide a building, medical supplies and a junior assistant for any missionary nursing sister’, but nothing arrived, except an assistant in 1959. Instead, the medical mission was set up on a shoestring, with a Jeep for taking emergency cases to Navrongo Hospital about 18 miles away, catering for around 70,000 Builsa in the region.¹⁴⁸

The Sandema missionaries struggled with disgust, contracting diseases, and treacherous journeys, and retold these experiences in terms of a volunteer’s sacrifice and overcoming. Unlike the settled hospital at Kwahu, the work at Sandema far more obviously exemplified the kind of adventurous ‘voluntarism’ that was being promoted in the os, the vso, and the Peace Corps in the 1950s. Some who staffed the medical mission were not even trained, and had to get used to dealing with sores and wounds. For example, Jean Paton, the wife of Colin Forrester-Paton, writes in her memoirs that when she had to bandage a septic leg in the dry heat of rural Sandema, she wished that she had had medical training. This visceral experience in a makeshift clinic without any real support or financial help pushed these missionaries to the edge. Similarly to how Julie Livingston has described negotiating disgust in Botswana, such experiences were also used in memory to construct a life-narrative of overcoming difficulty with self-sacrifice and by cultivating more dependence on the love of Christ.¹⁴⁹ Like many Peace Corps volunteers who reported not knowing what to do or how to help the places to which they had been sent, the Sandema missionaries were throwing their work together as it came to them.¹⁵⁰ Sometimes this was narrated in terms of impossible struggle, and other times in terms of achievement against the odds. Instead of working solely in the clinic, Jean Paton attempted to produce community health education and teach basic hygiene in order to best use her skills.¹⁵¹ Robert Duncan wrote to the mission board that ‘we are faced with the possibility of closing the clinic if we do not find someone. The great physical strain was seen in the contemplated outstation work, which has never been developed for obvious reasons. If a women’s worker were appointed of whom you had doubts about her ability to tackle the trekking, then there is no need for her do it. The clinic, the women’s class and the Sunday school in Sandema would offer her enough work without that strain’.¹⁵²

Local politics were a significant concern for the medical mission at Sandema. At the outset of the mission it was building relations with local chieftaincy, via interpreters, that ensured they were able to settle in the area. Across the life of the mission these negotiations continued to be vital. For chiefs the mission was useful: acting as ‘gatekeepers’ between the medicine, land, and community bolstered their legitimacy as spiritual and political leaders. In order to continually empower themselves, as Justin Willis has shown, chiefs constructed ‘elaborate political structures’ using different forms of knowledge.¹⁵³ Before colonialism most chiefs in the Northern Territories were not custodians of the land, but in the 1920s creating such administrative roles for them allowed ‘indirect rule’ to function.¹⁵⁴ Navigating these power dynamics was crucial: as Robert Duncan writes, for example, the chief in Doninga was pro-Roman Catholic so they could not go there. However, when a fight occurred between the Chuchiliga and Sandema Nabs the missionaries capitalised by joining in the peace process and making new contacts without having to travel. The result was that they ensured their welcome in Chuchiliga, and the ‘Kasem towns of Gbenia, Chiana and Ketiu’. As with many earlier pioneering missions, such as those described in nineteenth-century Uganda by Robert Rothberg in 1964, the Sandema missionaries were dependent on chiefs to make their ambitions grow into reality.¹⁵⁵ This was significant in an everyday sense. For example, Forrester-Paton describes how ‘by coming to our service in the Local Council Hall from time to time, with a group of elders and once at least with a large retinue of drummers’, the chief pronounced his authority as a Builsa and was able to surveil who was doing what. Forrester-Paton noted that this could be ‘awkward for the preacher who might find halfway through his sermon that he was speaking to a very different congregation’. The priority, he notes, was not in ‘converting the Chief’ but in ‘managing him’. The chief was the central authority in an area sidelined by the colonial state; he would invite an imam, he would attend the White Fathers events, and he would aid the Presbyterians because, as he once commented to Forrester-Paton, ‘when a girl has several suitors, she gets more gifts’.¹⁵⁶

In Marianne Gullestad’s Picturing Pity about a North Cameroon mission, she argues that missionaries fostered one-way relations with local communities because they only gave out aid instead of entering into meaningful, interdependent processes of exchange in which they received gifts too.¹⁵⁷ This has much merit: missions which had stronger and more formal relations with the voluntary sector in the Gold Coast did not need to ask communities for as much, and therefore they did not need to spend as much time considering the community’s way of seeing the world.¹⁵⁸ Situations of interpretation and exchange, in which intermediaries such as translators were critical power brokers, were not as common once missions had bureaucratised and formalised.¹⁵⁹

However, the missions Gullestad describes were still shaped by the cultural encounters into which they entered. As Jamie Scott has noted, even in contexts in which there was a significant imbalance of power, there was still a ‘constant commerce’ in which missions were changed by the places where they found themselves.¹⁶⁰ What was different about missions like the one in Sandema was that over a long period of living in the area, negotiating with political leaders, conducting clinic work and health care in homes, and eating in local markets, the missionaries became a part of the community. Robert Duncan wrote of one extraordinary moment when he led the community, who came to him for help during a drought, to pray over their crops – he recalled how rain suddenly began to fall.¹⁶¹

Though, for all their negotiations, not everyone in the community was enthralled by the Sandema mission – only illiterates, children, and the Sandema chief, according to nearby Catholics. From the local Catholic perspective, the Sandema and Assemblies of God missions were battling for influence amongst the population by negotiating with the chief and giving handouts to the poorest elements of the community (including soap and sweets), but not always successfully. In the White Fathers’ annual mission report for 1958 and 1959, the author wrote that the Sandema mission was brokering deals with the Sandema chief to its advantage. The Presbyterians were ‘working against the will of the Chief of Chuchiliga’, whereas in Sandema the chief seemed to be using ‘his influence and authority to more or less force some people to follow their catechism-classes’. The chief was also backing their move to place a Presbyterian teacher in their middle school by getting him to write to the Education Department at Tamale saying that there was no Builsa teacher capable of the post. The head teachers in the district attempted to force the chief to retract his letter regarding the lack of capacity. ‘Needless to say’, the White Father concluded, ‘the Presbyterians are looked upon with more and more suspicion by all the teachers and literate people’. The White Father noted that the Presbyterian pastor was giving milk to women and selling pieces of soap ‘at a greatly reduced price’, which was enabling them to enrol a ‘moderate group of illiterates’. By contrast, the literate classes had abandoned the Protestants and, according to the White Father, joined the Catholics. Finally, the report explained that another ploy of local Protestants, this time the Assemblies of God mission, had been to literally hand out ‘candies’ to children to attract them. This was followed, the report fumed, by a ‘violent outburst of shocking insults towards the Catholic Church’¹⁶² – though it claimed, with some satisfaction, that there were those who chose the Catholic Church over the candy.¹⁶³

Figure 1.4

‘White Fathers in the Northern Territories of the Gold Coast. The White Fathers – are responsible for a great deal of welfare work among the people of the Northern Territories of the Gold Coast … The motor cycle – which (more...)

Overall, the Sandema mission’s partial exclusion was part of a wider pattern in the 1950s; a key limit of the voluntary sector was that as the government focused on hospital provision, maternity and child welfare clinic work declined and then stagnated. New government funding was clearly not going into the same types of medicine that it was in the 1920s and 1930s when missions led the way in provision for child and maternal health. In 1952 the Ministry of Health had complained that it was struggling to find a sufficient number of trained health visitors.¹⁶⁴ In 1953 the death of rate of women during childbirth increased from 18.4 per 1,000 total births to 19.0 per 1,000. By 1954, it was at 21 per 1000 total births.¹⁶⁵ That year the medical report declared that ‘there appears to have been no real improvement in the Infantile Mortality Rate during the past 20 years’.

Infant and child mortality was generally lower in the 1930s than in the 1940s and 1950s; in the 1930s infant mortality was even reduced to 100 per 1,000 related births in one year. Obviously, the incorporation of greater amounts of people, population rises, and the extension of state surveillance will affect these statistics, but the general impression is of mixed success in the 1930s and serious issues in the 1950s. The infant mortality problem in particular was hotly debated in the Legislative Assembly, where the ministerial secretary for the Ministry of Health, J.K. Donkoh, blamed pregnant women for failing to attend hospitals regularly. At this some honourable members replied ‘Oh no! No!’ and Dr Ansah Koi argued that it was the lack of sufficient oxygen in hospitals. Another minister, Mr Boakye, blamed the problem on the lack of maternity clinics across the country.¹⁶⁶ Given how difficult a long journey to a hospital might be for a pregnant woman, and the general reduction in clinics and lack of local care, in a sense all these arguments had merit. As the American political scientist and sociologist David Apter wrote in 1955 from a field study with Gold Coast University on the Akuse dispensary, in the colony ‘the death rate is high, how high no one knows in precise terms. Dispensaries are few and far between. Health facilities are overcrowded. In some areas people are afraid to go to a hospital because so many people die there after having traveled many miles on foot, by canoe, or by lorry, arriving too late for effective treatment’.¹⁶⁷

Table 1.3

Gold Coast child and maternal health providers in 1945. (This was a considerable change from the dominance of the Red Cross in the earlier 1940s.)

Table 1.4

Gold Coast child health providers in 1950.

Table 1.5

Gold Coast child health providers in 1952.

Table 1.6

Gold Coast maternal mortality between 1934 and 1949. (Both rates reduced further slightly in the subsequent two years.)

Table 1.7

Infant and child mortality in the Gold Coast between 1934 and 1954. (It must be noted that for 1950–54 there was no accurate survey of the whole colony given the difficulty of gaining full government registration – for maternal morality, (more...)

Hospitals might provide a high level of care, but to even access one came with a high level of risk for most people. At the same time, it must be noted that when an antenatal care mobile clinic was run in HuHunya, it was ‘very poorly attended’.¹⁶⁸ At an antenatal care at Sandema some women were discouraged by their husbands from leaving the house to visit clinics. Therefore, house visits were required, which in turn required relationships of trust to be fostered over a long time so that decent care would be possible.¹⁶⁹ Skimming the surface of the problem could be just as ineffective as sporadically setting up white elephants. Though not everything had changed, in 1947 rising child and maternal health attendances had been assessed by the medical department as due to their becoming a ‘pleasant social event’, similarly to the Kumasi health weeks in the 1930s.¹⁷⁰ Overall, in spite of the issues, hospital construction continued apace.

CONCLUSION

The aim of the late colonial state was to create a large system paid for by government and staffed by Christian missions within a formal voluntary sector. Following the decline of the Scottish Presbyterians after 1927, the makeup of this sector was diverse, and the results of these various trajectories was complex, not uniform or unilinear. Mission culture was not simply determined by voluntarist political agendas, financial aid, or softly shaped voluntarist norms within the colonial state. Missionary responses and culture were determined by denomination, specific congregation, theology, location, timing, and generation – as much as by other forces. The concept of ‘voluntary’ was ambiguous and was deployed in contested ways across this period. The mission clinic at Sandema much more clearly shows the relevance of volunteering and the voluntarist lifestyle; however, unlike the sda mission at Kwahu, the Presbyterians could not fully benefit from the formal voluntary sector. The path was set for interventions which were scattergun and largely top-down, with much of state financing propping up hospital care that the majority of citizens were unable to access. A wholesale system based on sanitary policies driven by African voices was ignored. Instead, mission hospitals became the backbone of Ghanaian health care for the ensuing decades. This is the foundation on which later global health was based.