The international growth and influence of bioethics has led some to identify it as a decisive shift in the location and exercise of 'biopower'. This book provides an in-depth study of how philosophers, lawyers and other 'outsiders' came to play a major role in discussing and helping to regulate issues that used to be left to doctors and scientists. It discusses how club regulation stemmed not only from the professionalising tactics of doctors and scientists, but was compounded by the 'hands-off' approach of politicians and professionals in fields such as law, philosophy and theology. The book outlines how theologians such as Ian Ramsey argued that 'transdisciplinary groups' were needed to meet the challenges posed by secular and increasingly pluralistic societies. It also examines their links with influential figures in the early history of American bioethics. The book centres on the work of the academic lawyer Ian Kennedy, who was the most high-profile advocate of the approach he explicitly termed 'bioethics'. It shows how Mary Warnock echoed governmental calls for external oversight. Many clinicians and researchers supported her calls for a 'monitoring body' to scrutinise in vitro fertilisation and embryo research. The growth of bioethics in British universities occurred in the 1980s and 1990s with the emergence of dedicated centres for bioethics. The book details how some senior doctors and bioethicists led calls for a politically-funded national bioethics committee during the 1980s. It details how recent debates on assisted dying highlight the authority and influence of British bioethicists.
In 1954 a Nigerian man named L.S. arrived in the United Kingdom to study carpentry at the L.C.C. School of Building in Brixton.1 Within eight months of his arrival in the UK, L.S. suffered a mental breakdown. In April 1955 he was admitted to the Warlingham Park Hospital, having developed a ‘strong persecution mania’.2 Hospital attendants described him as ‘extremely depressed, agitated and unsure of his surrounding’. He claimed he was about to die and that he heard voices calling his name in his native language.3 With auditory hallucinations ongoing in a patient saddled with what his doctor termed ‘an inadequate and dependent personality’, his British doctors determined that it was ‘unwise to encourage his continued stay in this country’ and recommended that he return to Nigeria for further care.4 On 23 February 1956, L.S. sailed on the Elder Dempster ship Apapa, arriving in Lagos some twenty-one days later, repatriated under paid escort at the expense of the government of the United Kingdom.
L.S.’s repatriation was not unique. Over the course of the British colonial era in Nigeria, which lasted from roughly 1900 to 1960, hundreds of immigrant Nigerians succumbed to mental disorders while living outside of Nigeria. Many dozens were repatriated as a result, supposedly in their own best interests to optimise their recovery. Repatriation of those deemed mentally ill was, however, a complicated process involving a variety of medical, governmental and corporate authorities, not least of which was the shipping firm of Elder Dempster & Company, which held a virtual monopoly over the carrying trade between the UK and its West African colonies for more or less the entirety of Nigeria’s colonial history. This chapter examines the relationship between Elder Dempster and the medical and governmental authorities within the British Empire. I argue here that this relationship represents an example of the importance of public-private cooperation in the maintenance of the medical geography of Empire, even as it reveals significant tensions underlying such cooperation.
Histories of psychiatry in colonial settings remain significantly state centred.5 However, historical and anthropological studies of health and illness in Africa more broadly have established quite definitively that the state by no means controlled the ways that knowledge about health and illness was created and interpolated in colonial and post-colonial environments. 6 Indeed, the important and sometimes influential role of non-state actors in the development of psychiatric science has been increasingly recognised in more contemporary contexts, as psycho-pharmaceutical companies exert influence on both medical and state authorities, shaping the very understanding of the diseases that their products treat and blurring the line between patient and market.7 However, the pharmaceutical industry’s motivation for inserting itself into debates about mental health and illness is in many ways much more direct and its impact much more obvious than that of Elder Dempster. This chapter thus seeks to look ‘beyond the state’ by expanding upon the understanding of the indirect role that capitalist enterprises have played in reinforcing imperialist notions about the relationship between citizenship, psychopathology and cultural geography in the British Empire.
The first section of the chapter makes the case that Elder Dempster’s role in transporting mentally ill Nigerians allowed for the implementation of colonial psychiatric theories about the nature of mental illness in Africans in ways that would have otherwise been unfeasible. As such, Elder Dempster was engaged in a medical procedure as much as in a commercial shipping transaction. Repatriation was a vector of therapy similar to the syringe used in an injection or the capsule holding the active ingredients of a pharmaceutical concoction. Transporting mentally ill Nigerians was not just a political or economic expediency. In the context of colonial psychiatric theories that emphasised the psychological threats of cross-cultural exchange, returning mentally ill migrants to the geographical spaces where they ‘belonged’ was itself a means to a therapeutic end. Elder Dempster was therefore a role player in the medical infrastructure of the British Empire, just as it was in the facilitation of administrative and commercial networks.
The second section of the chapter moves from discussing the cohesive role of Elder Dempster as a medical collaborator to examine the tensions that arose from utilising a public-private relationship for such purposes. Organising repatriations of mentally ill immigrants revealed underlying tensions between the practice of colonial medicine (or, more accurately, the practice of medicine on colonial subjects), the legal rights of British colonial subjects and the corporate liabilities of privately held businesses like Elder Dempster. Despite the fact that Elder Dempster was performing this medical procedure (repatriation) on behalf of the government, it was not itself a government agency and, as such, never enjoyed the coercive powers of the state. As we will see, legally speaking, passengers on Elder Dempster lines could not be certified mental patients, despite the fact that they were being transported for psychiatric purposes. This made the prospect of transporting unstable individuals somewhat unappetising for the company. However, Elder Dempster also desired to maintain good relations with the British government and to continue to enjoy a privileged position as a monopoly over public shipping to and from West Africa. This sometimes required engaging in risky endeavours that the company would otherwise eschew based on strictly commercial grounds. Negotiations over the appropriate procedures for carrying out repatriations therefore became tense and their results somewhat nebulous from a policy standpoint, but they nevertheless usually resulted in the repatriation of the patient in question. Thus, in more than one way Elder Dempster became a ‘go-between’ for the British Empire. The company quite literally linked the physical spaces of the UK, Nigeria and other West African colonies, while it also figuratively inhabited the space between the will of government and medical authorities, on the one hand and the legal rights of their passenger-patients, on the other.
Elder Dempster, Nigerian ‘lunatics’ and the medical geography of Empire
This section examines the ways in which Elder Dempster’s involvement in the repatriation of mentally ill Nigerians were seen as part of a medical procedure designed specifically to address the psychological turmoil of the patient-passengers to whom it was prescribed and which medical authorities were ill-equipped to carry out on their own. In so doing, it addresses the construction of a medical geography of Empire that defined colonial subjects as psychologically suited to particular spaces and threatened by the crossing of cultural boundaries. Colonial medical departments across British-controlled Africa had played an extremely important role in developing this medical geography. They had established asylums throughout British Africa for the confinement of particularly violent and dangerous ‘insane’ colonial subjects and in so doing had created the space within which colonial ethnopsychiatrists developed theories about the nature of the ‘African mind’ that defined the African in general racial terms as mentally inferior to the European and therefore psychologically threatened by European ‘civilisation’. These theories, developed within the structures and institutions of colonial medical departments and, frequently, through the research and pronouncements of colonial medical officials (among others), filtered out from the colonies to affect the way medical and governmental officials in the United Kingdom thought about the causes of mental illness in immigrant Nigerians. However, it was through negotiations between the Colonial Office and Elder Dempster that repatriations were mostly arranged, with the colonial medical department in Nigeria playing only a minor role in confirming or denying accommodation for the patient on his return. But through these negotiations Elder Dempster became integral in the realisation of a medical process that colonial medical departments could not have enforced on their own: that of removing immigrant Nigerians from a society that was presumed to be psychologically damaging and returning them to cultural surroundings – and possibly the care of colonial medical authorities – in the places where they ‘belonged’.
Migration was a cornerstone of European empires in Africa in the nineteenth and twentieth centuries. Over the course of time African subjects of European empires migrated within colonies from rural areas to urban areas, from areas with depressed economies to places where jobs were available, and from places far removed from the centres of power, wealth and education to places of greater opportunity.8 Nigerians were no exception to this rule. In the early twentieth century, most migration of Nigerians took place within Nigeria and to neighbouring colonies in West Africa. Some, however, travelled to Great Britain, the United States or other Western countries as students, soldiers, or wage labourers in the shipping industry. Still others travelled eastwards, fulfilling their Muslim duty of pilgrimage to Mecca.
It is difficult to know at what rates Nigerian immigrants fell victim to mental illnesses severe enough to warrant the attention of medical authorities, and certainly the medical and governmental gaze varied in emphasis across space and time. Nevertheless, evidence exists that Nigerians whom local authorities deemed to have lost control of their mental faculties were present in all of these regions of the world.9 As early as 1916, British colonial authorities in the Gold Coast (Ghana) sought unsuccessfully to repatriate sixteen Nigerians resident in the mental asylum in Accra.10 In 1927, France unsuccessfully sought to repatriate a mentally ill African named M.Q., supposedly of Nigerian origin, who had suffered a brain injury as a soldier in the First World War and somehow found his way to Paris, where he was living in conditions of ‘starvation and exposure’.11 But by far the most prevalent source of documented requests for repatriation of Nigerian mental cases came from the UK, and came in the post-Second World War period as increasing numbers of Nigerians travelled to the UK for work and higher education.12 Although repatriation requests from before 1945 show scant documentation and were rarely successful, repatriations from the UK in the post-war era were commonly executed, and the repatriated mental patients almost always travelled home on an Elder Dempster ship.
Elder Dempster’s indispensable role in linking the UK and its West African colonies in terms of commerce, communications and passenger traffic stems from the twinned growth of steam shipping and the extension of the British Empire into West Africa in the second half of the nineteenth century. The first major British shipping mogul in West Africa was Macgregor Laird, who famously started the African Steamship Company in 1852, just one year after the British had officially annexed Lagos. Laird’s company was primarily interested in the palm-oil trade in the Niger river area, but also called at a variety of other West African ports and in the 1850s became the official mail carrier between the UK and West Africa. In 1868, two former employees of Laird’s Liverpool agents, Alexander Elder and John Dempster, founded a competing firm, named the British and African Steam Navigation Company. A third employee of the African Steamship Company, Alfred Jones, began his own line in 1878, and began chartering goods to West Africa in 1879. Jones’s early success resulted in Elder and Dempster bringing him on as a partner, forming Elder Dempster & Co. as agents of the British and African Steam Navigation Company. Jones became the senior partner and chairman of Elder Dempster in 1884 and worked to build Elder Dempster into the pre-eminent shipping firm for the British West Africa trade. Through the establishment of partnerships, stock purchases, and a shipping conference with its competitors, Elder Dempster established an almost complete monopoly over the carrying trade between the UK and West Africa by the turn of the twentieth century.13
This monopoly included the carriage of passengers. Olukoju has noted that, while official passenger data are hard to come by, it is likely that most passenger traffic was directly related to colonial governance, particularly the movement of colonial officials and their families booked at government expense. By the 1920s, with an increase in competition from foreign shippers in the wake of the First World War, the British government instituted a policy requiring all government bookings for passengers to and from West Africa be made through the British-owned Elder Dempster line.14 Although many officials balked at this policy because Elder Dempster did not always provide the cheapest, fastest or most comfortable passenger service, the policy remained in place through the 1950s. Therefore, when the British government wanted to repatriate Nigerian mental patients, it was bound to do so through Elder Dempster as a first resort, and Elder Dempster had every motivation to work with the government to illustrate that this privilege was deserved.
But why ask Elder Dempster to carry out the repatriation of Nigerian mental patients? Nigerians were British subjects, after all, and had full right of residency in the UK. They were legally entitled to live, work and receive medical care indefinitely in British-controlled territories and could not be compelled to return to their native homes against their will, even if they were certified mental patients. One might assume that the first and most obvious option was to care for them in hospital in the UK, providing treatment and accommodation until such point as they were capable of looking after themselves. Indeed, the spirit of both British and British West African law throughout the colonial period held that ‘wherever people become lunatics, there they remain’.15 Even after repatriation of Nigerian mental patients became commonplace from the UK in the 1950s, some colonial officials wondered what was the reasoning behind the procedure. Nigerian medical infrastructure certainly could not rival that of the ‘imperial motherland’. Psychiatric facilities in Nigeria were particularly unpleasant, characterised as overcrowded, understaffed and offering nothing in the way of therapeutic care.16 The disparity was stark enough that one Nigerian official queried,
I presume there must be full legal sanction for banishing these unfortunate people from Britain? Their fate on returning here must in most cases be pitiable … if they do not return home as useless and despised members of their own communities they have mostly, as the only alternative, to be confined in crowded and deplorable sections of prisons reserved for those in such a plight.17
That repatriation of British subjects to their lands of origin was a reasonable way to handle cases of psychological disorder was certainly neither a legal nor a medical inevitability.
The motivations for repatriating Nigerians who developed mental illnesses in the UK were based to a certain extent on financial concerns. British officials often saw the expenses incurred in their daily maintenance of non-native British subjects in their local hospitals and asylums as an undue burden on government resources. Financial considerations, however, were not sufficient to justify the relocation of a certified mental patient. Based on British and British West African law, mental patients could not be moved if the primary motivation was government convenience. British subjects could be repatriated only if medical authorities agreed that such repatriation would likely result in an improvement in the patient’s material circumstances or medical condition. Luckily for government officials who had a vested financial interest in repatriating Nigerian mental patients, in many cases medical authorities were, indeed, of the opinion that repatriation should improve the mental health of unstable Nigerians.
The medical justification for repatriating Nigerian mental patients was deeply rooted in ideological perspectives on the relationship between race, culture and human psychology that developed in the context of a European imperialism that sought to explain the power dynamics of Empire in scientific terms.18 The literature on race and colonialism is abundant, and beyond the scope of this chapter, other than to say that the cultural politics upon which the British Empire were based in the first half of the twentieth century overwhelmingly cast the European coloniser as the arbiter of justice, decency, intelligence, rationality and ‘civilisation’, in diametric contrast to black Africans’ presumed injustice, indecency, unintelligence, irrationality and overall primitivity. While innate biological differences were strongly purported to account for the perceived disparity between white and black races early in the twentieth century, particularly through the findings of eugenicists like H.L. Gordon, H.W. Vint and their cohort in the East African school, by the 1930s, anthropologists and social scientists had begun to explain the difference between the races largely in cultural terms.
Psychology and psychiatry had an important role to play in defining the differences between social and cultural systems and, ultimately, the presumed effects of culture on the psychological and intellectual processes of individuals.19 Pseudo-scientific studies created the impression that the black and white races were, if not innately different, at least very far apart in terms of cultural evolution. Such a presumption allowed for an explanation of European will to power in African environments in terms other than exploitation and extraordinary violence. However, it also created a context in which European scientists, anthropologists and, ultimately, colonial officials became preoccupied with the presumed consequences of the ‘clash of cultures’ that emerged when Europeans and Africans came into contact. If the intellectual and cultural nature of the European was inclined towards justice, order and progress, then this psychological predisposition would be significantly frustrated and or/degraded by living in the African’s diametrically opposite socio-cultural milieu. The trope of ‘going native’ so famously embodied by Joseph Conrad’s Kurtz in Heart of Darkness was representative of real concerns amongst Europeans about the psychological consequences of imperial domination. In fact, British West African colonial governments had developed de facto policies for the repatriation of Europeans who developed mental illnesses in Africa long before they ever contemplated having to repatriate Africans from Europe.20 For example, British and American medical thought frequently identified geographic locale as contributory to the causes of a nervous condition in whites living in tropical environments known as ‘tropical neurasthenia’. Repatriation of white neurasthenics became a common political, social and medical remedy to the problems posed by a mental illness presumably caused by exposure to alien environments.21
If crossing these racial-cum-cultural boundaries was a psychological threat to Europeans, the consequences were heightened for Africans. European colonialism in Africa brought significant upheavals of political, economic and cultural traditions of African societies. For European ethnopsychiatrists, such upheaval was a good thing in the long term, as it would bring Africans closer to the level of ‘civilisation’ that Europeans enjoyed. However, it posed serious short-term psychological consequences for Africans ill equipped to handle the transition from a presumably unchanging, ‘traditional’ existence to a highly dynamic ‘modern’ world. Although there were a few detractors, psychological studies of Africans before the 1960s tended to support the notion that, in general, adult African intelligence was inferior to that of the adult European. Inferior intelligence was deemed to be both a cause and a consequence of cultures that failed to produce productive, introspective individuals. Unlike in European cultures, which valued individuality, ambition and self-awareness, ethnopsychiatrists argued that African cultures emphasised conformity, communalism and the sublimation of the individual to the community and the supernatural. For acclaimed ethnopsychiatrists like J.C. Carothers, the communally oriented, extroverted, unambitious, superstitious, unintelligent African lacking introspective insight and living only in the present and without a care for the future became the default definition of the ‘normal’ African.22
Mental illnesses in Africans were characterised by deviation from this norm. As Megan Vaughan has noted, the ‘mad African’ was frequently constructed as the ‘colonial subject who was insufficiently “Other” – who spoke of being rich, of hearing voices through radio sets, of being powerful, who imitated the white man in dress and behaviour’.23 In other words, Africans who deviated from their ‘traditional’ norms and blurred the arbitrary cultural boundaries between white European and black African were considered the most psychologically vulnerable segment of African populations. Ethnopsychiatrists dubbed the adoption of European norms by Africans ‘deculturation’ or ‘detribalisation’, and considered it amongst the biggest threats to African mental health by the 1950s.
Such conditions were seen to be an encroaching threat in African spaces as a result of colonisation. However, when an African travelled away from his native home, particularly to Europe, the heart of modern civilisation, the psychological stakes were obviously raised further. By the 1950s, psychiatrists and social scientists were beginning to show serious concern over the perceived high levels of mental breakdown amongst West Africans in the UK. Both Margaret Field, an anthropologist working in Gold Coast, and Raymond Prince, a psychiatrist working in Nigeria in the late 1950s, expressed concern over the recognisable preponderance of psychiatric disturbance amongst West Africans who travelled to the UK for higher education.24 Studies conducted in the UK on psychiatric morbidity in student populations seemed to uphold the idea that Nigerian students were particularly vulnerable to mental breakdown while abroad. For example, in a 1960 study of mental health in overseas students at Leeds University R.J. Still found that Nigerian students had a more than double rate of ‘psychological reactions’ – ranging from the ‘severe’ to the ‘trivial’ – than native British students.25 In a later study, Cecil B. Kidd, of the Department of Psychiatric Medicine at Edinburgh University, saw similar results, with conspicuously high rates of mental breakdown amongst Nigerian students.26
Regardless of the purported ‘cause’ of the mental breakdown, medical authorities frequently articulated that their Nigerian patients were incapable of recovering in an alien cultural environment like that of the UK and, frequently, that returning to more familiar cultural surroundings would be psychologically beneficial. Repatriation was, then, not just a means for the British government to save taxpayer money, it was constructed as a medical intervention in its own right. Take, for example, the case of M.O., a nineteen-year-old Nigerian admitted to Saxondale Hospital in Nottingham with schizophrenia who applied for repatriation in 1950. The hospital staff supported the repatriation on the grounds that ‘the boy is unlikely to make a full recovery until he gets home’.27 Similarly, G.N., a twenty-six-year-old patient in Bristol Mental Hospital diagnosed with ‘reactive depression with gross hysterical phenomena’, applied for repatriation in 1952 and was supported in this decision by psychiatric authorities who considered repatriation ‘essential to complete recovery’.28 The doctor of P.A., a Nigerian ‘said to be suffering from serious mental disability’ in 1956 declared that ‘in view of his mental condition, he would best be treated in his own country’.29 The exact same wording was used to support the repatriation of N.U., who suffered from ‘schizophrenia of an intense and paranoid type’. The consultant psychiatrist at Long Grove Hospital in Surrey informed the Colonial Office in 1958 that ‘the sooner he can be repatriated the better’.30 All of these patients were repatriated on Elder Dempster ships.
In carrying out the repatriation of Nigerian mental patients, Elder Dempster was simultaneously engaged in a medical intervention and a reinforcement of the medical geography of the British Empire that both defined particular bounded spaces as natural cultural milieus for colonial subjects of different races and at the same time articulated psychological threats for individuals who crossed those boundaries. Clearly in these cases, and the many more not described in this chapter, the repatriation of West Africans was not just an exercise of their rights as British subjects, or of their desires as alienated individuals, but also an integral part of the treatment of their mental disorder. It should also be noted that the diagnoses in the cases mentioned above were diverse, yet in all of them, repatriation was considered to be a necessary therapeutic intervention, an intervention more powerful than anything that could be provided under current circumstances in a ‘modern’, but nonetheless alien country. Elder Dempster played the role of helping Nigerian mental patients to at least partially ‘un-cross’ some of the racial and cultural boundaries that had supposedly contributed so greatly to their psychological disturbance, thereby presumably simultaneously strengthening the social health of the Empire and the health of individual patients.
Repatriating mental patients and the tensions of Empire
Elder Dempster’s role in repatriating Nigerian mental patients is an illustration of the ways that business entities could be important participants in the reinforcement of the ideological underpinnings of the British Empire. Additionally, this trend should be seen as revealing of some of the anxieties of maintaining imperial order, particularly if one examines the tensions that clearly existed between Elder Dempster and the government during cases of repatriation. While desire to maintain a racially segregated social order may have implicitly motivated recommendations for repatriations, the logistics of carrying out these repatriations were not so simple. Transporting mentally ill Nigerians from the UK to their native homes proved to be a relatively complicated process that required balancing the medical needs and legal rights of the Nigerian patient with the financial constraints of government and the liability concerns of Elder Dempster, the central question being who, ultimately, was the responsible party carrying out the repatriation: the individual patient, the British government, the medical authority recommending the repatriation or Elder Dempster, on whose property the patient resided during the voyage home? On top of the difficulties posed by this question, the answer had to be agreeable to all parties and make more sense than simply not repatriating the patient at all. This section examines these tensions, illustrating the ways that Elder Dempster’s position as a private enterprise sometimes conflicted with the interests of its primary client, the British imperial government. Even within these tensions, however, we must recognise that neither Elder Dempster nor the Colonial Office particularly questioned the underlying notion that repatriation was good for mentally ill colonial subjects. They were mostly concerned with the legal contradictions of trying to give Elder Dempster – a private shipping company – the necessary coercive powers of medical and governmental authorities in order to carry out a procedure that those authorities had ordered and which Elder Dempster had agreed to execute, but for which no party wanted to take responsibility.
As mentioned above, British law did not allow for the forcible removal of any certified mental patient, regardless of race, culture or nationality, from one place within the Empire to another. In order to repatriate a non-native mental patient, the patient had first to be decertified, legally restoring all the rights and responsibilities of a normal, healthy individual. Patients then had to undergo travel to their homelands, where their psychological state could be re-evaluated on arrival. However, even after decertification from the mental hospital, no British citizen or colonial subject could be forced to return home. Consent to repatriation was a sine qua non for their removal. In most of the Nigerian cases for whom I have records, this was of little relevance, as the patient was usually keen to return home, particularly if it might mean release from a mental hospital in the UK. However, some were reluctant, even outright refusing repatriation when it was suggested to them.31 In these cases, the possibility of repatriation was a non-starter. So it is indeed possible to make the case that individual Nigerians themselves were responsible for their own repatriations, as their consent was necessary in order for it to happen at all.
Elder Dempster, however, was not satisfied to allow mental patients returning home to travel entirely on their own recognisance. Although Elder Dempster had been repatriating mental patients from the UK and in between British West African territories since the early twentieth century, there does not seem to have been a particular policy in place for such repatriations until after the Second World War. Several bad experiences had convinced the shipping firm that the patients being repatriated on their ships were frequently far more unstable than medical or governmental authorities knew or were willing to divulge. For example, in 1945 Elder Dempster transported a man named L.L. from Accra to Lagos. L.L. had recently been decertified and discharged from the Accra Mental Hospital for the purpose of repatriating him to Nigeria. It was presumed that L.L. was fit to travel, but he made a ruckus on the voyage, causing Nigerian officials to note when he arrived that ‘his behaviour en route to Lagos suggests … that he is still liable to fits and is of a violent nature’.32 Later, in 1950, Elder Dempster noted that ‘two recent deaths’ of mental patients en route from the UK to their homes in West Africa had illustrated to the company the need to have much more detailed medical histories of the mentally ill passengers it agreed to carry.33
Such outcomes should not necessarily be surprising. Indeed, for many of the cases mentioned above, the repatriation was implemented not as the happy ending to a medical crisis overcome but, rather, as a medical intervention in its own right, implemented in the belief that it would help to improve the health of patients who were clearly still suffering. Elder Dempster was quite aware that many of the patients suggested for repatriation remained unstable and were being decertified only for the legal purpose of putting them on a boat home, not because they were capable of looking after themselves. Carrying such passengers put Elder Dempster at some significant liability. Violent or uncontrollable passengers posed potential threats to the security of the crew and other passengers on the vessel, which reflected poorly on Elder Dempster. At the same time, Elder Dempster took on significant responsibility for the welfare of the patient during the voyage. And taking passengers with known behavioural issues without having a reasonable policy for their neutralisation on board only put the company at greater legal risk, should that patient cause any harm to person or property. Despite the legal responsibility placed on the patient for the decision to return home, Elder Dempster carried significant responsibility for making sure that the voyage went as smoothly as possible.
In order to address what it considered to be the ‘somewhat unsatisfactory’ experience of repatriating mental patients, Elder Dempster approached the Colonial Office in 1950 about developing a procedure that would simultaneously protect ‘abnormal passengers’, other voyagers on the vessel and the company itself from liability if and when things went badly.34 In a despatch from the Colonial Office to the Crown Agents of British West Africa, the Colonial Office made it clear that Elder Dempster was ‘agreeable to carry uncertified patients’, and that ‘normally no difficulties need arise with such bookings’. However, the company demanded that certain protocol be observed. First, suitable accommodation for the patient had to be available. Second, the person or authority making arrangements for the repatriation of the patient had to supply a case history of the patient to the ship’s surgeon and make arrangements for six passengers to act as attendants for the patient at the remuneration rate of £1 a day each.35 Finally, and most problematically, Elder Dempster was adamant that any medical directives suggested by the medical superintendent of the company for the treatment of the patient must ‘be accepted on behalf of the patient’ by a responsible third party.36
The rationale behind Elder Dempster’s demands was somewhat complex. On the one hand, Elder Dempster wanted to be informed of the case history of every patient and to have consultation with the doctor previously in charge of the case in order that the company’s medical superintendent might have the necessary information to make proper decisions regarding the care, treatment and accommodation of the patient during the voyage. However, on the other hand, the demand that the decisions of the medical superintendent were to be accepted on behalf of the patient suggested that the company wanted to transfer responsibility for the decisions that its employees made regarding the treatment of mentally ill patients. Simultaneously, the demand that the person or authority making arrangements for the patient also make arrangements for six attendants further guaranteed that Elder Dempster could not be held responsible for any action taken towards the patient by the very attendants that the company had demanded be there in the first place. In other words, Elder Dempster was trying to have its cake and eat it too.
Elder Dempster believed these requests to be perfectly reasonable in light of what the government was requesting of the company, i.e. the transport of unstable individuals who it knew needed serious medical attention and who could pose significant risk to other passengers and the company’s reputation and assets. However, from the perspective of some British officials, some of these requests were fantastical. Legally speaking, once the patient was decertified and discharged from the mental hospital in the UK, no ‘responsible party’ could consent to medical directives issued by Elder Dempster on his or her behalf. The Minister of Health made clear that in such cases ‘there would be no objection to a case history and a certificate being furnished’, but scoffed that ‘the Minister could not agree to … being asked to make arrangements for the passage which would involve his accepting responsibility for any untoward incident which might arise on the ship’.37 From the Colonial Office’s perspective, there were ‘grave doubts whether a patient could be lawfully compelled to undertake a voyage or constrained to comply with the conditions prescribed by the Medical Superintendent of the Company without his consent’.38 The point was moot anyway, from the Colonial Office’s perspective, since even if a third party took responsibility for the recommendations of the company’s medical superintendent, if the patient decided to sue Elder Dempster for mistreatment ‘the Company will not thereby be relieved of responsibility’, because no third party had the legal authority to consent to the forced medical treatment of an individual who at the time of the voyage was not a certified mental patient.39
The Colonial Office ultimately considered that in most cases the authority of the ship’s captain under common law would afford a ‘legal justification’ for the use of restraint, although not necessarily in all cases. Since no third party could provide such protection, the Colonial Office suggested that ‘where it is possible … the patient himself, or if he is under age, his parent or guardian, should be asked to give a written consent to the proposed conditions before the voyage begins’.40 Recognising the irony of this, Elder Dempster queried the Colonial Office, ‘to whom is it proposed a patient himself should give a written consent? If to an acceptable person or authority making arrangements for the voyage who in turn would instruct us in writing all well and good but we are afraid we would decline to accept any undertaking signed by a mental case, which to our mind would have no legal value.’41 Such a statement is a clear indication from Elder Dempster that the company did not consider these patients to be worthy or even necessarily capable of personal sovereignty.
The legal peculiarities put both the Colonial Office and the company between a rock and a hard place. While it was recognised that the individuals involved in these repatriation cases were frequently not capable of making decisions for themselves, legally no one else could take responsibility for them. The Colonial Office finally relented, informing the Crown Agents that ‘whether or not the patient gives such a consent, a member of his family should be asked to give his concurrence’ to the company’s prescribed directives. Barring a family member, ‘either the person or authority making arrangements for the voyage, or the medical authority in whose charge the patient has been, must assent to the prescribed conditions on his own responsibility’.42 In response to the legal absurdity of such an approach, the government of Nigeria pointed out the futility of the situation, declaring that ‘it is not clear what advantage the Company expects to obtain’, as ‘the consent suggested can be of no legal avail to the Company in respect of any liability which they may incur’.43 At best, the Nigerian government argued, such consent could be used to delude the patient, and possibly his or her family, that any actions taken were legal and that the company bore no responsibility for any outcomes resulting from their imposition. Regardless, the Nigerian government acquiesced, stating that ‘if, however, such a covenant will make the Company feel easier in accepting a patient as a passenger, this Government sees no further objection to its being obtained from them’.44 The Colonial Office also recognised the legal futility of such an arrangement for Elder Dempster’s purposes. In the first draft of its despatch to the Crown Agents on the subject, the Colonial Office had urged the Crown Agents to go along with it on the grounds that it was ‘unlikely that further discussions would secure terms in any way more satisfactory or precise’ and that ultimately it was ‘satisfactory to have received a recorded assurance from the Company of its readiness to accept bookings for mental patients’.45 This rationale, however, was edited out of the final draft.
The procedures outlined by Elder Dempster became official policy from 1950 onward, although particulars of each case were determined on an ad hoc basis. Over the course of the 1950s, literally dozens of Nigerians were repatriated using these procedures. So many mental patients were being repatriated that by 1955 a colonial official in Nigeria declared that ‘nearly every mail boat brings one such person’.46 Most repatriation cases seem to have gone quite smoothly, at least from the records left behind, although problems did still arise. Nevertheless, it is important to note that the policies put in place accomplished more than securing reasonable accommodation for patients and other passengers. Although the demands made by Elder Dempster to defray responsibility for mistreatment of repatriated mental patients did not in and of themselves provide legal absolution, the heightened levels of observation and longer paper trail resulting from the institution of this policy did tend to work in Elder Dempster’s favour.
Take, for example, the case of A.H., who had arrived in the United Kingdom in 1953 as a stowaway. Not long after A.H. arrived in the UK he found himself in prison for an unspecified crime. While in prison he applied for repatriation to Nigeria, presumably as a distressed British subject. Before his repatriation could be accomplished, however, he was admitted to Long Grove Hospital, Epsom, in February 1954, suffering from what was diagnosed as schizophrenia. As a result, his repatriation was temporarily postponed until 1956, when medical authorities finally cleared him for travel.
While an unambiguous assessment of A.H.’s mental state at the time of departure is impossible to obtain, there is some evidence that the authorities making his arrangements probably considered him to be in fairly poor shape, even by the standards of repatriated mental patients. Enquiries had been made prior to repatriation whether he could be admitted to a mental institution in Nigeria upon his arrival. This type of enquiry would be made only in a severe case in which it was considered unlikely that family would be able to take care of the patient when he arrived home. In Nigeria at the time, asylum space was restricted to only the most violent and dangerous cases, and repatriation of West African mental patients was usually predicated on the hope that they would be able to avoid further hospital care as a result of being back in friendly and familiar social surroundings. That A.H. was considered a likely case for admission to a Nigerian mental asylum before he even sailed for home is an indication that his case was quite severe and that he was at a heightened risk of causing difficulties on the voyage.
Despite his relatively unstable condition, A.H. sailed for home aboard the Elder Dempster vessel Apapa on 18 November 1956. The ship’s surgeon had examined Hughes and found him ‘quiet and reasonable’.47 Nevertheless, six paid attendants, all of whom were government employees of Nigeria, accompanied him.48 At 9:40am on November 26, A.H. stepped outside of the surgery quarters and headed towards the C deck of the ship, where, ‘seeming quite cheerful and quiet’, he enjoyed a smoke with a fellow passenger. As this passenger bent to set down the box of matches after lighting their cigarettes, A.H. took the brief window of opportunity to hurl himself overboard. The ship searched for his body for an hour, unsuccessfully. By 11:30am, the Apapa was back on course to its destination.
Official enquiry into A.H.’s apparent suicide produced no evidence indemnifying Elder Dempster or any of the passengers or attendants. In fact, the six attendants, as well as the captain, purser and ship’s surgeon all gave statements to the police indicating that A.H. had acted without provocation or warning and that under the circumstances nothing could have been done to prevent his unfortunate death. Nothing in A.H.’s medical history or behaviour on board prior to his jump had indicated that he was a suicide risk. While the efficacy of the six attendants as potential guards or restraints on the actions of A.H. might be questioned, they clearly served as important witnesses who could corroborate the course of events in a way that absolved anyone but A.H. himself of responsibility for what happened.
The procedures that Elder Dempster set in place, therefore, seem to have served their purpose in protecting the company from being held responsible for circumstances resulting from its agreement to carry mentally unstable passengers. What the statements do not discuss in any way, however, is why a schizophrenic patient who required institutionalisation in Great Britain and presumably was likely to require institutionalisation on reaching Nigeria had been deemed an appropriate person to be discharged for the purpose of undertaking a twenty-two-day sea voyage. Thus, ultimately, the governments of the UK and the British West African colonies relied heavily on Elder Dempster to implement a repatriation policy that had no particular legal basis but which nevertheless dramatically undergirded the ideological foundations of the British Empire. Although such awkward circumstances necessarily created tensions, the British government and the Colonial Office needed the cooperation of Elder Dempster, as a non-governmental, private enterprise, to navigate the space between what was politically and medically desirable and what was legally allowable. While the link between state power and medical knowledge was strong, the secured cooperation of private business interests was also extremely important in enforcing imperial biopower.
Elder Dempster’s cooperation with medical authorities and the Colonial Office over the issue of how to repatriate Nigerian mental patients contributed to the maintenance of a medical geography that reinforced notions of racial and cultural difference upon which the ideological justification of Empire depended for much of the twentieth century. Complicating the process, however, was the fact that the procedures governing how to repatriate these patients were a direct attempt to circumvent the medico-legal rights of individuals who were entitled to all the rights of British subjects, irrespective of their particular racial or cultural background. The inherent difficulties in such an endeavour illustrate on the one hand the symbiotic relationship that medical, governmental and private business interests shared in the imperial context, and on the other hand revealed the tensions between these groups over the issue of ultimate responsibility for the outcomes of their efforts. While it is a somewhat esoteric case study, it is hoped that this depiction of the role of Elder Dempster in carrying out the repatriation of Nigerian mental patients illustrates the extent to which the complexities of imperial medicine were by necessity broader and more intricate than the binary medicine/state relationship can account for.
In making this case for a broadening of perspectives in the history of psychiatry in British colonial settings, it is worth noting that existing scholarship in business history is remarkably consistent in its depiction of the relationship between Elder Dempster and the governments of the UK and its West African colonies. Overall, the impression is of a symbiotic but tense cooperation in which Elder Dempster and the Colonial Office relied on each other for the smooth operation of their various enterprises. Cooperation and collusion were commonplace. As Olukoju has recounted, when the United Africa Company threatened Elder Dempster’s position by attempting to enter the shipping business in 1929–30, Elder Dempster lobbied the Colonial Office to interfere on its behalf to prevent the United Africa Company’s move, which it did.49 At the same time, in addition to serving as the primary shipper for private merchandise between West Africa and the UK, Elder Dempster also served as the exclusive mail and passenger carrier for colonial officials traveling between metropole and colony,50 and granted the Crown Agents of the West African colonies discounts and rebates so long as they agreed to book exclusively with Elder Dempster.51 During the Second World War, the British government essentially took over the shipping industry, allocating shipping space and priorities and requisitioning Elder Dempster resources as it saw fit for the war effort.52
However, the insidious ties between Elder Dempster and the Colonial Office also brought frustrations, disagreements and, sometimes, outright defiance. For example, Sherwood has shown that Elder Dempster frequently treated its black employees in ways that were contrary to British law, refusing them rights to transfer ships and failing to repatriate undesirable employees, despite a legal obligation to do so. The British government was irked by such behaviour on the part of the company but generally allowed Elder Dempster considerable leeway in its illegal representations of employee rights.53 Also irksome to many colonial employees and policy makers was the requirement that they travel on Elder Dempster lines, even when they could obtain cheaper or faster service from other carriers.54
Despite the existence of such disagreements, however, it is clear in the historiography that the relationship between government and Elder Dempster was mostly mutually beneficial and predicated on a basic underlying principle that British private capital and British imperial governance should, at a basic level, reinforce each other.55 Whatever their quibbles about rates and fares and laws, Elder Dempster, the Colonial Office and the Crown Agents all generally agreed on the importance of British control over the West African colonies, on the maintenance of a strong link between the role of the government and the commercial exploitation of the colonies and, perhaps most importantly, on the need for private shipping lines to maintain the desired corporeal, material and ideological ties between the motherland and its West African colonies across several thousand kilometres of ocean.
As I have argued in this chapter, these dynamics are also reflective of the role that Elder Dempster played in carrying out the medical procedure of transporting mental patients between the UK and Nigeria. On a basic level, the British government desired to rid itself of responsibility for non-native mental patients who were unproductive and ultimately a burden on the public resources of their host country. The desire to repatriate mentally ill Nigerians was also supported by medical theories coming out of colonial environments and adopted in the metropole that suggested that black Africans were not psychologically suited for European ‘modernity’ and that the greatest psychological stability for Africans came from being in their own ‘primitive’, traditional environments. At the same time, these patients, as British subjects, had specific rights that could not be denied in the ways that either governmental authorities or Elder Dempster might ultimately have liked. Disputes between government and company about the procedures, laws and liabilities of repatriating Nigerian mental patients occurred, but ultimately they found a way to cooperate. At the same time, the collusion between Elder Dempster, medical authorities and governmental officials worked to reinforce desired geographies of Empire – geographies that privileged white, European power and medical authority through the pathologisation and marginalisation of black bodies.
The research for this chapter was made possible through a Patrice Lumumba Fellowship from the John L. Warfield Center for African and African American Studies at the University of Texas at Austin.