Weaving MAPS: Historiographical Perspectives on Writing Postcolonial Histories of the Modern Hospital

Abstract

This paper explores how we can write about the postcolonial histories of the modern hospital. With the Philippine General Hospital (PGH), Manila, Philippines as a starting point, I locate the colonial hospital in the broader and often separate historiographies of the modern hospital and the postcolonial histories of science, technology, and medicine in Southeast Asia. Broadly, hospital histories focus more on organizational management and less on the socio-material entanglements that emerge within the hospital space. Historical studies explicitly centered on the modern hospital are almost exclusively written from the perspective of architectural histories. While the current literature presents valuable discourse on the interface of medical and architectural ideas on hospital design, these histories may present Eurocentric and Whiggish narratives, largely excluding histories of modern hospitals in colonies. However, emerging intersections between emotional and architectural histories of imperial infrastructures highlight the potential of material-affective approaches for advancing postcolonial studies (MAPS) of the modern hospital. The second historiographical stream traces the formation of increasingly critical and agential postcolonial histories of science, technology, and medicine in Southeast Asia. Critical science studies have generated compelling analyses of modern hospitals as biopolitical sites in the colonial period. Moreover, the colonial hospital persists as fertile ground for revealing autonomous histories and new relations and subjectivities in Southeast Asia’s postcolonial reconfigurations. Critical historians of medicine and science in the region also urge more engagement between historical and ethnographic approaches. By weaving these historiographies, I argue that material-affective methods are vital to writing the postcolonial history of modern hospitals and propose a combined MAPS approach to potentially answer the question: how do we write the postcolonial history of colonial hospitals?

Introduction

In 1953, a four-panel set of mural-like oil paintings titled, The Progress of Medicine in the Philippines, was commissioned for display at the main entrance hall of the Philippine General Hospital (PGH), Manila, Philippines [1]. The hospital then was newly renovated following the 1945 Battle for the Liberation of Manila during the Second World War [2]. This painting depicts the history of medicine in the Philippines in broad strokes—during the pre-colonial times, the Spanish colonial period (1565-1898), the American occupation (1898-1946), and the post-independence era (1946-onwards). Established by the American colonial government in 1907, the PGH is a pavilion-style, public general hospital built to function harmoniously with the existing laboratory and medical school within the same complex [3]. The establishment of PGH was towards the fulfillment of then-Secretary of the Interior for the Insular Government, Dean Worcester’s vision that these institutions “mutually assist each other and might constitute an ideal combination for the investigation and the combating of disease [4, p.5].” The hospital provided clinical instruction to Filipino medical students from the then-Philippine Medical School and served the Filipino public beginning in 1910 [5]. The colonial hospital’s facade is immortalized in the painting’s third and fourth panels, along with depictions of scientists and health professionals in white coats wielding novel medical technologies.¹ This painting frames the PGH as a symbol of medical progress that begins in and extends beyond colonial Philippines.

The PGH, as a modern hospital, became a symbol of progress and benevolence during the American colonial period in the Philippines; however, Warwick Anderson also argued that the hospital space was designed to enact biopolitical governance² on Filipino bodies through “perilous” experimentation and disciplinary regimes of hygiene [5]. At the same time, the PGH was also a space of contestation—the tensions between Filipino medical staff and American hospital leadership reflected broader socio-political fissures surrounding colonial rule [6]. Altogether, these frame the PGH, a colonial and modern hospital, as a critical site at which Western and local notions of medical progress, American imperial ambitions, and burgeoning nationalist sentiments among Filipinos historically converged. Today, the PGH stands as the country’s largest government tertiary and training hospital that provides subsidized health services. The hospital is administered and operated by the University of the Philippines Manila, the country’s leading institution for medical education and health research [3]. Writing in the 21st century, Anderson asks: “Now about a hundred years old, the Philippine General Hospital continues to serve the sick of Manila—but what elements of this colonial legacy might an ethnographer reveal today [6, p.171]?”

There is hardly any analysis of the postcolonial history of the PGH, especially from a critical perspective. This, however, is not for a lack of significance since hospital-based healthcare, originating from the West, continued to impact the making of “modern” Southeast Asia [7]. Under the banner of scientific progress, the expansion of hospital-based medicine in the colonies, worked towards achieving the twinned goals of modernization and nation-building in newly independent nations in the region [8,9].³ The dearth of postcolonial historical analyses of these hospitals is perhaps partly due to a lack of primary sources, as is the case for many post-independence hospitals in Southeast Asia [7]. I suppose this methodological limitation is a consequence of the eventual return of colonial officers who have written regular reports and correspondence about proceedings in the former colonies, supplying much of the bread and butter of historians of imperial medicine. However, even if there were available textual sources for this period, the writing of “postcolonial” histories of medicine has been under scrutiny for becoming a “disciplinary enclave of implicitly nationalist historians of medicine” and for inadvertently multiplying histories of Western medicine, prompting Anderson to question postcolonial historiography at large and pose an important question at the turn of the 21st century: “Where is the postcolonial history of medicine [10]?” It is in and through this discursive space that I wonder about the particular historiography of the modern hospital, a “distinctly Western creation” [7] introduced to colonies through projects of “civilization” but endure and often gain a crucial role in building nation-states in their post-independence reconfigurations. In light of this, I ask: how do we write the postcolonial history of the colonial hospital?

Echoing Guenter Risse, the complete historical reconstruction of “the hospital” as an abstracted, generic term presents a formidable challenge because, in reality, there are only particular hospitals [11]. When I ask how we can write the postcolonial history of colonial hospitals, I am particularly thinking of the historiographical considerations for uncovering emergent histories of the PGH in the post-independence period, that is in view of the institution as a modern hospital established during the American colonial period in the Philippines.⁴ These historiographical considerations⁵ pertain to current debates and emerging approaches in the field or surrounding the topic. Also entailed in these considerations is the responsibility towards a historical scholarship of hospitals that is mindful of its colonial roots and continuing legacies of imperialism—often glossed over by triumphalist narratives of modern medicine. While the methodology I am carving out is concerned with a specific colonial hospital, it paves one potential workable path for approaching the postcolonial history of colonial hospitals in general. Working with this more defined subject also makes it possible to locate historiographical starting points. To address the main inquiry, I broadly trace the historiography of the modern hospital and locate where the “colonial hospital” fits in the existing narrative. Then, I review postcolonial histories of medicine, science, and technology in Southeast Asia to understand how historiographical movements and debates might inform a postcolonial examination of modern hospitals in the region. Studying the themes and approaches in these fields may provide a glimpse of current and potential directions for historical analyses of the modern hospital as colonial hospitals. I focus on Southeast Asia not only for the obvious reason of Philippines’ membership to the region but also since the region is arguably underrepresented in the archive of postcolonial studies despite being one of the most colonized regions in the world [12]. As a caveat, these are historiographical starting points that in themselves are fields I may not be able to exhaustively map out in this paper and whose borders I might likely transgress. In this paper, I am less concerned about lining the edges of these historiographies and more riveted by the ways in which they can be interwoven and expanded by less explored theoretical and methodological crossings. That said, by tracing and weaving these historiographies, I propose a historical ethnographic approach that combines material, affective, and postcolonial lenses in the study of modern hospitals.

History of the Modern Hospital

It is important to begin by acknowledging that there is no precise definition of the modern hospital. The term modern in itself is a nebulous qualifier for the hospital, a medical infrastructure often closely associated with scientific and architectural advancement. In the case of the hospital, the word modern may allude to a historical period beginning or following the European Enlightenment roughly around the 17th century or to the modernist movement in the arts emerging in the late 19th or early 20th century. The very notion of modernity is contested among historians of medicine [13] and other scholars from critical humanities, such as the anthropologies of science [14] and of development [15], often citing its Eurocentricity and connection to Western imperialism. Rather than circumscribing a definitive interpretation of the modern hospital, this paper is more concerned with understanding the modern hospital in its existing historiography while being cognizant of the equivocation that comes with the term modern.

Barry Doyle notes that, broadly, studies of hospitals by medical historians have tended to focus on “cost and capacity over the aesthetics of the physical fabric” while the hospital has been rarely discussed by architectural historians [16].⁶ Michael Murphy and Jeffrey Mansfield (2021) surmise that hospitals are largely understudied in the history of architecture because “its complications are prevalent, its authorship multiheaded, its forms jumbled, incoherent, inelegant, and bipolar [17].” However, there has been a renewed interest in the history of hospitals in the last two decades [16].⁷ It is interesting to note that these recent historical monographs specifically focusing on the “modern hospital” are almost exclusively written by historians of architecture, such as Jean Kisacky, Annmarie Adams, Julie Willis, Philip Goad, and Cameron Logan. Kisacky’s (2017) Rise of the Modern Hospital perhaps provides the “most thoroughly researched and most detailed” work in tracing the complex links between the developments of medical ideas and architectural design in American hospitals [18]. Kisacky pinpoints the main dilemma among historical examinations of American hospital design to this chicken-and-egg framing of medicine and architecture. Works like Henry Sigerist’s (1936) An Outline of the Development of the Hospital and John D. Thompson and Grace Goldin’s (1975) The Hospital: A Social and Architectural History operate under the idea that the design of hospitals is primarily shaped by medical and social transformations [19]. This view of hospital design as an index of shifts in medical history is not as obvious to historians of medicine as it is for historians of architecture [20]. Other scholars emphasize the influence of hospital design on transforming medical practice and theory—chief among them being Michel Foucault, who argued that the organization of the patients and physicians in the clinic “altered the eighteenth-century French doctor’s understanding of disease [19].”

In Medicine by Design: The Architect and the Modern Hospital, 1893–1943, Adams (2008) examines the development of the Royal Victoria Hospital in Montreal, Canada and argues the reciprocal influence of architecture and medicine. An important contribution of her work is demonstrating “how architects played an active role in the development of twentieth-century medicine” and similarly “how doctors played an active role in the development of twentieth-century architecture [20].” In Architecture and the Modern Hospital: Nosokomeion to Hygeia, Willis, Goad, and Logan (2018) also illuminate “how medical needs in providing therapy and care to patients have been deeply affected by, and have had deep effect on, architecture and design [18].” Their monograph, however, veers away from the more conventional focus on planning and functional arrangement of the hospital and examines the modern hospital in Australia at various scales, from the bed and the nurses’ station to the modern hospital and the wider city. Kisacky seems to maintain the same stance. She puts forth that “to imagine modern scientific medicine is to imagine a spatial pattern for it” but at the same time, the history of the modern hospital should go beyond a “history of changing details, materials, forms, and technologies in service of an increasingly limited physiological definition of health” and serve as a “chronicle of aspirations and disappointments as to the role architecture might play in a more inclusive conception of health [19].” While generally “form follows function,” Kisacky’s conclusion argues the role of architecture as form to contribute to well-being by broadening the understanding of the hospital’s function beyond biomedical notions of health. This more holistic view of health and well-being opens up to the political functions of the hospital. Murphy and Mansfield assert that architecture is a rights-based discipline that not only caters to people’s right to health care or the right to breathe but also to the most elemental right—the right to dignity [17].

The historiography thus far has focused on architectural histories that primarily focus on the modern hospital as a particular term for a building type. This is not to say that there are no other historical writings on modern hospitals from other perspectives.⁸ Likely, the “modernness” of hospitals is an implicit assumption in other hospital histories, most of which were written by doctors who belonged to the institutions themselves and adopted positivist stances to scientific modernity, viewing the history of medicine as a story of inevitable progress [21]. Historians of medicine, on the other hand, are likely more careful with the notion of modernity as they tend to frame “medical practice, research, and innovation as social and cultural constructs whose scientific claims resembled belief systems” tied to wider political, intellectual, and cultural contexts [22, p.710]. Beyond historical works, there is explicit and repeated use of the term modern hospital, often in the context of hospital management [23-26]. Paloma Fernández-Pérez, an economic historian, also wrote an ambitious monograph on the history of modern hospital management and organization from a global perspective [27]. The lack of historical monographs on the modern hospital from the perspective of medical historians is intriguing and, perhaps, may be a consequence of semantics. However, the more commonplace use of the term modern hospital in guidelines for hospital management also suggests that the term has been more practically and economically understood than it has been critically examined as a subject in the contemporary history of medicine.

The historical monographs written by Kisacky, Adams, Perez, Willis, and colleagues generally focused on the 1870s to the 1960s. This is the period in which the mission hospital, focused on charity and poverty relief, is posited to have been succeeded by the modern hospital in adaptation to the rapid technological advancements in clinical diagnostics and treatment, emerging architectural designs for disease control and hygiene, and the growing organizational demands of medical professionalization and education [28,29]. The shift in the hospital’s function from “care” to “cure” in the late 19th century is one of two main stories of the history of modern hospital architecture [30].

The convergence of architecture with new modes of treatment and care in that era resulted in the notable complexity involved in the planning and spatial arrangement of the modern hospital—a design that enabled “more effective and efficient medical practice” as compared to medical facilities prior to the 19th century, which were primarily for nursing [28]. The other story traces the history of the modern hospital as a building type at the end of 18th century France, around the same time as the emergence of schools, barracks, and prisons—all of which were marked by architecture that served a pattern of governance [30]. A third story—perhaps connecting the first two stories— might begin with the emergence of the pavilion hospital. The pavilion approach to hospital design emerged in 18th century France and was popularized in England in the mid-19th century in an effort to reduce mortality rates through improved ventilation [31,32]. As Thompson and Goldin wrote, the pavilion hospital is the sanitary code embodied in a building [33]. In 1859, Florence Nightingale wrote Notes on Hospitals, which championed the pavilion plan and became a fundamental reference for hospital design. This influential piece is generally considered as “the first treatise on modern hospital planning” [17]. By the late 19th century, the pavilion hospital was internationalized and could be found across Europe and North America as well as in Australia, Africa, and Asia [34]. This tells us that the history of the pavilion hospital is connected and perhaps even one and the same as the modern hospital. This story also suggests that the internationalization of the pavilion design may mark the beginnings of the movement toward a global standard for the modern hospital. A story less told, however, is what becomes of the modern hospital outside Europe and North America?⁹

Thus far, histories of the modern hospital have focused on the “hotspots” of innovative design, such as North America, France, and Central Europe [16] and often employed Whiggish narratives of how architecture and medicine have dialectically advanced each other’s fields. The histories of modern hospitals built in the colonies—colonial hospitals—do not usually get written into the historical narrative of the modern hospital as “a victory of science, philosophy and technology” [35]. Most of the attention has also focused on “growth, management, and financing” and less on what happens in modern hospital institutions in the everyday as well as how changing social processes have shaped the modern hospital as a built environment [16]. Logan encapsulates this in an important question: “So what should be done about the fact that the chosen historical representations of modern hospitals and healthcare are only representative in a very narrow sense [28, p.616]?” He answers his own question with a call “to expand the range of hospitals that we recognize as historically significant [29, p.616].” Sara Ebrahimi’s recent historical monograph on Protestant mission hospitals is arguably a crucial example of these alternative yet significant hospitals as it challenges assumptions of the pavilion plan as the international standard for the modern hospital at that historical moment. In Emotion, Mission, Architecture: Building Hospitals in Persia and British India, 1865-1914, Ebrahimi (2022) demonstrates how Church Missionary Society (CMS) missionaries made and remade hospital architecture prioritizing affective considerations, such as familiarity, over prevailing notions on health and hygiene embodied in the pavilion plan [34]. Her work brings new insight to the joint history of medicine and architecture not only by looking into the affective dimension of hospitals but also by exploring this innovative braiding through a postcolonial perspective. Ebrahimi’s work illustrates the usefulness of affect and postcolonialism as analytical lenses to historically examine the modern hospital and further interrogate the notion of modernity, often tied to Western constructs of rationality and objectivity. In light of this I wonder what architectural and medical transformations have taken place in modern hospitals as Western institutions reconfigured beyond the colonial period? What affective registers¹⁰ emerge from or possibly impact the design of the postcolonial hospital space? How do these sentiments relate to notions of medicine, management, and modernity in the context of the postcolonial hospital?

Postcolonial Histories of Science, Technology, and Medicine in Southeast Asia

Warwick Anderson is one of the most prolific contributors to historical and critical studies of science, technology, and medicine in Southeast Asia, with particular focus in the Philippines. While the following historiography also includes works from other important medical historians and scholars of science studies in the region, it draws largely from Anderson’s substantial contribution to the field over the last two decades, beginning with the question he posed at the turn of the last century: “where is the postcolonial history of medicine [10]?”

Histories of science and medicine in the region were scant prior to World War II and only gained traction as “epidemiologist historians” in the 1980s began to study the impact of war and imperialism on patterns of disease, touching on colonial and national reactions to epidemics [36]. As already witnessed in South Asia and Africa, social and cultural histories of colonial medicine proliferated the region by the 1990s—these histories analytically relied on Western theories and tended to anticipate later national formations that mimicked European trajectories to modernity [10,36]. Instead of seeing the rise of postcolonial historiographies of Western medicine, Anderson critiques the formation of a “disciplinary enclave of implicitly nationalist historians of medicine” that concerned themselves with how imported Western medicine—from center to periphery—has uniquely taken shape in a particular colonial setting [10]. While Laurence Monnais-Rousselot’s (1999) account of French colonial medicine in Indochina may fall under this enclave, her demonstration of Western medicine’s adaptation to local conditions and culture is important for reframing colonial medicine as simply a tool of empire [36,37]. Her oeuvre in the region, such as her historical account of the indigenization of biomedical practice in late-colonial Indochina, also provides often-neglected transitions from colonial to postcolonial temporal configurations [38]. Historical accounts of Indigenous physicians from the Philippines and East Indies as “medical modernists” and “national physicians” highlight the intertwining of modernizing ambitions with science and the emerging nation in the late-colonial state [9]. I suppose that the colonial hospital is implicit—at times even veiled—in these narratives as a key site in which colonial medicine is contoured to cater to local patient needs and cultural contingencies as well as where scientific patriotism is cultivated and mobilized by indigenous physicians increasingly assuming hospital leadership roles. Looking into the postcolonial history of hospitals may open new windows for discourse on syncretic medicine and scientific nationalism.

Science studies in the first decade of the 21st century [39-41] point to the “continuing impact of the mottled imperial past of Southeast Asia on contemporary scientific assemblages [38, p.167].” Anderson notes a salient feature of works in this period: the “experimental modern site, disciplinary micro-colony, in the developmental imaginary [38].” Citing works such as Mitchitake Aso’s (2013) article Patriotic Hygiene [42] and his own on the PGH [6], Anderson highlights a tendency in the region to erect biopolitical sites where new subjectivities might emerge. These sites are exemplified by the micro-colonies of “plantations, hospitals, and leper colonies” [36]. Taking a critical approach to the archives of American colonial officers on the PGH, Anderson (2009) argues how tensions between “benevolence and discipline, improvement and drill, liberality and efficiency, desire and paranoia” [6] within the hospital reflected and reproduced the broader colonial project and racialized hierarchies between the colonizer and the colonized. Here, we see increasing attention to the colonial hospital as a productive space for critical analyses of biopolitical regimes and relations in the colonial period. However, less explored is the potential of these spaces to reveal new forms of relations and subjectivities in their postcolonial reconfigurations.

Anderson traces two streams of scholarship in the more contemporary formations of science, technology, and medicine in the region—one focused on the localized impacts of globalization and the other on more autonomous histories or, in other words, “richly contextualized and agential regional histories” [36]. He criticizes the first of these streams for positioning the West as the primary driver of development and for conforming to conventional postcolonial modes of inquiry that focused on “the ongoing life of residues, living remains, lingering legacies [43, p.21].” Works like Rudolf Mrázek’s Engineers of Happy Land: Technology and Nationalism in a Colony characterize the latter stream. In this evocative and unconventional collection of vignettes on technology in the late colonial Netherlands East Indies, Mrázek (2002) examines people’s material and cognitive engagement with things, including infrastructure and architectural ornaments, and reveals non-conforming relations to Western modernity as notions of “their time, space, culture, identity, and nation came to feel awry [44].” While I am equally fascinated with the direction set out by the latter stream, I find this critique of the former stream rather self-contradictory when his own work speculates that scientific advancements in former colonies—underpinned by colonial structures and national aspirations—may chart a “genealogy for the globalization of Western science and medicine [9].” Here, he privileges a narrative of neocolonial dependence over nationalist independence when postcolonial developments of science and medicine in the region may not neatly fit into this dichotomy. He also suggests that looking at postcolonial histories of colonial artifacts is not the way to advance the field since it has little potential to generate insight beyond already known or conceivable “living legacies” of an imperial past. I fail to agree with these assertions since works of other historians provide illuminating alternatives. Loh Kah Seng’s (2014) study of hospitals and asylums in 20th century Southeast Asia is revealing of the continuing impact of Western notions of place-based healthcare on postcolonial Southeast Asia but is mindful of the ways historical actors have exercised agency in dealing with foreign ideas in this space [7]. In Translating the Body: Medical Education in Southeast Asia, Hans Pols, Michelle Thompson, and John Harley Warner (2017) similarly highlight the cruciality of agency expressed by indigenous historical actors in adopting Western medical models. In the case of postcolonial medical migrants, pertaining to indigenous students and practitioners who studied medicine abroad, the transplantation of medical knowledge to their home countries was selective and depended on cultural appraisals made by the potential couriers [8]. Seng makes use of the term “subaltern” to account for the Southeast Asian groups who, by way of “accommodating, appropriating, contesting, or redefining biomedicine…produced new cultures of healing and patient cultures that expressed their worldviews and differed from elite forms of modernity [7, p.181].” Moreover, Seng highlights how hospitals not only serve as conduits of international notions of health and medicine but also continue to be shaped by imperatives of a global capitalist economy, integrating Southeast Asian subjectivities into “the transnational flows of the capital even when they are ill [7, p.197].” All this to say that colonial hospitals persist as fertile ground for insightful and autonomous histories within an increasingly globalized postcolonial Southeast Asia.

The previous paragraph provides several formations of the postcolonial history of science, technology, and medicine in Southeast Asia—and I highlight how the hospital is one critical nexus in which we can continue to explore these intersecting histories—but Anderson’s question at the turn of the 21st century was actually more concerned with how we can write the postcolonial history of medicine. Over the next two decades, Anderson provides two seemingly cumulative yet actually bifurcating modes of approaching postcolonial histories in the region. I will start with his more recent approach. In 2009, Anderson notes that a distinctive style of science studies seems to be emerging in Southeast Asia and a decade after, he proposes to think of Southeast Asia “as method” [36,38].¹¹ He draws from Takeuchi Yoshimi ’s (2005) [45] and Kuan-hsing Chen’s (2010) [46] conceptualizations of Asia as method, where analysis can be characterized by “Asian values” as indicative of subject self-formation or how Asian societies can anchor analysis using each other’s reference points. This makes way for theory to be “de-imperialized” [45] by allowing scholars to analyze local data without relying on Euro-American framings. In other words, Anderson aims to “thicken transregional analysis as a heuristic or orienting device” [36, p.513]. Although, he admits its definition remains elusive and mobilizes the same repertoire of evasion as Takuechi, citing: “This I have called ‘Asia as method,’ and yet it is impossible to state definitely what this may mean [45].” While later Anderson [36] is convinced of more transregional but autonomous postcolonial histories of science, technology, and medicine, earlier Anderson [10,38] seems to be less bound by the conceptual borders of the region.

This paper builds more on his earlier approach to postcolonial histories, where he urges the “need to learn how historians might become, not imperialists or nationalists of the text, but true nomads themselves, understanding migrancy as much as situatedness [10, p.59].” While he already begins to frame science studies as area studies in his 2009 article, he does so to put an “emphasis on linguistic competence, the importance of fieldwork, the tendency toward a multidisciplinary approach, the opportunity provided for interaction of scholars within and beyond the region [38, p.169].” This is, arguably, a call for science studies in the region to adopt more anthropological approaches. I want to return to his 1998 article and highlight his call “to listen for the global circulation…of metaphor, assumption, and practice” [10] which I take as an invitation not to set boundaries but to cross borders in an increasingly porous postcolonial world.

Proposing MAPS: Weaving Materiality, Affect, and Postcolonial Studies

Tracing the historiography of the modern hospital reveals important gaps in the current literature, such as the often uncritical acceptance of West-centric and Whiggish narratives of the modern hospital as bastions of medical progress and societal development as well as the lack of representation of what modern hospitals are historically significant. In this paper, I highlight the often-neglected histories of the modern hospital in colonies. At the same time, I emphasize the need to situate the colonial hospital within the larger history of colonialism as a project of modernity. The notion of Western modernity arising from the “Enlightenment period” underpinned and justified imperialism as a project to civilize the non-Western world (ie, Mission civilisatrice, the White man’s burden, the Ethical policy). Writing about French colonies as “laboratories of modernity,” Paul Rabinow (1989) and Gwendolyn Wright (1991) articulate how colonial administrators, architects, and urban planners have designed colonial cities in view of the “advancements” in science and industry but also for social engineering and control [47,48]. The establishment of “modern” hospitals in colonies emerges within this context of the colonial re-ordering of space and, therefore, its scholarship cannot be removed from this historical framing.

While there is acknowledgement of the history of the hospital as a colonial apparatus, this paper demonstrates that these histories are not necessarily written as part of the larger historical narrative of the modern hospital. This points to the “peculiar genealogy of the colonial and postcolonial hospital” that emerged between the 17th and 20th centuries at the intersecting projects of modernization and social improvement in the “developing world” and the global dissemination of Western medicine [49,50]. The various temporalities of the history of the modern hospital in the literature not only reflect the uncertainty around its emergence but also raise the question of its continuity. Has the modern hospital been superseded? Are we now in the era of postmodern hospitals? I suppose that the modern hospital—its design and operation increasingly defined by efficiency, complexity, and technological advancement—persists as today’s hospital [26] and, thus, constitutes a history still in formation.

A postcolonial lens allows us to acknowledge histories of the modern hospital beyond the usual terminal point of the 1960s.¹² Within this, it is possible to reframe colonial hospitals as modern hospitals, acknowledging that histories of hospitals established during the colonial period and which endure beyond are not only connected to the history of the modern hospital but are one and the same. In terms of debates between autonomous and colonial histories, this paper recognizes the inherent duality of the modern hospital in colonies. The colonial hospital is both a Western artifact as much as it is a local artifact. An effort to provincialize¹³ the history of the modern hospital is to recognize that its postcolonial afterlife is connected yet distinct from its Western and colonial roots. I do not mean to imply the end of colonialism by saying “postcolonial afterlife.” Instead, I echo Anderson’s (2002) clarification that a postcolonial analysis entails a “critical engagement with the present effects” of European imperialism on former colonies and allows us to destabilize “durable dichotomies” and conventional historical accounts of “global” technoscience [51]. Weaving postcolonial histories into the dominant narrative is not only necessary to expand the histories of the modern hospital but also to position other narratives as equally historically significant. In this paper, I raise the need to pay historical attention to modern hospitals outside Europe and North America. The previous section situates the colonial hospital as a focal subject in the postcolonial historiography of science, technology, and medicine in Southeast Asia. Specifically, it shows the significance of Southeast Asian modern hospitals as critical sites not only for biopolitical analyses of colonial histories but also for understanding emergent subjectivities, relations, and cultures of healing in their postcolonial reconfigurations.

This historiography also echoes the call for deeper engagement with anthropological methods in critical and historical studies of science, technology, and medicine in Southeast Asia. Applied to postcolonial studies of the modern hospital, anthropology may promote more situated analyses of spatial relations and bring to fore emergent actors or even other actors historically rendered invisible by a lack of voice within this space. Alice Street’s hospital ethnography in Madang Hospital, a modern hospital in Papua New Guinea, demonstrates the importance of an ethnographic approach to postcolonial technoscience in exploring the “ways in which scientific practices become involved in people’s everyday efforts to improve their lives and build relationships with others in places of poverty and suffering [49, p.19].” Engaging anthropology in historical studies of the modern hospital presents an opportunity to address the current lack of focus on the socio-material dimension and everyday life aspect in and of the hospital. By attuning to everyday relational encounters within and with the hospital, Street illuminates the ambivalent experience of invisibility and failure as well as improvisation and hope in the postcolonial hospital [49,52]. Claire Edington’s monograph on asylums in French Colonial Vietnam also focuses on everyday exchanges between and among various indigenous and colonial actors involved in the micropolitics of psychiatric care [53]. Methodologically, Edington draws from anthropological insights and studies patient case files as a window into the lives of patients outside the asylum, which functioned as both hospital and prison. By looking into everyday social life—encompassing emotional ties, everyday pressures—Edington demonstrates not only how colonial authorities leveraged the power of local networks and norms to manage mental illness in the colony but also “how ordinary people have used colonial institutions for their own ends [54].” Treating the everyday as an analytical category is a way to approach the “ambiguities and ambivalences that helped structure the nineteenth- and twentieth-century social history of medicine [13, p.27].” This focus on everyday relations also deeply aligns with the turn towards maintenance in technology studies as opposed to histories primarily focused on innovation—this turn centers what Thomas Kuhn calls “normal science” [54].¹⁴

I argue that both material and affective approaches are vital to writing postcolonial histories of modern hospitals. To begin with, the current landscape of historical literature on the modern hospital tells us that the architecture of the hospital—its spatial ordering and material design—goes beyond fulfilling the hospital’s medical function and impacts the broader political and social realm (ie, constructing dignity). Materiality, therefore, is a principal dimension of the modern hospital as a historical subject. Drawing from Abidin Kusno’s historiography of postcolonial urban architecture in Indonesia, approaching the postcolonial history of the modern hospital as a built urban space might reveal the “unevenness of modernity” and challenge Whiggish narratives on national development [55]. This also views the modern hospital in relation to the wider built environment and the urban histories surrounding it. In a way, this look into the often uneven spatial expression of modernity provides an alternative pathway to avoid the pitfall described in Anderson’s critique of postcolonial histories of medicine as a disciplinary enclave of nationalist historians. Moreover, a focus on materiality also encourages the use of non-textual primary sources, since textual sources are often lacking for the postcolonial hospital and, if available, are likely written from a colonial perspective. Emulating Adam’s approach to hospital histories, I am also “curious to see how architecture and artifacts tell different stories than do printed sources in the history of medicine [20, p.xxii].” This may also be one way of circumventing “propagandist and didactic texts” on hospitals that venerate “the modern, the ideal, and the novel at the expense of the ordinary world of everyday adaptation” [16, p.228] and also perhaps a postcolonial strategy to avoid perpetuating what Derrida calls the “violence of the archive” [56].¹⁵

I propose that materiality is entwined with affect in the task of decolonizing the history of modern hospitals. Ebrahimi’s historical work on mission hospitals in Persia and British India as well as Street’s hospital ethnography in Papua New Guinea both demonstrate the potential of combining material and affective approaches to postcolonial studies of hospital history, which I call the MAPS approach. These works embody Razak Khan’s argument that “emotional and spatial categories are not only deeply entangled with, but constitutive of, imperial, colonial, postcolonial, and contemporary local and global spatial imagination [57, p.614].” While Khan writes in the context of South Asia, I wager this extends to the contexts of Southeast Asia and even the modern hospital itself. Miriam Ticktin points out that the hospital, historically an infrastructure of French colonialism, “inherits many of the affective hierarchies of colonial sentiment [58].” Therefore, modern hospitals in colonies are critical sites where we can explore the expression of what Ticktin calls “affective and biological technologies of governance.” While the modern hospital has been a generative site for biopolitical analyses of colonial relations, Jiat-Hwee Chang and Anthony King’s (2011) genealogy of tropical architecture points to the limits of Foucauldian biopolitics in making sense of asymmetrical power relations in the colonies [59], a limitation that likely extends to postcolonial contexts. Achille Mbembe’s concept of necropolitics may be useful here to take into account the influence of postcolonial relationships and racial dynamics on spatial governmentality.¹⁶ While hospital spaces act as “affective purveyors of colonial and postcolonial power relationships,” the multiple and often incongruous layering of hospital space over time results in the unpredictability and ambivalence of its affective capacities [52,60,61]. Therefore, postcolonial methods must take into account that a multiplicity of affective registers exist and go beyond the “disciplining emotional affect” [34] often associated with the hospital as an institution of care and control.

A MAPS approach to the hospital, as embodied but not explicitly stated in the works of Ebrahimi and Street, presents a promising method that brings to fore a diversity of relational dynamics between postcolonial governments and subjects, such as the desire to be seen [49]¹⁷ or alternative affective registers, such as hope and familiarity [34]. These works not only destabilize established readings of the modern hospital but also expand what we consider as historically significant in this space. This attention to the material-affective dimension also acknowledges that attachments to place have an ontological status [62].¹⁸ The method thus accounts for the often neglected significance of the hospital as a meaningful place in the lives of individuals and communities [20,28]. Applied to postcolonial studies, the interface of materiality and affect also helps us look into the politics of memory in the context of the modern hospital. As Kusno points out, architecture and urban built space can act as mnemonic technologies.¹⁹ In postcolonial Indonesia, architectural reconstructions and urban renewal are often exercised to circumvent histories of political violence [55]. Taking into account this material-affective dimension may allow both historians and ethnographers to zone in on what place-based memories are being remembered and forgotten in writing and in the everyday. Merging historical and ethnographic methods may also provide insight into a mnemonic study of hospitals by examining the intentions of designers (ie, architects and hospital consultants) in relation to the reception of users (ie, patients, family caregivers, hospital staff, and other individuals).²⁰

For a MAPS approach, I suggest it may be productive to draw from assemblage thinking. As articulated by Gilles Deleuze and Félix Guattari, “assemblages are complex constellations of objects, bodies, expressions, qualities, and territories that come together for varying periods of time to ideally create new ways of functioning [63, p.18].” Derived from the French word agencement, the term denotes not just the resulting arrangement of human and non-human elements but also the dynamic process of “coming together” and “coming apart” of these networks to perform multiple functions [64-66]. Assemblage thinking thus allows us to view the hospital as dynamic, multi-scalar, and simultaneously material and representational. Through this lens, the modern hospital is neither a unified whole or discrete collection of parts but an “assemblage of socio-spatial flows and intersections” [67]. Such a lens allows a historical study that emphasizes the fluctuating networks of heterogeneous yet interrelated human actors, material structures, medical concepts, and affective notions involved in the micro- and macro-politics of care in postcolonial hospitals. Moreover, framing the postcolonial hospital as an assemblage allows us to highlight “knots of social and political interests” [68] and to study how these “affectively animated forces” impact its “ongoing material remaking” [69], which may be visibly expressed in its architectural transformations.

Conclusions and Outlook

In this historiographical essay, I explore how we can write about the postcolonial history of modern hospitals. With the Philippine General Hospital as a starting point, I look at how the colonial hospital fits in the broader historiographies of the modern hospital and postcolonial histories of science, technology, and medicine in Southeast Asia. Histories of hospitals more broadly are focused more on management and organization and less on the socio-material entanglements that emerge within the hospital space. Historical studies explicitly centered on the modern hospital are almost exclusively written from the perspective of architectural histories. The current historical corpus on the modern hospital holds valuable discourse on the complex and reciprocal influence of medical and architectural ideas on hospital design; however, these histories are concentrated in the Western hotspots of innovative design and often employ Whiggish narratives of medical and architectural development. Histories of the colonial hospital are thus largely excluded from the historical narrative of the modern hospital. However, emerging intersections in emotional and architectural histories of imperialism, such as Ebrahimi’s work, point to the potential of material-affective approaches in advancing postcolonial studies of the modern hospital.

The second historiographical stream traces the formation of increasingly critical and agential postcolonial histories of science, technology, and medicine in Southeast Asia. Critical science studies have already generated compelling analyses of modern hospitals as biopolitical sites and scientific assemblages in the colonial period. This paper further emphasizes that colonial hospitals persist as fertile ground for revealing “autonomous” histories and new relations and subjectivities in Southeast Asia’s postcolonial reconfigurations. Scholars of postcolonial studies of technoscience and medicine in the region urge for more interface between historical and ethnographic approaches. Looking at the often separate historiographies of the modern hospital and of postcolonial technoscience and medicine in Southeast Asia, I highlight not only the significance of studying the postcolonial history of modern hospitals, particularly in the region, but also potential points of methodological intersection to inform this approach. I propose a methodology that draws from history, anthropology, and science and technology studies to approach the postcolonial history of colonial hospitals. This combined approach I call MAPS weaves material, affective, and postcolonial scholarship to reveal and examine emergent histories of the modern hospital. By emergent histories, I mean to say the untold or retold stories of the modern hospital that may be revealed as a consequence of destabilizing the notion of modernity; of attending to the situatedness and migrancy of the colonial hospital as a Western artifact and local lifeworld; of embracing the hybridity of modern hospitals as equal parts social institution and physical infrastructure; and of acknowledging the afterlives of colonial hospitals—their present lives—in postcolonial histories still in formation.

The MAPS approach to histories of the modern hospital responds to calls for critical-historical studies of science to engage posthumanist and new materialist theories [70]. This focus on materiality and affect reflects the ontological turn in critical humanities and expresses an “attempt to break away from the normative divides, central to the modern regime of truth, between subject and object, mind and body, reason and emotion, living and inanimate, human and nonhuman…and so forth [62, p.63].” This methodological turn is important for postcolonial studies because it privileges the “repressed side of the dualisms” and embodies feminist commitments to “exploring other ways of working, including new insights about what keeps the dominating ontologies in place [62, p.64].” There is no single rubric for taking up these fields as analytical lenses [70]. In this paper, I argue why they should be woven together in postcolonial studies of modern hospitals, highlighting historical and ethnographic works (ie, Ebrahimi, Street) that embody this approach as well as theoretical concepts (ie, assemblage thinking) that might facilitate such an analysis. Grounding these methods in history is critical because “the temporal connects the material, affective, and the social aspects of infrastructure, and so attention to temporality gives us the full weight of infrastructures in flux [71, p.11].” Approaching postcolonial histories of the modern hospital through MAPS hopefully carries on Anderson’s vision for postcolonial studies of technoscience to “recognize how these hybrid shapes and assemblages inhabit interstitial spaces, and how, like humans, they cross borders and mold to migration, exile, and diaspora [38].”

While this historiographical essay primarily engages medical and architectural historians as well as scholars of science and technology studies to make use of material-affective methods in postcolonial studies, the approach might also be helpful to other social scientists, such as medical geographers and medical anthropologists. For instance, a MAPS approach can inform emotional geographies of care²¹ in postcolonial hospitals as well as medical anthropological work focusing on the influence of built environments and culturally constructed emotions on access to hospitals in postcolonial health systems. Beyond the social sciences, there is also hope for the paper to be of relevance to physicians, nurses, and other scholars of the allied medical sciences who have more frequent engagement with and within the hospital landscape. A critical takeaway from this paper would be the destabilized assumption of the history of hospitals as a linear story of human advancement. Scholars and practitioners of medicine alike must reckon with the “inconvenient pasts” of Western medicine [72] and bear in mind that histories of imperialism continue to impact “modern” medical practice and knowledge production as well as power dynamics in the micro- and macro-politics of healthcare over the world.

A MAPS approach draws attention to important yet often unarticulated questions for healthcare personnel to be mindful of in their daily engagements within the hospital space or for hospital administrators to consider in the ongoing improvement of hospital design: as a public infrastructure and place of healing, what kind of hope is impressed upon patients as they enter and engage with the hospital space? What other affective registers emerge in the hospital (intended or not) and how do these impact access or navigation in this space? How do encounters between patients, hospital staff, and the wider society shape these sentiments? How does the structuring of the hospital facilitate health citizenship and broader nationalist aspirations? Does the design of the hospital neglect or cast aside certain populations or privilege some over others? Whose emotions are privileged in this space? How does the hospital space reinscribe legacies of imperial hierarchy into everyday social relations? What expressions of violence are memorialized or even unremembered through hospital reconstruction over the years? How do we restructure space to prevent engendering these forms of violence? How then do we (re)design hospitals into institutions that promote and uphold the overall well-being and dignity of patients, caregivers, healthcare staff, and other actors who may be rendered invisible or hopeless in the hospital?

Glossary

MAPS

material-affective approach to postcolonial studies

PGH

Philippine General Hospital

Author Contributions

JASJ: sole responsibility for the conceptualization, analysis, and writing of this manuscript.