SIX days ago, The Lancet published an extraordinary article, titled ‘The Lancet and Colonialism: Past, Present, and Future’. The authors include two Pakistanis: Prof Mishal S. Khan, the lead author, and Muhammad Naveed Noor, along with Thirusha Naidu, Irene Torres, Jesse B. Bump and Seye Abimbola.

The Lancet is a 200-year-old peer reviewed weekly medical journal from the UK. The first issue appeared on Oct 5, 1823, and the latest on March 30, 2024. As an influential journal it has the highest impact factor. Since its launch, the journal has expanded into a family of more than 20 specialty journals and has set up a number of global Lancet Commissions on various important issues in medicine and healthcare.

The journal has seen a lot in its last two centuries of existence — from the 1820s, when the first trains were just getting onto the track, to the present times, when we live in a hyper-connected global village powered by IT and AI. Apart from pivotal advances in medical sciences, many of which The Lancet itself reported over the 200 years, the journal also lived through many eras of political, economic and social upheaval. When it started, slavery was still the norm and colonialism was rife.

While beginning the bicentennial year, the editorial in the journal in January last year mentioned that, “while we cherish our independence and acknowledge our privileged position … we also recognise that The Lancet has, at times, been complicit in grievous violations of human rights. The legacy of colonialism inevitably looms large in our history. During the coming year, we will not only reflect on our contributions to medicine, but also invite scholars to review the journal’s role during a period of imperial expansion”.

In reinforcing existing prejudices and inequities, the journal reflected its times.

This is a brave introspection. It is also a sign of confidence and maturity. Credit goes to the maverick editor-in-chief of The Lancet, Richard Horton, who has held this position since 1995. He is a bold and bright man who has been raising issues of health inequities and social justice through the years.

This is the context in which Prof Mishal was invited to lead with an opinion piece. Below are some paraphrased key points from the article.

The launch of The Lancet took place during a time of great political agitation against colonial slavery, but the founder of the journal, Thomas Wakely, is not known for having taken any position on Britain’s Slavery Abolition Act of 1833 or against colonialism. However, research shows that the editor did publish “deliberate misinterpretations of the protest of enslaved people against oppression”, labelling them as insane.

In 1851, a US physician resorted to ‘disease mongering’, coming up with the term ‘drapetomania’ to describe the pathological mental state of an enslaved person itching for freedom. In 1874, The Lancet published “similarly ignorant views” and belittled the “insanity” of slaves who wanted to be freed.

There are also some examples of how The Lancet kept publishing on the superiority of Western medical knowledge, describing local knowledge in the colonies as “magic”, “supernatural” and “the fetish worship of native races”. This prejudice precluded any effort to explore and understand local knowledge systems.

The Lancet also helped legitimise the field of tropical medicine at the turn of the 20th century. For example, in 1904, Patrick Manson and his British colleagues were credited for linking sleeping sickness and tsetse fly bites, without acknowledging indigenous peoples’ previous discoveries on which their work was based. Similar is the case regarding the ‘discovery’ of Kwashiorkor (a protein deficiency condition among babies) by Cicely Williams in 1935. Instead of recognising the value of local African knowledge in this case, Williams noted in The Lancet that “the idea that the ‘simple savage’ has instinctive knowledge in caring for her children is without foundation”.

Of course, the journal was not alone in this; it reflected its times by reinforcing existing prejudices and inequities. That said, some attitudes have carried over — with a prevailing sense of supposedly superior medical knowledge. The idea of stringent clinical trials as a gold standard reflects such attitudes. Covid-19 has raised questions about these straitjacketed research methods.

In The Lancet’s 200-year existence, only a small proportion of the overall papers published have been primarily qualitative studies, which are considered essential for exploring and disrupting entrenched inequalities.

Another reflection of the superiority of Western knowledge and knowers is in a comment published in 2020 which analysed three Lancet Commission reports published within the previous decade and found that “more than 70 per cent of Commission authors originated from institutions based in North America and Europe, home to less than 20pc of the world’s population”.

All editors-in-chief of The Lancet over its 200-year history have been white, male and educated exclusively in European institutions.

To its credit, however, things are improving after the establishment of The Lancet‘s internal Group for Racial Equity, supported by an external Racial Equity Advisory board. The Lancet Global Health is also taking some initiatives to tackle inequities in access to the journal’s content in crediting authors from low-income and middle-income countries.

Late Prof Owsei Temkin of the Institute of the History of Medicine at John Hopkins University saw medicine as embedded in the culture and social life of a particular period and the role of the historian as interpreting, rather than merely documenting.

The Lancet’s commissioning of this viewpoint is a step in the right direction. The clock cannot be reset but continued recognition and reparation for exploitation during the colonial era are moves to redeem its inglorious history. The opening of hearts and minds and methodological pluralism will only broaden the scope of studying and improving human health and healthcare across the world.

The writer is a former SAPM on health, and professor of health systems at Shifa Tameer-i-Millat University.

zedefar@gmail.com

Published in Dawn, April 5th, 2024