Book Review

Colonised medicine and transformative learning – Lessons from Downs’ book: Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine

Book Title: Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine

Author: Jim Downs

ISBN: 0674971728

Publisher: Belknap Press, 2021, R462.88*

*Book price at time of review

Review Title: Colonised medicine and transformative learning – Lessons from Downs’ book: Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine

Nontsikelelo O. Mapukata1 symbol

1Department of Public Health Medicine, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa

Corresponding author: Nontsikelelo Mapukata,

How to cite this book review: Mapukata NO. Colonised medicine and transformative learning – Lessons from Downs’ book: Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine. J transdiscipl res S Afr. 2022;18(1), a1287.

Copyright Notice: © 2022. The Authors. Licensee: AOSIS OpenJournals. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


In an article that was published in the University World News: Africa Edition, Tomaselli1 declared the task of reviewing books, a framework and building blocks towards a scholarly process. This, he argued, is a process that is likely to not only accrue benefits for the author and readers but also contribute to a flourishing career. Although Tomaselli does not labour this point, one assumes that if the book review is undertaken as an academic exercise, the reviewer cannot expert to reproduce what has been published by expert reviewers nor seek to undermine their efforts. To that end, a few months after I submitted my thesis, I accepted a call to review Jim Downs’ book,Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine.2 Everything about the title of the book was relatable to me as a gendered self – a black female in South Africa (SA), for we have been victims of a silent war. In post-apartheid SA, that war transformed and morphed itself to become a war on women and children.3

My brief was to determine whether Downs’ book should be included in our reading list as we embark on a plan to decolonise our curriculum offering in the School of Public Health at the University of Cape Town (UCT). This was, after all one of the students’ demands during the 2015–2016 #RhodesMustFall at UCT, which culminated in a nationwide #FeesMustFall students’ protests in SA.4 Prior to the localised and nationwide university students’ protests, changes in higher education institutions, particularly in the historically white institutions (HWI), were limited to changes in enrolment targets in response to a policy directive that was issued by the Ministry of Education.5 Although this yielded an increase in the number of black students who were admitted to study in HWI, an observation that was made by Heleta6 was of macro boxes that were ticked whilst colonial structures remained untouched. As such, as reported by Otu and Mkhize in 20187, attrition rates among black students remained high as students took longer to complete their degrees.

A prevailing perception was of students who were ill-prepared for university studies, particularly if they matriculated from poorly resourced schools in rural and underserved areas within SA. What was overlooked was the impact of a teaching and learning approach that had not embraced the diversity of learning experiences, diversity of contexts, diversity of skills and a range of personal experiences derived and defined by spaces that were occupied by the learners prior to them becoming university students8. Thus, beyond #FeesMustFall, the urgency was in defining initiatives to decolonise and facilitate the pursuance of a transforming curriculum.

In preparing for this review, I submitted a request to our librarians to purchase a physical copy of Downs’ book. In no time, I was informed that an e-book was available on short loan. Within a few minutes of downloading a PDF copy of the book, I made three observations. Firstly, I did not need the 3 days – the book was a page-turner. Secondly, Downs’ peer-reviewed book is an asset to novices as well as public health experts as it provides a detailed historical timeline of three major maladies of the empire, namely, slavery, colonialism and war. The third aspect caught me off guard. As I turned each page, I became increasingly upset by the power and patriarchy that dominated the pages and the violations that were metered on children, the very vulnerable and disenfranchised communities. Down’s book validated the struggle of women scientists who are often overlooked and disregarded. Not only that, I was also shocked by the myriad of ethical dilemmas. I had no choice but to pursue a value-based approach.

Taking into consideration our historical perspective, the demands of the student body I referred to earlier and the efforts to decolonise curricula in post-apartheid SA, in reviewing this book, I had no intentions of reproducing the work of the experts. Bearing in mind the role of public health as a transdisciplinary offering that is concerned with preventing disease, prolonging life and promoting health through organised efforts of individuals and their families; communities; public and private organisations9, I had to demonstrate that Down’s book met the criteria to fulfil UCT’s commitment to transform teaching and learning. Not only that, although I approach this review from my teaching base in the Faculty of Health Sciences, there are opportunities to engage students in other faculties such as Commerce, Engineering and the Built Environment, Humanities and Law at UCT and other universities in keeping with Winslow’s definition of public health as an art and a science. Two exploratory questions informed my approach:

  • What aspects of the book were likely to add value to the curriculum of health sciences students in their first year, fourth year and final year?
  • What aspects of the book were likely to create opportunities for undergraduate and postgraduate students to pursue context-specific research in public health?

Contextualising teaching, learning and research

The first chapter in Downs’ book proved to be a great resource to introduce undergraduate students to research and the application of two research methodologies, namely, the unobtrusive research methods and the mixed methods approach, that have informed processes in this chapter. Later, Downs introduces the narrative, yet another methodology. Tracing the historical context of epidemiology, Thomson makes critical observations about Africans and introduces four concepts that can be explored with students in group activities.

The first one is resilience and self-determination in cases of human trafficking. This section defines the role of healthcare workers in managing prisoners of war (asylum seekers) who embark on hunger strike. Two local cases, Steve Biko’s death10 and the Life Esidimeni tragedy,11 could be referenced in discussions on human rights violations in the public sector.

Secondly, groups can explore insufficient nourishment as the cause of disease as Thomson deduced that Africans could survive without food in crowded and unventilated environments for 10 days. Using the poverty cycle, students can trace the impact of undernourishment on health and education outcomes and link this to policy initiatives such as the feeding scheme in South African schools and, more recently, the Social Relief Distress grant that is administered in terms of section 32 of the Social Assistance Act No. 13 of 2004, to provide relief to unemployed citizens beyond the global pandemic. A debate that can be pursued would allow selected groups to examine the involuntary effects of inedia (fasting) and the incidence of malnutrition and kwashiorkor in underserved and rural communities. Students can contrast this to the practice of intermittent fasting as a lifestyle weight management plan for the middle class. Alternatively, groups can explore the incidence of overnutrition and sedentary lifestyles and its contribution to the burden of chronic diseases. The session can be concluded by introducing students to research as an instrument for mediating population challenges in low- and middle-income countries. Downs’ book offers many other opportunities that are likely to facilitate transformative learning in the examples I present below.

The role of journalists in exposing war crimes

Educators can use this exercise to encourage students to reflect on instances where investigative journalism has exposed inefficiencies in the delivery of health care. Within the South African context, students have an opportunity to reflect on the crisis of personal protective equipment (PPE), the impact thereof on frontline health care workers and potential threats to the implementation of universal access to health care. Students can conclude the discussion by reflecting on their role in advocating for equitable access to health care. In a transforming democracy, such debates can be pursued by students across disciplines to curb corruption and promote ethical leadership. In a group exercise, students can explore differences between colonialism and imperialism. On the one hand, postgraduate students have an opportunity to explore the role of imperialism in advancing epidemiology as a scholarship. Multidisciplinary studies can be pursued that explore the role of imperialism in perpetuating the dominance of the ruling party. For example, health sciences, humanities and law students can analyse the impact of Guptacare on the health outcomes of people residing in the North West Province. On the other hand, multidisciplinary groups can investigate the effect of arson attacks as weapons of war and the impact thereof on oncology services at the Charlotte Maxeke Johannesburg Academic Hospital. In a country with high levels of youth unemployment that have not spared university graduates, another group can evaluate costs that are borne by families and students pursuing professional training in teaching hospitals as well as sunk costs and opportunity costs to service providers.

Florence Nightingale as a revered nurse who is silenced as an epidemiologist

Drawing on Nightingale’s efforts in advancing the practice of record keeping and its value in monitoring and evaluating the emerging threats and patients’ response to interventions, students across disciplines have an opportunity to evaluate the role of social media in advancing access to information about a contagion. The coronavirus disease 2019 (COVID-19) is a realistic reference for this task. Educators can challenge students across disciplines to explore the role of descriptive statistics in contributing to policy formulation and the use of implementation science as a practice approach to address public health challenges. In addition to that, students could pursue collaborative inter-faculty partnerships and address emerging problems that are likely to impact health outcomes such as the 2018 water crisis that had implications for people living and working in the Western Cape province. Other opportunities that are likely to contribute to transformative learning may include an exploration of the shift from case finding to protocol development as a faculty-mediated response to the recent mental health crisis, a malady that is not limited to the students of health sciences but one that has affected university students across disciplines. In a country that is overburdened by crime and gendered forms of violence, educators can encourage students to explore the benefits of making a shift from curative approaches to implementing salutogenic approaches such as hiking and walking clubs, thereby creating safe spaces for university students as they pursue practice-based research.

Race and racial differences

A critical component in Downs’ book that is relevant to SA’s apartheid history is exploring the role of race as a defining factor in the pathogenesis of diseases. In advancing the decoloniality project, working in groups, health sciences and humanities students can draw from Woodward’s reflections on the attitudes of black soldiers to death and dying and contrast that with their understanding of the role of culture and patient health-seeking behaviour in determining health outcomes. Senior students across disciplines have an opportunity to examine the role of observational studies in facilitating an understanding of the use of language as a form of subtle oppression and exploitation of disenfranchised communities when undertaking research as an experimental science. Another group can collaborate and examine Russell’s role in advancing scientific racism or that of physicians in perpetuating racial differences in the 17th, 18th, and 19th centuries. Watching the 1998 documentary on the life and times of Sarah Baartman should instil an appreciation of pedagogical innovation as a form of enhancing transformative learning.

Ethical dilemmas in practice

In introducing students to ethical dilemmas in practice, the violations that are metered against children can be explored in discussions that are guided by the South African Bill of Rights12 and related legal provisions such as the Children’s Act of 200513. In Downs’s book, three critical points of reference include the use of children as research objects, children as vaccine intermediaries, as well as orphaned and marginalised children as the property of physicians. As a transdisciplinary activity, students can carry out an audit of published research to evaluate the role of research committees and institutional commitment in protecting the interests of children when they are enlisted as research participants.

In conclusion, Downs’ book offers many opportunities for educators across disciplines to engage a diverse group of students in discussion as they explore a range of context-specific topics in public health. As we embark on a range of curriculum transformation initiatives, Downs’ book creates opportunities for students to appreciate the role of the three maladies of empire in contributing to transformative learning.


  1. Tomaselli, K. G. Book reviewing should be a measurable academic output. The Conversation: Africa Edition. 2021 [cited 2021 Apr 21]. Available from:
  2. Downs J. Maladies of empire: How colonialism, slavery, and war transformed medicine. Harvard University Press; 2021.
  3. Younger DS. Health Care in South Africa. Neurologic Clinics. 2016;34(4):1127–1136.
  4. Langa, M. (Ed.) #Hashtag: an analysis of the #FeesMustFall Movement at South African universities. Johannesburg: Centre for Violence and Reconciliation; 2017.
  5. Department of Education, R.S.A. Education White Paper 3: A programme for the transformation of higher education, Government Gazette, 386, Pretoria: Government Printers; 1997.
  6. Heleta S. Decolonisation of higher education: Dismantling epistemic violence and Eurocentrism in South Africa. Transformation in Higher Education. 2016;1(1):1–8.
  7. Otu MN, Mkhize Z. Understanding black African student attrition in the context of transformation in South African higher education institutions. Journal of African Foreign Affairs. 2018;5(1):149–171.
  8. Mapukata NO, Couper I, Smith J. The value of the WIRHE Scholarship Programme in training health professionals for rural areas: Views of participants. African Journal of Primary Health Care & Family Medicine. 2017;9(1):1–6.
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  10. Mclean GR, Jenkins T. The Steve Biko affair: A case study in medical ethics. Developing World Bioethics. 2003;3(1):77–95.
  11. Dhai A. The Life Esidimeni tragedy: Moral pathology and an ethical crisis. South African Medical Journal. 2018;108(5):382–385.
  12. Nthai SA. A bill of rights for South Africa: An historical overview. Consultus. 1998;11(2):142–143.
  13. Dawes A. The South African Children’s Act. Journal of Child & Adolescent Mental Health. 2009;21(2):iii–vi.

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