Stanford fellow investigates how literature shapes transnational fields of medicine

By Barbara Wilcox

Alvan Ikoku's experience conducting archival work on malaria control helped him recognize the public health significance of literary writing. (Photo: Linda A. Cicero / Stanford News Service)

In a 2005 lecture at King's College London, before an audience of scholars and practitioners in literature and medicine, physician and editor-in-chief of The Lancet Richard Horton called for a new literature of public health for the current global era.

He envisioned novels of global humanism – fiction that would engender empathy by providing insight into the medical plight of others living far away.

"Horton's call is interesting because it represents a new effort in medicine and the humanities," said Alvan Ikoku, an Andrew W. Mellon Fellow in the Humanities at Stanford, who himself completed studies in medicine at Harvard before pursuing a doctorate in comparative literature. "The prevailing idea is for literature to directly represent societies, their peoples, their ills," to induce an emotional response in readers, which health specialists may harness as they work to gather financial, technological and human resources toward advances in care.

"It is essentially a call," Ikoku said, "to return to a notion of how literature seemed to work in the 19th century," when novelists like Charles Dickens and Elizabeth Gaskell could be cited as advocates-in-fiction for developments in public health.

But according to Ikoku there has long been an intimate and complex relationship between science and literature in the evolution of modern medicine.

As a scholar of 19th- and 20-century movements in international literature and health, he studies the place of long narrative forms, especially novels, in the development of tropical medicine and global health.

In his current book project, Forms of Global Health, Ikoku reads not Dickens or Gaskell, but writers such as Joseph Conrad and Andre Gide, who added to a "library of metaphors about the tropics and colonial spaces," one that was referenced by "the fathers of tropical medicine" – returnees from colonial medical services, particularly malariologists, who wrote and lectured publically about the need to establish a new medical specialty for the colonies.

Ikoku points out that literature provided an opportunity for readers to not simply feel an emotion, but to also actively help define a medical field and its knowledge base.

Examining empiricism

As the study of diseases in the colonies developed, a confluence of fictional and poetic works, travel accounts, disease chronicles and research articles created a "vital medium for advancing notions of geographic and scientific discovery, as well as medical ideas about ecology and native Africans," Ikoku said.

As they facilitated a metaphorical mapping of the tropics, Conrad and Gide in their writings questioned several tenets of medical empiricism and imperialism.

They deployed devices, such as ironic scenes and language, that compelled readers to examine the rhetoric of colonialism, to doubt the ethical ideals of civilizing projects and to see the limits of technology and diagnosis.

"And they produced journal-mimicking narratives," Ikoku said, "fully aware of the growing status of medical journals and explorers' diaries as vehicles for scientific knowledge."

To read these authors closely – as the physicians of the time could have done – is to recognize a literature of world health that emerges through modernism, postmodernism and postcolonialism, in tandem with other genres of public health.

Thus, as he explores this relationship between literature and medicine, Ikoku studies a range of source materials, including fiction by Albert Camus, Antonio Olinto, Bessie Head and Amitav Ghosh; philosophical physician memoirs by Albert Schweitzer, Frantz Fanon, Abraham Verghese and Paul Farmer; and international declarations by the League of Nations, the World Health Organization and UNICEF.

"It isn't that Richard Horton hasn't read these other kinds of novels. It's that he doesn't openly recognize them as doing global health work," Ikoku said. And this is a shared non-recognition, at times facilitated by scholars in literature.

"Reading this corpus narrowly wouldn't simply mischaracterize the literature," Ikoku said. "It would also preclude the 'new global humanism' called for by humanist scholars and physicians alike."

Rewriting malaria

As a quintessential disease of tropical medicine, malaria has proven to be a valuable case study for Ikoku, since its description was taken up by literary and public health figures in the early and late 20th century.

He recognized this confluence while a master's student at Oxford, where he became fascinated by the history of malaria control and conducted archival work in Kenya.

He focused on the colonial era, when medical officers deployed literary and scientific rhetoric as they worked to study and prevent malaria epidemics.

His source materials included medical reports, research journals, scientists' notes and health pamphlets – none of which were housed in a national archive, but haphazardly stored in an old hospital dissection laboratory.

This surprising storage site doubled as a reading room, Ikoku recalled, and a reminder that the blurred boundaries of colonial health led to an undisciplined archive – that the rewriting of malaria as a microbial disease drew from a confluence of ways of knowing, both fictional and nonfictional.

For example, Karen Blixen's 1937 memoir, Out of Africa, famously opened with an almost direct figuration of Kenya's malaria problem in spatial terms – into zones of "good air" and "bad air" – which 1930s health pamphlets had referenced when calling on settlers to imagine their verandas as a stage for battle between themselves and infected female mosquitoes.

The authors of both texts imagined and wrote toward a malaria-free community, Ikoku said, with consequences for the health of European settlers and Kenyan natives.

The archival experience helped Ikoku recognize the public health significance of literary writing, and to see the work being done in later novels of the 20th century.

Ikoku found Ghosh's 1995 The Calcutta Chromosome particularly illuminating as its protagonists are employees of a global health NGO, on a quest to unravel the mysteries of malaria research conducted a century ago, visiting real and fictional archives in India.

Ghosh's characters – and his readers – come to understand that in the setting of global health, malaria research cannot truthfully be presented as tropical medicine had attempted in the 19th century.

Rather, Ikoku said, "the responsibility one has is to examine the history and institutions of a field, to recognize how one's predecessors had altered the nature of disease by rewriting it. As one character puts it, 'to know something is to change it.'"

Teaching different readers

Ikoku introduced Stanford students to this relationship between literature, ethics and health in his spring course, The Literature of Global Health.

Students in literature, biology, engineering and African studies spent the past quarter studying how literary and medical writers have used narrative to explore the ethics of care in the developing world.

An early highlight was juxtaposing the World Health Organization's constitution and Albert Camus' novel The Plague – both drafted and published in 1946-47.

The comparison revealed for students two ways audiences were asked to think about reform. "We can argue that the problem was in the air: How, after war, to represent an international community that gets people to think more ethically about world health?" Ikoku said.

Teaching has been a place of return for Ikoku, who was himself introduced to medicine and the humanities while an undergraduate at Stanford (AB '96). He majored in human biology and wrote his honors thesis in literature, focusing on language in Samuel Beckett and Vladimir Nabokov.

"Both endeavors challenged me as a student," Ikoku said. "I was taught that interdisciplinary work was possible, but it should be done with depth and rigor. That's why I think some of the tougher questions now being raised by medicine and the humanities do not have to be simplified. We can read literature more collaboratively than our training often permits."

Barbara Wilcox is a student in the Master of Liberal Arts program and writes about the humanities at Stanford.

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