Hospitals in the 19th century
To get an impression about the coverage of European health care in the Netherlands Indies a survey around the year 1890 shows a total of 79 civil hospitals. It should be noted that the number of 36 indigenous hospitals changed from year to year and that their capacity usually was very limited. One may assume on average some 10 beds per hospital. This means a total capacity of some 360 beds. For the 5 largest general hospitals on Java (2 Chinese and 3 Stadsverbanden) the average number of occupied beds was 1,093 in 1890. There were 6 company hospitals (5 on the Outer Islands, 1 on Java) with an estimated capacity of some 300 beds. The remaining specialized hospitals, a total of 33 hospitals had together a capacity of some 2,500 beds (9 leprosy (223 beds), 15 syphilitic (150 beds), 3 beriberi (1587 beds), 3 psychiatry (502 beds) and 3 health resorts (75 beds). Altogether, these 79 hospitals offered a capacity of roughly 4,300 beds. It may be observed, that the number of European and native doctors increased substantially, compared to the situation at the end of the 18th century when at the end only 86 surgeons remained. The availability of civil hospital beds was 0.14 per 1000 inhabitants. By this time, there were almost the same number of military beds (4,200) and as some of these beds also were available for the civil population, the availability ratio will have been higher than the mentioned 0.14 per 1,000. To compare: at the same time this availability amounted to 1.7 per 1000 in the Netherlands. The admission rate was 1.1: more than 1 % of the population on average attended once a year to a hospital.
Public Health Policy in the 19th century
General medical policy
The public health policy of the Government of the Netherlands Indies towards the civilian population in the 19th century was laid down in regulations that were published in Staatsbladen (Statute books) and Bijbladen (Auxiliary Statutebooks). All of them stressed the principle that the BGD (Civil Medical Services) bore no responsibility as to making available individual hospital care, whether it be paid or supplied free of charge. In an additional regulation issued by the Director of Onderwijs, Eeredienst en Nijverheid (Education, Religion and Industry) it was stated that provisions would be made available only for the medical treatment of pradjoerits (native policemen), syphilitic prostitutes, insane and badly wounded patients or other patients taken in by the police force.
Such a policy appeared to be no exception in colonial settings. Looking at British India, we may cite David Arnold, who stated: “The colonial power took a narrow view of its own responsibility for the health and welfare of the bulk of the Indian population and, until well into the second half of the nineteenth century, tried to restrict its financial and administrative commitments to those areas of immediate concern or inescapable involvement like the army and the jails.”The author compared this attitude with Britain’s own social history in which private philanthropy and public charity had played a major part, visible in the founding of hospitals, dispensaries and medical schools. One might remark however, that governments like the Dutch and British central government seldom embarked on initiatives in the field of individual healthcare and that in both cases (British India and the NI) private initiatives like missionary hospitals became the equivalent of the charitable initiatives in the mother countries. Later on, in the 20th century, contrary to public policies at home, the NI government played a prominent role in collective as well as individual healthcare.
Soon after Daendels started to organize military medicine, a remarkable change took place in the quality of surgeons. Well-educated military surgeons were engaged for the new military hospitals. They were called “officers of health” and had passed the newly started training for medical practicians by Professor Brugmans at Leiden. Some had passed examinations in the NI that were attuned to the program of Leiden. In the next decennia it became clear that the actual number of officers of health did not fit the needed quantity.
The Chief of medical services, Dr. Bosch, made efforts to improve the professional situation in health care. About halfway the nineteenth century, he initiated two separate training courses at Batavia: one for native doctors, called dokter djawa and one for native midwives. There had been an earlier initiative to train native midwives, during the Daendels regime in the beginning of the century. Town doctors at that time gave obstetric lectures to indigenous women in order to replace the doekoens baji. Regrettably, this had not been successful and neither was the new attempt of June 1851 by which 20 pupils were admitted to the school for midwives. By 1875 it was even decided to close temporarily this school. It was not the training itself that failed, but the graduated midwives did not get calls from the population to assist at childbirth. The pregnant women preferred the female doekoens. If this effort to improve the situation in the field of professional health care training did not prove to be successful, the training for native dokters too suffered from the beginning by quality and status problems. However, contrary to the case of the midwives, by the end of the century, and after the necessary adjustments in the curriculum, the dokter djawa became a widely accepted professional who had a meaningful share in the care of patients. By 1890, the number of dokters djawa came near to that of the European (military and civilian) physicians: 108 dokter djawa’s on 143 European physicians. That these numbers could not mean much for a population that in the course of the century had grown to some 32 million inhabitants may be concluded from the calculated ratio of 1 physician/dokter djawa per 125,000 people.
In the year 1803 a remarkable medical article made its entry in Java. After a journey from India to Isle de France and from there to the East Indies the ‘vaccine’ arrived at Batavia. Unfortunately, the vaccine proved to be ineffective due to the long sea-voyage. The NI Government then sent a vessel back to the Isle de France with 10 or 12 children aboard under supervision of the military doctor M. Gauffre. The precious article had to be kept ‘alive’ during the long sea-journey by inoculation from child to child. From its arrival a war started against what was called the scourge of the East-Indies: small-pox. While not many health care programs in the colony proved to be effective, this one at the end appeared to be. After quite a number of problems and failures the number of children affected by small-pox decreased and this became one of the factors to count for the large population growth on Java, especially during the second half of the century. Quite an army of vaccinators was mobilized, starting with local priests, who succeeded in some cases to get the population cooperate. Sometimes they even succeeded in having parents consent in sending their children around the archipelago to keep the vaccine alive in the same way as during the initial voyage. The priests were followed up by doekoens, indigenous schoolmasters, and missionaries. Finally dokters djawa became assigned to train professional vaccinators.
The first initiative to introduce small-pox vaccination into the NI had been from Dr. Laborde, French medical chief of Reunion and Isle de France. Lieutenant Governor Raffles continued and extended the vaccination program on Java. But after his leave there was stagnation during some decennia.Some of this may have been caused by the opposition from the population. There was quite some resistance when the coming of a vaccination team was announced at a village and children were held back. The parents often had heard rumours; sometimes coming from their religious leaders, about the spell that came upon their children after these underwent the vaccination. From 1850, when an Inspector of vaccination was appointed, Java became divided into circles, the so-called straalsysteem (Circle or radius-system), intending to minimize the distance people had to walk to a centre of inoculation. The largest distance being 5 paal (7.5 km). From then on the number of vaccinations and of revaccinations grew.In 1879, the Parc Vaccinogène was established in the Residency of Buitenzorg. Starting with an annual budget of ƒ 2,103 this institution expanded and became a powerful institution in the end. The introduction of the ‘straal-system’ together with the improvement of the service and the foundation of a Parc Vaccinogène became the foundation of an effective fight against this public enemy that at the beginning of the century signed for a 20 % death-toll.
In the middle of the 19th century a debate took place in the motherland about the influence government and medical establishment should exercise on the circumstances of life of the population. Committees were installed to supervise the medical and hygienic circumstances of towns, regions and provinces. The members regularly met to discuss how to ameliorate the living and housing conditions of the population in order to influence the health situation and to prevent diseases. To get a grip on the circumstances of living and housing, these had to be described. Quite a number of these descriptions were composed and covered various subjects, like the local weather over periods of time and per month, the quality of the soil, the quality of school-buildings, of houses, of hospitals, etc. These geneeskundige plaatsbeschrijvingen (medical topographies) offered a source of information on which appropriate measures could be taken. Beside these descriptions, much value was attached to setting up and maintaining statistics about demography, health situation, occurrence of diseases, costs of living, number of patients and a lot of additional subjects. At last, authorities (medical and political) took measures in the field of water-management, of constructions and to combat pollution.In the wake of these developments, similar impulses took place in the colonies abroad.
Policy regarding leprosy
The government policy regarding leprosy switched from an active policy holding the view that leprosy was an infectious and transmittable disease towards the opposite opinion. As a consequence, at first leprosy asylums were built to house the affected people, while later on these provisions were abandoned. In the Netherlands Indies such institutions could be found outside the island of Java on the Moluccas, the island of Celebes, Riouw and some other places outside Java. Schoute mentions a number of 9 institutions for leprosy of which 4 in the Moluccas, 2 on Celebes, 1 on Sumatra, 1 in Riouw and 1 on the isle of Banka, which existed around 1850.For the island of Java the head of the MGD held a count among the Residencies in 1853 and came to a number of 2,239 leprosy cases, which was estimated to be too high, possibly while all kind of skin diseases had been included. The reports showed that the number of inpatients had decreased for quite some time. Thereupon, the government decided to ask for an extensive survey with recommendations as to the necessity and the possibility to isolate leprosy cases. Based on the findings of this research, the Council of NI arrived at the conclusion that leprosy was not contagious and that therefore leprosy patients should not be compelled to leave society and become hospitalized in leprosy institutions. Those who had been inmates for some time could stay on a voluntary base. Others could be admitted into general hospitals for treatment like other patients. Therefore, care of the leprosy patients became a matter for charity institutions and there was no need for the government to intervene.
Policy regarding syphilis
Lieutenant-Governor Raffles not only took care of an extensive small-pox vaccination program, he also embarked upon the fighting of venereal diseases. He ordered the isolation of syphilitic prostitutes by establishing Women hospitals. The first one was founded in Djocjacarta in the year 1816. The second Women hospital was built in Soerabaya in 1820. Later on in this century the policy of the NI authorities concerning syphilis became formulated in regulations of 1852 (averting the harmful consequences resulting from prostitution) and a larger budget became available in the fight against venereal diseases. These regulations followed the French system: registration of all prostitutes, compulsory examination, if necessary followed by treatment and the assembling of the women in brothels wherever possible. The regulations became operative in most Residencies of Java and in some places in the Outer Provinces. For instance, in 1878 the regulations were applied to Pontianak, the capital town of West Borneo and to the Residency of Banda (Moluccas). This implied that the medical authorities took the responsibility to periodically examine prostitutes and provide for their hospitalization, if necessary. In the same year 1878, standards were established to fix the number of staff in accordance with the number of women that was admitted into this type of hospitals. These standards should be applied by the heads of regional administration like provincial governors, Residents and assistant-Residents. In the years to follow the Annual Koloniale Verslagen (Annexes to the Proceedings of the Houses of Parliament) comprised messages like: The government of the Netherlands Indies authorized to erect two houses for the inspection of prostitutes in the kampongs Bandaran and Sawahan (Soerabaya). Similar notes came in the years to follow. The effect of all these measures was questionable and so the regulation of 1852 was withdrawn in 1874. The combat against prostitution should be a matter of “police regulations” henceforth, being entrusted to the local authorities. Schoute remarks in a comparison of the struggle against small-pox: “we may say that the latter struggle subjected the population to moderate inconveniences, as compared with the essential advantages obtained, while the struggle against syphilis often brought about serious inconveniences in exchange for doubtful gain.”
Policy regarding psychiatry.
The developments of psychiatric institutions during the 19th century deserve special attention. In the paragraph on psychiatric hospitals, mention was made of the so-called Humane Decree of King Willem I, in which the King ordered to look into the performance of krankzinnigengestichten (foundations for the insane) and ascertain the purpose of those institutions. They should focus on curing the patients instead of keeping them lifelong hospitalized. Actually, the King tried to centralize the care of poor people, the care of Gasthuizen and the care for the insane. However, the opposition against the King’s effort to change the situation in these fields was very strong. The governors of these institutions and the lower administrative bodies like municipalities and provinces were determined to remain in charge.In the meantime, from about halfway the 1820s, efforts were made to reorganize the Dolhuizen and to improve the treatment thus that the character of these institutions became more curative. However, it lasted till 1841 before the first Krankzinnigenwet (Insanity Law) was passed. From then on, though on a decentralized level, a remarkable improvement of care took place, following the track of the new science of asylum management. This new approach in treatment of psychiatric patients comprised a non-restraint policy and inventive use of the asylum environment by introducing work therapy in horticulture and agriculture. In 1849, a modern new psychiatric hospital, with the name Meerenberg, was founded by the province of North Holland at Santpoort. The course of new developments in the Netherlands Indies was initiated by the chief of the MGD, doctor Wassink, who in the years ’60 investigated into the destiny of the insane on Java and Madoera. His report about the situation of the psychiatric patients in a number of prisons and hospitals and his recommendations for improvement were met with disbelief and abhorrence by the inspectors of mental health in the Netherlands. After ample deliberations two doctors were appointed (one by the Minister of Colonies and one by the Governor General) who had to cooperate in executing the Decision of the Crown to build one central hospital at Buitenzorg (near Batavia) and two auxiliary institutions at Semarang and Soerabaya. The central hospital at Buitenzorg was established in a prolonged building process. It started its activities in 1882 and was compared to the newly built model psychiatric hospital at Santpoort of royal dimensions and costs: on behalf of 212 patients at Buitenzorg the same annual amount was spent as for 800 patients at Meerenberg. From then on the care of the mentally ill got continuous attention of the authorities and a more or less autonomous status in the health policy of the colony. By 1910, the capacity to nurse and treat psychiatric patients on Java reached the eightfold of the numbers reported by doctor Wassink in 1862.
Looking back at the period of VOC health care and at the achievements during the 19th century, different aspects may be evaluated. Regrettably, a number of problems were not solved during the period discussed: First of all, a number of diseases could not be fought by effective measures. Before the end of the 19th century cholera took numerous victims from time to time and this was also the case with beriberi, malaria and other diseases. By the end of the century, medical science stood at the brink of discoveries that explained the causal factors of some diseases, but effective therapies still needed to be developed (beriberi, yaws, syphilis). As for hospital care in the VOC period: Whereas in the Netherlands, hospital care faded away during the 18th century, in the colonies hospital care became essential and almost identical to medical care. The VOC kept on investing in hospitals, in buildings and in budgets. As quite a number of hospitals was founded on Java and in the Moluccas, it were the employees of the Company and not the civil indigenous population, who were admitted to these hospitals. However, a far larger part of healthcare took place beyond the scope of Europeans. Chinese doctors and traditional healers continued their services for the autochthonous population, as they did before VOC-time. The passing from the VOC-situation to health care of the 19th century was less abrupt than the political transitions that took place from 1795 to 1816. Some civil hospitals continued their existence and new ones were established. However, during quite some time they suffered from neglect, disposed of very basic budgets and deteriorated. By the end of the century a better and promising future could be expected for civil hospitals, as new and modern company hospitals and mission hospitals were founded. The old Stadsverbanden had to wait the 20th century for new and better perspectives.
On the positive side of the balance may be found:
- The effects of a thorough vaccination program that substantially diminished the death-rate by small-pox of children.
- The results of a training program and a school for indigenous medical doctors, which substantially increased the capacity to treat patients in NI.
- The penetration of Western health care in the NI after three centuries of founding and exploiting hospitals and educating doctors.
- Improving of health care by casuistic meetings and publications of the Medical Association of the Netherlands Indies.
- As for the military hospitals that were dominant in the 19th century: by founding new large hospitals and taking notice of new insights in design, water supply, refuse disposal and airiness of the surroundings, the quality of military hospitals improved.
- The improvement of the care of psychiatric patients by establishing modern psychiatric hospitals with modern therapeutic programs like labour therapy in agriculture and horticulture.
- Preventive actions to fight malaria by sanitation works (assaineering) and supplying a better quality of water.