Legacy of Slavery & Indentured Labour – Linking the Past with ... · Web viewZemon Davis Natalie, 2015. Physicians, Healers, and their Remedies. AMS Paterson Lecture–Conference

Legacy of Slavery and Indentured

Labour

Linking the Past with the Future

Conference on Slavery, Indentured Labour, Migration, Diaspora and Identity Formation.

June 18th – 23th, 2018, Paramaribo, Suriname

Org. IGSR & Faculty of Humanities and IMWO, in collaboration with Nat. Arch. Sur.

Revisiting F.A. Kuhn's "Reflection on the situation of the Surinamese plantation slaves; an economic-medical contribution to its improvement (1828)”

Marthelise Eersel MD MSPH,

lecturer Public Health Department,

Faculty of Medicine, Anton de Kom University

Introduction:

J. Wolbers’ “History of Suriname” (Amsterdam, 1861) elaborates in the third chapter entitled “The situation and treatment of the slaves” on the deplorable working and living conditions of the enslaved who were considered production machines which wore out due to hard work, bad food, housing and clothing. Once the enslaved were considered not worthwhile any costly medical treatment, they were put aside and “new production machines” were purchased. Here we find a footnote referring to a publication of F.A Kuhn M.D. on the situation of the Surinamese plantation slaves. Wolbers notes in the footnote that this publication, which appeared almost 40 years earlier, was very important ‘even in later times’.

Figure 1: Drawing of a plantation hospital. Source: cover page of Kuhn’s

Reflection on the situation of the Surinamese plantation slaves; an economic-medical contribution to its improvement (1828)

Wolbers’ and Kuhn’s works were both published during the period of the abolitionist movement in the first part of the 19th century. Wolbers concludes his “History of Suriname” expressing the hope that with his work the aversion of the public against slavery would be increased. Kuhn on the other hand is not so explicit in his final remarks. At the end of his work he expresses the hope for an improvement of the health care for the plantation slaves. In the introduction he remarks that his work is the result of observations in Suriname as a doctor and that he thought it to be his duty to provide an expert judgment; however it was not without a certain amount of trepidation since he was aware that as a practicing physician it was not entirely without the risk of offending people. Having worked for almost eleven years as medical chief of the troupes and hospitals in Suriname, including as a private doctor and physicist, he propagates good medical care specifically for the plantation slaves without explicitly condemning slavery. It is most likely that being employed by the government Kuhn probably could not openly express any abolitionist views.

In this paper we will revisit Kuhn’s work “Reflection on the situation of the Surinamese plantation slaves; an economic-medical contribution to its improvement, Amsterdam: C.G. Sulpke, 1828”. In Kuhn’s days the germ theory had not been developed yet, let alone the germ theory of disease which only became more accepted by the end of the 19th century. During the larger part of the 19th century the miasma theory (polluted air causing disease) was commonly accepted and we find the medical treatments derived from this theory repeatedly throughout Kuhn’s document. Kuhn presents the most prevalent diseases in the plantation slave population and identifies the causes from an early 19th century medical knowledge perspective. His presentations are more descriptive and narrative than of quantitative. Epidemiology which studies the occurrence of diseases in mankind in quantitative terms such as incidence and prevalence only started developing in the latter part of that century. Still it is interesting to read Kuhn’s descriptions of the most frequently occurring diseases in the slave population and their causes which he more than often attributes to poor living and working conditions; an priority area within Public Health nowadays called social determinants of health. His expertise as a physicist obviously contributed to some of the practical solutions he proposes to tackle causes of certain diseases for instance adaptations of working equipment to prevent repeated strains and injuries, conservation techniques for food and filtering techniques for drinking water. Some of these solutions (in Public Health called interventions) are still relevant today for many parts of the world. Kuhn describes in detail the medical services at the plantations such as the work of the doctors and their assistants, the medical treatments, the remuneration of the doctors and the role and influence of the traditional healers and the administrators of the plantations. He also gives a critical analysis and recommendations for improvement of the health care system in Suriname, including in terms of its cost effectiveness.

We will present Kuhn’s main observations, conclusions and recommendations and will highlight from a public health and health systems perspective that many issues are still relevant in our 21st world.

Diseases among the plantation slaves:

Kuhn started by listing some general diseases which occurred among all other people.

The most frequently occurring in this category were: fevers due to repressed exhaustion , respiratory infections, shortness of breath, watery and bloody diarrhea, constipation, consumption, edema, scrophule and venus disease , chronic skin eruptions, malign skin ulcers, delay in menstruation, lock jaw. Obviously almost all of these were infectious diseases highly prevalent in an era before the advent of antibiotics.

He then lists some specific diseases not indigenous to Suriname but imported by the enslaved the most frequently occurring being: leprosy, jaws (guinese smallpox), crabbejas (water in the joints of the knee, foot and hand), swelling disease (cachexia aricana better known as earth eating). Kuhns gives a description of the latter: “there is a tendency to eat dirt, earth and in particular charcoal. I saw some who had such a craving for charcoals that they put them burning hot in their mouth and chewed them. This is a childhood disease which I frequently observed and which was imported from abroad”. Kuhn does not provide a scientific explanation for this disease. Dirt eating has been observed in many populations around the globe at all times, but was highly prevalent among the enslaved. Several explanations have been offered by the scientific literature in Kuhn’s time such as witchcraft, depression and suicidal behavior. Some forms of dirt eating are nowadays associated with intestinal helminthes infestations.

We found some other prevalent diseases and conditions which Kuhn listed under other chapters, but which we consider useful to list here as well. These as burns, fractures, amputations, lacerations etc. due to frequently occurring accidents or physical punishments. Also frequently occurring were childhood diseases such as tetanus, caused according to Kuhn by the improper treatment of the umbilical stump and diseases caused by the practice of forceful feeding of babies (called “kanten”) . The negative growth rate of the slave population could according to Kuhn be attributed to a list of causes among which he mentioned the high infant and childhood mortality rates as well as diseases of the reproductive organs in men and women leading to low fertility rates.

Description of the living and working conditions of the slaves:

The slave huts, mostly made out of the bark of palm trees, into which the cold night air could easily penetrate, and which were built on damp earth and low land prone to flooding, are described by Kuhn as bad for the health of the slaves. He mentions that where the slave huts were made of wooden planks with shingle roofs on high land the negroes were healthier.

Kuhn observed that the health situation of the plantation slaves depended on the number of working hours and the type of the plantation. Slaves at the cotton plantations worked around 8 hours per day, while at the coffee plantations especially during harvest season 14-15 hour workdays were common. Working conditions at the sugar plantations were the worst, where during 9-10 workdays and during grinding and boiling processes 16-17 hours workdays were normal. Slaves at the timber plantations had the ‘most favorable working hours’, working from Monday till Thursday afternoon, being free to tend their own “business” during the remaining days. Sleep deprivation , especially at the sugar plantation and working under the heat of the sun were according to Kuhn detrimental the health of the negro. He provided a counter example of the situation a particular plantation where a steam engine was used to grind the sugarcane thereby relieving the slaves of night shifts; where consequently the slaves were healthier and the slave population was growing.

He described several activities of the slaves in more detail such as the working with a tool called tjap to plough the earth by hand which caused, especially when the earth was dry, repeated smacks to the chest leading to chest diseases. Even working with a machete to cut grass and weeds in an uncomfortable bending position lead to chest and arm fatigue. Furthermore the crushing of the coffee and the bumping of cotton which occurred in an enclosed warehouse caused an enormous accumulation of dust consequently leading to lung problems. The carrying of heavy loads on the head caused prolapse in the groins. The grinding process of sugar cane where the latter had to be placed between iron rollers was hazardous as the upper extremities could get caught and crushed, whereby underarm amputations had to be performed. Sometimes the whole body could get crushed up till the skull. The boiling of the sugar juice till crystallization especially during the night was also a hazardous activity since the floor became slippery and it occurred that slaves slipped and fell into the boiling kettle leading to severe burns and death.

Figure 2: The grinding of sugar cane

The clothing, according to Kuhn essential to protect the slaves from the cold night air was prescribed by law and each slave was annually entitled to a certain amount of clothing and sewing materials but this happened on many plantations only once every three years . Furthermore some slaves when receiving their clothing rations exchanged them for liquor or other hazardous commodities.

The food of the plantation slaves was according to Kuhn in general insufficient. On some plantations there was an abundance of food while on others scarcity, the main reason being that bananas which were the main staple food, could not thrive very well on the coastal plantations especially during the dry season. According to the prevailing law each slave should receive 2 bunches of bananas per week which did not occur on many plantations. During times of scarcity of bananas and other staple food, the negroes had to still their hunger with searching for fish, crabs, wild fruits and vegetables. Access to good drinking water was problematic since the rainwater reservoirs were too small to supply the entire slave population, especially in the dry season. Moreover at the coastal plantations surface water was inundated by sea and brackish water. In search of drinking water slaves resorted to drinking hazardous swamp water. Distribution of salted fish (a mix of hake, bullock and haddock) occurred on prosperous sugar plantations every 2-3 months, but on many other plantations only once or twice per year and on some plantations never.

Regarding the punishments inflicted upon the enslaved, Kuhn stated that no bodily punishments , no type whatsoever, could ever have a positive effect on the health, but on the contrary result in all kinds of ailments. Severe whiplashes resulted in sores and this was the worst in case of the in Kuhn’s words malpractice of the so-called Spaansche bok.

Medical services at the plantations:

The description of the medical services for the plantations is the most elaborated chapter in Kuhn’s work . He provided a fairly detailed description of the availability and status of medicines and medical supplies and equipment. Responsible for the medical services were physicians who either had their practice along the rivers in the proximity of the plantations or in the capital Paramaribo where the sick plantation slaves were sometimes referred to. Kuhn remarked that most of the physicians practicing in Suriname came as military or boats men and learned the practice in the country so that most of them, with some exceptions, had very little medical knowledge. Involved in the medical services at the plantations were the plantation directors and the dresinengre. The plantation directors were expected to have some medical knowledge based upon their limited practical experience. The dresinengre were slaves who after an apprenticeship of 5-6 years with a physician, were supposed to have obtained enough practical experience to treat the most prevalent illnesses. Kuhn stated that the dresinengre after his training would be considered adequate for the job, but in reality many dresinengre were cruel against the enslaved which could be explained by the fact that often they also acted as overseers of the work in the buildings. Lastly Kuhn mentioned the dresimama’s, female traditional healers who were quite influential on the plantations because of their perceived supernatural powers and knowledge of indigenous herbs. He warned physicians who wanted to tackle quackery to seriously consider the influence of these dresimama’s which could backfire on them. Each plantation had some sort of hospital facility which was generally badly constructed and unhygienic and as such conducive for the spread of diseases. An arsenal of medicines was available but the quantities were often inadequate. Moreover medicines were not stored properly, invaded by mice and cockroaches with faded labels and consequently a lot of medicines were wasted by the careless behavior of the caretakers. Pharmacy equipment such as scales etc were either not present or in a bad state resulting in doing measurements by subjective estimations.

For most plantations there was a service contract with the physician based on an annual fixed fee per person. Some surgical procedures or other treatments were not included in this fixed fee and had to be charged separately. According to this contract the physician was supposed to visit the sick plantation slaves weekly or when called upon in case of emergencies. The supply of medicines was the responsibility of the plantation director. Other physicians had an arrangement where a total sum of money was paid without extra charges for medicines or treatment at the practice of the surgeon. Some plantations did not have any arrangement with a physician but relied on the plantation director, the dresimama or other local quacks.

According to Kuhn it occurred that physicians who practiced along the rivers had a fixed contract with more than seventy plantations. He attributed this enormous patient load to the low price of the fixed fees which forced the physicians to increase the volume of the patients at the plantations. Kuhn reported that obviously it was impossible to regularly visit this large number of plantations for which the physician was responsible. The lack of qualified assistants at the plantations and the fact that it was up to the plantation director to look after the sick and make decisions on treatments aggravated the poor quality of the medical services. Sometimes gravely ill slaves were sent to the establishment of the physician too late only to die over there.

During his visits to the plantation the physician had to report first to the plantation director after which they were accompanied by the dresinengre to visit the sick slaves in the hospital facility. The director provided information on the status of the illness and the treatment, and the physician made recommendations and modifications if necessary. However not all plantation directors took good care of the sick. Kuhn provides an example of a plantation director who reported to the doctor that a slave, previously in a healthy condition suddenly had died. The truth was that the director was not at the plantation at the time of death and had not seen the slave prior to his death. The director fearing the scorn of the plantation owner that such a valuable strong slave had suddenly died, begged the doctor to predate the time of death and write down stroke as the cause of death.

Figure 3: Drinking plantation director

Kuhn characterized some plantation directors as uncivilized, fat creatures, drunk before sunset using a shot of alcohol every 10-15 minutes and describes how one plantation director boasted to have “cured” a slave, who had been tended previously by the physician for shoulder pains, with 100 whiplashes. Kuhn stated that it happened that some physicians while visiting the plantation sold alcohol spirits such as Dutch gin to the plantation directors. He described how the physicians upon returning to their establishment after a long journey past plantations often had to tend to the numerous sick which had been sent in the meantime from other plantations. As stated before the annual doctor’s fee per slave was not sufficient to cover the expenses, and for some therapies additional costs had to be charged. Often the physician had to wait for the approval of the plantation director for the coverage of the additional costs and it occurred frequently that additional treatment was rejected because the plantation director did not consider it worthwhile to invest in a slave who would not return to his previous health status.

Medical services for the plantations slaves in Paramaribo:

Some sick slaves of plantations who did not have a contract with a physician and who could not be “cured” by the plantations director or dresinengre were sent, after approval of the owner, to one of the 2-3 registered slave hospitals in Paramaribo where they were tended by a private physician and his apprentices. Kuhn explained that the fees which were paid for hospitalizations in Paramaribo were by far not sufficient to cover the actual costs incurred by the physicians, especially when the number of admissions in the facility were low. Moreover physicians could not, as of a resolution of 1826, prepare any medications for internal use anymore. This had outsourced to a registered pharmacist. Kuhn states that the aim of this resolution was to establish boundaries between the medical and pharmaceutical professions and thus would prevent the frequently occurring malpractices and even quackery. He concludes that this measure should be welcomed by “every decent doctor ”.

Kuhn explains the elaborate verification system before physicians’ bills were actually paid by their debtors in this case the plantation owners. Some of these bills were sometimes approved right away, but often times they were sent back with notes in the margins asking the physicians for clarifications. Many plantation owners requested a taxation of the bills by the Collegium Medicum (Medical Council). Kuhn criticized this bureaucratic procedure and proposed that only in cases of doubt a taxation should be done. He stated that malpractices indeed occurred where physicians overcharged and these were either not paid at all or only received halve or a third of the charged amount.

He concluded this chapter on the medical services with the remark that he had informed his readers about the naked truth of the medical care of the plantation negroes, so that they could acknowledge its deficiencies. In his last chapter he proposed measures to improve the health situation and medical services of the plantation slaves.

Kuhn’s main recommendations:

Banana flour and breadfruit trees

He stated that a good nutrition is necessary for the life and health for laborers and even more so for the plantation slaves. It should be the responsibility of the owners to provide nutritious food since the slaves themselves were not allowed enough time to tend to their own needs. To guarantee the continuous availability of staple foods in particular, Kuhn proposed to preserve the surplus of bananas at certain plantations as banana flour in order to supply the plantations with shortages. From his own experience he stated that banana flour is tasty and can be preserved for longer periods. Another proposal of Kuhn’s was planting of breadfruit trees since it had been shown that entire populations in the Indian and South sea regions lived from the fruits of this easy growing tree. He also proposed that the government forced “the lazy free people” in Paramaribo to plant their overgrown gardens with these trees so that they could not only feed themselves better with these staple foods but the plantation slaves as well. Another recommendation to the government was to specify the rations of bananas for the slaves in terms of pounds of peeled weight instead of bunches because the actual nutritional value of the bananas depended on the size of the bananas rather than a bunch.

Water purification

The tackle main cause of the many diarrheal diseases which was the lack of and the poor quality of the drinking water, he proposed, quite revolutionary, to introduce a water purification device developed by two befriended Dutchmen from Utrecht, the Netherlands. Kuhn stated that he himself had used this device successfully for his family and most of the passengers during his boat travel from Holland to Suriname.

Figure 4: Water filter device adapted by Kuhn

At the end of his publication we find a design of a water filter adapted by Kuhn himself

Housing

Kuhn recommended building the slave houses on high sandy grounds preferably off the earth on stone feet with wooden floors to prevent flooding and the intrusion of cold air into the houses. Kitchens should be built outside at a distance from the houses to prevent the development of smoke in the house.

Labour

Kuhn proposed some recommendations which were quite ahead of their time. For instance he advocated enough night rest for the plantation slaves and cautioned against labor which diminished the hours of night rest, considering that too few hours of sleep were considered bad for the health . He proposed the introduction of steam machines which would be beneficial not only for the sugar plantations but for the coffee and cotton plantations as well (he provided examples of plantations where steam machines were operational). This introduction would, according to Kuhn, prevent the decline of the slave workforce due to harsh labor conditions and would increase production. In order to prevent repetitive muscle strains of shoulders and arms, he proposed the introduction of the European spade to replace the conventional tjap which would provide a better grip and leverage when digging. He also proposed the use of wheelbarrows to prevent carrying heavy loads on the head. Furthermore he proposed modifications at the sugar mills by positioning the iron rollers for grinding of the sugar cane in a horizontal instead of the conventional vertical position to order to diminish the risk of body parts being caught between the rollers.

Recreation

Kuhn supported recreational activities among the slaves such as dances but cautioned against “exaggeration” and particularly against dances which continued into the early morning hours since he considered the cold of the night harmful. In general Kuhn displayed dismay against cultural and religious practices of the slaves which obviously originated from the perceived supremacy of western culture and the white race in his days. He promoted the distribution of tobacco to enable the slaves to smoke 2-3 pipes a day.

Corporeal punishments

Kuhn considered whiplashes especially the Spaansche bok harmful and stated that they prevented the slaves from working. He proposed that by law the number of whiplashes and the number and the thickness of the whips should be limited.

Reproduction

To tackle the causes of the decline in the growth rate of the slave populations in particular low fertility rates and high maternal and infant mortality, Kuhn had quite a number of recommendations of which we can be summarized as follows:

-prevent sexual initiation of girls who are too young and not fully developed

-promote a better proportionality of males to females at the plantations

-promote engagements between men and women at the plantations

-promote better care of pregnant and nursing women

-promote better medical care of young children

Medical services

To improve the quality of the medical services for the plantation slaves Kuhn proposed important measures such as:

-the development of a medical handbook written in a simple and for lay people comprehensible manner. This handbook should include a description of the most prevalent diseases among the negroes and their treatments. Also included should be safe home remedies and signs of intoxications due to treatments and the home remedies. He argued that since medical handbooks were written for European populations, they were neither applicable nor understandable for the plantation populations. Such a handbook could, according to Kuhn, be used in case no doctor was available and would also improve better storage and handling practices of medicines and medical supplies at the plantations.

-the establishment of a centre for the training of plantation doctors and dresinengres. He proposed that the Military hospital in Paramaribo could provide a facility to which 200-250 sick slaves could be referred and treated as part of these training programs. Since the Military hospital was owned and funded by the government, the costs would be less than half of what was currently being paid at the slave hospitals of the private physicians. This facility could also serve as a training centre for doctors from Holland to provide them with an opportunity to get acquainted with the medical care for the negroes and learn the language.

Figure 5: Military Hospital Paramaribo circa 1903

-the recruitment by the government of 5-6 experienced physicians and midwives from Holland to practice in the districts for a fixed salary. He also promoted a training program for midwives at the Military hospital.

Other recommendations Kuhn to improve the medical services were the construction of a new model for the plantation hospitals and guidelines for their exploitation. Furthermore he proposed the introduction of salaried district physicians who would report to the Medical Director. These district physicians wouldn’t be in a fixed agreement with any plantation which would allow them to devote more time to provide medical care anywhere when called upon. They also would provide vaccinations and assistance in case of epidemics and would conduct investigations into all sudden deaths and accidents.

Kuhn proposed financial measures such as substantially increasing the fee per capita for the plantation physicians and the introduction of more cost-efficient payment schemes for boat transportations and hospitalization costs since the fees were no longer covering the actual costs.

An important last recommendation of Kuhn was the installation by the government of a Medical supervisory board. This board would be responsible for the supervision of all public hospitals where plantation slaves were admitted. The board would also supervise all physicians providing medical care to the plantation slaves, and those working in the leprosaria. The board would be responsible for the examination of suspected leprosy cases and for vaccinations. It would also conduct the medical screening of professionals from abroad before they received a work permit. Lastly the board would advice medical doctors on various medical issues.

In the concluding paragraph of his publication Kuhn stated that this contribution for the improvement of a medical treatment of the plantation slaves should now be judged by “better experts”.

Epilogue: Kuhn and our modern times

Reading Kuhn’s work almost two centuries later, we agree with Wolbers that this was an important publication and well ahead of its time; even in our times sadly enough some aspects Kuhn addressed are still relevant. We are impressed by his honest and bold statements and conclusions regarding the dire situation of the medical services in general and the medical treatment of the plantation slaves in particular. Bold because Kuhn, being a high level officer employed the government which was responsible for the continuation of slavery, took a risk of being ostracized by his employers and peers alike in describing the deplorable situation not only of the medical services but also of the plantation slaves were continuously exposed to an unnecessary variety of factors detrimental to their health and survival. In his days slaves were considered working equipment not worth a lot of ‘maintenance’. Contemporaries of Kuhn’s in the United States for instance considered blacks to be physiologically inferior, especially with respect to the nervous system, than the white race and concluded that they required entirely different medical treatments. Some contemporary physicians of Kuhn’s even suggested that illnesses of the negroes originated out of a state of mind . Indeed Kuhn stands out, well ahead of his time with his observations and recommendations to improve the health and well-being of the plantation slaves, even under the dire conditions of slavery. We can consider his work still relevant in our modern times. During the past two hundred years, slavery has been abolished, major medical scientific discoveries and inventions have been made. Also sanitary, living and working conditions have been improved substantially, even before the advent of modern therapies. These development have led to epidemiological and demographic transitions and an increasing life expectancy in Suriname and most other nations worldwide as well. In 21st century many infectious diseases endemic during Kuhn’s days have been controlled in Suriname thanks to improved sanitation and the availability of effective diagnoses and treatments. It is important to note here Kuhn’s proposition regarding the containment of infectious diseases such as leprosy which required that patients, even the suspected cases, had to be sent to leprosaria in complete isolation from the community. This procedure widely accepted in his days, has proven to be detrimental in the control of leprosy .

Many of the causes of our modern days’ health hazards point to some of the same social determinants which Kuhn has identified as causes of illness in his days.

Figure 6: Sustainable development goals, United Nations

The access the safe drinking water is still low in the hinterlands of Suriname where people rely on rainwater collected in barrels and in the dry season to unsafe river and creek water . The provision of water filters, the ones Kuhn proposes, for families living under these circumstances still is in our modern days a practical short time solution and has indeed been proposed but however to date not implemented, at least not in Suriname.

Figure 7: Design of modern water filter, World Health Organization (2016)

Kuhn tackled in his writings the gross nutritional deficiencies in the food supply for the enslaved. Nowadays our food supplies have improved. However most of the processed food we consume daily is considered deficient as it is contains too much salt, sugar and fat leading to a variety of health risks such as diabetes, hypertension, obesity etc. Regulatory measures to improve the availability of nutritious foods to our populations should be a top priority of governments . However not a lot has been done, not only in Suriname but sadly enough neither in other parts of the world. Kuhn described the harsh and hazardous working conditions of the enslaved leading to illness, accidents and premature deaths. Nowadays this is a specialty area within medicine called occupational health. He proposed some examples of adaptations for working equipment used by the plantation slaves to prevent repetitive strain injuries in contemporary terms called ergonomics. In this regard Kuhn is quite ahead of his time and his statements about dire working conditions still resonate with us 21st century public health professionals. Sadly in our times people still work under extremely hazardous conditions because of deficient legislation, regulations and supervision. As of to date transatlantic economic powers are exploiting people in one part of the globe in order to enable people in other parts to buy cheap commodities.

Even within countries grave inequities in working conditions continue to persist. Migrant workers contribute with their, often harsh labor, significantly to the economy of many countries, however they frequently lack decent payment, medical services, housing etc . Apparently not much has changed in this regard since the colonial days.

The need to improve the coverage and quality of medical services, which Kuhn addresses, is also relevant in our situation although our health system has evolved considerably over the past century. We do not know how influential Kuhns’ recommendations have been on the establishment of the School of Medicine in 1882 with the Military Hospital (later called the sLands Hospital) as the training hospital for physicians. Neither do we know if it was his recommendation regarding the establishment of a medical inspectorate for the supervision of the hospitals, doctors etc. that lead to the establishment of the position of a medical inspector in 1938, the highest medical officer in Colonial Suriname who predated the current position of Director of the Ministry of Health. Kuhn’s analysis of the prevailing payment systems for the doctors and the hospitals appeal to us as well. In our times studies have also shown that a low per capita payment system ‘stimulates’ doctors to increase the number of patients leading to a shorter time spent per patient consultation and consequently to a poorer quality of care. The payments for the hospitals were too low in Kuhn’s days and ironically enough this has not been resolved yet two centuries later. Kuhn proposed some specific, in his own words economic-medical, measures to improve the cost effectiveness of the health services. Nowadays as our health care system consists of an increasingly complex network of medical, paramedical, diagnostic and therapeutic services current payment models are quite very diverse and are continuously evolving requiring specific expertise in the field of health systems management and health economics. Still it is very interesting to revisit the economic-medical evaluations of Kuhn which from our perspective appear quite simple and straightforward and make us reflect on how we ended up entangled in this increasingly uncontrollable health financing problem.

In conclusion revisiting Kuhn ‘s ‘Reflection on the situation of the Surinamese plantation slaves; an economic-medical contribution to its improvement’, as “better experts” living two centuries later, we find that this document is worthwhile to reflect upon. It makes us appreciate his work especially since he wrote it seemingly against all odds. We do not know the fate of his work, whether it ended on a shelve, and of himself. This should be further explored in order to have a better understanding of Kuhn and his writings in his times. For now we should take an example from this work and continue to expose, discuss and tackle the health challenges and health inequities of our modern times and their root causes. We will be judged two centuries from now by better experts as well……….

References

Dahan Yossi et al, 2014. Global Labor Rights as Duties of Justice. Journal of Social Philosophy. Volume 45, Issue4.

Haller Jr John S., 1972. The negro and the southern physician: a study of medical and racial attitudes 1800-1860. Med Hist. Jul; 16(3): 238–253.

Kuhn F.A., 1828. Reflection on the situation of the Surinamese plantation slaves; an economic-medical contribution to its improvement. Amsterdam. C.G. Sulpke

vd Kuyp E. , 1985. Surinaamse medische en paramedische kroniek, tijdvak 1494-1949. Sur. Med Bull, Vol VII, 68-99.

Snelders Stephen, 2017. Leprosy and Colonialism: Suriname Under Dutch Rule, 1750-1950. Manchester University Press.

Surinaams medisch bulletin, december 2002. Celebrating 100 years of health.

Tsiachristas Apostolos , 2015. Payment and Economic Evaluation of Integrated Care.

Wolbers J., 1861. History of Suriname. Amsterdam.

Unicef, 2010. Monitoring the situation of women and children; Multiple Indicator Cluster Survey Suriname.

United Nations, 2012. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases.

United Nations, 2017. International Migration Report.

WHO, 2016. Results of Round I of the WHO International Scheme to Evaluate Household Water Treatment Technologies.

Zemon Davis Natalie, 2015. Physicians, Healers, and their Remedies. AMS Paterson Lecture–Conference AMS Paterson University of Ottawa / Universite´ d’Ottawa.

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Figure 2: Punishment by Spaansche bok

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� This was the highest medical office in those days in Colonial Suriname . Surinaamse medische en paramedische kroniek, tijdvak 1494-1949, Sur. Med Bull, Vol VII, 68-99, vd Kuyp E. (1985).

� Based on the prevailing miasma theory

� Later called tuberculosis after the discovery of the bacillus (1882)

� Enlargement of lymph nodes

� Later called syphilis after the discovery of the pathogen in 1905

� Later called tetanus after discovery of the microbe in the late 19th century

� The negro and the southern physician: a study of medical and racial attitudes 1800-1860, John S. Haller, Jr

� This was misspelled in Kuhn’s publication. It should be: cachexia africana

� Could be a complication of jaws

� Nowadays called pica

� Especially at the sugar plantations during the process of grinding and boiling of the sugar cane.

� Which is a possible cause according to contemporary medical science

� Which practice could cause asphyxia pneumonia

� Such as swelling of the testicles and delayed menstruation

� Kuhn mentioned having himself had to perform 3-4 amputations due to this kind of accident per year

� Translated: medicine-negro

� According to historian Natalie Zemon Davis work ‘Physicians, Healers, and their Remedies’ (2015) this “medical pluralism flourished in Suriname. White physicians and surgeons, trained in European medicine, existed along with Indigenous priest/healers and herbalists, slave priest/diviners,

and healers of African origin, their diverse practices played out on the plantation itself”.

� Nowadays called capitation fee

� Nowadays called an all-in lump sum

� Kuhn does not mention how often this falsification of the causes of death by the surgeons occurred. It certainly puts some doubts about the reliability of the statistics of causes of death of the slaves at the plantations.

� Kuhn describes the dances of the slaves as too exhaustive as they danced like being ‘bitten by tarantula’s’.

� Which sadly enough still prevails in our 21st century

� The detrimental effects of tobacco were of course not known at that time.

� We can compare Kuhn’s proposal with a medical handbook with the same objectives published in the 1970s by David Werner entitled “Where there is no doctor”. It was translated into many languages.

� In order to alleviate the shortage of doctors at the plantations

� Kuhn attached a hospital design to his publication

� The head of the Medical Inspectorate to be established

� “….dysentery, colic and other illnesses in the Negro originated, in many instances, out of a state of mind”. See: John S. Haller, Jr (1972) “The negro and the southern physician: a study of medical and racial attitudes 1800-1860”, page 250.

� Celebrating 100 years of health, Surinaams medisch bulletin, december 2002, page 21.

� Celebrating 100 years of health, Surinaams medisch bulletin, december 2002, 12-15.

� According to Stephen Snelders’ Leprosy and Colonialism: Suriname Under Dutch Rule, 1750-1950.

(2017), due to these regulations a relatively big part of the Surinamese population was ‘locked’ up in a leprosarium.

� See: Monitoring the situation of women and children; Multiple Indicator Cluster Survey Suriname, Unicef (2010)

� See: Results of Round I of the WHO International Scheme to Evaluate Household Water Treatment Technologies, WHO (2016).

� See: Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, United Nations (2012).

� See: Progress on the prevention and control of non-communicable, United Nations (2017).

� Dahan et. al state in their work “Global Labor Rights as Duties of Justice” (2014) that it is common knowledge that basic labor standards, such as safety and health regulations, limitation on

weekly working hours, and prohibition on child labor, is often minimal or nonexistent for many workers in the developing world.

� See: International Migration Report, United Nations (2017).

� In 1938 legislation on the Medical Inspection was enacted with the “Landsverordening Overheidstoezicht op de Volksgezondheid door de Dienst Volksgezondheid” and in 1939 the first Medical Commission responsible for advice, examinations and medical screening was installed. See: vd Kuyp E. (1985) Surinaamse medische en paramedische kroniek, tijdvak 1494-1949, Sur. Med Bull, Vol VII, 68-99 .

� Capitation provides caregivers with an incentive to spend a little amount of time on each

patient such that more patients can be enrolled that generates compensation. See: Apostolos Tsiachristas (2015), “Payment and Economic Evaluation of Integrated Care, Apostolos Tsiachristas “Payment and Economic Evaluation of Integrated Care, page 14.