INTRODUCTION:

CORES/PERIPHERIES – RURAL/REMOTE:
MEDICINE, HEALTH-CARE DELIVERY AND
THE NORTH

Stephan Curtis

This collection of essays emerged from a conference held at Memorial University

in St John’s, Newfoundland, in 2007 in recognition of the Fourth International

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Polar Year (IPY). One theme of the IPY was the investigation of the ‘cultural,
historical and social processes that shape the resilience and sustainability of cir-
cumpolar human societies, and to identify their unique contributions to global
cultural diversity and citizenship’.1 The maintenance of health and treatment of
illness and accidents in locations such as northern Scotland, Scandinavia, Fin-
land, Russia and northern Canada, and coastal regions such as Newfoundland
and Labrador can certainly be easily linked to notions of human ‘resilience and
sustainability’ (even if some of these northern locales are not circumpolar).
Of course climate, topography, cultural animosities or at least suspicions
between providers and recipients of health care, and the financial capacity of
various governments in other remote areas of the world, all shaped what could
be done just as they do today. The essays in this volume focus on northern, polar
societies but the strength of this collection is best demonstrated by envisioning
‘the North’ not solely as a unique geographical part of the world. Of course it
is that but it also kindles in us images of numbing cold, and constant hardship
and isolation on the one hand, and of opportunity, excitement and welcome
solitude on the other. Thinking about what the ‘North’ means or, better still,
the images it evokes enables us to see the many similarities between the socie-
ties studied in these papers and other parts of the world that were and are best
understood as frontier regions characterized by the obstacles, challenges and
opportunities they present.
Historians and others have modified Frederick Jackson Turner’s concept of
frontier and used it to frame studies in far-flung regions of the world. Many early

–1–
2 Medicine in the Remote and Rural North, 1800–2000

works argued that frontiers were pushed back either because of the demands of
domestic and/or export markets, or because of the initiative of adventurous peo-
ple eager to carve out a livelihood for themselves. Neither case involved any great
concern for people already living in these areas. More recently, Magnus Mörner
demonstrates that this ‘policy of exclusion’ did not characterize all attempts to
move into new territories. Instead, he argues that Swedes who moved north-
ward during the nineteenth century generally pursued a ‘policy of inclusion’
that involved taking into account the needs and concerns of the local Sami. This
is not to say that there were no sources of contention or that the relationship
between the Sami and the new settlers was free of conflict and suspicion.2
The point here is that there are considerable advantages to envisioning ‘the
North’ in a variety of ways that has little to do with its geographical location. The
most useful of these encourage us to focus our attention on the way government
officials, new arrivals and local inhabitants perceived this area. It is also worthwhile
to view this area as a fluid frontier best characterized as a region of compromise and
negotiation but also one where underlying sources of conflict were often aroused.3
Both approaches offer the opportunity to discover many regions in the world that
were and are, in some way, similar to the northern societies studied here.

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Numerous themes and topics are raised in these essays that are relevant not
only to a discussion of how medicine was practised in rural and remote areas of
the recent past, but also to current attempts to improve medical care in more
isolated regions of the world in the twenty-first century. For example, it is no
secret that many governments and NGOs are engaged in an ongoing struggle
to improve maternal and infant health throughout much of the world. These
organizations and individual practitioners are confronting many of the same
logistical and cultural obstacles as did their counterparts in northern Europe and
North America who are the subject of this volume. How can these governments
of today rationalize access to medicine and entice trained medical practitioners
to work in remote areas? There has been a long history of opposition to outsid-
ers attempting to impose new medical practices on local populations.4 How did
those doctors and midwives earn the trust and respect of their patients? What
role is there for traditional and unlicensed practitioners with the encroachment
of more modern medical practices?
There is obviously an argument for extending the geographical and temporal
scope of any collection of essays that addresses such questions but those pre-
sented here focus on the various challenges and rewards of practising medicine
in northern latitudes from the second half of the nineteenth century to the late
twentieth century. It would be impossible to overstate the hardships that doctors,
nurses, midwives, folk healers and patients confronted in their pursuit of good
health or, at the very least, a little less discomfort in their daily lives. Similarly, it
would be unfair to belittle the efforts various governments have undertaken in
 Introduction 3

the past to improve the provision of health care for small and widely dispersed
populations while being simultaneously constrained by very limited financial
resources. However, instead of dwelling solely on these formidable obstacles
that confronted practitioners and government officials, these contributions also
make a compelling case for highlighting the sense of duty, of responsibility, and
of genuine care for the sick shared by all those charged with bringing medical
care to those who needed it.
In addition to providing a window on the development of medical practice
and health care delivery in remote areas and harsh environments, these papers
also augment our understanding of illness and health by complementing the
numerous historical studies dealing with more densely populated environments.
People who lived and worked in remote northern settlements were subject to
illness and injury just as were their southern or urban counterparts but perhaps
even more so. Yet our understanding of the history of medicine and health care
in these pockets of population remains spotty owing in part to a lack of interest
by professional historians and in part to the logistical difficulty of accessing and
retrieving archival evidence from such areas. The few existing studies that touch
upon medicine in isolated areas are generally focused on the United States of

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America and particularly the rural South. Many of these can be more accurately
described as histories of rural medicine and small-town doctoring and are not
particularly germane to our northern project.5 Nonetheless, their concern with
‘everyday medicine’, race, class, gender and the role of the state in nation building
and other related bureaucratic activities in under-populated and under-funded
rural and remote areas provides additional context in which to ground this col-
lection of essays.
If it is wise to consider ‘the North’ in a way that downplays its geographical
characteristics, a similar case can be made in reassessing what we mean by ‘rural’.
There are many reasons for defining ‘rural medicine’ within larger social, cul-
tural, political and even medical frameworks than simply using the geographical
location in which that medical care occurred. One can, albeit unwisely, conjure
up dichotomous images of rural, generally healthful environments with inhab-
itants engaged in all manner of quaint folk cultures on the one hand, and the
disease infested urban centres with their more cosmopolitan and allegedly more
scientifically advanced populations on the other. Using simplistic spatial or
demographic definitions to define rural and urban areas in the regions of the
world examined in this volume is bound to fail. One would be hard pressed to
consider the locales and regions examined here as being even remotely ‘urban’
but they were all rural and remote in many different ways.6
These essays can certainly stand individually on their own merits or, as has
been done here, be organized into groups centring on various themes such as
gender, professionalization and the increasing role of the state in the provision
4 Medicine in the Remote and Rural North, 1800–2000

of medical services. They also make contributions to studies investigating how

innovations – whether administrative or cultural – gain support among local
populations, particularly those living in rural parts of the world.7 One way to
frame such a discussion is to explore the nature of relationships between core
and peripheral regions while remaining constantly aware of the limitations of
such terms and particularly the potentially negative associations often made
with the latter.
A recent conference held in Heidleberg entitled, ‘Global Developments and
Local Specificities in the History of Medicine and Health’ attempted to move
us away from core/periphery models because of the inferior characteristics
often and mistakenly attached to the periphery vis à vis the core.8 While the
objective to provide more ‘value neutral’ terms is a noble one, a designation of
‘local’ or ‘global’ can easily evoke the same sense of struggle, domination, com-
pliance, weakness etc. often attached to cores and peripheries. More important
than perceiving our areas of study as being divided into two distinct and largely
antagonistic entities engaged in a constant struggle to either impose or resist a
particular practice or relationship, it is far more useful to explore the mecha-
nisms that enabled these relationships to serve the interests of both parties. This

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is neither an attempt to suggest that conflict did not exist, nor is it the intention
to offer a rose-coloured interpretation of the past in which everyone was pre-
pared to sacrifice their own wishes and wants for the common good. The essays
presented here make it abundantly clear that suspicion if not outright loathing
often coloured the relationship between the providers and receivers of medical
care. However, these essays also demonstrate that the form of care that finally
emerged was the product of negotiation rather than declaration, and of compro-
mise rather than intransigence.
Immanuel Wallerstein’s seminal work of the early 1970s examined the eco-
nomic relationships and mechanisms by which core regions of the world were
able to exploit those at the periphery.9 Historians and other academics quickly
adopted this model of exploitation and dominance and applied it to their own
studies. For example, Heikki Vuorinen’s examination of infant mortality patterns
dating from the late 1980s identifies core regions as those that exert ‘economical,
social, cultural and political dominance over [the] periphery at the hierarchial
[sic] level under investigation’.10
In recent years two major challenges to the assumptions underlying Waller-
stein’s work have emerged and this collection of essays adds support to these
new interpretations. The first questions the ability of the core to exert hegem-
onic control over areas outside of it, and the second recognizes the multiplicity
and fluidity of core and peripheral regions within single countries.11 Historians,
especially those engaged in anti-colonial studies, are increasingly challenging
the assumption of an inherently passive periphery and the result has led to the
 Introduction 5

not surprising discovery that peripheries have not always been as acquiescent as
politicians and central bureaucrats may have wished.12 To some degree this oppo-
sition was possible because of the logistical difficulties central governments faced
when trying to introduce and enforce new reforms in remote areas. However,
ascribing the delayed acceptance of new innovations solely to the inefficiency of
past bureaucracies is only a partial explanation and increasing attention is being
placed on the fortitude of local populations to influence decisions and prac-
tices. Nonetheless, the importance of local providers of health care and regional
administrations who brought improvements to distant communities continues
to be frequently overlooked and this is especially so when discussing underde-
veloped regions of the world.13 Instead the focus of attention tends to fall most
heavily upon the efforts of leading bureaucrats and medical officials who more
often than not lived in far distant capital cities.
We have also become more aware that countries typically consist of multiple
domestic cores and peripheries. This is an important development for two rea-
sons. First and foremost, it highlights that research ought to focus on exploring
the mechanisms by which these different areas form relationships rather than
looking at them in isolation. Secondly, it demonstrates more clearly than exam-

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ining international connections the fluid nature of relationships. That is to say,
one region might be considered a ‘core’ vis à vis some other territory but it may
well find itself to be peripheral to developments occurring elsewhere.
Certainly the articles in this volume examine the relationship between core
regions of political and medical authority and the peripheral, distant outposts
in which many of the doctors and other medical practitioners found themselves.
However, while many of these locales certainly shared the geographical and
demographic characteristics we associate with designations of ‘rural’, they were
also defined by their social and cultural distance from the nearest administrative
centres. City-trained doctors, nurses and midwives frequently complained about
the relative isolation of the communities and regions in which they worked but
many also found it difficult to understand and adapt to local cultures that were
as alien to them as the remote locales in which they lived. Simply stated, these
articles examine medical practice in rural settings but these environs were more
than just physically distant from the centres of administrative influence. Those
charged with the responsibility of bringing medical innovations to these areas
also had to consider the unique environments consisting of unfamiliar cultures
and social structures, and the local concerns of the people they encountered.
These challenges were as daunting as were the logistical obstacles to delivering
medical care to a sparse population in largely isolated communities.
This collection of essays also adds to the recent literature that employs
notions of core and peripheral areas to help understand the process by which
ideas are spread through a community and the circumstances under which inno-
6 Medicine in the Remote and Rural North, 1800–2000

vations are either accepted or rejected by local populations?14 There has been a
large shift away from Torsten Hägerstrand’s works of the mid-twentieth century
that explained geographical patterns of innovation diffusion largely as a result
of ‘distance decay’.15 Researchers have more recently included in their analyses
many more social, demographic and cultural variables into their calculations to
understand the forces that determine receptivity to innovations.16 By so doing
they are challenging the largely top-down model of diffusion and emphasizing
instead a process of dissemination that takes into account the role played by
those who are encountering new methods and ideas for the first time.17 In short,
emphasis has shifted somewhat away from exploring the way in which innova-
tions are spread through a society, to examining why they are either accepted or
rejected. This requires a thorough understanding of the environment in which
those new methods and ideas were introduced.18
The work of Thomas Valente and others who explore the importance of
social networks in determining an individual’s decision to either accept or reject
a new innovation is particularly relevant to the works in this volume.19 While
none of the articles presented in this volume specifically examine processes of
diffusion and dissemination, many of them do demonstrate the importance of

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local networks to the acceptance of new innovations. These networks came in
many forms: the numerous lay women Megan J. Davies studies who incorpo-
rated various medical theories in the Peace River region of British Columbia,
Canada; the distant networks of patients in northern Newfoundland and the
local physicians who kept in contact with their colleagues in the United States
of America that are the subject of J. T. H. Connor’s research, or the Greenlandic
midwives with their ties to Danish and indigenous societies that Mette Rønsager
examines. In each case the creation of networks between practitioners and their
patients contributed to the gradual acceptance of new medical techniques and
forms of organization.
It is within these larger debates about the characteristics of cores and
peripheries and the relationship between them that these papers make signifi-
cant contributions. These authors are not simply examining rural medicine as a
wholly autonomous entity produced and delivered in parts of the countries far
from central authorities. Instead, they all illuminate the interaction of medical
practitioners and the people they encountered, and how the medical care that
emerged was the result of cultural negotiation, administrative limitations, politi-
cal agendas and the initiatives of local doctors, midwives and nurses.
What did medical care entail for those charged with providing it in the nine-
teenth century and onwards? For many of the practitioners studied here it meant
much more than simply attending to the physical needs of the sick. Sören Edvin-
sson demonstrates that for Dr Ellmin in nineteenth-century northern Sweden,
providing medical services to the people in his region was both a consequence
 Introduction 7

and an expression of a political radicalism that demanded he provide the best

care possible to all who needed it regardless of their social status. At the same
time, there is no denying that he very much wanted to ‘improve’ and ‘civilize’
many of those he encountered in much the same way as colonial powers wanted
to do the same to the people they encountered in far distant colonies. Teemu
Ryymin shows that early twentieth-century physicians in northern Norway
who were responsible for bringing medicine to the Sami, and the state officials
who sent them there, expressed similar goals as did Ellmin almost a century ear-
lier. Norwegian voluntary groups also saw the medical care they provided as a
means to introduce modern ideas to what they perceived as a largely ‘backward’
population. Mette Rønsager’s contribution to this volume reveals that Danish
authorities tried to use midwives to bring more advanced medical practices to the
people in Greenland throughout the nineteenth and into the twentieth century.
There is no doubt that many practitioners were attracted to their profes-
sion and the remote parts of their countries by a sense of adventure. Dr Ellmin
certainly felt it as he set off to tend to those in distant villages. The nurses in
New Brunswick, Canada, who are the focus of Linda Kealey’s contribution,
and their counterparts in twentieth-century northern Finland who are the

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subject of Marianne Junila’s study, also saw their work as an adventure and
enjoyed the professional autonomy of working without the close supervision
of a physician.
We should not forget that medical care also had a political function. It could
be used to try and create a sense of unity among the people as was attempted in
nineteenth- and twentieth-century Norway. By the late 1900s numerous coun-
tries sought ways to safeguard the cultures and rights of indigenous peoples. The
Norwegian Government, for example, recognized that native medical practices
were integral to preserving Sami identity and therefore introduced measures to
ensure that they survived. In Scotland, the Highlands and Islands Medical Ser-
vice attempted to bring medical care to a region that quite simply could not
otherwise afford it. As it turned out, this experiment was so successful that its
influence can still be seen in how the National Health Service (NHS) is organ-
ized today.
This collection does not specifically try to interpret the wishes, fears, con-
cerns and frustration of those who needed medical care, but their voices are not
entirely absent. Of course we are limited by the sources available to us. Very few
people indeed kept personal diaries of their innermost thoughts or their usu-
ally infrequent encounters with medical practitioners. If such sources did, at one
time exist, it is highly improbable that they are still extant. It is sometimes pos-
sible, as Davies does so brilliantly in her contribution to this volume, to conduct
interviews or rely on oral histories to inform our knowledge of relatively recent
times. Unfortunately, the range of sources available when seeking a more com-
8 Medicine in the Remote and Rural North, 1800–2000

prehensive understanding of earlier times is much more limited. In most cases we

only have the records of those responsible for bringing medicine to those people
who either needed it or, in some cases at least, had it imposed upon them; the
patients themselves are seldom clearly heard.20 Despite the emphasis of the essays
presented here and the limitations of the authors’ sources, one can discern the
constant murmur of patients’ voices in the background. Whether we are relying
on official documents, physicians’ reports, diaries, interviews or the multitude
of other sources used in this collection of essays, there is no mistaking patients’
suspicions regarding new methods and practitioners, their concerns about the
possible consequences of those innovations for their culture and their fears when
confronted with childbirth, debilitating diseases or severe accidents. Finally, we
are constantly made aware of their demands to be included in decisions regard-
ing their health and the medical care they would receive. These sentiments were
as present in the nineteenth century as they were in the twentieth and were heard
throughout the regions studied here. Nonetheless, even today governments and
other agencies continue to ignore the wishes and concerns of those living in
remote regions upon whom new innovations are to be practised.
The first group of papers by Steven Cherry and Francis King, Marguerite

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Dupree, Teemu Ryymin and Astri Andresen provide a thorough examination
of the attempts by the Russian, Scottish and Norwegian governments to exert
greater control over the medical services in the distant parts of their respective
countries. In ‘Medical Services in a Northern Russian Province’, Cherry and
King explore the cultural and logistical obstacles to providing improved medi-
cal care in the period of zemstvo government between 1864 and 1917. On the
one hand, local officials faced a well-entrenched hostility directed towards out-
side authority, a peasantry that was loathe to accept new medical innovations
and a constant shortage of funds. Bureaucrats worked diligently to address these
problems but there was nothing that they could do about the region’s isolated
location, extreme poverty or harsh environment. For all of these reasons it is not
surprising that they found it difficult to recruit medical practitioners. Russia’s
defeat in the Crimean War highlighted the need to rationalize the administra-
tive districts and the provision of medicine. The various levels of administration
quickly learned that the number of trained medical practitioners was far short
of the number needed; but a lack of funds made it impossible to hire additional
doctors or even the less-skilled feldshers. One option was to find ways to entice
those few physicians already present to take on additional duties. Unfortu-
nately, this met with only very limited success and the state found it necessary
to improve the training of feldshers who could attend to the medical needs of
the rural population. Such measures proved fairly successful but the cultural dis-
tance between the trained practitioners and the people they tried to help was
 Introduction 9

not so easily overcome. Local traditions were difficult to change, and efforts to
impose new public health measures were often met with suspicion.
Dupree’s contribution demonstrates the ability of a remote, relatively poor
and scarcely populated area, in this case the Highlands and Islands of Scotland,
to influence the reorganization of the NHS in 1974. After the creation of the
national insurance legislation in 1911, the Highlands and Islands Medical Ser-
vice (HIMS) was devised to respond to the very poor health of the population,
and the poverty and lack of medical care that characterized the region. Trained
medical practitioners were in especially short supply and hospitals were few and
far between. The goal of the HIMS Fund was to provide finances that could
be used to entice practitioners to the area and to improve communications and
hospitals. As part of the plan, in return for providing medical services regard-
less of where the patient lived, a doctor was able to charge a fee collected from
the patients themselves or, if they were too poor to pay, the doctor received
compensation from the HIMS Fund. In this way doctors received state fund-
ing administered directly by the Scottish Office in Edinburgh, but remained
‘independent contractors’, neither entirely dependent upon the state for their
livelihood nor on the patients they treated. The HIMS received glowing rec-

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ommendations in the Cathcart Report of 1936 and again a decade later when
the NHS (Scotland) Bill was introduced. The question emerged how best to
administer a healthcare system to which everyone had access, and in 1948 in the
Highlands and Islands the NHS replaced the HIMS with the same tripartite
mixture of agencies as in the country as a whole. It consisted of regional hos-
pital boards, executive councils overseeing local general practitioners, and local
authorities employing medical officers of health responsible for enforcing pub-
lic health measures. Another examination of the provision of health care in the
Highlands and Islands occurred between 1964 and 1967 and, although some
measures were recommended similar to those found in rural Norway, there was
little sense that anything substantial had to be changed. This is not to say that no
problems existed; many of those that had prompted the creation of the HIMS
still remained. The high costs, difficult transportation and the large distances
between physicians and widely dispersed patients could not easily be overcome.
The major problem, however, was with the way in which the different types of
medical care were provided. Few people in the Highlands and Islands felt that
the tripartite division of administration was particularly efficient and welcomed
the proposal that all health services be brought under one central authority. This
structure was to serve as the basis for the reorganization of the NHS in 1974.
Teemu Ryymin’s article examines the Norwegian Government’s campaign
against tuberculosis among the Sami during the first half of the twentieth
century. There had been a long history of ‘Norwegianization’ which sought
to eliminate or certainly minimize differences within the population and this
10 Medicine in the Remote and Rural North, 1800–2000

policy survived until the mid-1940s. Underlying this official policy was the
assumption that the Sami people were a backward people who needed to cast
aside their culture and language if they were to survive. Government appointed
medical officials and voluntary organizations were responsible for providing care
to the inhabitants of the northern County of Finnmark where extreme poverty
contributed to very high rates of tuberculosis. Early missionaries to the region
in the late 1800s flouted official policies and preached to the population in the
local language in an effort to spread the word of God which they assumed would
help the Sami avoid poverty and disease. Various religious associations were
responsible for providing much of the care the Sami received and, despite some
opposition, they found that the people were grateful for it. The problem was that
these missionaries were caught trying to preserve Sami culture and identity on
the one hand, while simultaneously trying to ‘improve’ the Sami on the other in
what Ryymin calls a ‘paternalistic civilizing project’. It was in this context that
the state and various voluntary organizations launched their campaigns against
tuberculosis which included the construction and staffing of nursing homes,
sanatoria and hospitals. In addition to these physical improvements to the medi-
cal landscape, it was also decided that there should be a comprehensive health

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education programme put into place. What is crucial here is that tuberculosis
was no longer blamed primarily on the alleged backwardness of the Sami but
rather on the effects of industrialization and the introduction of modern society.
This did not mean that the Sami were seen as being as culturally advanced as the
Norwegians but rather that economic and social change was now considered to
have contributed to their plight. The state began providing funds to improve
housing and education – most often in Norwegian – all in the hope of ‘improv-
ing’ the Sami. The agenda shifted in the 1920s and 1930s when the state began
screening children throughout the country for signs of tuberculosis. Part of the
reason for this shift was new medical knowledge that no longer saw tuberculo-
sis as one of the inevitable consequences of economic growth and civilization,
but as an infectious disease that could be combated by purely medical rather
than cultural means. Nonetheless, efforts to create a homogenous, Norwegian-
speaking population persisted until the early 1950s when the government agreed
to print public health information in the Sami language at the same time as its
screening campaigns became ever more comprehensive. The period from the late
nineteenth century to the mid-twentieth century had witnessed a major change
in the status of the Sami. From being perceived as a backward people who needed
to be Norwegianized for their own benefit, state officials in the 1950s became
more attuned to the needs of the Sami and to providing medical care on their
own terms.
Astri Andresen examines the provision of health care to the Sami in north-
ern Norway during the second half of the twentieth century. Immediately after
 Introduction 11

the Second World War, the state committed to providing a uniform standard of
medical care across all of Norway. During these early years there was little atten-
tion paid to the possibility that the Sami ought to be recognized as a distinct
population: this only occurred in 1989. Language was one of the major obstacles
to providing health care to the Sami and recognizing them in their own right.
Initially they were simply expected and required to learn Norwegian but in 1959
Sami became an official language in the area where they lived. This was partly
seen as a way for the state to disseminate public health information to those
whose command of Norwegian prevented them from discussing such things
with local, Norwegian-speaking physicians. By the 1950s there was no doubting
that levels of health among the Sami were much lower than among those living
in the rest of the country and medical authorities, and the Sami Committee (the
group charged with making recommendations to the government) in particu-
lar, saw this not only as unacceptable but contrary to the government’s alleged
goal of ensuring the health of everyone living in Norway. By this time it was no
longer accepted that the poor health of the Sami was due to some alleged racial
or biological inferiority. The only agreed upon remedy was greater state inter-
vention but the question then arose about what form that involvement should

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take. While it may have been advantageous to provide physicians who spoke the
local language, this was not seen as practical especially as the number of patients
who spoke Sami seemed to be declining. Nonetheless, the government did
begin to encourage Sami students to attend medical schools with the hope that
they would be able to take what they learned back to their communities. The
problem of language was only one of those faced by government officials. There
also remained those of large distances, poor transportation and a harsh climate
which made it difficult to recruit physicians and other health practitioners. One
solution was to create a northern university that could recruit students from
the Sami-speaking population and train doctors who could tend to the needs of
those living in the north.
The 1980s and 1990s saw the question of how to provide adequate health
care to the Sami take on an international perspective with the ratification of ILO
Convention 169 in 1990 concerning Indigenous and Tribal Peoples in Independ-
ent Countries. Matters of health were now framed within the larger context of
legal rights and, as such, now demanded not just equal access to medical care but
also the preservation of Sami identity. However, as Andresen demonstrates, this
did not result in the Sami assuming sole control over the social services provided
to them. Instead, the Norwegian government now addresses the specific needs
of this population but as part of the national policies it offers. An example of this
can be seen in the government’s willingness to promote knowledge of traditional
medicine as a way to preserve Sami culture while simultaneously providing doc-
tors with all the skills and knowledge one might expect them to receive from a
12 Medicine in the Remote and Rural North, 1800–2000

medical school. This contribution demonstrates the process by which the ‘mar-
ginal’ or ‘peripheral’ Sami was assimilated into the larger Norwegian discourse
of medical care and how they were able, despite this assimilation, to maintain
their distinct culture and to at least partially dictate the pace and form of their
inclusion into Norwegian society.
The second group of papers in this volume explores how physicians
attempted to establish identities for themselves and the strategies they employed
when interacting with local populations and central authorities in their strug-
gle to combat a plethora of medical problems. Here cores and peripheries are
not solely administrative or geographical constructs but rather suggest a cultural
distance between those who are bringing new methods to remote communities
and those who are exposed to them. Sören Edvinsson locates Dr Ellmin, a physi-
cian who found himself under suspicion because of his alleged radical activities
in Stockholm, firmly within the various cultural ideas and medical debates that
characterized nineteenth-century Europe. Ellmin found himself stationed in a
remote part of the country and his annual reports to state authorities not only
fulfilled his professional obligations, but also reflected a desire to discover, record
and enlighten a people about whom he felt much of Swedish society knew noth-

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ing. His topographies also illuminate debates within the medical field about the
direction that state medicine should take. Should it be primarily concerned with
improving the environment in which people lived, or modifying the behaviour
of those people to ensure they adopted more suitable and healthy habits? Here
then is a doctor who had considerable experience working in the Swedish capital
thrust into an economically, socially and culturally peripheral society. One sees
in his annual medical topographies the nineteenth-century obsession with the
discovery of new lands and new peoples. Ellmin certainly believed that he and
the state had a moral obligation to civilize the people he encountered but he was
no mere government lackey. There is no doubt that he was a hard-working doc-
tor who took his duties seriously but his reports also reveal his genuine concern
for the local population and his sincere attempts to exert pressure on the govern-
ment to improve their living conditions and access to health.
Øivind Larsen uses a combination of several physicians’ medical topogra-
phies from much of the nineteenth century and modern statistics to reveal the
tremendous obstacles that Norwegian physicians encountered in their efforts to
ensure a healthy population. More importantly, these sources reveal what these
doctors thought were the most pressing areas of concern and how legislation was
often the product of perception rather than quantitative data. The Sanitation
Act of 1860 represents one of the key pieces of legislation as it marked the state’s
commitment to preventing outbreaks of cholera. As a result of this legislation the
powers of district physicians expanded and, as representatives of the state, they
worked closely with local officials. The doctors’ annual reports thus record a vari-
 Introduction 13

ety of voices representing different levels of administration particularly during

the last third of the nineteenth century. Larsen’s work demonstrates that there
was not always a clear correlation between the doctors’ perception of the general
state of the public’s health and levels of mortality or morbidity. For example,
doctors in the capital of Christiania (Oslo) appear to have paid little notice to
the high level of mortality in the city. Larsen suggests this may have been due to
the fact that they had become somewhat accustomed or perhaps immune to it.
Whatever the case, it appears that simply exploring quantitative mortality data
will not always explain the introduction of legislation aimed at improving the
public’s health. If we are to make sense of the actions of bureaucrats and physi-
cians we must recognize the importance of what they perceived to be the causes
of concern and at what point those concerns demanded action. As Larsen sug-
gests in his work, although urban centres may have been characterized by their
lack of sanitation and their unhealthy populations, this did not necessarily mean
that physicians were more active in the towns and cities than in rural areas. In
fact, it is entirely possible that outbreaks of disease among formerly healthy peo-
ple living in pristine and wholesome countryside may well have been more likely
to gain the attention of health officials.

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J. T. H. Connor’s study of Dr Robert Ecke, who came from the United States
to work in the small, isolated town of Twillingate, Newfoundland, during the
1930s illustrates the importance of personal networks for the diffusion of ideas
– in this case from Europe via Baltimore in the United States of America, to this
distant island community in the North Atlantic. The provision of medicine in
and around the town had a relatively long history and Ecke certainly continued
many of the local traditions. However, this study illuminates the importance of
Henry Sigerist, Director of the Johns Hopkins Institute of the History of Medi-
cine, for the type of medical care that the people of Twillingate received. His
‘fervent advocacy of socialized medicine’ was to influence those who later moved
to this isolated town to deliver health care. However, the local population also
had a tradition of helping one another and this practice of mutual assistance
in times of need served as the foundation upon which Ecke and others were to
build their medical careers. Although Ecke certainly came from an urban envi-
ronment and possessed considerable formal medical training, Connor shows
that he was forced to adapt quickly to local customs and the limitations imposed
upon him by the harsh environs in which he worked. Twillingate was indeed
far removed from the life and intellectual climate of Johns Hopkins University.
Nonetheless, this geographically peripheral town was very much the centre of
the medical and cultural world of north-eastern Newfoundland.
Sasha Mullally examines the creation of a medical profession in the Canadian
maritime and bilingual province of New Brunswick during the early twentieth
century. Using the case of an American trained physician who may or may not
14 Medicine in the Remote and Rural North, 1800–2000

have completed his studies, Mullally demonstrates that the New Brunswick
College of Physicians and Surgeons took its gate-keeping function very seri-
ously indeed. However, despite the provincial College’s efforts to marginalize
and eliminate unlicensed medical practitioners, the geographical and cultural
distances between the trained, primarily urban physicians and the rural popula-
tion divided between anglophones and francophones were not easily overcome.
It is in New Brunswick, Mullally argues, that we see tensions emerge between
different economic, political, social and cultural regions. One common feature
of all these areas was a population determined to receive good medical care. This
demand enabled unlicensed doctors and midwives to practise despite the best
efforts of the College to prosecute them and remove them from the medical
landscape. What we see is not the emergence of a clear-cut division between pro-
fessional physicians united against unlicensed and ‘unorthodox’ practitioners, or
between urban and rural. Instead, the medical landscape of New Brunswick dur-
ing the 1920s and 1930s allowed for compromise, accommodation and shifting
alliances and agendas.
The final group of contributions examines the role of women as medical
practitioners in the past two centuries as they negotiated the fuzzy bounda-

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ries between orthodox and unorthodox, core and peripheral medicine. There
is no doubt that women have a long history of being the main providers of care
although their role has often been marginalized in the historical record partially
because of their presumed lack of formal training. Of course recent research has
done much to restore both traditional and formally trained female practitioners
to the medical landscape. The contributions of Mette Rønsager, Linda Kealey,
Megan Davies and Marianne Junila represent important additions to this litera-
ture and illuminate the importance of midwives, nurses and unlicensed healers
in bridging the gap between administrative and cultural cores and peripheries.
Moreover, in all four works we see women challenging the constraints that soci-
ety imposed upon them. While it might be argued that here were women still
confined to the more traditional roles of midwives and nurses, they fulfilled
these roles in very untraditional ways. They often undertook lengthy and danger-
ous journeys by themselves during which they demonstrated that they were very
well skilled and could act independently of male supervision. Their activities,
devotion to duty and the proficiency with which they carried out their responsi-
bilities frequently earned them the respect of all their patients.
Rønsager explores how Greenlandic midwives in the nineteenth century not
only mediated between Danish authorities and the native population, but also
how they brought ideas and methods from Europe into the periphery of Green-
land. In this case we see the coming together of two disparate cultures aided by
the ability to overcome the problem of distance between two widely separated
geographical regions. It is not surprising that early Danish doctors seldom treated
 Introduction 15

native Greenlanders. First, the distances they would have needed to travel were
enormous. Second, the language barrier made it almost impossible for patients
and doctors to converse with one another. High infant and maternal mortal-
ity was of primary importance to local authorities and physicians and all agreed
that well-trained midwives could do much to improve the likelihood of mothers
and infants surviving childbirth. Greenlandic women were initially trained in
Greenland but increasingly were sent to Copenhagen to receive their training.
However, those who travelled to Denmark usually belonged to the Greenlandic
elite and this introduces a class dimension, in addition to those of gender and
culture, to the analysis of medical care in Greenland. As does Edvinsson, Røn-
sager shows the cultural distance that existed between the urban administrators
and trained male practitioners on the one hand, and the native population that
they perceived as childlike and primitive on the other. Although intrinsically
important to the introduction of modern medicine to the people of Greenland,
the midwives educated in Denmark fulfilled an additional role that was no less
important. This was to bring European culture to the people. Some did so quite
eagerly but the majority did so only reluctantly thereby enabling them to main-
tain their native identity at times that suited them.

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The contributions by Kealey and Davies also examine the essential role that
nurses and unlicensed female medical practitioners played in providing care
to people living in rural parts of Canada during the 1920s when the govern-
ment and other organizations first began to focus more attention on the state
of rural medicine. As Kealey demonstrates, those living in non-urban parts of
New Brunswick were particularly dependent upon the public health nurses of
the Canadian Red Cross Society (CRCS) who remained a main source of medi-
cal care into the 1970s. These women often worked far from urban centres and
found that they were very much on their own during times of medical emer-
gency. While this autonomy provided tremendous opportunity for improving
one’s skills and certainly appealed to many of the nurses, many also found it
intimidating to be forced to engage in practices for which they were not trained.
Moreover, there was always the possibility, if not the likelihood, that physi-
cians would perceive them as encroaching upon their areas of alleged expertise.
While these women initially responded primarily to the medical needs of the
local populations, by mid-century they were also taking on the responsibility of
introducing public health measures as dictated by the provincial government.
What we see throughout the whole period from the 1920s through to the 1970s
was the close relationship between the voluntary CRCS and the provincial
government as they pursued the common goal of improving the health of the
population in New Brunswick.
Davies shifts our attention away from the formally trained female nurses
and focuses instead on the importance of lay women as healthcare providers in
16 Medicine in the Remote and Rural North, 1800–2000

a remote interior region of northern British Columbia during the 1920s. The
case of Emily Tompkins reveals this woman’s resourcefulness in dealing with a
serious emergency and the plethora of lay and scientific medical practices that
she and others employed when dealing with common ailments and diseases. By
using a variety of different oral and local histories, Davies is able to conclude that
women used their capacity as primary caregivers to create an identity for them-
selves which they used to enhance their social position in the ‘belated frontier’
of the Peace River region. This contribution clearly illuminates the intersection
of lay, folk medical practices and the more ‘scientific’ ones to which the sick were
exposed. During the 1930s the Peace River region was increasingly integrated
in the provincial economy and roads linked it to other centres. In this envi-
ronment doctors, nurses and midwives provided medical care but so, too, did
women with no formal training whatsoever. ‘Home medicine’ competed equally
with ‘scientific medicine’ and the experienced (or most resourceful) women of
the communities were afforded the same respect as their more formally trained
female and male counterparts.
Junila also examines the challenges that distance can bring to the provision
of medical care in her study of northern Finland during the two decades after

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the Second World War. It continues to be the case in the countries examined in
the volume that it is in the most remote areas that medical practitioners are least
likely to be found. Various strategies to entice trained physicians, midwives and
nurses to these regions have seldom proven entirely successful. However, Junila is
less concerned with illuminating how these difficulties hampered efforts to bring
medicine to Lapland and instead focuses her attention on the allure of such
harsh conditions on the women who became public health nurses. For some it
was the sense of duty that enticed them to head north; for others it was a sense of
adventure, while others welcomed the opportunity to enjoy much more auton-
omy than was available elsewhere. Whatever the case, there was no doubt that
they were embarking on an often dangerous journey that would put tremendous
geographical and cultural distance between them and all that had been familiar.
Far from urban centres and the supervision of doctors, these women performed
diverse tasks that they otherwise would have been prohibited from undertaking.
In many cases public health nurses had to adapt to local customs while simulta-
neously trying to introduce new medical techniques to a sceptical or fatalistic
population. In other cases, these women were welcomed by enthusiastic and
grateful people who had long sought access to a skilled medical practitioner.
These essays deal with nineteenth- and early twentieth-century societies
found in the northern latitudes that shared similar topographies and similarly
harsh northern climates. They were, then, in what we commonly call ‘the North’.
While some of the characteristics of this region were unique to it, there were
and still remain other frontiers and peripheries of the world that present many
 Introduction 17

of the same challenges and opportunities. The medical practitioners found in

these essays were responsible for providing health care to local populations.
They endured the daily hardships of surviving in such an inhospitable environ-
ment and had the added burden of negotiating between different cultures. They
represented the state and outside authority, and brought new innovations to pre-
viously isolated communities. It is no wonder that their arrival often caused the
sick to view them with no small amount of suspicion. Nonetheless, in relatively
short order these practitioners became integral members of community life. This
was no small feat and can be attributed only to the perseverance of these men
and women, their resourcefulness, and their willingness to find areas of com-
mon ground between them and their patients. Government officials similarly
struggled to provide the best level of care possible within often strained financial
circumstances. It would be a gross exaggeration to suggest that these bureaucrats
were able to divorce themselves entirely from their own prejudices and beliefs
about those living in the rural, distant lands. These people were seldom seen as
social and cultural equals but it would be difficult to see in these essays anything
but a sincere effort to improve their health and well-being.

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