What better place to begin, as Downs does, than the Black Hole of Calcutta. A jail cell the size of a small walk-in refrigerator, 146 British soldiers were packed inside on a sweltering day in 1756. Some 23 lived through the night. The news got out. Slave ships provided the same lesson, with chattel captives stowed too close together to breathe, fed next to nothing, and vulnerable to such diseases as scurvy. A supply of air, it turned out, is essential for survival. It is a mistake to think that’s an obvious detail. Similar death-dealing conditions were to be found among dispossessed peoples wherever agents of imperialism subjugated, confined, and put them to work. But Downs sketches a picture not only of cruelty and callous disregard. He also depicts colonial medics’ perplexed yet enlightened observations and advice on how to better treat and interview people, even describing efforts at what today would be called “contact tracing.”
As European nations went about exploiting, damaging, and sometimes destroying discovered environments and the people in them, doctors in far-flung places were challenged well beyond their powers. Out of necessity, they made concerted efforts to figure out the cause of such frightening killer diseases as typhus, plague, and cholera. Contagion theory suggested some vile substance was responsible, transmitted by contact among people or with contaminated things. Rival anti-contagionists were skeptical and often contested the use of quarantine, a measure employed since the 14th century; some of them began to emphasize hygiene and sanitation. Only in the 1890s with the germ theory of disease, arriving with Robert Koch’s microscopy, would an end be put to the arguments.
Although medicine and bureaucracy are ancient, putting bureaucracy at the systematic service of medicine (and vice versa) in order to track disease emerged in this period as crucial to imperialist adventures. “By studying the spread of disease throughout the world, mapping its coordinates, pinpointing its origin, and defining its behavior,” writes Downs, “physicians developed key epidemiological methods.” He makes this point again and again, accumulating evidence from various colonial and military sources. Physicians sent to the far-flung outposts of empire had no textbooks to consult when it came to epidemics and so little choice but to compile and share information. Downs does his best to recover their stories. He finds that some of them did it well, collecting and making sense of stories even as the people they interviewed were all but lost to history. Epidemics begged for such record-keeping, and bureaucracies “offered a way for physicians to communicate with each other.” They functioned as “a subregime of knowledge production.”
The Epidemiological Society of London was founded in 1850, and the prehistory of epidemiology, culminating when John Snow identified contaminated water as the source of a cholera outbreak in 1854, is well established. Scourge diseases such as tuberculosis and plague have long intrigued and puzzled both doctors and historians. Downs describes yellow fever on the Cape Verde Islands, off the coast of West Africa, where some 13 washerwomen (those who had survived the disease) served as informants about its spread in the epidemic year 1846. He brings into play cholera’s eruption in Jamaica in 1850, killing 30,000 to 40,000 people. He also points to the tremendous cost of the military’s dreadful hygiene during the Crimean War. This test of the British Empire proved to be the first media war, owing to the newly invented telegraph and photograph, and to determined journalists, some of them also imaginative. Bloody and costly, this conflict also brought Florence Nightingale to prominence in 1854.
In tandem with creating the image of the modern nurse, Nightingale made potent demands for sanitation and hygiene. With regard to her work, Downs reveals an interesting disconnect between epidemiology and medical history more generally. Like several recent sources he cites, he argues that statisticians have neglected Nightingale’s contributions to epidemiology. To use today’s vocabulary, she was in fact “data-driven” from the beginning, used statistical methods in compelling and original ways, and benefited from epistolary contact (her preferred social modality) with Adolphe Quetelet, the French scientist who introduced numbers into sociology. That professional epidemiologists need to be reminded of this work, as Downs suggests, argues not merely for Longfellowesque oversight-via-poetic-mystification (“A lady with a lamp I see […] flit from room to room”) but serious parochialism in a central medical discipline.
The most compelling chapter in the book, “From Benevolence to Bigotry,” offers an original look at the dynamics of what today we’ve begun to call institutional racism in medicine. Downs focuses on the workings of the United States Sanitary Commission (USSC), a relief agency formed in 1861 and empowered by such disasters as the bloody rout of Union forces at the First Battle of Bull Run. It soon developed into a complex organization in which doctors, and some notable women such as Elizabeth Blackwell and Dorothea Dix, attempted to institute sanitary regimens and improve hospital conditions for the wounded. But as Downs tells it, their efforts, often sabotaged by Union officers, also came to involve a “Trojan horse” — the use of racial categories with a spurious scientific basis.
It might have been otherwise, Downs argues. During the Civil War, Union forces included 180,000 Black soldiers, most out of bondage, and a vast number of just-freed slaves who had fled Confederate states. To understand the health consequences of this influx, doctors might have used interview methods to trace disease outbreaks, as they’d learned to do in the past. But instead, using questionnaires based on racist notions, USSC doctors brought to bear “ideas from slaveholders and Southern physicians that flagrantly violated the political, legal, and social promise of the Civil War.” Speculation around innate racial differences, including the wild notion that miscegenation would create sterile hybrids destined for an early death, infiltrated the organization. “The Civil War ended the institution of slavery,” writes Downs, “but the USSC resurrected slaveholding ideologies to amplify racial difference and to contribute to medical knowledge.”
One USSC doctor, Ira Russell, observed more than 2,000 Black soldiers while they bathed in order to estimate the extent of body hair, or “pilosity,” with the notion of improving sanitary science. Advancing research by historian Margaret Humphreys on the health of the Black soldier, Downs recounts how Russell went on to perform autopsies on Black soldiers, measuring the size and weight of various organs; in doing so, he employed antebellum beliefs promulgated by Samuel Morton, the famed expert in craniology who claimed skull size was a metric for racial classification. Although the Civil War ended with a Union victory, USSC adopted as its own the racist pretensions of the slaveholding ideology. “Physicians’ fascination with gradations of color became a way to further theorize about Black people’s health,” writes Downs, which in turn helped turn them into “experts.”
With this chapter, Maladies of Empire passes from historical account to an implicit but incisive critique of today’s institutionalized racism in medicine. Just this year, in a now-infamous JAMA (Journal of the American Medical Association) podcast in February, two eminent white doctors pondered whether racism was even possible in American medicine because that would be “illegal” and, besides, being taught as a child “not to hate” would prevent it. That podcast, abetted by another featuring the congenial but poorly informed Howard Bauchner, who was then editor-in-chief of JAMA but has since stepped down after being put on administrative leave, betrayed a shocking level of ignorance in the highest echelons of American medicine. Biomedical racism and health-care disparities are not exactly new topics. These fields have an institutional presence at major universities and have produced a significant literature over the course of nearly a generation. As with the knowledge fog around Florence Nightingale, the podcasts underscore the lamentably siloed character of so much American medicine.
Downs’s presentation of the facts around post–Civil War medicine comes, fortunately, at a time when race as a concept has been partly deconstructed, at least in terms of its biological versus cultural use and definition. Although historians have long dug into the dread afflictions of the 19th century, Downs both synthesizes recent research and brings to bear much that is drawn from untouched archives. Charles Rosenberg’s classic The Cholera Years, from 1962, depended mainly on newspapers and periodicals, such that slavery was mentioned only in passing. Downs, who is both a historian and medical anthropologist, moves the story closer to the lived reality that included slaves, soldiers, freedmen, and ordinary people who acted as informants for early investigators.
At a time when issues of race and health care occupy center stage in American life, Maladies of Empire is all the more powerful for not being particularly polemical. It’s not a screed. Downs, who teaches history at Gettysburg College, fleshes out a crucial part of a larger tapestry to help explain the onset of racial segregation in the United States. The people whose experiences he tries to recover “appear only as fragments” in the historical record, but they impart a crucial dimension that remains utterly germane to the present. Epidemiology would soon focus on quantitative data as doctors from the mid-19th century started to seriously learn how to count and make numbers matter. They’ve never stopped, which is all well and good. But it’s time they took a step back and applied an understanding of the lived past, with respect to colonialism and slavery, to the fraught and aleatory present.
John Galbraith Simmons is a science and medical writer, novelist, and translator.