Diseases of Empire: How Colonialism, Slavery and War Transformed Medicine Jim Downs Belknap (2021)
“History performs a social task,” wrote George Rosen in his classic 1958 book A history of public health. “It can be considered the collective memory of the human group and, for good or ill, helps shape its collective consciousness.” Rosen’s book grounded modern American public health in the experiences of European immigrants in urban areas. He barely mentioned the poor health of slaves or former slaves – but his words were prescient.
Historian Jim Downs has now given a global context to advances in medicine and public health in the 19th century, beyond the mainstream stories rooted in Western Europe and the ancient world. In Diseases of the Empire, he centers slave ships, the inhabitants of colonized countries, prisoners and wars in the narrative of medical discovery, the foundation of epidemiology. He barely mentions what is often cited as the field’s origin story, when British physician John Snow removed the handle from a London water pump and ended a cholera epidemic in 1854.
Downs’ first goal is to “make visible” how epidemiological thought emerged from imperial conquest and the exploitation of enslaved peoples. He dives into the archives to tell how Western doctors – they were almost always men – tapped into the transatlantic slave trade. These researchers studied the health consequences of slavery and thus began to understand the transmission of diseases. For example, the study of ventilation emerged from the holds of slave ships and overcrowded prison cells. British and European doctors observed and discussed cholera outbreaks in the Caribbean and elsewhere before Snow stopped one in London.
The gruesome record keeping of the slave trade and colonial governments provided the infrastructure for collecting epidemiological data. Downs shows how diaries of illnesses and deaths on slave ships, in prisons and at quarantine stations – not mentioned in standard histories – played a central role in the emergence of public health. A bureaucracy “established in the service of war, colonialism and imperialism emerged as the foundation for the development of epidemiology”. Downs provides the story as truth.
Its second goal – to put marginalized people on the historical record as active creators of knowledge – is more thwarted. He frequently notes how slaves and other oppressed people “made visible” patterns of disease. For example, when the fans pumped in cool air, the cries of captured Africans huddled below deck would diminish. Downs argues that their moans served to create knowledge and ensured that they “were not merely passive objects”. Perhaps he seeks to honor those slaves who advanced medical knowledge with their bodies but without their consent. But I struggle to see how viewing their experiences as a “generation of knowledge” restores dignity to people subjected to barbaric treatment.
Finally, Downs takes issue with the way epidemiology strips data from human action. This is a valuable point. He argues that knowledge should arise from the perspective of those most affected. How to achieve this in the field of epidemiology is less clear. For example, Downs notes how a 19th-century observation that the washerwomen of Malta did not contract the plague, despite their alleged exposure, left the women unnamed. This omission would probably still occur today. Epidemiology is concerned with gleaning patterns of population health expressed as numbers, not personal stories. The COVID-19 pandemic has shown how the public is getting used to numbers. In the United States, people over the age of 65 account for three-quarters of deaths from COVID-19. But that doesn’t tell the full cost – for example, to indigenous peoples who have lost valuable native speakers of their languages. Storytelling must exist alongside, not within, epidemiological methods.
To bring a human dimension absent from the historical record, Downs offers fictionalized stories. The book begins by recounting the details of an enslaved man aboard a ship. Originally from “Ghana”, he was sold out of “revenge” when he was accused of “witchcraft” after having argued with a “chief”. In my opinion, these shots detract from the purpose of imagining the real people who have been subjected to brutality.
Diseases of the Empire also adds to better known stories. It reminds us that Florence Nightingale, the pioneering 19th century British nurse, was an accomplished statistician. His graphical depictions of mortality data foreshadow sociologist WEB Du Bois’s equally striking visualizations of the demographics of the newly liberated black population at the end of the 19th century. Downs also examines evidence that during the American Civil War, which ended legal slavery in the country, doctors in the South intentionally infected enslaved children to produce smallpox vaccination material.
A chilling chapter shows how the United States Sanitary Commission (USSC), a private relief agency that supported Union soldiers — including black soldiers — during the Civil War, helped solidify the idea that the races were biologically distinct. For example, USSC doctors did “scientific” studies of the alleged differences, sending doctors to watch black soldiers as they bathed and note various physical characteristics. As a result, race, rather than the terrible living conditions of the newly liberated black population, was thought to account for poor health. The legacy of this story lives on in current public health and medicine – for example, in the algorithms that propagate race-based decisions in the clinic.
While many institutions and disciplines attempt to reframe imperialism, slavery, and colonization as central elements, not aberrations, of the modern era, Downs contributes to studies showing that medicine and public health share these erased stories. It recovers lost and untold stories and makes visible things that need to be seen.