Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine

Book Title: Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine

Author: Jim Downs

Publication Details: The Belknap Press of Harvard University Press, 2021, 262 pp., $30, hardcover

The classic origin story of epidemiology taught in introductory medical school and public health courses is that of Dr John Snow, who stopped a cholera outbreak in mid-19th century London by convincing authorities to remove the handle from a public pump which he had identified as the probable source of contaminated water.¹ This narrative is heroic, tidy, and incomplete. For those interested in the rest of the story, Gettysburg College historian Jim Downs has written Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine. This book unearths the contributions of soldiers, enslaved persons, and colonial subjects between 1756 and 1866 to medicine’s understanding of disease propagation. Downs’s stated purpose is “to shift the discussion in the history of medicine away from medical authorities to the people who made their theories visible” (p. 200). In an era that predated human subject protections and institutional review boards, systematic observations of illness in these captive populations were essential to formulating and refining epidemiologic theories.

As the COVID-19 pandemic reminded us, crowded places with poor air circulation are hazardous to health. The first chapter, “Crowded Places,” introduces a case study in which 123 of 146 British soldiers confined to a single, overheated 18 cubic foot prison cell suffocated to death. Africans being transported across the Atlantic Ocean in the holds of slave ships experienced similar conditions for months at a time. On one trip, a naval physician connected a diet devoid of fresh fruit to a fatal outbreak of scurvy among enslaved persons and later published a widely read treatise on the disease. He recommended that slavers carry fewer persons on larger, well-ventilated ships and provide sufficient water and a higher quality diet.

Subsequent chapters discuss how observations of plague, cholera, and yellow fever epidemics in British Middle East and Caribbean colonies improved doctors’ understanding of susceptibility and immunity to contagious diseases. The British physician James McWilliam noted that while yellow fever caused substantial illness and death among White men on a missionary expedition, it spared most of the Black men who had already survived prior infections. In a later outbreak in Cape Verde, McWilliam interviewed more than one hundred people to assemble an explanatory framework of yellow fever’s origins and transmission, more than a decade before John Snow’s famous London investigation.

Maladies of Empire also recounts the work of Florence Nightingale, who led female nurses in a British military hospital during the Crimean War. After returning home, Nightingale wrote reports about the unsanitary conditions she witnessed and their deleterious effects. Downs re-envisions the famous nurse as an epidemiologist “interested in using her observations to learn what caused disease to spread and how to prevent it” (p. 93). Working with a statistician, she determined that seven soldiers died from preventable diseases in camp for every soldier who lost his life in combat. During the colonial rebellion of 1857-1858, Nightingale was invited to produce an authoritative report for the Royal Commission on the Sanitary State of the Army in India.

Nightingale’s work inspired the formation of the US Sanitary Commission after the Civil War began in 1861. Inspectors visited army camps “to ensure that camps were kept as clean and orderly as possible in order to prevent the spread of infectious disease” (p. 119). They were largely successful; the ratio of deaths from disease to combat deaths fell to 2:1 during the Civil War. However, beliefs about White racial superiority caused Union army doctors to attribute higher disease susceptibility and mortality in Black soldiers to a defective constitution, rather than to poverty, malnutrition, and less early-life exposure to infections such as the measles. Physicians on both sides expressed no qualms about deliberately infecting Black children with cowpox so that they could later serve as human reservoirs of smallpox vaccine matter for soldiers and prisoners of war.

During a critical century when Western epidemiologists developed the tools that would enable their successors to fight future epidemics such as HIV/AIDS and COVID-19, victims of imperialism, slavery, and war were the original case studies. A more compelling read than any textbook, Maladies of Empire illuminates the main characters of the complex and ethically fraught story of public health’s origins. Outside of those who teach or enjoy reading about the history of medicine, though, it is likely to have a limited audience among family medicine educators.