The pandemic has inspired many books, most dealing with some immediate aspect like the American response to it, or its economic impact. But a growing number go into the deep background of COVID-19 and other outbreaks, looking for their social factors as well as their microbial causes. Read individually, such books are enlightening and often surprising. Read together, they begin to look like a revolution in medical history, if not in medicine itself.
Most of us, of course, have only the haziest concept of medicine’s history: Doctors used to bleed people. Somebody named Louis Pasteur proved that some microbes can cause disease, and he pasteurized milk. Somebody else developed a vaccine for polio. Such history is a series of heroic individuals, usually white males, often fighting their reactionary colleagues to improve both public and personal health.
The reality is rather different. Historian Jim Downs makes vital connections between white supremacy, public health and epidemiology in his book Maladies of Empire, published last year by Harvard University Press. Yes, medicine advanced largely through the work of white males of European ancestry, but most of them were in the service of empires that ruled over millions of racialized people. By studying disease in such folks, doctors built both epidemiology and widespread belief in white supremacy. But their studies also undermined white supremacy, with consequences that have begun to shake our whole civilization.
Some of the first steps in modern medicine, Downs tells us, occurred in the service of the 18th-century slave trade. Slave ships bound from Africa to the Americas carried ship’s doctors who looked after the crews and captives alike. This was the age when the illness was attributed to “miasmas” — foul air. Dr. Thomas Trotter, a physician on one slave ship, advised the owners to improve ventilation in their ships and allow the enslaved up on deck more often. I have also documented the improved survival rates of enslaved captives fed fresh fruit to cure scurvy.
The point was not to save lives, but to deliver human merchandise to markets.
Such physicians were a growing element in Europe’s empires. They were needed to keep Europeans healthy in the colonies, and to control disease outbreaks among local workers, whether enslaved or nominally free. They also had to deal with the health of imperial armies, especially in war.
Unrecognized collaborators in the seeds of public health
As doctors, they were part of imperial bureaucracies that served as a kind of “print internet”: a medical report written in Jamaica would go to London and then be distributed as far away as Bombay and Sydney. Such physicians, Downs says, became investigators, studying the health not of individuals but of populations. They were also skilled debaters, presenting evidence taken from their studies of enslaved people and what were then known as sepoysIndian soldiers serving England’s East India Co.
Yet somehow, the people in their studies disappeared. “Although slave ships were a crucial site of investigation,” Downs writes, “they often entered medical journals and reports, like Trotter’s treatise on slavery, simply as ‘cases’ or as ‘ships,’ which had the unintended effect of erasing slavery from the discussions of the importance of fresh air for health.”
The maladies of empire were the maladies of racialized people, who became the unrecognized collaborators in the foundation of epidemiology and of public health itself. Colonized and enslaved people were often close observers of outbreaks, and provided imperial doctors with detailed descriptions of cases and the movement of diseases.
The doctors, meanwhile, were still believers in the miasma theory, supposing that disease was the result of “foul” air and even bad smells. The health benefits of good ventilation suited that theory—but even more important, doctors were beginning to keep track of whole populations, and to report their findings to London or Paris in an increasingly consistent format.
So as evidence supported or challenged existing medical theories, it was far from anecdotal. Doctors followed cholera from India to the Red Sea and on to Europe. They reported to the metropole, using narrative descriptions of how it affected populations. When John Snow identified the source of a cholera outbreak in London — not a miasma, but contaminated water delivered by a neighborhood pump — he was following the same practice, but with the novelty of a map showing the address of every case.
But health science in the 19th century didn’t benefit everyone. As Downs says, “The same colonial structures that allowed ideas about sanitation to crisscross the Atlantic Ocean had also created the structural inequities that left Black people suffering on plantations throughout Jamaica without medical care.”
Florence Nightingale, statistician
Downs sees Florence Nightingale as a key figure in the development of epidemiology. We remember her as a nurse, but she was far more influential in public health and epidemiology.
When Nightingale served in the Crimean War in the 1850s, she found British soldiers dying from cholera, typhoid and typhus in filthy military hospitals. After a parliamentary commission identified a bad sewer system and airless buildings for the high mortality rate, Nightingale paid attention to hospital sanitation. Queen Victoria and her consort, Prince Albert, agreed to support a royal commission on the health of the army.
Using statistical methods, Nightingale and her colleagues shocked the generals: “For every soldier who died from battlefield wounds, they found, seven soldiers died from preventable disease in the camps.” She established the importance of hospital hygiene and the importance of prevention — principles we have often forgotten in the current pandemic.
Nightingale herself was a disease victim; she seems to have contracted brucellosis. Brucellosis in the Crimea, and once back in Britain she was almost never well enough to leave her bedroom. Yet she continued her work de ella, pioneering the use of charts, tables and diagrams in presenting statistical data. During the late 1850s, a revolt among the East India Co.’s sepoys drew attention to that army’s health conditions. Information flowed from India to Nightingale and her colleagues on the print internet, and good advice flowed back.
But it was advice to improve soldiers’ health to maintain the British Raj. “Nightingale,” Downs observes, “like many other people in power throughout the 19th century and beyond, he recognized the power in using science to subjugate a population.”
Nightingale, like most Europeans and North Americans of the time, believed in a hierarchy of races, with the white Anglo-Saxon at the top. But she and other early epidemiologists did not invoke race as a cause of disease. If Black people suffered more cholera, Nightingale blamed their crowded, unsanitary housing — not the color of their skin.
‘scientific’ racism
Still, Nightingale’s findings on military hospitals soon led to the founding of an agency dedicated to scientific racism: the United States Sanitary Commission, created early in the American Civil War to provide better conditions for Union soldiers. There, the doctors in charge debated such issues as whether mixed-race people — namely people with one Black and one white parent — made better soldiers than Black men. The commission doctors blamed Black people’s tendency to lung diseases on their race, not on their living conditions. They also measured the skulls of dead Black soldiers and reported that Black people’s brains were smaller than whites.
Meanwhile, the public health service of the Confederacy embarked on a program to vaccinate every man in the rebel army against smallpox. To provide enough serum, they infected enslaved Black infants, who would suffer lifelong scarring.
After the war, southern and northern doctors shared their wartime findings and consolidated the concepts of scientific racism.
To this day, the US monitors racial aspects of disease. This has provided consistent evidence that Black Americans experience more illness and shorter lives due to their unequal treatment.
‘Easier for governments to attack specific bacteria rather than improve the living conditions of the poor’
Meanwhile, a critical debate had broken out in European medicine: some, like the German pathologist and politician Rudolf Virchow, argued that disease resulted from inequality, poverty and squalid living conditions. Others sided with Pasteur and his germ theory of disease (just backed up by Robert Koch’s identification of the bacterium). Vibrio cholerae as the cause of cholera). Both sides should have won; Obviously, the poor and malnourished are more vulnerable to infection. But it was easier for governments to attack specific bacteria, and then viruses, rather than improve the living conditions of the poor.
Downs makes a strong argument that epidemiology (and much else in modern medicine) stemmed from close observation of non-European populations under conditions of European oppression: in slave ships, on colonial plantations and in armies. Often the oppressed provided the real observation and descriptions of how diseases broke out and travelled, while the doctors simply took notes.
To maintain empires built on white supremacy, Europeans supported brilliant medical progress along with scientific progress in general. But while the great medical men and women of the 19th century might be white, they were really the pupils of their non-white patients.
Yet the doctors’ reports and journal articles edited racialized people out of their own story. Slave ships became simply ships. South Asian sepoys became simply soldiers.
While Downs doesn’t say so, it looks as if imperial doctors sensed a dangerous implication in their findings: diseases were no respecters of race. If an infectious disease could sicken an African person, it could sicken a European, Asian or Indigenous person as well. What helped a non-white person recover would help a white person, because they really weren’t different.
And if they weren’t different, how could anyone run empires based on white supremacy?
For over a century, this question has haunted the imperial nations of Europe and their settler colonies: the same science that made whites masters has also shown all humans as equal. But some prefer to stick with being masters, even if it means ditching the science.
The racism that poisoned the United States Sanitary Commission continues to poison American and Canadian health-care systems. Black and Indigenous populations have suffered more illness and death in the pandemic as a result, and many mistrust the systems that have exploited them. And so, ironically, have the white supremacists who no longer trust the validity of medicine in the midst of a pandemic.
Yet some of us recognize the scientific truth of human equality, and we would welcome a new society built on such equality. That puts us in conflict with others who cling to the comforting racism of the past, who blame disease on poor people, immigrants and refugees.
The conflict ranges from the insurrection at the Capitol building in Washington, DC, on Jan. 6, 2021, to the January 2022 truck convoys that shut down Ottawa. It makes it easy for Ukrainian refugees to find a welcome in eastern Europe, while dark-skinned people from Syria, Africa and even Ukraine are turned away.
To paraphrase Antony’s funeral speech in Shakespeare’s julius caesar, the evil empires do live after them; the good is oft interred with their ruins. Maladies of Empire studies imperial good and evil alike, and presents us with a choice: stay with science, including that of oppressed peoples, and accept equality — or reject science, and cling to endless oppression. ![[Tyee]](https://feeds.feedblitz.com/design-article.thetyee.ca/ui/img/yellowblob.png){kind=small}