In Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine, Jim Downs tells a new origin story for epidemiology. In the nineteenth century, everyday people’s experiences and accounts of disease in crowded, unhygienic conditions led to the epidemiological revolution, Downs argues. Whether confined to the bowels of a slave ship or a prison in India, enslaved people, washerwomen, and soldiers around the world were put in extreme epidemiological positions. Their trials helped educate physicians on how diseases spread.
In taking this emphasis, Downs departs from previous histories of the origins of epidemiology. Prior scholars point to figures like John Snow in metropolitan sites like London, who mapped cholera’s spread across the city. Yet Downs contends that epidemiology “developed not just from studies of European urban centers but also from the international slave trade, colonialism, warfare, and the population migrations that followed all of these” (3).
Thus, Maladies of Empire’s contribution to the history of modern medicine and epidemiology is two-fold. First, he illustrates how the construction of the modern medical profession played out on a global scale and cannot solely be understood through the histories of white, male doctors in their home countries. Second, the physicians themselves are only a part of the story. To build their knowledge, they relied on the observations, accounts, and sometimes cries for help of unfree people across several continents.
The book is organized into eight concise (and highly teachable) chapters that focus on critical episodes in the history of epidemiology in the nineteenth century. Throughout the book, Downs employs the methods of feminist scholars like Saidiya Hartman, Marisa Fuentes, and Deirdre Cooper Owens to center the stories of colonized, indigenous, and enslaved people, along with exploited soldiers.
The first three chapters highlight the contributions of colonized and enslaved people to epidemiology. Downs mines medical texts to find veiled accounts of how diseases spread, including enslaved people’s protestations about the poor ventilation of slave brigs, the sanitary practices of Indian hospital attendants, and the strategies of washerwomen in Malta. For instance, Downs explains that such accounts sometimes appear in the form of anecdotal evidence such as parenthetical notes within medical texts. “Laundresses, Muslim pilgrims, sailors, and the poor,” Downs asserts, “helped the medical community and government agencies visualize how diseases spread” (34). In the chapter on fever in Cape Verde, the voices of everyday people come through clearest. Downs’s account is possible through British physician James McWilliam’s many interviews with everyday people in Cape Verde in 1846. Black laundresses were critical to charting the fever’s spread. They “knew who was sick, who had been in contact with whom, and who had transported and buried the dead bodies” (59).
State bureaucracies’ ability to collect, organize, and transmit large volumes of data was also crucial to creating epidemiology. For example, mid-nineteenth-century cholera pandemics highlighted that effective epidemiology must often be global in scale and demanded innovation on the part of nineteenth-century European imperial states.
In the chapter on Florence Nightingale’s epidemiological work, bureaucratic expansion and female expertise intersected in illustrative ways. Her efforts stand out in a nascent epidemiological print culture dominated by men. In the wake of a rebellion of native Indian soldiers (sepoys) in 1857, the British formally took control of the subcontinent, thus further increasing the scope of the imperial medical bureaucracy. Nightingale took advantage of this shift. In 1863, she completed an influential report on the need for greater sanitary measures in British stations. Unlike in the Crimean War, she did not need to be on the ground in India to study epidemiology. The bureaucracy of the British empire had already collected immense volumes of data, which she analyzed at home.
Later chapters take this story into the history of the United States during the Civil War and beyond. Here, Downs unpacks how this epidemiology could be racialized, despite doctors’ diverse sources of information. While racial ideas were certainly spread through Britain’s bureaucracy in the nineteenth century, the U.S. Sanitary Commission overtly set out to study supposed racial differences. They cataloged vital statistics and measured the bodies of Black soldiers to bolster ideas of innate Black inferiority. On the corollary, their opponents in the Confederacy cultivated vaccine matter in the bodies of enslaved children.
Downs’s account of the rise of epidemiology is a welcome addition to a historiography that has focused heavily on the breakthroughs of white, male physicians while generally overlooking the influence of people from subordinated groups. The book makes a compelling case that epidemiology’s origins are much more bottom-up in nature than has previously been recognized. In short, much of epidemiology and public health in the past (and today) is a collaboration between state experts and everyday people who supply bureaucrats with information.
Maladies of Empire is a must-read book for historians interested in the intersection of the history of medicine, slavery, and other forms of unfreedom. Downs’s talent for storytelling also makes this book compelling reading for students and lay readers alike. Moreover, he strikingly reveals that epidemiology is not just the product of state bureaucrats and elite medical professionals. Instead, epidemiologists regularly rely on the bodies and accounts of society’s most vulnerable members.permission.