Jim Downs. Maladies of Empire: How Colonialism, Slavery and War Transformed Medicine. Cambridge, MA: Harvard University Press, 2021. 272 pp. $29.95 (cloth), ISBN 9780674971721.

Reviewed by Shibani Das (University of Exeter)

Jim Downs’s Maladies of Empire studies the impact that colonialism, war, and slavery had on the field of epidemiology in the 19^th and 20^th centuries. Its geographical focus stretches across North America, the Atlantic, West Africa, the United Kingdom, and its colonial possessions in the Indian Subcontinent. It addresses the inability of historians of science, until the 1970s, to question scientific thought and embrace what Warwick Anderson calls ‘universal knowledge’.[1]  Through this book, Downs, a professor of Civil War era studies and history, attempts to adjusts popular and academic perceptions of our medical past, as well as of our understanding of inventions, innovations, and intellectual achievements by highlighting the forgotten contributions of the colored, conscripted, enslaved, and oppressed in the production of new ideas about medicine. Downs’s overarching argument is 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).

Slavery pervades Downs’s book. This theme is presented in an accessible and emotional tone, often transporting the reader to the underbelly of a slave ship or to the shadow of the hickory tree amidst a cotton plantation, to better situate the reader in the realities of forgotten human experiences that informed their contributions to epidemiology. He, therefore, strongly situates slavery as a pervasive factor in the equation, a continuity that flows rather seamlessly from his 2012 publication, Sick from Freedom: African American Illness and Suffering During the Civil War and Reconstruction.[2]

Another constant is colonialism, which gave rise to a ‘military and bureaucracy that served a central, often under-appreciated role in advancing the field of epidemiology’ (5).  As the reigning political force during the book’s periodization, colonial governments provided the institutional, ideological, and financial support for the growth of epidemiology. Governments and monarchies commissioned medical reports on diseases wreaking havoc in its colonial possessions, allowed physicians to conduct investigations, intrusive medical practices on locals, with or without their consent. An association with the reigning power provided the amateur scientists an undeniable legitimization, platforms to publish, discuss and gather to theorize on data, to generate knowledge which aided in the controlling of populations. These often-untrained scientists and physicians did not attempt to isolate their scientific investigations from their personal stereotypes, biases, and notions of racial superiority, but rather arguably allowed their racism to fuel their intellectual pursuits. As Frantz Fanon put it, ‘the Hippocratic oath in no way immunized the medical establishment from complicity in colonial repression.’ They did so ‘out of a desire for knowledge but also to further colonial interests by learning how to deal with subject people.’[3]

A sense of comradery and patriotism also motivated inter-colonial competition amongst physicians, which led to a greater number of recorded inventions. The ideological facet of colonial rule, allowed for the impunity with which White European-American physicists disregarded colored contributions, bodies, or knowledge systems in their studies. The supremacy of Western science, its principle of ‘rational’, experimental practice, admonished native medical practices as primitive and superstitious. This institutionalized condemnation of knowledge systems aided what Ngũgĩ wa Thiong’o calls the colonization of the mind.[4] Colonialism gave rise to an institutionalized slave labor and thrived on expansionist strategies championing war.

Slavery and war, argues Downs, created unique opportunities for physicians. ‘Slave ships, plantations, and battlefields created social arrangements and built environments that allowed physicians to observe how disease spread and prompted them to investigate the social conditions that led to the outbreak of disease’ (4). They instigated the movement of large populations, confined them to barracks or plantations, and denied their victims of their freedoms. Episodes of gaol fever, plague, cholera, yellow fever, scurvy, and smallpox caused death and, worse still for capitalist players, economic loss due to enforced quarantine and the loss of slave labor.

All this sparked a debate on the contentious ‘Contagion theory’. European physicians and medical theorists such as Gavin Milroy, Charles Grey, Amariah Brigham, and Arthur Holroyd travelled, often on slave ships, to colonies such as Jamaica, Cape Verde, Bermuda, and Cape of Good hope, to investigate, collect data and theorize. This data, argues Downs, was collected by interviewing, experimenting on, and abusing enslaved men, women and children, or conscripted men, confined to plantations, on estates or in barracks, without power, value, and rights. These medical enthusiasts and professionals produced their theories in journals which were read across the network of colonial possessions but published by institutions in western Europe or America. Their work sparked discussions about hygiene in penitentiaries, plantations, as well as convict and slave ships. New discoveries expanded intellectual horizons and realigned the legal framework to more humanistic ideals. These included the abolition of slavery, regulations on prison room sizes for proper ventilation, pneumatic chemistry, and basic sanitization for all men, free or enslaved.

Celebrated in history as ‘the lady with the lamp’, Florence Nightingale’s contribution to the field of public health and epidemiology has been overshadowed by her historical memory as a nurse. Downs corrects this misconception, aided by her contribution to the sanitary standards imposed in British India as well as during the Crimean War (1853-56). The latter allowed Nightingale, the superintendent of the Hospital for Invalid Women in London to travel to Scutari, to aid the ‘wretched wounded’ British soldiers falling prey to disease and infection. As elucidated by Downs, she quickly identified the lack of sanitary practices and amenities in army barracks as the primary factor determining mortality among British troops. She set forth, with the aid of bureaucrats within her personal network to establish practices for disease prevention, sanitization, civil engineering practices that, upon implementation, contributed positively to the war effort.

The US Civil War (1861-1865) provides the most substantial battlefield for Down’s argument. The war exposed the country’s ‘unpreparedness for the challenges of wartime medicine’ (117). There were no hospital systems, supplies, or plan in place to accommodate the large demographic movement of battalions, of fleeing enslaved persons and prisoners of war. This created an environ replete with smallpox, gangrene, diarrhea, and general emaciation. It also necessitated the detailed documentation of daily medical practices, actions, observances, and remedies. Studies highlighting the importance of fresh air and hygiene, codified through examples of the Black Hole of Calcutta,[5] the high morbidity on slave ships, and the literature produced by the likes of Florence Nightingale influenced the medical practices standardized by the United States Sanitation Commission for the Union army. This application of medical theory to a battle fought over enslaved colored peoples, caused the reinforcing of racial hierarchies by medical theories that tapped into a latent cultural bigotry and cemented it with scientific process. This, argues Downs, led to the emergence of fields such as craniology.

Emancipated Black troops in the Civil War were considered more prone to pulmonary diseases due to their presumed weaker lungs, a lazy disposition, and smaller skulls. While ‘mulattos’ were accused of being physiologically and intellectually inferior, making wanting breeders and nurses. Detailed data was compiled on their height, weight, and weight of organs. Refugee former slaves from the Confederate South were considered ‘contraband’, often having to face hunger and cold upon their escape from their masters. Black men and boys enlisted in the army to access food and shelter, leaving infants easy targets to be put to work to produce vaccine matter. Downs evaluates their contribution as the primary source of vaccination for plantations and barracks alike when wartime sanctions and scarcities denied access to supplies. Untouched by the vagaries of plantation labor, and unexposed to sexually transmitted diseases, the bodies of Black infants were enlisted in the war effort.

Black bodies suffered nonconsensual inoculation. They face either death or lifelong abrasions, neither of which were acknowledged in the medical developments to which their sacrifice gave rise. Downs also highlights the plight of prisoners of war (POWs) at the Andersonville camp, eternalized in the Federal accusation on the Confederacy, of knowingly poisoning POWs in their care. After the war, Downs traces the movement of Southern racist perceptions into Northern academic practice.

Colonialism, war, and slavery thus created spaces and conditions that allowed for the study, experimentation on, and documentation of numerous diseases. The men credited for these medical advancements in their lifetime and posthumously, argues Downs, should be accompanied by the numerous slaves, free men and women who contributed their emotional, psychological, and physiological labor to the process but slipped through the lines of numerous medical journals and academic discussions. Linda Tuhiwai Smith can be contextualized to support Downs, in her argument that the format of western science can acknowledge a plant or shard of pottery but cannot address native contributions to scientific developments.[6] The evolution of medical practice is, however, a positive impact of Downs’ story. The standardization of medical surveillance, data collection and assessment, and the use of awareness-building campaigns gave rise to a practice that has saved innumerable lives throughout our history.

The book provides a succinctly written exploration of the rise and development of epidemiology. Its wide range of case studies, however, at times makes for uneven analysis. For example, Jim Downs’s argument indicates greater blame for racist medical practices to American scientists as opposed to British. When addressing the evolution of medical knowledge in the European subcontinent in comparison with its North American counterpart, Downs relates the former as morally superior due solely to the US Sanitary Commission’s treatment of race as a ‘valid biological category’ (128). American sensibilities are reproduced without contextual information, in an anachronic bubble of current moral values that is disgusted by the existence of slave holdings. While Americans are critiqued for their racial ideologies, similar beliefs in British doctors are judged with kinder eyes. James McWilliam, founder of the Epidemiological Society of London, claimed African medicine to be primitive, to include the worship of the devil, treatment with fetishes and human sacrifices. He rejected all local medical cures and practices as superstitious.  Downs claims McWilliam’s white supremacist and orientalist comments are not an example of the British portraying Africans as peculiar, uncivilized, and primitive. Rather, it is ‘offering a panoramic view of West Africa to provide a context for understanding the disease.’ Downs explains that the ‘focus on racial difference’ is in reality, concern with ‘the influence of climate, and environment, not with the physiology of the African people’ (55). Similarly, Gavin Milroy, a co-founder of the Epidemiological Society, refers to African residencies as ‘filthy negro yards’ or ‘hovels’ but is exonerated by Downs for keeping his racist beliefs separate from his study of disease.

Downs readily acknowledges the issue that often arises when writing histories of disadvantaged groups: the inability of colonial and military archives—mostly in English—of representing the voices, thoughts, and aspirations of the enslaved, imprisoned, or conscripted. His analysis, however, has little alternative but to be based on assumptions, hints, and clues that may be influenced by contemporaneous morality and conventions. In sum, Maladies of Empire is a widely researched and insightful read for those interested in the history of medicine, slavery, or international histories.

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[1] Warwick Anderson, Decolonising Histories in Theory and Practise: An Introduction (2020).

[2]  In an interview with Director of Education, John Lustrea (National Museum of Civil War Medicine), Dr Jim Downs claims Sick from Empire to be a prequel to Maladies of Empire. ‘Maladies of Empire with Dr. Jim Downs Livestream’, YouTube video (9 Dec 2021), at 57:55 mins.

[3] Deborah Baker Wyrick, Fanon for Beginners (2014), 55.

[4] Ngũgĩ wa Thiong’o, Decolonizing the Mind: The Politics of Language in African Literature, (2011).

[5] The name given to an incident in 1756 where 146 British soldiers were confined in a prison cell in Calcutta (Kolkata). Only 23 survived the imprisonment. This incident highlighted the importance of fresh air for human life.

[6] Linda T. Smith, Decolonizing Methodologies: Research and Indigenous Peoples (2013).