Saturday, September 23, 2023

Review: Maladies of Empire by Jim Downs

Maladies of Empire tells the usually-untold story of how epidemiological and medical advances were made directly as a result of the institutional aspects of colonialism. The “told” story usually includes Onesimus, an enslaved man who told his master, an 18th century New England priest by the name of Cotton Mather, about the practice of inoculation against smallpox using exposure to a small quantity of the virus to prevent a more severe, systemic infection. Mather tested this process on some 250 enslaved people and eventually his own son, convincing the aggressively skeptical medical establishment of the validity of this Black “folk” wisdom. Good discussion of this episode in history is usually limited to the ethicality of experimentation on enslaved people (see Medical Apartheid). But there’s sort of a comforting aspect to this narrative too: Onesimus was a relatively well-treated slave, and that his master listened to him and learned from his cultural traditions plays into the story the Anglo empire likes to tell that cultural mixing was beneficial for itself and all the civilizations it conquered.

Where Maladies of Empire goes beyond this is to document how the very processes through which the British Empire colonized much of the world also enabled the medical field to understand the spread of diseases. The story starts with slave ships:market forces drove slavers to keep costs down as much as possible without hurting the sale price of their human wares. This captive population was carefully documented and experimented upon, and from here, the medical establishment learned about the minimum fruit or vegetable intake required to stave off scurvy.

The mechanisms of the spread of infectious disease, however, necessitated the aggregation of records from across the world. Who was living where? Where did these ship passengers come from? Where did they go? After how many days did symptoms start? The meticulous records through which the British Empire tracked their ships and military and subjects allowed medical doctors to track the spread of yellow fever and cholera. For the first time, scientists were analyzing data that others had collected, possibly from the other side of the globe. 

The birth of epidemiology is therefore also, in a sense, the birth of data science, and the dark sides of data science were present from the start. The individual names and stories of the people who contributed the data — often racialized or institutionalized or poor — are lost to the sands of time, while the knowledge gleaned from their data goes on to benefit the wealthy and white. Downs’ story-telling is up for a challenge: how do you bear witness to these lost narratives and humanize the individual subjects whose suffering taught us how to cure or prevent disease, without getting mired in details? I don’t think the result is fully successful — there were some episodes where I felt the main themes became a little lost in the weeds of names and locations. But the work is excellent for understanding how intimately linked the development of science was with imperialism.

We see similar beats today: the bureaucracy of institutionalized people supports medical advances. For example, the link between the Epstein-Barr virus and Multiple Sclerosis was shown quite definitively only because of the mandatory monitoring and testing of American military recruits (themselves an imperializing force).

Downs contrasts the racism of the British Empire in the 19th century with that of the United States. In general, the British were certainly white supremacist, but more accepting of belief systems that allowed for similarities between races. For example, see Florence Nightingale and some of her peers’ views of racial differences in disease susceptibility:

Although Florence Nightingale believed in racial difference, regarding the English as the finest race on the planet, she did not use race as an explanation for the spread of cholera or other infectious diseases. Even after germ theory became widely accepted, she insisted that unsanitary environments led to disease. She did not believe that the source of disease transmission could be found in innate characteristics of the patient (...). Similarly, while Gavin Milroy and other doctors working in the Caribbean certainly harboured racist beliefs, they too searched for the cause of disease in the natural and built environment. Milroy condemned Black people’s living conditions and blamed their high rate of illness on their failure to maintain clean homes, but he did not focus on racial difference as the cause of disease spread.

Because their economic system depended on enslavement (and later, subjugation and segregation) of the Black race, American doctors approached medicine quite differently, and sought to reify the impact of race in health. The answer to “why is disease more prevalent in slaves?” could not be that they were oppressed, and forced into terrible living conditions, since that was a threat to the social order:

Many doctors in other parts of the world were turning to the physical world and the built environment to understand how disease spread; they observed symptoms in a patient and then turned outward to housing, sewers, drainage, and crowded conditions to understand why patients were sick. USSC surgeons did the opposite. They turned inward to the patient, trying to find the answer to the illness within or on their body. While they considered the natural or built environment, they emphasized racial identity as the cause. 

This approach had a long-lasting impact on the medical establishment: while slavery ended with the Civil War, “the USSC resurrected slave-holding ideologies to amplify racial difference and to contribute to medical knowledge.” These were not the first scientists to seek to justify their pre-existing beliefs with “evidence” and refuse to consider alternative explanations, and they were certainly not the last.

A challenge with books of this sort is where they stop. The British Empire is no more, but the world is still scarred by imperialism. Science has developed into a far more robust practice, but is still often racist, and the fruits of its research are unequally distributed. The author set out to tackle this topic for a reason, and I would imagine it is because he saw similarities between this part of history and our world today. If so, I agree, and I have highlighted some of these themes above. But Downs never goes so far as to explicitly draw out the link, to comment on practices of the twentieth century and beyond. I suppose it is the careful conservative nature of most academics, who don’t dare step outside their field of expertise — but that just leaves me, with my considerably smaller extent of expertise, to apply what I’ve learned on my own.

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