Healthline spoke with Jim Downs, PhD, about his new book that brings to light the darker truths surrounding the foundation of modern medicine

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Jim Down, PhD, (pictured above) is a medical historian whose new book, “Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine” brings to light the overlooked, hidden histories that shaped medicine. Photo Provided by Jaci Downs Photography

Jim Downs, PhD, is the Gilder Lehrman-National Endowment for the Humanities Professor of Civil War Era Studies and History at Gettysburg College.

He’s also a medical historian whose work gives us perspective on how the often overlooked, hidden histories we aren’t taught can shed light on the issues facing modern society.

His books include “Sick from Freedom: African American Sickness and Suffering During the Civil War and Reconstruction,” “Stand By Me: The Forgotten History of Gay Liberation,” and “Beyond Freedom: Disrupting the History of Emancipation,” among others.

One connective thread running through all this research is the reality that the experiences of oppressed, disenfranchised populations were driven by — and in turn shaped — the culture and norms of the times, both past and present.

Especially key is that understanding and centering the narratives of Black and brown communities is critical in documenting this history.

His latest book, “Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine,” will be released on September 7, published by Belknap Press, the trade imprint at Harvard University Press.

The book aims to look past the lauded stories of Western medical innovators like Florence Nightingale and John Snow — the man credited with tracing London’s cholera outbreak of 1854 to a water pump, not to be confused with the “Game of Thrones” character.

Downs establishes that it’s actually the people unrecognized in history books — Black and brown people enslaved by Western nations, conscripted soldiers, and those displaced by the expansion of colonial empires — who have contributed to our understanding of infectious diseases.

Some of the stories he uncovered include how slave ships proved the existence of oxygen, as well as the early records of colonized and enslaved people in Cape Verde describing an epidemic, the first “contact tracers” if you will.

Another disturbing passage has echoes of the medical racism of the 20th and 21st century, describing doctors in the Civil War-era American South harvesting smallpox vaccine matter in the bodies of enslaved infants and children.

Through each story, he highlights that modern science is what it is today because of cultivating, recording, and experimenting on oppressed people without their consent.

Healthline recently spoke with Downs about his book and what its revelations about the history of epidemiology say about our current pandemic.

How did you get started on the journey of researching this book, and what was the initial kernel of an idea or the initial inspiration to delve into this history? 

Downs: It grew out of my first book called “Sick from Freedom,” which was a book that really speaks to this moment. It was about the fact that when Black people were emancipated from slavery, they faced this enormous epidemic.

Oftentimes, when we talk about emancipation, we talk about this ability for political and legal rights. What happens at the moment of emancipation is, they enter a world where they’re faced with an unprecedented amount of infectious disease.

When we think about the Civil War-era, we realize more soldiers died from disease than from battle. They didn’t understand bacteriology or epidemiology, so the story was really just this idea of ‘Wow all of these people end up dying at the moment of ‘freedom’ and then there is a cholera epidemic.’

When I found records of the smallpox epidemic, the government would say things like ‘We don’t have the resources to get doctors from Washington, D.C. down to Louisiana, or just getting reports from Louisiana back to Washington was hard, we can’t do it.’ Then, all of a sudden, a cholera pandemic blows up in India, crosses into Europe, crosses the Atlantic Ocean, makes its way into Canada, then into New York, then down into the South, and basically the government creates this really effective plan to stop this cholera pandemic.

There’s tons of reports of what to do, and I thought ‘Wait a minute, you couldn’t do smallpox but cholera you could?’

Smallpox has been around for centuries, but cholera was relatively new. So basically what happened was I sort of resolved that in my book and said that cholera affected white people — and as far as they were concerned, ‘smallpox just affected Black people,’ so they ignored it.

I was concerned with the questions: ‘How did they understand it? How did they understand enough to stop a pandemic in 1866? What was their protocol? Where did they learn this information?”

How did people understand the idea of epidemics back then?

The beginning of epidemiology as a field is often traced to a cholera epidemic in London around the same time, to a guy named John Snow.

He was an anesthesiologist, and when he heard of the cholera epidemic blowing up throughout London in a poor neighborhood in Soho, he started interviewing people, investigating it, and looking at the number of people that died. And ultimately he says ‘Look, this is connected to the water pump; you’re all drinking from the same water pump, and thereby that is why you’re getting infected.’

A lot of historians and popular scientists tend to trace the story of epidemiology to John Snow and the water pump in London.

How did you come to look beyond this more conventional approach to understanding epidemics?

I met a very wise archivist at the Wellcome Institute for the History of Medicine who suggested I go to the National Archives in London. I soon uncovered documents of dozens of doctors that predated John Snow that were actually investigating the spread of disease. And what they were doing was going into places like India and the Caribbean, mostly into Jamaica and other places, and they were watching how infectious diseases were spreading.

I have a chapter in the book on Cape Verde, where a doctor starts interviewing washerwomen and slaves and notices they’re mostly Black people. Some are described as ‘mulatto’ — these are all 19th century terms — biracial, all colonized, some of them are enslaved. He interviews them, writes up their interviews, records it, and then starts to publish the interviews.

I found 100 pages of these interviews, and I was blown away. What that meant was that our knowledge of epidemiology didn’t come from some guy in London, and it didn’t come from some laboratory; it came from talking to enslaved and colonized people.

When the infection broke out, these washerwomen who were enslaved and colonized were watching the symptoms. They knew that if you vomited, it was black vomit, and thought ‘this vomit doesn’t look right.’ This was yellow fever. They were timing the incubation; they were trying to trace the origins.

In other words, all our tools in epidemiology can be found at the local level by ordinary people. John Snow has become this sort of hero, and this story about Africa and Cape Verde gets pushed away.

What role did colonialism play in the development of epidemiology?

John Snow and this other doctor, James McWilliam, were buddies. They were part of this thing called the Epidemiological Society of London — this society that gets developed in 1850 as a result of doctors going out to other parts of the empire to study infectious disease.

When you think of epidemiology as this science that grows out of colonialism, I think that’s something that people don’t think about. They would say, ‘Oh epidemiology grew out of Snow and what happened in the city,’ or ‘Let’s look at these statistics of white soldiers versus Black soldiers in the Caribbean in the Crimean War.’

No, the bigger theme is colonialism and how colonialism itself contributed to epidemiology. 

A lot of people since the ancient times — Aristotle, Hippocrates, everybody — were studying ‘why does an epidemic blow up, why do we have an epidemic?’ Starting in 1755 you have social transformations — the international slave trade, the expansion of the British Empire, and then, by the middle of the 19th century, the Crimean War and the Civil War.

Those big social transformations create an unprecedented environment where you’re congregating large populations of people in an artificial environment, when doctors begin to study the spread of disease. 

People in Ancient Greece or colonial Boston or New York in 1820 could only see the people in their district, parish, or neighborhood. Colonialism means that, all of a sudden, ‘wait a minute, I have this bird’s eye view, I can see everything. I have the power of the empire to get the reports, and to get the data.’

Now, things like slavery, colonialism, and war have taken people off the farms and out of their homes and congregated them, and now you’re able to see epidemics spreading across a large part of the population. 

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“Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine” by Jim Downs, is available September 7, 2021 from Belknap Press, the trade imprint at Harvard University Press.

How does it feel to be able to pull the curtain back for people who have been going to school and over the decades of current (at least Western) education, haven’t heard this history before?

To be honest, I’m anxious. Because people are committed to their way of seeing things, and they don’t want to see this.

Within the field of African American studies, in which I’m trained, they say ‘yes, we’re excited about this,’ because this is a part of a larger current, like the ‘1619 Project.’ What’s the point of the 1619 Project but to foreground slavery as central to the story of the United States and say ‘Listen, there is all this history about how slavery contributed to the advance of capitalism, how slavery contributed to the making of a nation?’

My research joins that chorus and says ‘here’s how slavery contributes to the advancement of science.’

For historians of medicine and for doctors, it’s unclear. Are they going to really listen or pay attention, or are they going to dismiss this as ‘woke history?’ Are they going to dismiss it because it contradicts what they want to think of when it comes to colonialism?

I am very sensitive toward issues about race in the [historic] record. My argument is saying, it’s not about a doctor’s personal viewpoint that’s simply racist, it’s about how colonialism as a system creates a structure that allows these people to be studied — that’s racist.

The racism is colonialism, the racism is you’re placing these people in Jamaica into a subjugated position, where the political economy has subordinated them, and you come in as a doctor. That is the racism.

The book is saying that even the most subjected, ordinary people — the prisoners of war, the washerwomen, the enslaved, colonized populations — they have, since the jump, brought us this knowledge we now have about infectious disease. 

So, it’s about democratizing how we get this information and who delivers it? 

It’s showing us where this information comes from and that we should really be careful about creating these binaries or hierarchies within medical knowledge.

With these binaries — there’s medical people here, but patients over here — it’s a much more intertwined narrative, and it’s a much more mutually constitutive narrative. We should be careful of a hierarchy where the doctors’ knowledge is superior to that of the ordinary person.

Is there a story or a history that really shocked you when you were going through these records?

I would say one of them is definitely the Cape Verde example. When I did my first book, which was centering Black people as patients during this period, I was pulling from a range of records that never included a first-person testimony of Black people.

During this period, Black people may have given a first-person testimony about when they went to vote or got to attend school or owned land, but I never got a patient testimony.

I found it when I was at the Wellcome. I just walked around these open stacks of basically secondary sources. I pulled out this huge binder and I was shocked. I’d never seen this. It was all these testimonies of these people — ‘mulatto,’ Black, enslaved, colonized, washerwomen — that blew me away. It was one big find.

The second find is the piece on oxygen. Basically, every historian knows that so many enslaved Africans died during the voyage from Africa to the Americas, millions in fact. A lot of historians recognize that many people on the ships died — part of it was malnutrition, part of it was the spread of epidemic disease, like smallpox.

A lot of different things were plaguing the ships. Thanks to this guy named Thomas Trotter, you see in the records on this ship that we know humans need a fresh supply of air.

So, since Aristotle, he went around collecting everything. He knew ‘air’ was important, but they didn’t know that the composition of the air begins to change its quality when you crowd people together. So, at this point, you don’t have tenement houses, but there are prisons, and at this point people are dying in prisons because the air is changing its quality and people are getting sick.

Reformers were saying ‘There are too many incarcerated people dying, but no one knows why.’ By the 1750s, you have the rise of the slave trade and the beginning of chemistry. In general, chemistry began as alchemy, but by the 1750s, it started to become a real field, with chemists in England and in Germany and France.

The understanding of oxygen was based on the laboratory, with these scientists competing to see who would be first.

But then it was with the slave trade where people realized ‘wait a minute, we can see this and what it means for human beings. We can see what it means for us. It’s no longer a laboratory experiment, no longer the beginning of this field of chemistry. It actually has an effect on humans.’

We owe our understanding of chemistry to the slave trade. That blew me away. You have the invention of mechanical ventilators, the slave ships being used as evidence of the need for ventilation.

Your book reveals that Southern doctors tested smallpox vaccines and harvested that material within enslaved infants and children during the Civil War. What was it like delving into that history, and what does it reveal about the state of medicine in the years, decades, centuries since those experiments were carried out? 

One, it’s a deeply horrific, unsettling history that hasn’t been told, and it’s buried in the record. When we talk about the ‘1619 Project’ and about capitalism, we have this image of gang labor, 100 slaves on a plantation, or four or five slaves on a family farm. You have this notion of labor as physical labor or agriculture labor.

When I saw this [the information on smallpox vaccine development], I thought ‘they are literally putting infants in labor.’ They’re saying: you’re my property, you’re an infant and your body is going to work for me. You can’t talk, can’t walk, can’t do anything, but we will infect you with this virus so your body produces the ooze that comes out of the vesicles and that can be used as vaccine matter.

That chapter makes me really angry and sad. The documented stuff I have I know is only a fraction, because again, people aren’t writing and recording everything they’re doing back then.

It raises a lot of medical ethical questions today. I am deeply, deeply opposed to the notion of a booster shot for COVID-19 when a part of the world doesn’t have a first shot. From a completely public health perspective, sure, get a third booster, get a fourth booster — but if the global south is continuing to develop COVID-19, we will never kick this thing.

So there’s this notion about vaccines — the poorest populations, the most dispossessed populations don’t matter, and all we have to care about is ourselves.

I think that’s the lesson from this chapter. The mentality of ‘It’s just about us, it doesn’t matter if it’s an infant, I just need to be protected,’ or ‘it doesn’t matter what is happening in the rest of the world, even though it’s a pandemic, I need a booster shot.’ I think that’s the connection between now and then.

Is there a final takeaway you want a reader to have when they reflect back on this book? 

I would say that our understandings about how to control infectious diseases developed at a moment of crisis — during the height of slavery, colonialism, and war.

These are ideas that didn’t come from a lab or smart scholarly discussions. The legacy of slavery and colonialism created a set of tools that are guiding us through the pandemic today, and I don’t think most people think of that. They say ‘oh, it’s just Fauci,’ — well Fauci has a history, Fauci comes from a particular context, Fauci comes out of a school of epidemiology that began here [with slavery].

Now, most people understand anthropology as a field that grew out of the colonial gaze, but we don’t think of epidemiology growing out of a similar field. But it did.

This interview has been condensed and edited for clarity.