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Downs’s subject is how, beginning in the mid-18th century, violence associated with colonialism, slavery, and war influenced the theory and practice of medicine and, allegedly, of epidemiology. In eight chapters, an introduction, and a conclusion, he presents some well-known and some less-known evidence to justify his argument.

Each chapter is a case study of one or several episodes in the relationship between violence and the history of medicine. Downs begins by presenting the speculations of doctors on slave ships and prisons about the effects of bad air in “crowded places” (pp. 17–18). There is a chapter on the “decline of contagion theory and the rise of epidemiology.” The next chapter is a detailed study of “tracing fever in Cape Verde.” Downs then generalizes from this study to describe “epidemiological practices in the British Empire,” emphasizing the centrality of “recordkeeping” in imperial bureaucracies.

Moving away from medicine, he then focuses on the contributions of Florence Nightingale, commonly considered to be the founder of modern nursing and hospital epidemiology,1 whom he calls the “unrecognized epidemiologist of the Crimean War and India” (p. 88). The book summarizes Nightingale’s contribution to the conceptualization and analysis of data about populations experiencing severe infectious diseases. He follows this chapter with studies of the history of the US Sanitary Commission during the American Civil War and the subsequent influence of its work, a history he summarizes as “from benevolence to bigotry.” His cases conclude with a study of the “narrative maps” devised to document the interaction of Black troops and Muslim pilgrims during the cholera pandemic of 1865–1866.

Downs offers many examples of clinical observations made by doctors in captive populations, but the weakness of Downs’s thesis is his attempt to link these episodes that belong to the history of medicine, as the title of the book clearly indicates, to the history of epidemiology. Downs seems to believe that doctors practice epidemiology when they examine their cases within large-scale “captive” populations such as military hospitals and camps, slave ships, prisons, and so on (p. 6). But doctors have attended large numbers of people since antiquity—that is, thousands of years before the emergence of epidemiology in the 17th century. Downs does not seem to realize that a clinical practice, even within a ship, a prison, or a concentration camp, remains a medical act as long as the multitude of individual cases itself does not become the new dimension of analysis—that is, assessed as a population, divided into groups, and compared.

Consider the example of Robert Dundas Thompson and Pierre Louis. Thompson who, in 1839, observed an enslaved African man refusing food and dying after nine days and a captured woman refusing to eat and dying after “about a week,” concluded that “inhabitants of Africa can only live without food for ten days” (p. 2). Thompson speculated on the basis of clinical observations. There is no epidemiological approach. In contrast, a decade before Thompson, Louis, the French physician, assessed the efficacy of bloodletting in the treatment of pneumonia comparing patients bled at different times after the onset of the pneumonia. Louis concluded that those bled early did not survive more frequently.2 Louis was performing population studies and was a pioneer of clinical epidemiology.

A similar contrast can be made between Nightingale and the other Parisian clinicians who worked concurrently in the same large Parisian hospitals as Louis and speculated based on extrapolations from their multiple individual clinical observations.3 They were not even aware of the insights that a population approach can provide. In contrast, Nightingale’s epidemiological (sometimes referred to as statistical) work has been described by many authors,1,4,5 including in AJPH.6 In the studies during the Crimean War that Downs reports, she counted the deaths from different causes by month and compared them across time in an indisputable epidemiological approach.

The other surprising aspect of the book, which undermines its novelty, is that it ignores the role of violence and racism in many other cases of alleged medical research. The infamous Tuskegee study was conducted on African American sharecroppers of Alabama to learn about the natural history of syphilis.7 Concentration camp prisoners were used as subjects of the experiments on typhus treatment,8 the Dachau hypothermia experiments,9 the twin studies,10 or to illustrate medical anatomy books.11 None of these examples are mentioned by Downs even though they stem from the same susceptibility of Western medicine to abusing captive populations under the protection of dominant biases, of a racist, xenophobic, or chauvinistic nature, to accrue clinical observations. Most of the results, if not all, from research carried out in these unethical conditions for medicine have proved to be of no scientific value.12

Altogether, the claim that the episodes reported have constituted the “DNA of epidemiology” (p. 196) is not supported by the evidence and therefore is unwarranted. Except for the case of Nightingale, who strove to reduce violence against wounded and sick military, epidemiologists will not recognize in the book’s examples the foundations of their discipline. This does not mean that genuine epidemiology has not been carried out in similar unethical conditions, but the evidence of that will not be found in Downs’s book. This book is, nevertheless, an informed contribution to the history of medicine in conditions of colonialism, slavery, and war.


The authors have no conflict of interest with the contents of the book review to report.

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