Book Review

Epidemics and History: Disease, power, and imperialism

N Engl J Med 1998; 339:55July 2, 1998

Article

Epidemics and History: Disease, power, and imperialism
By Sheldon Watts. 400 pp. New Haven, Conn., Yale University Press, 1997. $35. ISBN: 0-300-07015-2

In ancient Greece, the great medical teacher Hippocrates taught his students that medicine may consist of many things, but it is always concerned with the patient, the physician, and the disease. In the past two decades, spurred on, no doubt, by a worldwide AIDS epidemic that caught the Western world unprepared to acknowledge that infections can still be such threats to our well-being, the history of disease has become a veritable scholarly industry. Epidemics have always struck terror and have always been of dramatic interest.

Nancy Gallagher, a historian of medicine and public health in Tunisia, described three main historical approaches to the analysis of epidemics in the past: epidemics as causative agents of change, epidemics as mirrors reflecting social processes, and epidemics as ways of illustrating changing medical theories and practices (Medicine and Power in Tunisia, 1780–1900. New York: Cambridge University Press, 1983). In Epidemics and History, a large and at times complex work of historical synthesis, historian Sheldon Watts, who has taught in Nigeria and Egypt and lives in Cairo, brings together all three of these approaches and an immense body of secondary literature on the history of diseases and their social, political, economic, and cultural consequences. Watts has read widely and perceptively. He is not the first to tackle the subject of disease and the public health response to it as a tool of empire building, nor is he alone in showing that disease is one of the ties that binds industrialized societies to those in the Third World. “Migration of man and his maladies is the chief cause of epidemics,” Alfred Crosby noted in Columbian Exchange: Biological and Cultural Consequences of 1492 (Westport, Conn.: Greenwood Publishing, 1972).

The heart of Watts's book consists of six long chapters about seven diseases that have plagued humankind: bubonic plague in Western Europe and the Middle East from 1347 to 1844, leprosy in the West in the Middle Ages and as a tropical disease in more recent times, smallpox from 1518 to its eradication in 1977, syphilis in Western Europe and East Asia from 1492 to 1965, cholera in Great Britain and India from 1817 to 1920, and yellow fever and malaria from 1647 to 1928. To give some notion of the breadth and depth of this book, the last chapter is 55 pages long and has 213 notes, most with multiple references.

The convenience of so much history of disease in one place is obvious. To obtain such broad coverage, readers would have to consult the dozens of monographs Watts has read and cited. Curiously missing from his extensive list of readings is The Cambridge World History of Human Disease, edited by Kenneth Kiple (New York: Cambridge University Press). Published five years ago, Kiple's book, with nearly 160 contributors and more than 1100 pages, is an indispensable source of information about the history of disease, both epidemic and endemic.

For readers who do not want to consult many separate monographs or an encyclopedic work such as The Cambridge World History, this book is a good place to start. Epidemics and History is very well written, though dense in parts. It is also remarkably free of the jargon that too often characterizes discussions of the social consequences of disease. That the germ theory is a theoretical construct and that diseases may be viewed as both biologic and social constructs now finds wide agreement. Watts unfortunately adds yet another variant, the notion of a leprosy construct or a yellow fever construct. If what he means to imply here is the political or social responses to the disease, I would have preferred simply speaking in terms of response.

One oversimplification Watts indulges in is to ascribe the advent of modern scientific medicine to the work of one man, Robert Koch, which ignores the much more complex story of our understanding of the germ theory of disease. To blame Koch for the excesses of his followers in turning medicine into a highly specialized undertaking with more emphasis on disease than on those who suffer from illness is also an oversimplification. By now, most medical readers are quite used to such charges. They can be overlooked in this otherwise engrossing book.

Gert H. Brieger, M.D., Ph.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21205