With Maladies of Empire: How Colonialism, Slavery, and War Transformed Medicine, an ambitious, globe-crossing book, Jim Downs seeks to reframe the history of modern epidemiology. Following histories of race, empire, and medicine, Downs shifts the origins of disease study from urban metropoles and European publics to peripheral sites and dispossessed subjects. Nascent epidemiologists, he reveals, relied on data and observations drawn from bystanders subjected to the concurrent phenomena of colonialism, slavery, and war. Downs argues that this trifecta invariably shaped and enabled modern epidemiology.

This is a broad argument, familiar by various degrees to historians of medicine, and the eight case studies that Downs presents within cut a wide swath. Readers interested in iconic facets of British history—from the slave ship Brookes to Florence Nightingale—find them recast alongside a cadre of lesser-known subjects such as Maltese washerwomen, Jamaican freedmen, African American soldiers, and enslaved youths. Downs begins with a focus on the eighteenth-century British world. Moving across the empire, Downs highlights how major shifts in the study of disease were enabled by the surveillance of unwitting patients and participants. Physician Thomas Trotter's reports of the necessity of fresh air relied on observations drawn from the transported enslaved. Naval surgeon James McWilliam's conclusions about the cause of a yellow fever epidemic in Cape Verde relied on testimonies provided by local colonized and enslaved subjects. Florence Nightingale's campaigns for military and public sanitation pulled from statistics collected by a far-flung colonial bureaucracy. Many of these studies, Downs argues, circulated and informed analogous work in North America. In chapters 6 and 7, Downs moves to the United States. Here, he is on his firmest ground in his account of Civil War medicine, detailing how the bodies and lymph of the enslaved, particularly children, were used by American doctors for smallpox inoculations. A final chapter on the cholera epidemic of 1865–66 brings the two medical worlds together. Downs sees the epidemic as a transnational crisis that prompted physicians to “think more globally” (173). As burgeoning military and medical bureaucracies created “narrative maps” (167) of cholera's global spread, institutions like the US Surgeon General's Office and the International Sanitary Commission could further shape the public health management of vast populations.

This is a text rich in detail, though the novelty and nature of Downs's conclusions fall short of the scope promised by its title and introduction. Downs identifies this as a global history, yet it might more appropriately be framed as a study of the Anglo world. This comparative scaffold prompts interesting questions about the confluence and divergence of British and American epidemiology. At times, however, it produces unanswered questions. Downs is closely attuned to the contents of American and British studies, but illuminates less about how their differing contexts might have affected their conclusions. Forms of bondage, rule, and warmongering differed drastically across time and place. Downs points to the cause of some epidemiological situations as “colonialism” (80)—but what about the specifics of changing political and social structures in the British Caribbean, Cape Verde, or the American South?

As Downs illustrates, medical projects across British and American worlds intrinsically did, and continue to, rely on acts of power, violence, and inequity. In the later chapters, Downs argues that while many British epidemiologists turned to the built and natural environment as contributors to disease, those from the United States, specifically the North, continued to use “race as a category of analysis” (127). In articulating this apparent divergence between British and American approaches, Downs might have more directly addressed the work of historians of British imperial science who have insisted on the importance of race as a factor in disease susceptibility and spread. Far from a case of American exceptionalism, British sanitarians and scientists never ceased to consider race alongside other categories of analysis. Throughout, Downs is at pains to establish that race was not a central factor in British characters’ conclusions: while Nightingale and Gavin Milroy “made derogatory claims about nonwhite racial groups, their main focus on was sanitary conditions” (198). In weighing and ranking the degree of racial thinking in American discourse, Downs risks downplaying the very real—yet even more masked—effects of its British counterpart.

Throughout the book, Downs repeatedly asserts that Maladies of Empire is “an effort to shift the focus away from medical theorists, doctors, and other professionals to the people whose health, suffering, and even death contributed to the development of medical knowledge” (7–8). This is a critically necessary act for historians of medicine, one that scholars have acknowledged and grappled with for over thirty years. Downs is certainly right that the expert continues to be a focal point in studies of imperial science and health. Yet despite these observations, he often utilizes the records of “anonymous people” (195) in the same way as the subjects he seeks to pivot away from, recounting their occupation, race, and family status bluntly in the context of white experts’ reports. The latter are reinscribed as Downs's main characters. With the partial exception of chapter 3, his efforts to “excavate the lives” (7) of his subjects more often consist of sparsely cited, speculative narration at the start of chapters. While claiming to be guided by Black feminist criticism, there is a curious lack of accounting for how dispossessed lives are recovered within the body of the text itself. Downs often reaffirms the narrative that the oppressed were used by nascent epidemiologists, without allotting them deeper character and agency.

Perhaps more clues lie within the textual forms that enabled disease study. Contrary to what Downs suggests, the idea that “military and colonial bureaucracy . . . functioned as a subregime of knowledge production” (85) is well established to historians of science and expertise. But Downs updates this in notable ways that warrant further rumination. From India and Jamaica to the United States, he muses on bureaucratic records that seem less like straightforward, data-driven treatises than detached yet personalized artifacts of local lives. Read as narrative accounts rather than statistical files, these so-called narrative maps may hold more in store to recover the experiences of the dispossessed. A book that prompts more questions than it answers, Maladies of Empire nonetheless adds to the growing and vital debate on the inequities of global health.