Man's ascent in epidemic leaps

The days when disease and medicine occupied little more than a footnote in history are, it seems, finally over. While the role of medicine in reducing or eliminating major diseases remains controversial, the idea that disease has had a crucial role in shaping human societies is now widely acknowledged and extensively documented. And yet the question remains: what is the proper place of disease in history? Does disease itself have the capacity to make history or is history more often shaped by what society and those in authority over it understand about a disease and the responses appropriate to it?

In his introductory remarks to Plague, Pox and Pestilence, Kenneth Kiple leaves readers in little doubt as to the power that a formidable battery of viruses, bacteria, parasites and nutritional disorders have had over history. Espousing a kind of long-term biological pessimism that seems increasingly in vogue, he sees diseases as the price human societies have paid since the neolithic revolution for defying nature and for pursuing "progress". Foraging peoples, it seems, enjoyed good health, well-balanced diets and, by virtue of their mobility, escaped a build-up of parasites and pathogens. With sedentism came sickness. To cease wandering in small bands, to domesticate animals and grow dependent upon a few crops, to nestle together in dense populations, build cities and promote international trade and transoceanic migrations, might all have helped to build civilisations, but also brought a devastating army of plagues and poxes in their wake. Far from being a "giant step upward on the ladder of progress", the neolithic revolution was, in terms of human health, "a backward tumble that transformed tall and robust hunter-gatherers into shorter, weaker farmers". Nor was that all, for the industrial revolution spawned a new host of epidemics and nutritional disorders arose to plague society, cholera and rickets among them. Progress, in short, is a "disease-causing agent".

This is more than history in the extremely long term. Kiple and his collaborators (who include such distinguished contributors as Alfred Crosby writing on smallpox and influenza, Ann Carmichael on leprosy, plague and cholera, Margaret Humphreys on yellow fever, malaria and tuberculosis, and Stephen Beck on syphilis, pellagra and beriberi) argue that diseases intervened dramatically at crucial moments in time, robbing would-be conquerors of their spoils, liberating besieged cities, wasting indigenous populations that might otherwise have mounted more effective resistance to the onslaught of Europeans overseas. There is even the suggestion that, but for plague, the emperor Justinian could have held back the remorseless rise of Islam.

This is also a history of medical ideas and the emergence of a modern understanding of aetiology and counter-measures. Despite the pessimism inherent in equating progress with a kind of "ecological Russian roulette", some of Kiple's contributors cannot fail to find some redeeming features in the history of scientific medicine, though even here the achievement of eradicating smallpox in the 1970s is overshadowed by the failure to achieve comparable success against resurgent diseases such as malaria and tuberculosis. In the age of Aids, the plagues, it seems, still have the upper hand.

Kiple and his colleagues have less to say about diseases as cultural rather than epidemiological phenomena, though the linking of ergot-poisoning from infected grain with "diabolical possession" and the witch trials of Salem offers one fascinating illustration of how medical knowledge has come to enrich our understanding of biological influences on social history. There is even less discussion of how diseases have been perceived in non-western societies, though Carmichael writing about cholera and plague is a part-exception to this.

By contrast, Sheldon Watts in Epidemics and History, while considering it important to establish what a disease actually is in modern scientific terms, is far more concerned with disease as discourse and the political consequences that flow from the cultural interpretation of epidemic disorders. Instead of the 26 diseases covered in the brief, almost encyclopaedic entries in the Kiple volume, Watts confines himself to seven - plague, leprosy, smallpox, syphilis, cholera, yellow fever and malaria - using each in turn to contrast the experience and perception of disease between Europe as the centre of political and economic power and Africa, Asia and Latin America as its "other". Watts thus makes a distinction between a disease as understood by modern medical science (beginning with Robert Koch in the 1880s) and disease as a social construction. Hence "construct yellow fever" and "construct plague" take on an identity and authority that extends far beyond the actual epidemiological inroads of the disease itself. This distinction is most effectively realised in the case of leprosy. Watts demonstrates that the disease itself (ie Hansen's disease) was by no means as widespread in medieval Europe as the large number of people designated "lepers" and the opening of thousands of lazar houses would lead one to expect. Rather, in the course of the "great leper hunt" between 1090 and 1363 ad, leprosy served as a convenient means of stigmatising, ostracising and confining Jews and other targeted religious and social groups. Leprosy was "a mindset rather than a physical disease"; for the authorities of church and state the "leprosy construct" was a useful "tool of social control". Equally, leprosy did not dramatically disappear in early modern times as some historians have assumed, for it had never been particularly widespread in the first place, but other "construct" diseases, like syphilis and plague, did take its place in marginalising potentially disruptive social groups and in strengthening class and gender control.

This instrumentalist understanding of disease is seen to be no less applicable outside Europe. In a manner that erodes some of the distinctiveness lately claimed for medical intervention in the colonial context (while yet drawing upon that literature as a guide), Watts argues that what was being done in Europe found later parallels overseas. Having served to stigmatise Jews in medieval Europe, leprosy performed much the same role for European colonialism in the 19th and early 20th centuries in relation to Africans, Asians and Pacific islanders. Yellow fever and malaria provide him with striking examples of how disease was used to bolster arguments about racial superiority and segregation in the American south and colonial west Africa. In what is in effect a critique of Kiple's earlier work on disease in the West Indies, Watts stresses the importance of avoiding "disease determinism" and of recognising the role that perceptions and other non-disease factors had in making the West Indies seem an unsuitable place for European settlement by 1750 even though poor whites had previously laboured there alongside enslaved blacks.

Watts is concerned to represent disease in the service of its political and moral masters as more than a rhetoric of class and race. In speculating on the connection between cholera and irrigation in 19th-century India, he shows that disease could be a deadly reality and blames British arrogance, greed and neglect for the resulting massive mortality. Watts is, however, fond of injecting 20th-century concepts into earlier eras. It is illuminating to transpose the "domino theory" from Southeast Asia in the 1960s and 1970s to the fear of slave insurrection in the West Indies in the 1790s and 1800s, but less helpful to represent the Highland clearances as a form of "ethnic cleansing". His persistent use of "development", seemingly a loose synonym for capitalism (and perhaps for what Kiple calls "progress"), is unhelpful and indicative of the underlying poverty of Watts's theoretical framework. A concept of development as such had little significance before the 1930s, and its retrospective application to early Dutch and French involvement in the West Indies or British rule in 19th-century India imposes on five centuries of Euro-American imperialism a homogeneity it hardly possessed while failing to unravel the more specific and often contradictory manner in which disease, medicine, capitalism and empire intermeshed.

This is a challenging but erratic work. Its wide chronological and geographical scope is remarkable, its broad theoretical sweep at times exhilarating. But it necessarily relies upon a vast secondary medical and historical literature, and the original insights are sometimes overwhelmed by an imperfect grasp of local circumstance and the sheer volume of source material. The audacity of some of his claims and connections will make many regional and medical specialists gasp or wonder at the reduction of so many complex forces into what appears to be a single-stranded equation of disease with economic and political power. Could disease, even as ideology, be so easily manipulated? Was there no countervailing deployment of disease against ruling regimes?

Both works have their merits. Kiple's volume represents a more conventional but also more immediately instructive and accessible account of the place of disease in history, but it is burdened by its editor's deterministic approach to disease. Lavishly illustrated, Plague, Pox and Pestilence misses an opportunity to explore the iconography of disease: some of the illustrations add little to the accompanying text and simply serve as a kind of decorative frieze that belies the contributors' earnest scholarship. Watts is the more provocative read and constitutes a bold and imaginative attempt at synthesis. As such it is to be welcomed, but the "uses of epidemic diseases" is an argument pursued too far, and the book suffers from a worrying lack of precision. These represent two very different, but also in some respects rather complementary, contributions to the continuing debate about the role of disease in history and about the meaning of disease itself.

David Arnold is professor of South Asian history, School of Oriental and African Studies, London.