By Zachary Dorner* – Boston Review
Global trade, enslaved labor, and colonial warfare created demands for medicines that would work for anyone, anywhere. That pressure to view patients as interchangeable remains with us today.
COVID-19 has made the connections between population health, labor, and political economy so clear that the notion that bad health is bad for the economy can be heard across the political spectrum. The virus has also renewed concerns about who the institution of modern medicine is for: who it serves and who it leaves out or even renders disposable. These questions have deep historical roots. Looking to the past shows that keeping people healthy enough to work has long been a core component of health care provision in the Western world—especially at the population level, where care has often been less about individual wellness than group productivity and management. This idea gained wide application during the age of early modern empire—a period not unlike our own, with global trade, inequality, environmental challenges—when political economic pressures encouraged new ways of thinking about and responding to sickness.
Keeping people healthy enough to work has long been a core component of health care provision in the Western world.
During the long eighteenth century, imperial administrators, plantation owners, medical practitioners, merchants, and consumers yoked a population view of health care to the goals of empire, uniting them to turn people into patients on a broader scale than ever before. Changing political and economic exigencies have dictated how we understand ourselves, our neighbors, and the world around us. Over time, humans have shifted from being part of nature to its masters, from being open to the environment to assailed from outside by pathogens, from being individuals with a particular physiological constitution to generalized patients treated in bulk.
Today we can point to the benefits of these changes in medical thinking, but we must acknowledge their history and their limitations, as well. These new ideas of universality might have obliterated bodily difference, but instead they became a framework used to justify it and inscribe hierarchies on people, most notably around nascent categories of race. From that historical moment when understandings of bodies shifted, we can see a logic emerge that has shaped our relationship to health care and, conversely, health care’s goals for us.
In Europe, the classical humoral understanding of ill health as internal imbalance predominated for millennia. Staying healthy meant achieving one’s optimal balance of the four humors—phlegm, choler, blood, and black bile—according to one’s unique bodily composition of them (one’s “constitution”) in the face of environmental and bodily events. Health, in this framework, was a matter of balance rather than one of cures. A night of carousing or a sexual encounter, even a foul mood, could disrupt one’s humors and thereby lead to sickness—an idea that perhaps does not seem so strange given current understandings of the mind-body connection. The body seemed porous and sensitive to imbalance from emotions, injuries, variations in diet, sleep, and activities, the position of the stars, and meteorological phenomena. Within such a physiological view, health and illness were not strictly oppositional, nor were avoiding pain or curing an ailment necessarily the goals of healthy living. Rather, the aim was to keep or restore balance, which required a personalized interpretation of bodily signs, followed by diagnoses and prescriptions to re-equilibrate the humors.
During the age of early modern empire, political economic pressures encouraged new ways of thinking about and responding to sickness.
This approach to health relied on a careful reading of the body that afforded agency to self-diagnose and self-treat to some, but it also inscribed power dynamics founded on ideas of perceived racial, gender, and class difference onto the bodies of the sick and in pain. Who had the status or authority to interpret bodily signs and connect them to behavior, for instance, remained not only a medical issue but also a social, cultural, and political one involving power relations of patronage, kinship, and community. Nevertheless, the physiological framework reflected an attention to the individual in the world, an approach open to myriad influences on one’s wellness. This was not a prelapsarian Europe of agrarian folk living harmoniously with the land, growing their own remedies in fulfillment of centuries of medical tradition. But it was also not yet the commercialized marketplace for prepackaged medicines available from a range of vendors that would eventually become the norm across the Atlantic world.
Indeed, European empire began to change conceptions of the body. Intellectually, this happened as learned men began to see themselves as not within nature but rather able to bend nature to their will, exemplified by improvement projects such as establishing botanical gardens or draining wetlands. It also occurred in the material realm as a result of attempts to maintain physical health, productivity, and competitive advantage in an era of merchant capitalism. The humoral focus on individual health ran up against the labor demands of empire during the seventeenth and eighteenth centuries, when attempts to wrest control of territory—and access the real and imagined natural bounty it offered—provoked large-scale mobilizations and movements of people.
More than twelve million African captives alone were forced onto ships across the Atlantic during the Middle Passage. Between 1688 and 1815 the British Royal Navy mobilized roughly 500,000 men, volunteer and impressed, in wars against France and Spain. The army and trading companies sent scores more overseas as well to face new disease environments where their bodies were seen as in danger of transformation in foreign landscapes and under unfamiliar stars. Despite new threats to the mind, body, and soul, death acknowledged neither skin nor rank and remained a constant companion in terrifying new guises. European medicines and medical approaches, embodied in a vial of cinchona tincture perhaps, offered some hope for relief and survival, helping transform populations of free and unfree migrants into mass markets of patients.
Early modern empire’s characteristic flows—of people, goods, ideas, pathogens—incentivized a pragmatic, bulk attention to health that at once foregrounded matters of political economy at the group level alongside more personal feelings of desperation. In the long eighteenth century, disease accounted for a higher portion of military deaths than injuries sustained in battle. (During the American Revolutionary War alone, disease deaths outnumbered battlefield deaths by a factor of ten to one, by some historical estimates.) The expansion of colonial trade and warfare prompted reconsideration of what was desired from medicines and, by extension, what they could do.
During the Nine Years’ War (1688–97), for example, an abundance of sick men overwhelmed the English army’s medical service while disease disrupted successive expeditions to the Caribbean. Naval forces abandoned an attack on the French island of Martinique in 1693 after fever decimated sailors across the fleet, despite the use of medicines furnished by the London College of Physicians. Soon after, in 1695, several ships undermanned due to disease sank on their return voyages from the region. The Lords of the Admiralty then began to reevaluate the Royal Navy’s medical supply to avoid repeating the recent misfortunes. They sought more economical and reliable remedies that departed from the humoral and place-based logics of the physicians’ medicines that had apparently failed them during the war. The Admiralty instead sought simpler medicines that would not require complex individualized care according to a person’s constitution but rather remedies that could be applied more broadly for curative, instead of rebalancing, purposes. Manufacturers jumped at the opportunity to lobby the Admiralty for a contract, recognizing that the Royal Navy could invest substantial sums in efforts to keep its sailors alive.
The humoral focus on individual health ran up against the labor demands of empire, when attempts to wrest control of territory provoked large-scale mobilizations and movements of people.
Under these geopolitical circumstances, the longstanding idea that ill health came from internal imbalance began to see competition from another view: that diseases had essential qualities of their own and attacked the body from outside. This idea made it simpler and more cost-effective for institutions and individuals to manage the health of groups, especially those such as bound laborers or impressed seamen who had less of a choice about what went into their bodies. Seeing illness as an ontological matter external to a more sealed-off body, no longer as an internal physiological one, enabled the popularization of medicines taken to be specifically for the treatment of particular diseases and with the goal of curing them. New printed texts by notable researchers, including Thomas Sydenham, Herman Boerhaave, and Carl Linnaeus, classified and characterized diseases based on their ontological properties, and remedies known as “specifics” were taught in Europe’s most prominent medical schools. By the Enlightenment of the mid-eighteenth century, following a similar pattern across a range of scientific pursuits, the allegory used to describe disease and the body in the Renaissance had been replaced by more material terms that followed mechanical laws of bodily function.
This approach made both sense and cents for those intent on plundering the resources of overseas landscapes. Larger patient groups, such as those on a sugar estate or a ship of the line, could be more conveniently treated with medicines designed, materially and conceptually, to be administered on interchangeable bodies. Faced with easily communicable and infectious diseases, such as malaria and yellow fever, that could move quickly through a susceptible and proximal population, colonial medical practitioners found pre-packaged medicines designed to treat a certain disease much simpler and cost-effective than the more time-consuming and patient-centered process of reading someone’s humoral balance, considering his lifestyle, and consulting the weather to determine treatment. Medical supplies comprised a growing part of the expenditures for imperial institutions, since high mortality and morbidity rates could doom a military expedition or harvest. The perceived labor needs of empire spurred a depersonalization of medicine within mass, faraway patient groups that were tasked, often violently and against their will, with carrying out the work of empire. Whatever their efficacy as judged from modern pharmacological standards, such substances came to play a central role in helping large populations of people manage pain and preserve life, and choices in the marketplace both reflected and helped to reinforce such beliefs.
During this same period, credit-based finance underwrote greater manufacturing and exportation capacity in Europe. Partnerships of apothecaries, chemists, and druggists coalesced in mid-eighteenth-century London to service overseas demand for health care by producing in bulk medicines capable of being transported across oceans without spoiling and applied more-or-less uniformly to groups of people believed to be suffering from similar ailments. In return, silver, bills of exchange, and agricultural produce flowed into European port cities. Pharmacies employed wage-earning workforces to stoke fires and stir vats in laboratories, while others labored in counting houses to pack and ship orders across the globe. These partnerships also fostered and profited from ties to the armed forces, trading companies, and plantations. As medicine exports grew exponentially, especially to destinations dependent on bound labor, self-sufficiency in medicine supply was framed as a key to winning the mercantilist game against European rivals. Over time, the bulk, long-distance medicine trade became concentrated around several well-capitalized partnerships, which limited others from accessing the financial opportunities generated by imperial health care. GlaxoSmithKline, for example, which along with Sanofi holds the largest U.S. government contract to produce a COVID-19 vaccine under “Operation Warp Speed,” can trace its origins back to the Plough Court pharmacy, founded by Silvanus Bevan in 1715 off Lombard Street in London.
Out of this cauldron of blood, silver, and sugar emerged a radical idea, for the time: that people would react similarly to a particular medicine regardless of who (noble, poor, free, bound, man, woman, child, rural, urban) or where (Europe, Americas, Asia) they were. In other words, the effectiveness of medicines need not be sensitive to the idiosyncrasies of a particular person in a particular place. By such logic, a Chinese Emperor could find relief from a fever with a tincture of cinchona just as would a cooper in London, an African captive at sea, or a nurse in Boston. This idea propelled medicine exports, offering a simple solution to the omnipresent challenge of manpower across imperial spaces. Consider how convenient this would seem to a surgeon on a navy vessel or a physician on a sugar estate. (In an effort to quell a “bloody flux [that] raged” onboard, the St. Michael’s surgeon gave African captives “ye Same Medicines” he provided the crew while they lay at anchor off Madagascar during a South Sea Company slave-trading voyage in 1726.) Instead of examining each person individually to decide a prescription, he could identify a disease and then prescribe a single medicine for the entire group thus streamlining treatment and reducing individual attention while theoretically protecting the labor force.
Under these geopolitical circumstances, the longstanding idea that ill health came from internal imbalance began to see competition from another view: that diseases had essential qualities of their own and attacked the body from outside.
While the notion of universal effectiveness might seem to obliterate rather than reinforce racial hierarchies, it actually enabled a new form of systematic exclusion. In the face of supposedly universal medications, differing medical outcomes within oppressed groups could easily be used to justify emergent racial ideologies across the slave societies of the Atlantic world. Under the coercive conditions of plantation slavery, disparities in health outcomes were common given the institutionalized deprivation and violence of enslaved labor. Those disparities, however, were often attributed to racial pathologies rather than the structural patterns of enslaved labor. These perceptions informed the genre of plantation manuals that laid out directions for the medical care and discipline of enslaved people who worked the land.
One such influential text, Dr. Collins’s Practical Rules for the Management and Medical Treatment of Negro Slaves in the Sugar Colonies (1803), articulated an idea of physiological difference marked by skin color based on disease susceptibility and treatment effectiveness in Caribbean plantations. Dysentery, according to Collins, affected Black people more severely than white people “so that the two varieties of men seem to pass out of life by two different outlets; the one by fluxes, and the other by fevers.” Though he differentiated between the severity of ailments suffered by those of Afro-Caribbean and European descent based on his experience as an estate owner and medical practitioner, Collins lamented that “the knife of the anatomist, however, has never been able to detect [different internal organization].” In other words, though he based his belief in the inherent bodily difference of people with varying skin color on observations of how they responded to disease and treatment, Collins could find no physiological basis for such difference from his reading of anatomy texts or perhaps his own grisly forays into dissection. Such conclusions normalized a logic of overdosing and forced medication for the enslaved in response to common ailments. Lacking physical evidence, however, did not stop Collins or others like him from propagating such racial ideologies even as they insisted they were making plantations healthier and more productive in the age of abolition.
This example illustrates that at the very moment when medical practitioners gained access to bulk, manufactured medicines and began prescribing them with greater authority, racialized ideas about bodily difference gained legitimacy within the institutions underwriting those medical developments and profiting from ideas of human sameness. The notion that migratory and vulnerable populations presented lucrative opportunities for medicine sales has remained, as have the take-this-for-that and one-size-fits-all approaches inaugurated within the early modern European empires. Health care also emerged as a means of regulating behavior and changing perceptions of people’s bodies. Within an imperial framework, universality thus offered a vector for ideas of human difference to shape routines of health care and interpretations of unequal outcomes. Forces of empire, subjugation, and exploitation conspired to turn a more nuanced, individualized approach to health into an all-or-nothing, generalized, and interchangeable population view of sickness and treatment more bent toward curative measures than wellness or palliation.
The perceived labor needs of empire spurred a depersonalization of medicine within mass, faraway patient groups that were tasked, often violently and against their will, with carrying out the work of empire.
This change in the delivery and conceptualization of health care happened over a long period of time and looked different in various times and places. The resulting population approach within the Atlantic world remained only one of many ways of understanding medicine, disease, and the human body across a vast and vibrant world rife with competing medical cultures. Individualized therapies certainly continued to be used quite frequently in the home, for example, alongside medicines that could be purchased in a marketplace or institutionalized in the navy, for instance. The commercialized and generalized approach, however, gradually came to predominate across European systems of thought during the age of empires that would shape future questions about credentialing, cost, efficacy, and access to care in the periods to follow.
The medical revolutions of the next two centuries cloaked these early modern logics in new vocabularies and technologies but did little to displace them from expectations shaping the forms of health care to come. The nineteenth century brought advances in sanitation and real declines in mortality, while ideas forwarded by scientists like Robert Koch, Louis Pasteur, and Paul Ehrlich and the subsequent development in the twentieth century of new drugs such as antibiotics encouraged paradigm shifts in considering the human body and disease. Nevertheless, the fact that envisioning people as interchangeable patients—comprising both workforces and markets—has remained so economically and medically axiomatic, often at the expense of considerations of individual wellbeing, speaks to the relevance of this history to our current moment.
The political and economic factors that shape the goals and delivery of health care are normalized over time until they become part of how we view patients as interchangeable and, ultimately, expendable. The same historical threads that helped justify ideologies of inherent bodily difference based on race, sex, and class are the same that enable us to walk into CVS to buy a drug from GlaxoSmithKline nearly anywhere in the world. There are clear benefits in terms of medical technologies and treatment outcomes to this form of thinking, but it also enables differences in outcomes to be explained away as natural, physiological, or behavioral rather than byproducts of the violent, unequal circumstances of their development. Those are both legacies of the early modern shift toward viewing people as patients.
The COVID-19 pandemic has shown the tension between these legacies to be far from resolved in the rhetoric surrounding essential workers, professional and collegiate athletes, and those receiving unemployment insurance benefits. Yet the logic underpinning that rhetoric preceded the pandemic and will likely persist long after it. Labor and productivity have always been bound up with the provision of modern health care. Take-this-for-that and one-size-fits-all approaches to medicine arose from a patchwork of medical routines at precisely a moment of widespread interstate competition and merchant capitalism. It is a form of thinking that continues to demand scrutiny today.
*Zachary Dorner is a historian of medicine and commerce. He is Assistant Clinical Professor in the University Honors program at the University of Maryland, College Park, and author of Merchants of Medicines: The Commerce and Coercion of Health in Britain’s Long Eighteenth Century (University of Chicago Press, 2020).