Ross on Downs, 'Sick from Freedom: African-American Illness and Suffering during the Civil War and Reconstruction'

Jim Downs. Sick from Freedom: African-American Illness and Suffering during the Civil War and Reconstruction. Oxford: Oxford University Press, 2012. 280 pp. $29.95 (cloth), ISBN 978-0-19-975872-2.

Reviewed by Karen Ross (Troy University)
Published on H-South (July, 2013)
Commissioned by David Carlson

Civil War, Emancipation, and the Struggle for Health and Freedom

In Sick from Freedom, Jim Downs brings together the medical history of African Americans in the Civil War and Reconstruction with the politics of emancipation. Historians have long explored the role of disease in the war, especially among soldiers, and more recently have turned their attention to issues of health and well being of emancipated slaves. For Downs, historian of race and medicine at Connecticut College, health, disease, and emancipation are intractably intertwined. Rather than an abrupt political or legal event, he defines American emancipation as a process; central to that process was the health and suffering of former slaves in the wake of liberation. 

By defining emancipation as a process, Downs is able to link the unforeseen consequences that this process had for freedpeople’s health to the policies and actions of the federal government via the Medical Division of the Freedmen’s Bureau. Emancipation, he argues, spanned the years from the seizure of slaves as contraband to the geographically limited Emancipation Proclamation, and finally to the civil rights acts and constitutional amendments of Reconstruction. In this process, as the legal and political identities of freedpeople were negotiated and transformed, medical crises (and federal mismanagement of these crises) created obstacles to freedpeople’s ability to experience freedom and independence. During the war, many ex-slaves sought refuge in Union camps, where they often lacked the most basic necessities. In some instances, the Union army expelled nonlaboring ex-slaves from such camps, leaving them to fend for themselves. Rampant infectious disease, particularly smallpox, as well as hunger, exposure, and other privations were abetted by poor sanitation in the chaos of war. After the war, the Medical Division’s inadequate and patchwork responses to these problems contributed to a tremendous biological crisis. Newly freed slaves who “embraced their freedom with hope and optimism did not expect that it would lead to sickness, disease, suffering, and death” (p. 4).

Besides drawing attention to the suffering of former slaves, Downs’s central point in Sick from Freedom is that the unforeseen medical consequences of emancipation significantly altered how Americans conceptualized freedom, citizenship, and federal power (perhaps too ambitious an undertaking in only 178 pages). He argues that freedpeople not only suffered disproportionately from disease, but also were too debilitated by the lack of adequate food, shelter, and clothing to benefit from their freedom. Contrary to the triumphant liberation narrative favored by reformers and federal officials (as well as historians), Downs portrays ex-slaves seeking freedom as “defenseless” and contends that the “obstacles that freedpeople faced ... could not have been defeated no matter how willing or independent they may have been” (pp. 8, 6). Freedom without adequate means to maintain some level of health was meaningless. The anemic response from the federal government left thousands of freed men, women, and children without the ability to survive emancipation, much less rise above slavery to succeed in the new era. Freedom required health.

African Americans’ attempts to gain access to medical care, therefore, were among their first demands for rights, thereby redefining the meaning of citizenship. The collapse of slavery disrupted the old social and economic networks that provided some level of medical care for slaves, and in the transition to a free labor economy, the health of freedpeople suffered greatly. This is complicated by the unclear and evolving legal status of ex-slaves from contraband to refugees to, finally, U.S. citizens with the Fourteenth Amendment. Downs does not discuss more broadly the contemporary debates concerning citizenship in this period. Instead, he argues that by “requesting medical intervention, Freedpeople expanded the notion of political rights,” which he ties to American citizenship (p. 9).

Downs demonstrates this most effectively when examining the demands of black soldiers, many of whom were former slaves, for medical treatment and support for their families as recompense for their military service. During the war, black soldiers wrote to numerous authorities to secure aid for their families in the Union camps. Later, when Congress established the U.S. pension system, black veterans and their families applied for benefits, which linked access to medical care to the rights of freedpeople who had sacrificed their health and bodies for the cause. The inclusion of medical reports in these applications offers first-person accounts of illness and injury, including names and individual patient histories, rather than the strictly statistical reports of the Freedmen’s Bureau. For Downs, these applications connect freedpeople’s health, suffering, and understanding of their rights to citizenship and military service.

Downs also analyzes citizenship through the negotiations between Freedmen’s Bureau agents and southern state and municipal governments for access to hospitals and asylums. Initially, southern state institutions refused to admit freedpeople on the basis that they were not citizens. The Medical Division responded by creating special institutions to serve the needs of freedmen. Bureau leaders, and more important Congress, were reluctant, however, to provide adequate funding fearing the specter of perpetual dependency. This in turn contributed to the resolve of the federal government to legally define African Americans as citizens. By the late 1860s, constitutional amendments and more cooperative state governments in the South enabled freedpeople to gain access to state charitable systems and the Freedmen’s Bureau eliminated its hospitals and homes. Citizenship, Downs claims, had become tied to access to medical care.

The actions of the Medical Division reflected not only a change in rights of citizenship, but also a significant expansion of federal power. The “Medical Division placed federal officials for the first time in U.S. history in direct and intimate contact with the bodies of ordinary people,” even if only temporarily (p. 12). Bureau leaders recognized that this intervention was necessary to facilitate the transition to a free labor economy in the South, and bureau doctors and nurses treated an estimated one million ex-slaves. According to the author, these institutions, nearly all of which were disbanded by 1872, marked the federal government’s first foray into health care; however, concerns over encouraging dependency kept them underfunded and “ultimately led to the mismanagement of Freedmen’s Hospitals and undermined the operations of the first-ever federal health care program” (p. 74). Labor was the federal government’s central concern, Downs notes, and importantly, he frames federal power, however mismanaged, within the larger context of reconstructing the South’s slave economy. Additionally, Downs incorporates a gendered analysis, explaining how the bureau categorized black women as dependents rather than laborers, synthesizing several streams to create an ambitious retelling of the story of emancipation.

To a large degree, Sick from Freedom is an institutional history of the Medical Division of the Freedmen’s Bureau. In chapters 2 and 3, in particular, Downs analyzes its formation and organization, and in chapter 6 he traces the dissolution of the division as southern states assumed responsibility for the health of these new citizens. Downs makes excellent use of the division’s records and reports, as well as memoirs and autobiographies of important officials, such as Oliver Otis Howard, former head of the bureau. In particular, letters from bureau agents and doctors detailing the great need for resources and describing local conditions flesh out the more statistical reports produced by bureau leaders. Slave narratives, black and white abolitionists’ reports and letters, and newspaper accounts also help track the health and suffering of former slaves.

His analysis of a series of smallpox epidemics from 1862 to 1868 provides a window into racial theories of disease and susceptibility, as many whites interpreted high mortality and morbidity rates among African Americans as a sign of racial inferiority and looming extinction. Downs argues that the “leaders of the Medical Division of the Freedmen’s Bureau also expected the extinction of the black race and consequently did not provide Bureau physicians in the South with adequate money and resources to build pest houses to quarantine infected former slaves or to conduct vaccination campaigns to protect freedpeople from the virus” (p. 103). It is often difficult to establish definitively the official motive behind a policy, and this assertion would have benefited from more evidence to explain the ineffective federal response to the smallpox outbreaks. Downs’s richly documented descriptions and analysis of local conditions tells us more about the impact that the federal government had on freedpeople’s health.

The most tenuous claim of Sick from Freedom comes in the epilogue in which Downs attempts to demonstrate that the experience of federal officials managing a mobile and transitional population in the postwar South served as a model for federal policy in the West. Downs draws parallels between the western reservations where Native Americans were contained and the contraband camps of the Civil War. There, he asserts, the federal government could keep tribes under tight surveillance and “easily draw on this pool of workers when labor opportunities arose” (p. 175). Dislocation and the destruction of traditional ways of providing for their societies resulted, predictably, in hunger and the rampant spread of disease as the military and Office of Indian Affairs sought to establish a free labor economy in the West. Presumably the topic for his next book, it will be interesting to see how Downs elaborates on this very short epilogue.

Sick from Freedom joins other recent scholarship on the history of Civil War medicine and the health of African Americans, such as Margaret Humphrey’s excellent Intensely Human: The Health of the Black Soldier in the American Civil War (2008) and Gretchen Long’s Doctoring Freedom: The Politics of African American Medical Care in Slavery and Emancipation (2012). Sick from Freedom is a welcome addition to the historiography and will prove useful for graduate students and scholars alike.

Printable Version:

Citation: Karen Ross. Review of Downs, Jim, Sick from Freedom: African-American Illness and Suffering during the Civil War and Reconstruction. H-South, H-Net Reviews. July, 2013.

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