Segment from Contagion

Listener Calls

A BackStory listener wonders about the process of deciding who gets care and who doesn’t. Another listener asks about the relationship between disease and immigration. Then, BackStory answers a question about the use of language when talking about disease.

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BRIAN: We’re back with BackStory, where today’s debates find some context in American history. I’m Brian Balogh, 20th Century Guy.

ED: I’m Ed Ayers, the 19th Century Guy.

PETER: And I’m Peter Onuf, 18th Century History Guy. Today on our show, a history of epidemic disease. As we do with each of our shows, we’ve been inviting your comments and questions on and on Facebook. Today, we’re calling up a few of the folks who left us a note.

We’ve got Chivani on the line from Providence, Rhode Island. Chivani, welcome to BackStory.


PETER: So what’s on your mind today?

CHIVANI: So I’m a graduate student in health economics. So I’ve taken a few epidemiology classes in the last year, and I was struck by how difficult it can be to identify who is in the need of most help following a disaster or an epidemic. So I was wondering if you could talk more about the process of how they allocate who gets care and who doesn’t.

PETER: Yeah, great question, how do we allocate health care? How does that happen now? Of course, that’s a current events question. We’re going to try to give it some deep background. Ed, Mr. 19th Century, what do you say?

ED: I think there were two criteria back in the 19th century. One, who could afford it, and two, who posed a threat to those people who did have those resources. I generally try not to be cynical and generally succeed in not being cynical. But health care in the 19th century is a pretty clear example of those who have taking care of themselves and taking care of the other people when they have to.

PETER: Yeah, that’s certainly true, Ed, in the 18th century as well. It maps on pretty neatly to the social order that maybe the great achievement of Brian’s 20th century is to begin to pick that apart and to come up with new conceptions of disease and where you need to intervene. I mean, how are you going to stop the spread of a disease? In some ways, you have to go to the poor people first, right?

BRIAN: Yeah, well, a couple of things happen in the 20th century, Chivani. We treat people that we can get our hands on because they are in public spaces. So there are huge campaigns in the 20th century to vaccinate school kids. Why? Because it’s in my century that we start requiring people to go to schools.

That’s where the potentially diseased people are. That’s where we can access them. And it’s really not until quite recently that we started getting all of these vaccinations in doctors’ offices and private spaces. And the great irony is that, too, is changing, as you probably know, Chivani, if you’re in public health. Now you can get vaccinated in Walmart or CVS.


BRIAN: The privacy of vaccination is morphing yet again back towards these public spaces and back towards some of the things that Ed and peter were talking about, the people who can afford to do it.

PETER: Yeah, I want to throw something out for Ed, and that is the idea of the analogy of fire fighting. Early firefighting, the 18th and your century is the big fire century, all those wood buildings and growing cities. That’s a case where you have to intervene in ways that’s going to stop the spread. And it doesn’t matter who’s in your way. I wonder, is that a model for what becomes public health delivery?

ED: Yeah, and it’s a healthy model, so to speak, Peter, because it reminds me– this is not necessarily that people were worse in the 19th century. As Brian was suggesting, they simply did not have the capacity of understanding the origins of disease or what they would do if they did try to minister to people. And of course, sometimes the worst thing that could happen was to be ministered to with leeches, and bleeding, and all that.

PETER: Well, it was, true. Yeah.

ED: So I think that in some ways the idea that you could actually do something for an entire population about health is a very recent innovation.

PETER: Yeah, good point.

ED: And even now is deeply contested, So, Chivani, what do you think? Are you and your classmates filled with a sense that we’ve crossed some kind of bridge, and now we have a sense of how to really intervene in a useful way?

CHIVANI: Well, I think you’re right that there is that assumption that we do know what we’re doing as public health workers.

ED: Thank goodness.

CHIVANI: And the way public health is taught, I think we still have this faith that most actions are based on evidence. There is evidence-based medicine, and most public health practices do reflect the most current research. So there is still that faith that when we intervene, it’s to better social welfare.

PETER: Yeah, I got a question for you, Chivani. And maybe you don’t want to say this on national radio, but what do public health people think about the people in general? Do they sometimes think that they’re ignorant, bigoted, and reactionary?

CHIVANI: It depends on who you talk to. I think if you are talking more in the developing world, I think there is kind of a lot of looking down at the masses and prescribing what we think would be best for everybody. When it’s more about the developed world, it seems that people do take into account cultural norms and education.

PETER: Yeah, what an upbeat characterization of the American people. I love to hear it. You’re reviving my faith in democracy. Brian?

BRIAN: Well, one of the things I love about American history, Chivani, is for much of it, we are a developing country.

CHIVANI: Right, I agree.

BRIAN: And I think so much of what Ed and Peter had to say kind of demonstrates that.

PETER: Chivani, thanks for your call. It’s been fun talking to you.

BRIAN: Thanks a lot.

CHIVANI: Yeah, great, thanks for taking my call.

BRIAN: Bye bye.

ED: Sure, bye bye.

BRIAN: This is BackStory. If you’re just tuning in, we’re talking about the history of contagious disease in America.

PETER: And we’ve got Peter on the line from Montpelier, Vermont. Peter, welcome to BackStory.

PETER (CALLER): Thank you very much.

PETER: So what’s your question?

PETER (CALLER): Well, my question is the relation between disease or public health and immigration through our history.

PETER: Well, you have hit the big one, Peter, that is disease and immigration. Many people throughout American history would have said it’s the same thing.

ED: That’s right.

PETER: Yeah.

ED: Well, let’s go back to the beginning, Peter.

PETER: Yeah, OK.

ED: Let’s think about 17th-century Virginia. Goodness gracious, to be immigrant was to be dead, basically, wasn’t it?

PETER: Yeah, and of course, but then it was clear, because of course the immigrants were the settlers, the slave holders, the Indian killers. But they didn’t bring disease. They got hit by the diseases when they arrived. The big story of early American history is that immunities for smallpox and other contagious diseases which Europeans had earned over the millennia, they didn’t have them in native America.

And so you had a vast killing off of native populations, up to 90% of New World population. So in some ways, it’s the locals who are killed by the immigrants in the early period. But that idea lingers on in many ways. And of course once a population is established, the European population– that is the largely Northern European if not British population is established– then there’s great concern about foreigners bringing in not only their nasty habits, their foreign ideologies, but also diseases.

ED: You’re right. And the 19th century was the great century of massive immigration, from the Irish coming in who were seen as diseased and bringing not just unhealthy bodies, but unhealthy habits and neighborhoods with them. Where they came, they created places where diseases would flourish. And so on the other coast, the Chinese coming in were seen as especially dangerous.

European Americans were at least European at one time. But Chinese immigrants were bringing these kind of Asian diseases that seemed especially frightening. And in fact, at the turn of the century the plague comes to San Francisco and is seen as the great warning of what happens if we don’t curtail immigration from Asia. So all the way from the Irish in the early 19th century to the Chinese at the end of the century, it’s perceived that the immigrants are just bringing one wave after another of health problems.

BRIAN: Yeah, and what I would add to that in the 20th century is that we begin to use this very longstanding association between immigrants and disease as a substantive basis to cut off systematically the flow of immigrants into the United States. One of the arguments behind the Immigration Restriction Acts of the 1920s is that these immigrants are bringing diseases, epidemics, and what we would call today more genetically defined diseases, such as imbecility, that kind of thing, mental retardation we would have called it in the 1950s.

And the other thing that happens in the 20th century is that we target immigrant neighborhoods for the eradication of disease. So they’re here, but when there’s an outbreak of an epidemic, it’s usually the immigrant neighborhoods that are targeted.

PETER: But I think it’s important to suggest that the very fact that government gets involved the way Brian suggests as a response to immigration and the pathologies associated with it means that that’s the threshold of genuine, substantive exploration of public health issues. So in some ways you’ve got to start with these less than honorable passions, and concerns, and reflexes. And that’s the energy that’s channeled toward real improvement. I think that’s maybe the upbeat way to formulate that.

ED: So what do you think, Peter? Have we begun to address some of your curiosity about this?

PETER (CALLER): You have. It’s very helpful. It plays into the politics. It plays into the reality of both 18th, 19th century American science and what we knew about public health at the time, right up to the present. It has a moral aspect to it as well as a political one.

PETER: Yeah, hey, Peter, thanks.

BRIAN: Thanks, Peter.

PETER (CALLER): I appreciate it.

ED: Thanks a lot.

PETER (CALLER): Thank you.

PETER: Our last caller today is going to be Jhanavi. She’s in Saint Petersburg, Florida. Jhanavi, welcome to the program.

JHANAVI PATHAK: Thank you, professors.

PETER: Hey, whoa, we like those honorific titles. They make us feel really important. So, Jhanavi, we’re talking about disease. Share with us.

JHANAVI PATHAK: I am really excited about today’s topic. Not that I’m excited about disease, but my family, my father has been fighting cancer for the past eight years. And I started a nonprofit called the War on Cancer Foundation.

And a lot of thought went into what name we wanted to use. So it was a really deliberate choice. And I know why we use specific language, but given today’s topic, I would love to hear from you about the history of language in discussing sickness over the years as a war or a race.

PETER: Yeah, Jhanavi, a wonderful question that is the use of language to shape perceptions, ways we think about disease as a conquering host that we need to resist. And in a way, the response to disease, even back in my benighted period, was that the state had to step up and exercise what were then called police powers to maintain public health by keeping diseases out. They didn’t know how they traveled, but they knew they were coming.

For instance, the yellow fever, that came from the Caribbean. So you’re going to have to block trade, because somehow or another, this disease comes with that lucrative trade to the Caribbean. So war has been the trope of choice throughout American history. And we can see in that historic context why you would call your organization a war against cancer.

BRIAN: Yeah, Jhanavi, there’s a very noble tradition of wars on cancer that go back to the early 1950s. This is Eisenhower and some of his advisers who, in the wake of the tremendous success of World War II, decided to use that wartime metaphor to take on your topic, to take on cancer. And they called it a war on cancer.

And they invoked the success of the Manhattan Project and mobilizing federal research and development to defeat an implacable enemy and to do it with one clean sweep, as many felt the bomb had done to the Japanese. Now, of course, World War II and its ending was much more complicated than that.

And as you know better than anybody, Jhanavi, the war against cancer has turned out to be pretty complicated. But this clean metaphor and emotional metaphor of mobilizing the entire nation against this dread disease was very effective going back to the 1950s.

ED: It’s interesting, Brian, to think about in the post-World War II era how widespread this language becomes, because we have not only a war on cancer. We also have a war on poverty and then later a war on drugs.

BRIAN: And crime, don’t leave crime out.

ED: And crime, yeah, exactly. In the 19th century, in which I specialize, we weren’t confident enough to wage war on any disease. Basically there’s a sense of, oh my god, here it is. What are we going to do? And I think the metaphor is much more like a fire department than it is an army.

Here is something that has emerged in our midst that we need to mobilize ourselves all across the usual class boundaries and racial boundaries and try to extinguish it for the greater good. But then our goal is to get back to go normality as quickly as we can.

PETER: I have one thing about Brian’s century that I think might complicate a little bit, and that is the Cold War. Now, that’s the big war. And you could have said for many years, hey, that’s never going to end. And it didn’t seem like it was going to.

But that was a war that continued to energize and mobilize for good reasons and bad, paranoid and progressive. And ultimately, well, it was over. So sometimes they work. Sometimes the trope does too much work and people become cynical, too many wars.

BRIAN: Great point.

ED: So Jhanavi, you said that you had really thought this through for your own purposes. So what led you to go ahead and use that language?

JHANAVI PATHAK: Well, I think– I was 16 when my dad was diagnosed. So for the past eight years, essentially a third of my life, this has been a highly impactful element of my life. And when you mentioned the Cold War, for example, I think that is a great analogy for what cancer is for so many people.

People sort of coming in and out of these hot periods, whether they go into remission or the disease comes back. And one of the huge elements in naming the foundation the War on Cancer Foundation was the fact that for be it individuals or their families, it is so damaging, and not just in the physical or the clinical sense, but what we as a foundation have come to call collateral damage.

ED: Oh, that’s great.

PETER: Yeah.

JHANAVI PATHAK: What was funny, as you had mentioned, the use of the word war can have positive and negative connotation and effects, like with the war on drugs. But we actually got overwhelmingly positive responses from caregivers and especially women when using verbiage like the War on Cancer Foundation. Because it sort of gave testament to the experience that they’re having. It’s just this daily war with the disease, and then especially all the collateral damage that comes as a result of it.

PETER: Yeah, and we have so many combatants, and we have so many veterans. I think all of us have good friends who have had bouts with cancer as personal triumphs. And there are triumphs on various fronts of particular cancers that we seem to have under control. But the metaphor of war is one that does organize our holistic sense of the evil empire that we’re trying to overcome.

JHANAVI PATHAK: And I think one thing that resonated with me especially was the fact that, when you’re fighting something, I think we tend to think of war as the active period of fighting, but then there’s also the period of recovery and rebuilding.

BRIAN: There is winning the peace.

JHANAVI PATHAK: Exactly, and I think for a lot of people, even if they get through the cancer, then it’s a matter of that rebuilding and reconstituting a semblance of normalcy in their lives. How do you get back to even having a job to put food on your table and keep a roof over your head?

There’s so much rebuilding that goes on. And I think for us, one of our goals is not only in addressing this collateral damage. It’s doing a lot to provide support to the caregivers and the families as opposed to just the patients. And in that sense, that’s where we really see this notion of a war being so far reaching.

PETER: Yeah, Jhanavi, thanks for your call.

JHANAVI PATHAK: Thank you all very much.

ED: Good luck.

BRIAN: Bye bye.



BRIAN: That’s going to do it for us this week. You can find us at Facebook, Tumblr, and on Twitter @BackStoryRadio.

ED: You can also download all of our past shows virus free, which is important after hearing this one, at our website,

PETER: Remember, a little BackStory every day helps keep the doctor away. Thanks for listening, and don’t be a stranger.

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Not So Safe Space Listening Notes By Hayley Duncan, Middle School Social Studies Teacher, Lake Lure Classical Academy