A review of Biopolitics and the Influenza Pandemics of 1918 and 2009 in the United States: Power, Immunity, and the Law, by Alina Baciu.
Like horses and carriages, wars and epidemics appear to be made for each another. Indeed, the notion of a “war” on microbes is so embedded in immunological discourses that we rarely pause to reflect on how the natural world became so bellicose, let alone whether such metaphors have real explanatory power. It is greatly to the credit of Alina Baciu, a health policy researcher at the Institute of Medicine, that she recognizes there is nothing natural in what Roger Cooter has called a “problematic” couplet (Roger Cooter, “Of War and Epidemics: Unnatural Couplings, Problematic Conceptions” in Social History of Medicine 16 (2003), pp.283-302), and that she has set out to probe the way in which such metaphors have come to define the American experience of two pandemics separated by nearly a century: the 1918-19 “Spanish” influenza pandemic and the 2009 swine flu pandemic.
Social historians of medicine have long characterized the Spanish flu – so-called because Spain was one of the few countries in World War I where the press was free to report the flu’s depredations – as the “forgotten” pandemic. Explanations for the flu’s excision from public memory vary but the coincidence with a world war, and the way that war deaths tended to “overshadow” the mortality from the pandemic, are usually cited as key factors (See Niall Johnson, “The Overshadowed Killer: Influenza in Britain in 1918-19” in Howard Phillips and David Killingray (eds.), The Spanish Influenza of 1918-19: New Perspectives. London: Routledge, 2002, pp. 132-154).
Alina Baciu’s approach is different. Rather than seeing the pandemic as overshadowed by war, she is interested in how the American medical community and public health officials drew on the militaristic framing of the flu and coercive, statist approaches to its control — what she characterizes as a extreme form of biopolitics and what Michel Foucault called “force relations laid bare” (Michel Foucault, Society Must Be Defended: Lectures from the Collège de France. New York: Picador, 1977, p. 46). At the same time, she explores the discontinuities and points of tension in these flows of biopower, showing how the mass mobilization of troops in war and the need to keep men and arms flowing to the European front, disrupted and sometimes worked in opposition to the “war” on flu. These tensions, she suggests, are still very much with us today — hence the way that in 2009 swine flu became a site for biomedical knowledge production that drew on pre-existing discourses of bioterror and “bio-preparedness” that seemed to justify the suspension of the rule of law, while clashing with public health imperatives that aimed to provide the public with some degree of immunity.
Taking as her point of departure Foucault’s inversion of Clausewitz’s famous maxim – about politics being war by other means – to argue that biopolitics is also a form of war by other means, Baciu melds approaches and perspectives from medical sociology, anthropology, philosophy and public health law to create what she calls a “partial genealogy of the ‘clinical gaze’ of public health at two points of history in humanity’s perpetual war against microbes” (p. vi). Her principal sources for this genealogy include the archives of the United States Public Health Service (USPHS), which include letters, memoranda and telegrams from health officers who served in the field in 1918, as well as the archives of the Office of the Surgeon General of the Army, which contain reports of medical officers stationed at various army mobilization camps during the epidemic. In addition, she draws on the archives of the New York Times and Washington Post , public health journals, and transcripts of Congressional hearings and bills.
Besides Foucault, Baciu draws on the works of the Italian philosophers Giorgio Agamben and Roberto Esposito. In particular, in Chapter 1 she cites Agamben’s notion that epidemics, like wars, represent crises or tumultus in the life of nations and can lead to a “dark spiral in power” in which the rule of law is suspended and a “state of exception” is normalized (p. 6). By contrast, Esposito’s notion of immunity/community offers the hope that this process can be arrested so that rather than communities turning in on themselves they can forge a “common immunity” (p. 6). At the same time, social determinants of health models show how epidemics and other health crises fall unequally on the advantaged and disadvantaged, meaning that what one social group or individual experiences as coercive another may regard as altruistic and protective. Where, Baciu asks, does the line “between heroic care for human life and violent coercion end? Who should decide what constitutes a health threat and issue a societal prescription for preventing or controlling it?” And “what should be done if the threats and solutions are not the same for society as they are for individuals?” (p. 35) Baciu is disarmingly frank about her own biases as a public health “insider” and the challenges she faced combining public health discourse with the often opaque language of the human sciences and social theory (p. 33). This struggle leads Baciu into Chapter 2 where she develops her theoretical framework. In particular she draws an analogy between biopower and the operation of immune system, visualizing individual, social and national immunological responses as a series of “nested immunities” (pp. 72-75). However, there are also some neat aperçus and she never loses sight of the way that, in policing a body boundary, public health or social medicine embeds biopower at multiple levels.
In Chapter 3 Baciu brings these theoretical lenses to bear on the 1918 pandemic, drawing on contemporary reports by public health officers, newspapers and US military authorities to analyze the relationship between the demands of the military and public health officials as they struggled to respond to the crisis. Although the war had given rise to a “state of exception”, for the most part officials eschewed coercive measures, preferring to rely on persuasion and optimistic messages disseminated in the press. Quarantines were imposed at some ports to stop Europeans infected with flu entering the United States. But on the whole, the priority was to ensure that nothing should interfere with mobilization for the draft and other forms of assembly necessary to the war effort, such as Liberty Bond parades. Baciu shows that these conflicting imperatives led to frequent clashes with public health officials. However, while in some regions like Alaska, officials were able to enact restrictive measures that Baciu finds may have actually have weakened group immunity, by and large quarantines and other strict social distancing measures were avoided, with Federal authorities tending to defer to the principle of “States’ Rights”. Instead, the overriding priority was negating discourses of fear. The result was that concern about the high mortality from the flu tended to come “a distant second to lifting morale and the spirit of patriotism” (p. 195).
Chapter 4 explores the alliances between the US military, public health practitioners and scientists through the theoretical lenses outlined in the first two chapters. The military has long been at the forefront of infectious disease research, not least because of the heightened risks faced by soldiers crowded together in unhygienic trenches and barracks. But at the same time as military science seeks to neutralize infectious disease threats, military biopower creates the very conditions that precipitate epidemics. These contradictions are encapsulated by the USPHS, a uniformed corps whose origins dates back to the Marine Hospital Service and which has long been organized along military lines. While the military is responsible for patrolling national borders and “immunizing” the nation against external threats, the public health corps performs a similar function internally. However, drawing on archival sources, Baciu shows how in 1918 these missions often clashed. This was especially the case in and around Army camps where troops amassed for deployment to Europe, risking spreading disease to extra-cantonment zones. Another point of “maximum tension” (p. 211) between military and civilian biopower was the Council for National Defense, the war-time council established by Congress and signed into law by President Wilson in 1916. It was here that the USPHS was formally placed under the aegis of the Secretary of War and that Baciu speculates “the power effects produced by the discourse of war and patriotism began to impinge on public health” (p. 227). Tracing this relationship through the Cold War and up to the present day, Baciu argues that the bureaucratic linkages between the Department of Health and Human Services and Homeland Security are simply “new variations on an old theme” (p. 249). The bio-preparedness movement, she concludes, had helped to institutionalize and inscribe Agamben’s “state of exception” into biopolitical governance structures.
Chapter 5 builds on these themes to show how in the twenty-first century the state of exception constituted by military public health has spread ever wider, focusing ever more intently on the biological status of its subjects. Reviewing the preparations for a twenty-first century pandemic sparked by swine flu, H5N1 bird flu, or some other iteration of the virus, Baciu examines how vaccination, rationing, quarantines, and tactics such as scapegoating, are once again becoming tools of biopower. The chapter includes an interesting discussion of the case of Andrew Speaker, the American citizen infected with extensively drug-resistant tuberculosis while travelling in Europe and who was tracked by the Centers for Disease Control and eventually hospitalized under armed guard after being placed on a “no-fly” list. Baciu concludes by asking a series of provocative questions, such as when and under what circumstances are such quarantine measures “acceptable” and “when is a pandemic and who decides?” (p. 302). Unlike in 1918, when no vaccine was available, today we have the theoretical ability to immunize the entire population against a pandemic virus. At the same time, the possibility of biopolitical excess looms ever larger, threatening what Baciu, paraphrasing Esposito, characterizes as an “autoimmune reaction” against the very lives public health seeks to protect (p. 303).
While much of the writing on the 1918 pandemic is preoccupied with narratives of scientific triumph and failure, Alina Baciu’s dissertation focuses on how these pandemic discourses got up and running and how they continue to be deployed in public health and political contexts today. For this reason, it is a very welcome addition to the growing literature on the modern uses and abuses of epidemics.
Institute and Museum of the History of Medicine
University of Zurich
Appendix A (pp. 334-341) of the dissertation provides a detailed discussion on primary sources and archival materials
United States Public Health Service (USPHS) influenza records, 1918: reports, letters and memoranda, including correspondence with Surgeon General’s office, The National Archives at College Park, Maryland.
Records of Surgeon General of the US Army, 1918-19: reports on influenza outbreaks at various military camps, The National Archives at College Park, Maryland.
Newspapers: New York Times, Washington Post (1918)
Journals: Public Health Reports; American Journal of Public Health; Journal of the American Medical Association; Health Affairs.
George Washington University. 2010. 343 pp. Primary Advisor: Andrew Zimmerman.
Image: “1918 Flu Pandemic: The Oakland Municipal Auditorium in use as a Temporary Hospital” by Edward A. “Doc” Rogers (1873-1960), Wikimedia Commons.