How is epidemiology shaped by the political structures of class, race and colonial power? Consequently, how might public health practices perpetuate global inequities? Steven Wilson reviews Epidemic Illusions: On the Coloniality of Public Health (The MIT Press, 2020) by Eugene T. Richardson.
Arthur Frank, in his seminal 1995 monograph, The Wounded Storyteller: Body, Illness, and Ethics, posits that “Colonisation was central to the achievement of modern medicine” (10). Viewing illness from the perspective of sociology, Frank used the term metaphorically to describe medicine’s colonizing tendencies with regard to the diseased body, which render the patient speechless and, therefore, powerless. Establishing the parallel, he explained: “Just as political and economic colonialism took over geographic areas, modernist medicine claimed the body of its patient as its territory, at least for the duration of […] treatment” (Frank 1995:10). Thus, for the postmodern, or specifically “post-colonial” patient, the reclaiming of voice allows for the reconstruction of self. Twenty-five years later, redirecting our attention to the structures of public health, physician-anthropologist Eugene Richardson contends that colonialism remains endemic in the critical discipline of epidemiology.
The publication of Epidemic Illusions comes at a time when the intersections between colonial, (neo-)imperial and epidemiological imaginaries are the subject of renewed interest. A global bestseller during the initial wave of the COVID-19 pandemic, Camus’s La Peste/The Plague can be read as an allegory of the Nazi occupation of France in spring 1940, and/or the literary tale of a plague sweeping the imaginary city of Oran in French-colonized Algeria. In the preface to Epidemic Empire: Colonialism, Contagion, and Terror, 1817-2020, a remarkable recent study of the “global war on terror” from a postcolonial literary perspective, Anjuli Fatima Raza Kolb cites comparisons between the new coronavirus and the events of 9/11 made by New York Governor Andrew Cuomo in the context of what she analyzes as a broader (neo-)colonial worldview of contagion. Invoking the memory of the terrorist attack on the Twin Towers, Cuomo called the pandemic “a violent explosion that ripples through society with the same randomness, the same evil that we saw on 9/11” (Kolb 2021:xii).
Epidemic Illusions thus appears against a backdrop of multidisciplinary scrutiny of the rhetorical and ideological connections between discourses and power systems of colonialism and science, broadly defined. And yet, in the force of its argument and the unconventionality of its structure and style, it stands apart. At a time when the global response to the COVID-19 pandemic has been coordinated by the World Health Organisation, Richardson’s thought-provoking book – or “pseudomonograph”, as he idiosyncratically terms it – not only reminds us that the ideal of universalism eludes global health, but points to the Global North’s very “complicity” (65) in health inequalities. Taking as its focus the Ebola outbreak in West Africa, the book’s “simple” but inexorable thesis is laid bare in its opening lines:
The continuation of disproportionate amounts of suffering and death from infectious diseases in the Global South is not the result of an intractable problem thwarting our best efforts to prevent and cure disease; we have the means. However, as an apparatus of coloniality, Public Health manages (as a profession) and maintains (as an academic enterprise) global health inequity. It does this through “bourgeois-empiricist” models of disease causation, which serve protected affluence (i.e., the possessing classes) by uncritically reifying inequitable social relations in the modern/colonial matrix of power, making them appear commonsensical or elevating them to unchangeable facts. (1; italics in original)
Richardson’s reference to the appearance of sound power relations discloses his critical aim in this study, as alluded to in its title: to dispel some of the illusions of global public health. In particular, his overarching purpose in the book is to shed light on the structure of colonialism – “the racial, political economic, social, epistemological, linguistic, and gendered hierarchical orders imposed by European colonialism” (3) – that persistently manifests itself through, inter alia, institutionalized racism, religious discrimination and economic exploitation in the exercise of public health in the Global South. For while the “structural and material determinants of infectious disease epidemics have been well described”, less attention has been paid to “examining the ideological content of how diseases are represented” (41).
The book does not have conventional chapters; rather, it is structured according to seven “redescriptions”, each exposing an aspect of public health’s perpetuation of “bourgeois-empiricist epidemiology” (85). These include the presentation of graphs, models and charts that (re)construct a colonialist worldview; the ideological use of Big Data; the imposition of specific language by organisations such as the WHO and the UN; the selective framing and definition of ‘superspreaders’; and a narrow appreciation of deterministic ‘risk factors’ in morbidity and mortality that includes diet, blood pressure and lifestyle but does not give sufficient consideration to socio-historical factors and forces, such as the legacy of the slave trade or the role of exploitative foreign companies in Africa. The general effect of such strategies is to “diver[t] the public gaze” and “mask the history of exploitation” and underdevelopment (85-86); but more specifically, such approaches to public health can result, Richardson argues, in the generation of narratives of mistrust among locals, including in respect of vaccines developed by outsiders.
Epidemic Illusions, while powerfully written, is an unashamedly polemical text, one that “blur[s] the boundaries between manifesto and scholarly pseudomonograph” (111). It emerges from Richardson’s extensive lived – or what he terms “insane” (5) – experience of working in several African countries, including the Sudan, Swaziland and the Democratic Republic of Congo, with organisations such as Doctors without Borders, the World Bank and the WHO. But it is not merely an excoriating attack on the maintenance and production of public health power structures in the Global South. Instead, it presents what he terms a “call” (131) – though it is, in fact, a compelling critical case, argued with reference to theories on power and (post)colonialism by Bakhtin, Bourdieu and Said – for a more inclusive, democratic and equitable structure of global health. Intriguingly, Richardson suggests that such a model must necessarily be polyvocal, giving voice to local populations, so that “more just vocabularies” (136) for representing world health are put into circulation. The book could have developed this significant line of thought on the potential for language to revolutionise global health, to include further consideration of the role of medical translators and interpreters, or the capacity and use of local languages to project more sensitive public health messages. It would also be interesting to read further research on the import of Richardson’s central thesis in relation to epidemics beyond Ebola and West Africa. Yet, in some ways, the questions raised by Epidemic Illusions are the greatest testament to its critical force, for this is a ground-breaking study, replete with opportunities for a more thorough and systematic reconsideration of how global health epidemiologists present their arguments (an excellent example of such work is provided by Lukas Engelmann’s ERC project, The Epidemiological Revolution. A History of Epidemiological Reasoning in the Twentieth Century). As COVID-19 once more highlights transnational inequalities, Richardson’s book presents a timely challenge for deep-seated change in the dominant structures of epidemiology. We might even wonder if a (more) decolonized global public health might one day become our “new normal”.
Frank, Arthur W. 1995. The Wounded Storyteller: Body, Illness, and Ethics. Chicago and London: University of Chicago Press.
Kolb, Anjuli Fatima Raza. 2021. Epidemic Empire: Colonialism, Contagion, and Terror, 1817-2020. Chicago and London: University of Chicago Press.
Richardson, Eugene T. 2020. Epidemic Illusions: On the Coloniality of Public Health. Cambridge, MA, and London: MIT Press.
Dr Steven Wilson is Senior Lecturer in French Studies at Queen’s University Belfast. His research examines the ways in which modern French literature and thought contributes to culturally-aware, linguistically-sensitive understandings of disease, illness, medical practice and dying/death. He is a previous AHRC Leadership Fellow on a project entitled Global Disease: Language(s) and the Literary Imagination. His monograph, The Language of Disease: Writing Syphilis in Nineteenth-Century France, was published by Legenda in 2020. Other recent publications include French Thanatology, a special issue of L’Esprit Créateur (co-edited with Prof. Enda McCaffrey, Nottingham Trent University). His current projects include Languages of Disease in the Contemporary Francophone World, co-directed with Dr Hannah Grayson (University of Stirling), and The Languages of Covid-19: Implications for Global Healthcare, a British Academy-funded project co-directed with Dr Piotr Blumczynski (QUB). Steven can be followed on Twitter @DrStevenWilson.