In Sick from Freedom, Jim Downs (Connecticut College) gives an account of the medical care the federal government[1] offered to African-American civilians[2] during and after the Civil War, including refugees/contrabands as well as those who did not leave their homes. He draws on relevant official papers from the Freedman's Bureau and the US Army, as well as, for political background, the writings of abolitionists. His work is well grounded in the scholarly literature on Reconstruction, but not in the history of hospitals and nineteenth-century government healthcare.

Downs's thesis is that the government owed Blacks a healthcare system because it had caused the poor state of their health to begin with. During the Civil War, many Blacks were moved by their owners away from advancing federal forces; others fled to freedom or were relocated by government-mandated refugee measures; and nearly all were affected by the economic damage the war wreaked. Downs argues that the government should have anticipated that such wartime and postwar dislocations would leave freed Blacks without adequate health care. This is problematic, since it was not clear what the postwar situation would be; Downs does not examine in detail the debates in the government over the formulation of policy. In his view, emancipation was a process and African-Americans were not truly free until after the passage of the Thirteenth Amendment.

In his Introduction (3–17), Downs maintains that no one had an interest in the health problems of freedpersons. Southern whites no longer had an economic interest in maintaining their property and disliked the new political system. Most Northern whites opposed slavery but showed little concern for flesh-and-blood African-Americans. Both the federal government and abolitionists chose to gloss over the severe deficiencies of the health system. Downs's distress over the poor care given to freedpeople sometimes leads him into hyperbole. For instance, describing a refugee suffering from frostbite, he writes "It is difficult to imagine how badly someone's feet must be frozen that an Army official [sic] had thought that the best solution would be amputation" (5). In fact, the vascular system, if sufficiently damaged by cold, ceases to function. The only options are in fact gangrene or amputation; imagination does not enter into it.[3]

Downs focuses on certain government healthcare organizations while omitting others. He explicitly notes that keeping the workforce healthy was the mission of the Medical Department of the Freedmen's Bureau (MDFB), but seems unaware that the Marine Hospital Service, founded in 1798, had the same charge. He also ignores the Army Medical Department's then-customary care for dependents, on the grounds that it was not necessary for a healthy workforce. Downs may be affected by the current American debate over healthcare as an entitlement, of which the MDFB was the archetype. Further, he does not draw on the historiography of the hospital[4] (9) and criticizes the MDFB for its paucity of diagnoses and treatment protocols (9, 11). But, given the state of medical science at the time, more precise diagnoses were not feasible and the lack of therapeutic drugs made rigorous treatment measures almost impossible.

Chapter 1, "Dying to Be Free: The Unexpected Medical Costs of War and Emancipation" (18–41), starts with some narrative history. "Self-emancipators" who fled slavery clustered around federal forces, which had no policy for treating them. Downs blames the Army: "During the war years, the military did not create a policy that responded to [refugees'] medical needs or a program that provided them with resources; the only support promised was not realized" (21). Yet the Army did what it had authority to do, providing care for its Black enlistees and sometimes their dependents; it did the same for its Black civilian work force. Downs does not mention that, before 1884, no law specifically allowed this. Army physicians provided healthcare for military families and local civilians, but not free of charge. By concentrating on individuals, Downs misunderstands how organizations worked: in not acting, the Army was simply executing government policy. Citizens (mainly abolitionists) demanded action by the government; only then did it enact some healthcare measures for refugees. Not until chapter 6 does Downs acknowledge that the federal government was "a limited institution" (164).

The following chapters are structured more thematically. Since most of the book covers the Reconstruction era, the MDFB bulks large. The approach is bottom-up, highlighting the effects of government policy on individuals. This both humanizes the story and makes it difficult to grasp just what policy was and how it changed. It is also unclear whether the book's personal vignettes typify government policies or local implementation of those policies. While the Freedmen's Bureau (and its Medical Department) were established in 1865 within the War Department, no funds were appropriated for medical care during fiscal year 1866 (i.e., June 1865 to June 1866). But the Secretary of War directed another of his organizations to provide care for African-Americans—the Army Medical Department. Over 15 percent of the Army's doctors were assigned to it,[5] civilian doctors were hired, and over $267,000 allocated.[6]

In chapter 2, "The Anatomy of Emancipation: The Creation of a Healthy Labor Force" (42–64), Downs discusses government healthcare for freedmen in the context of emancipation as a process rather than a single fiat. Abolitionists, recognizing the dire conditions faced by runaway slaves, quickly and successfully lobbied the government to provide healthcare. The Army acted as well, in the interest of maintaining the health of its workers. Downs sees this quid pro quo as oppressive. He does concede that the Army lacked authority to act (50, quoting both U.S. Grant and S.P. Heintzelman) but cannot accept that as sufficient reason for inaction: for him, human suffering itself mandates action. But wishful thinking is not history. As he admits, "Maybe the historian, here, falls into the same trap … emotionally hooked by the drama of death and dying" (44); he cannot refrain for contemplating "what could have been."

On healthcare and labor, Downs writes that "the federal government callously employed former slaves for the shortsighted benefit of the Union cause" (63). Since the government could give healthcare only to its workers, who both aided the military and sustained the economy that made the war possible, it is not obvious what was shortsighted about employing escaped slaves. As Downs asserts, "freedpeople themselves understood chronic and unremitting illness compromised their ability to exercise their rights" (57), but the same could be said of slaves who had not been freed, child workers in Massachusetts mills, immigrants in New York City slums, farmers working long hours, or, for that matter, white slaveowners.

Chapter 3, "Freedmen's Hospitals: The Medical Division of the Freedmen's Bureau" (65–94), looks at MDFB-operated hospitals. A few permanent facilities were established in the South, mainly around the larger refugee camps, but more common were temporary hospitals set up in response to outbreaks of disease. This was the best that could be done, given the exigencies of personnel and budget. Downs correctly argues that the government's intention (like that of present-day employers) in providing medical care was to keep workers on the job, but it was not the only goal: any person or group funding a hospital presumably wishes patients to recover. Downs's focus on individuals rather than organizations sometimes leads him into self-contradiction. Thus, he states that there were no set procedures for establishing and running hospitals (74–75), but then mentions centralized control (76), an operations manual (83), and "bureaucratic regulations" (82); further, the director of the MDFB "issued numerous circulars to physicians on ... medical issues relating to the treatment of the freedpeople and the operations of the Bureau hospitals" (107).

Chapter 4, "Reconstructing an Epidemic: Smallpox among Former Slaves, 1862–1868" (95–119), describes a severe smallpox epidemic that was underreported because it afflicted mostly Blacks.[7] Downs complains that the purely "quantitative form of reporting on the virus [sic] provided federal officials in Washington with a largely statistical portrait of the smallpox epidemic…" (101). He does not, however, explain why that was a bad thing. What information should policy makers have sought? Qualitative data? Emotional data?

Chapter 5, "The Healing Power of Labor: Dependent, Disabled, Orphaned, Elderly, and Female Freed Slaves in the Postwar South" (120–45), concerns the MDFB's treatment of the unemployed. Initially, its hospitals served not only the sick but those unable to care for themselves—orphaned children,[8] the elderly, the insane, among others. When hospitals reached full capacity, orphanages and homes for the elderly were created. Once the permanently dependent left their rolls, some hospitals closed.

Chapter 6, "Narrating Illness: Freedpeople's Health Claims at Reconstruction's End" (146–61), tells the story of Blacks getting a voice and, for the first time, appearing as individuals in the documentary record. This chapter violates the timeframe denoted in the book's title, dealing principally with developments in the 1880s and 1890s. But Blacks actually appear earlier in the record, for example, in the Medical and Surgical History of the War of the Rebellion.[9] Downs's sections on specific groups of patients (the insane and smallpox sufferers) feature no individual voices. He does present vignettes about Blacks whose pension petitions were delayed or denied (157–58), but without indicating whether their plight was better or worse than that of white pensioners.

Downs's Conclusion (162–70) is a recap of the book's leading arguments; at times it evokes today's debate about government healthcare. Being a proponent of historial research as a spur to social change,[10] Downs excoriates the Freedmen's Bureau and (by extension) the rest of the government for not doing more. His claim that the temporary provision of healthcare by the MDFB "reveals how health became embedded in the meaning of citizenship" (167) seems more germane if we see the book as a brief for healthcare as a right rather than as a history of the achievements and failings of the Freedmen's Bureau. The extension of free care to emancipated Blacks is more remarkable than Downs allows. From the 1790s, merchant sailors had access to the Marine Hospital Service, but it was funded by deductions from their wages. From 1775, men in the military had free healthcare but low wages. Conversely, the ineffectiveness of the healthcare and Downs's disappointment with the MDFB and its bureaucrats are hard to square with his apparent faith in the efficacy of government intervention. Would extending 1860s-era healthcare have much improved the health of its recipients?

In the last analysis, Downs's understandable sympathy for those individuals who suffered personal tragedies prevents him from assessing objectively just what the government could have done to alleviate their pain. In many cases, the authority to provide care was altogether lacking and military officers and government officials who spent public funds without authorization risked serious consequences. The fault lay with policy makers, not with those who did not (and could not) take action on the local level. It is fair to criticize officials who chose not to act when action was possible, but until the Freedmen's Bureau was created, there were no legal means to provide healthcare for civilian Blacks, although the Army nevertheless afforded some care to African-Americans in its employ and to soldiers' dependents. That the Army did not do everything does not mean it did nothing. Downs does not clarify the possible legal basis for providing healthcare only to Blacks as a right.

Finally, Downs is guilty of an anachronistic understanding of nineteenth-century medical science, as in the following critique of diagnostic terminology:

As if the MDFB had access to the methods and instruments of twentieth-century audiology and ophthalmology, or to the Diagnostic and Statistical Manual of Mental Disorders.

Jim Downs has written an impassioned book about the shabby healthcare that newly freed Blacks received after the Civil War. But factual and interpretive errors[11] make it a resource to be used only with due caution.