Searching Eyes: Privacy, the State, and Disease Surveillance in America (review)

The practices, technologies, and knowledges associated with “public health” today were conceived largely in the eighteenth century under the rubric of “medical police.” Medical police was a confederate science (composed of a number of discreet fields) that had public health and safety as its objective. It involved everything from regulation of the medical professions and the safety of traffic and buildings to sanitation and the wholesomeness of food. The words used to describe practices aimed at health and safety mutated throughout the nineteenth century, becoming, for instance, “public hygiene,” “political medicine,” and “state medicine,” before a decisive shift toward the nomenclature of “public health” began at the end of the nineteenth century.

In the Anglo-American world, talk of medical police aroused great suspicion. Hence, Anglo-American historians in the second half of the twentieth century construed medical police and public health as “opposite models” for achieving health. They characterized medical police as distinctly continental, tied to absolutist regimes, basing it on a model of authoritarian intervention and coercion, whereas they construed public health as a function of education and persuasion. As such, public health was meant to represent a specifically Anglo-American trend toward liberal government, unaffected by medical police.

The first, and most significant achievement of this painstakingly researched book, is to fully explode the historiographical myth that medical police and public health were irrelevant to each other. Though not centrally concerned with the “policing” of disease, by focusing on disease surveillance, Fairchild, Bayer, and Colgrove demonstrate that police, understood as the combined practices of inspection, investigation, information gathering, and forceful intervention, did not disappear from public-health practices in America. This demonstration alone makes Searching Eyes a major breakthrough in research about government efforts to secure the population of twentieth-century America.

The book, however, has other achievements that also recommend it for serious consideration by historians, sociologists, and students of public health. If (as I have suggested elsewhere) all modern states are police states, this book brilliantly reveals the complexities entailed by policing disease in the context of a democratic state.¹ It shows how both physicians and patients reacted to disease surveillance at different times and for different illnesses. In the case of venereal disease, public-health authorities and physicians were in agreement about the need for strong interventionist and coercive measures. However, as efforts expanded from a focus on the compulsory examination of the poor to surveillance of the population as a whole, physicians became more reluctant, struggling with a “divided loyalty” between individual patient privacy and the health of the community as a whole. A national study in 1970 showed that only one out of every nine private physicians reported cases to public-health officials. Indeed, the earliest form of resistance to surveillance efforts came from physicians trying to protect the privacy of their patients—a phenomenon that the authors term “paternalistic privacy.”

In the case of occupational disease, the response was even more complex. Private physicians and public-health officials had to deal with trade-union representatives, business interests, and company physicians. The targets of surveillance in this case did not resist it. On the contrary, through their union representatives they demanded it. Similarly, in the case of breast-cancer registries, activists led the charge for increased surveillance in the hope of enhancing an understanding of the etiology of the disease. It became a case of having “the right to be counted.”

In the case of hiv, however, the authors show that patient resistance was significant. Many activists at the time rightly viewed surveillance as a threat, but this book shows that they were wrong to assert that surveillance efforts in the context of hiv marked a qualitative shift from supposedly established practices of education and persuasion. Indeed, many activists labored under the traditional misunderstanding that education and police represented fundamentally opposite poles of public-health policy. This book shows that both...