Infectious Fear: Politics, Disease, and the Health Effects of Segregation (review)

Infectious Fearmakes a telling contribution to historical scholarship on the intersection of race and big-city public health in the United States. Though not evident from its title, this book is a deeply researched and probing case study of tuberculosis in Baltimore from the mid-nineteenth to the mid-twentieth centuries. However, whereas Nayan Shah and Susan Craddock on San Francisco and Natalia Molina on Los Angeles focus on Asian immigrants, Baltimore's encounter with tuberculosis was characterized by an ongoing tension between the city's African American community on one hand and the white residents and ruling elite on the other. Roberts points out that race has not been central to histories of tuberculosis in the United States, nor has tuberculosis featured much in studies of race and politics; a worrying indictment that he begins to put right.

The introduction and subsequent two chapters set the scene in terms of the historical epidemiology of tuberculosis of African Americans and the wider context of tuberculosis in Baltimore and Maryland. Baltimore, an understudied city in the history of public health, was one of the nation's economic powerhouses in the early nineteenth century. Geographically, culturally, and socially, Baltimore sat betwixt America's northeast and south. The city's 100 percent increase in population between 1870 and 1900 to over half a million people included an influx of European migrants and black Americans. By 1910, only four other U.S. cities had African American populations that surpassed Baltimore's 84,000. Around 15 percent of the city's population was black, and this increased to almost 20 percent by World War II. Baltimore had the worst black tuberculosis mortality rate of any southern city, three times that of the city's white residents. Tuberculosis mortality rates from this period should always be treated with caution—Roberts certainly does—but some things cannot be gainsaid: first, the scale of historical racial inequality in mortality is irrefutable; second, this mortality inequality was the product of massive social and economic disadvantage; and third, these rates were used by Baltimore's ruling white political class, not least the city's health department, to exploit white fears and discriminate against black residents.

The quality and the location of rental housing stock in Baltimore were central to the rhetoric and reality surrounding tuberculosis. Gradual official acceptance of "house infection theory," which Roberts shows was less inflected with the principles of hereditary disposition than one might suppose, drove the implementation of the nation's first universally compulsory system of tuberculosis reporting in 1896. This system located and defined areas in the city with the conjoined existence of high tuberculosis prevalence, degraded housing, and a predominantly African American presence. Dot maps of tuberculosis cases exposed the "lung block" in Baltimore's Druid Hill district, which then became focus of unprecedented social inquiry, stigmatization of black consumptives and caricatures of failed citizenship. Racial residential segregation was high on the political agenda. Four times between 1910 and 1917 city government attempted, and failed, to introduce an ordinance preventing the residence of blacks in white neighborhoods and vice versa. In the last of these years, the health commissioner was asked to identify districts of urban blight for redevelopment. The geographic distribution of tuberculosis mortality was one criterion. Another was projected tax revenue from the renewed areas. Redevelopment and an ineffectual housing ordinance from 1908 failed to deal with Baltimore's "alley house" problem. The lung block was not demolished until the mid-1930s. Health education, expansion of the dispensary network and visiting nurses proved largely inadequate at reducing disparities. Institutional underprovision for African Americans was only partially rectified by the opening of a state sanatorium for blacks at Henryton in 1923, about which Roberts writes brilliantly. The foundation of this facility was heavily influenced by quarantinist arguments in favor...