Published by Oxford University Press on behalf of the International Epidemiological Association
ß The Author 2009; all rights reserved.
Commentary: Epidemiology in context
Charles E Rosenberg
Accepted 7 October 2008
In the spring of 1948, Erwin H Ackerknecht, a
physician-historian newly settled at the University of
Wisconsin in Madison, regretted that he might not be
able to attend the annual meeting of the American
Association for the History of Medicine in Philadel-
phia. Two young children, shallow pockets, and
chronic stomach problems made travel for the
German refugee-scholar difficult and expensive. But
he received a last-minute invitation to deliver the
Association’s prestigious Fielding Garrison lecture.1
That talk, on ‘Anticontagionism between 1821–67’
written hastily in the 2 months available to him, has
since become something of a landmark—in the words
of a distinguished practitioner, ‘one of the most influ-
ential essays in the history of epidemiology . . .’2 In its
article form, his argument has remained a reference
point for debate. The issues Ackerknecht raised have
retained their heuristic value, despite a variety of
objections to his characterization of particular stu-
dents of disease and the implementation of particular
policies in particular places,3 e.g. or his perhaps overly
schematized articulation of the etiological choices
available to his protagonists.4
What was the burden of his argument? It turns first
on an irony. Anticontagionism as a self-conscious
doctrine—defined by its militant opposition to con-
tagionism—flourished in the decades immediately
preceding the articulation and ultimate triumph of
germ theory. In terms of conventional medical history
this was a kind of darkness before dawn. Contagion-
ism (and especially that version of it presuming a
living substance or thing) appeared to its antagonists
not a progressive way forward but instead ‘old and
obsolete’, an antique doctrine that had not been
proven by epidemiological or experimental data. It
had, in fact, been discredited by its association with
centuries of failed quarantines and sanitary cordons
and the authoritarian regimes that imposed them:
‘what to us appears a vanguard action’, Ackerknecht
argued in reference to Jacob Henle’s retrospec-
tively much-admired contagionism, ‘impressed . . .
contemporaries rather as a rearguard action, the last
The Department of the History of Science, Harvard University,
Boston, USA. E-mail: rosenb3@fas.harvard.edu
International Journal of Epidemiology 2009;38:28–30
doi:10.1093/ije/dyn257
Downloaded from https://academic.oup.com/ije/article-abstract/38/1/28/699057 by guest on 10 April 2020
gallant defense of a dead hypothesis’ (563).5 Second,
as Ackerknecht examined the controversy, he sought
to link etiological thinking with a particular policy
history (opposition to quarantines and cordons) and a
particular intellectual and social location: bourgeois
liberals suspicious of traditionalism in medicine and
the authoritarian states which enforced quarantines
that seemed ineffective and economically destructive.
It was a practice based on dogma and groundless lay
fears rather than evidence. Ackerknecht developed
his argument by examining the debates surrounding
yellow fever, cholera, plague (and, more tangentially,
typhus which was both difficult to diagnose and
generally conceded to be contagious in certain well-
understood pathogenic local circumstances such as
ships, prisons, and military camps).
Ackerknecht argues that the terms of debate were
set in the conflict over yellow fever at the end of the
eighteenth and beginning of the 19th centuries. The
controversy over transmission of the ‘black vomit’ was
a focus for epidemiological and policy discussion
before cholera moved center-stage in the early 1830s.
And yellow fever was elusive. It certainly did not fit
the smallpox paradigm—the model of a truly conta-
gious disease, passed from person to person by a
substance capable of reproducing itself in the bodies
of sufferers; inoculation and then vaccination had
made this undeniable. Yellow fever did not seem to be
spread by personal contact, though outbreaks were
often associated with ships arriving from ports ridden
with the disease. Moreover, those caring for sufferers
did not seem particularly vulnerable. And yellow
fever was seasonal. Why would a disease passed
from person to person by some material contagion
be seasonal? It seemed more likely evidence of
its environmental—and, to this generation, thus
atmospheric—origin.
Cholera like yellow fever was difficult to prove
contagious. It was hard to reconstruct a chain
of transmission during local epidemics—while the
cordons and quarantines that had been established to
fend off its relentless spread from the east to Europe
and the Americas had shown themselves repeatedly—
and didactically—ineffective. Many of those strongly
opposing a theory of person to person contagion
were, Ackerknecht emphasized, critical, data-oriented

scientists like Virchow and Magendie. In sum, the
cumulative experience of medical science had, by the
1840s, failed to demonstrate that yellow fever or
cholera were communicable from person to person.
Ackerknecht was well aware that a large middle-
group of moderates avowed neither an exclusive
contagionism nor its polarized opposite; they
embraced what contemporaries called contingent
contagionism.6
But it was the centrality of quarantine in the policy
arena, Ackerknecht contended, that made many
physicians take sides (11–12). It was not just that
that quarantines were ineffective: they exerted a
debilitating effect on economic activity (and thus
indirectly the health status of working people) In this
sense, they predisposed the poor to the epidemic. And
perhaps more importantly, they directed attention
away from local improvement—the clean streets and
ventilated rooms, the sewers and personal cleanliness
that seemed in fact to protect a community against
disease. Anticontagionism expressed and legitimated,
that is, a positive and powerfully motivating activist
component, as well as what might be termed a
negative anti-quarantine and anti-authoritarian iden-
tity. The bottom line, in the words of a representative
American sanitarian, lay in the ‘superiority of sanitary
measures over quarantines’.7 The anti-contagionists
were, as Ackerknecht put it, ‘more than mere mouth-
pieces of a ruthless and economy-minded bourgeoisie’
(14). Opposition to germ theory was in some minds a
defense of environmental reform.
In retrospect, Ackerknecht’s argument seems novel
and has remained visible because it appears to
prefigure a contextual style of argument—one embed-
ding medical thought in a situated world of time-
bound actors and not in a timeless aggregation of
increasingly precise statements about the nature of
nature—the trajectory of gradual revelation that still
seems to so many of our contemporaries the appro-
priate framework for approaching the historical devel-
opment of science and medicine. But Ackerknecht is
far from a relativist, even if he can be characterized as
what might—anachronistically—be called a contextu-
alist. His analysis is based in fact on his retrospective
understanding of yellow fever and cholera—ailments
whose etiology and modes of transmission were
clarified only after the 1860s. They were, he argues,
a frustrating challenge to even the best-informed
medical men in the first two-thirds of the 19th cen-
tury. Epidemiological idiosyncrasy implied continuing
controversy; neither contagionism nor anticontagio-
nism could claim the explanatory high ground.
‘Intellectually and rationally the two theories balanced
each other too evenly’, Ackerknecht argued. ‘Under such
conditions the accident of personal experience and tempera-
ment, and especially economic outlook and political
loyalties will determine the decision. These, being liberal
and bourgeois in the majority of the physicians of the
time brought about the victory of anti-contagionism’
ANTICONTAGIONISM BETWEEN 1821 AND 1867 29
(17, ital. in original). But social location and class
orientation determined medical discourse only in that
residual space created by the gap between perceived
phenomenon—epidemics of yellow, fever, let us say,
plague or cholera—and the learned world’s ability to
explain them. Once explained in terms of a world
of mosquitoes, rat fleas, contaminated water and
pathogenic organisms, the space for debate—and for
the role of social and economic commitment—grew
ever-narrower.
Ackerknecht was by no means a consistent
relativist—but rather a socially aware positivist.8
Some ideas were wrong and others were right—
Downloaded from https://academic.oup.com/ije/article-abstract/38/1/28/699057 by guest on 10 April 2020
closer to the natural world. Some scholarship was
of value, in this sense of contributing to scientific
knowledge; other academic work was more a reflec-
tion of prevailing attitudes, assumptions, and stake-
holder interests. Ackerknecht’s position may, from
today’s perspective, seem inconsistent but it is far
from irrelevant. Understanding the relationship
between the natural world and our construction of
it remains a fundamental and elusive problem—for
historians as well as philosophers and sociologists of
knowledge. In medicine it is particularly intractable.
Born in 1906, Ackerknecht was trained as a phy-
sician, as a medical historian in Leipzig, then as
a social anthropologist in Paris after fleeing Germany
with Hitler’s ascent to power in 1933. He was
interned in a labor camp with the outbreak of war
and managed finally to find his way to New York in
1941. And though his politics had changed, from
Communist, to Trotskyist, to unaffiliated Socialist,
to jaundiced witness to the Cold War and finally
disdainful observer of the student movements of 1968
and its associated cultural skepticism, he remained
committed like many of his German-trained peers
to a notion that medicine was not simply an applied
science, that it was a social function and deeply
embedded in every aspect of human culture and
social organization.9 Even the definition of what
constituted a disease was determined culturally
as well as biologically. ‘Disease and its treatment
are only in the abstract purely biological processes’,
he wrote in 1947. ‘Actually such facts as whether
a person gets sick at all, what kind of disease he
acquires, and what kind of treatment he receives,
depend largely on social factors.’10
Ackekrknecht had been influenced not only by the
intense politics of his Weimar youth, but more
specifically by his Leipzig doctoral thesis (directed by
Henry Sigerist). It was a study of medical reform in
1848 that focused on the youthful Rudolf Virchow
and his influential investigation of a Silesian typhus
epidemic.11 In Virchow’s iconic formulation, the causes
of the disease were social, economic, and institu-
tional—and thus remediable. Virchow’s anticontagion-
ism assumes a rather different meaning in this context
of social and necessarily political criticism. ‘Economic
factors’, as Ackerknecht explained, ‘did not only
30 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
determine the stand of many in the anticontagionism
discussion. Economic factors were consciously used by
many to give a causal explanation of epidemics’. . .
in the middle-third of the 19th century. (18).
His familiarity with Virchow’s history as social
reformer and witness to the conservative reaction
following the revolutions of 1848 must all have
influenced Ackerknecht as he sought to understand
how a great scientist like Virchow could have been so
firmly an anticontagionist at mid-century. Ackerknecht
retained, nevertheless, the ability to keep his distance
from a political position—disease as the consequence of
remediable social conditions—that he found emotion-
ally attractive. ‘The sociological theory’, he warned,
‘claiming a kind of ‘‘social epidemic constitution’’,
suffers often from the same haziness that is so
characteristic of the theories of telluric ‘‘epidemic
constitution’’ ’.(9)
Medicine is particularly in the social world, both
indicator and substance of that world. Like many of
his generation on the left, Henry Sigerist, his teacher,
e.g. and George Rosen, his friend, Ackerknecht, saw
medicine as a part of society in all of its aspects. It is
this sense that his discussion of the controversy
over contagionism and quarantine is most obviously
didactic—an example of the ways in which social
and economic orientations are inevitably part of that
set of practices and ideas we call medicine. This was
in fact the central vision of Henry Sigerist’s Institute
for the History of Medicine in the 1940s (and one
not always congenial to Sigerist’s Johns Hopkins
colleagues in clinical medicine). It is no accident
that George Rosen’s still widely-cited article ‘What
is Social Medicine’, appeared in the Bulletin of the
History of Medicine, the year before Ackerknecht’s
study of anticontagionism.12 Both reflect a broad,
inclusive, policy-oriented—and potentially activist—
understanding of medicine. Rosen even saw this
broadly social approach to the teaching of medical
history as a potential tool for the implementation of
social change. ‘. . . a medical history which approaches
medicine with an understanding that it has always
been involved in a matrix that is at once social,
economic, political, and cultural can be developed into
a method that can contribute to the solution of urgent
social problems of medicine’.13
But belief, no matter how benevolent or seemingly
enlightened, was never to remain unquestioned.
Ackerknecht ends his paper with a plea for an
ethnographer-historian’s humility. We are not
immune to errors because we are intellectually or
morally superior, because we are somehow wiser than
our predecessors, because we have somehow trans-
cended the quaint imperfections of past belief. We live
with contingency, within assumptions and seeming
certainties that are time and culture-bound—even if
that culture is a subculture of science or medicine.
Having barely survived the ruthless certainties of
authoritarian politics, he sought to live with that
disquieting irony. There is a liberating humility in the
acknowledgement that we live in history and are its
prisoners.
Downloaded from https://academic.oup.com/ije/article-abstract/38/1/28/699057 by guest on 10 April 2020
References
1
Ackerknecht EH to Sigerist HE, Sigerist Papers. Yale
University, May 20, 1948.
2
Coleman W. Yellow Fever in the North. The Methods of Early
Epidemiology. Madison: University of Wisconsin Press,
1987. p. 187.
3
Baldwin P. Contagion and the State in Europe, 1830–1930.
Cambridge: Cambridge University Press, 1999.
4
Hamlin C. Predisposing causes and public health in
early nineteenth-century medical thought. Soc Hist Med
1992;5:43–70.
5
Rosen G. (trans.). Jacob Henle: on Miasmata and
Contagia. Bull Hist Med 1938;6:907–83.
6
Pelling M. Cholera, Fever and English Medicine 1825–1865.
Oxford: Oxford University Press, 1978.
7
Clark HG. Superiority of Sanitary Measures over Quarantines.
An Address delievered before the Suffolk District Medical Society.
Boston: Thurston, Torry, and Emerson, 1852.
8
Cooter R. Wright P. Treacher (ed.). Anticontagionism and
history’s medical record. The Problem of Medical Knowledge.
Examining the Social Construction of Medicine. Edinburgh:
Edinburgh University Press, 1982. pp. 87–108.
9
Rosenberg CE, Erwin H. Ackerknecht, social medicine,
and the history of medicine. Bull Hist Med 2007;81:
511–32.
10
Ackerknecht EH. The role of medical history in medical
education. Bull Hist Med 1947;21:135–45, 143.
11
Virchow R. Beitrage zur Geschichte der Medizinalreform von
1848. Leipzig: Barth, 1932.
12
Rosen G. What is social medicine? A genetic analysis of
the concept? Bull Hist Med 1947;21:674–733.
13
Rosen G. The place of history in medical education.
Bull Hist Med 1948;22:625.