1.3.5: Social Engineering

The sanatorium and hygienic interventions discussed in this section and the previous one were not isolated (1.2.4; 1.2.5; 1.3.4); medical professionals were also active participants in social engineering discourses. Tuberculosis was not a singular object which could be stopped in the body of a single patient; it was instead an invasive body that reproduced, manifested in different hosts, and presented a threat to a broader social fabric (2.3.2). Seeded in these arguments is a notion of the body politic, which views the health of a community in broad strokes and engineers solutions to address the subject in aggregate. These arguments articulate a pernicious notion of disease by imagining it as foreign aggressor, which if not properly handled could and would invade the bodies of the ruling class. The control of disease was displaced onto the subject themsleves. These patients were blamed for becoming ill, and then blamed for making others sick.

This can be seen most obviously in a report published by the state of Virginia’s tuberculosis commission in 1915. They write,

The careful consumptive, who has been taught not to spread his germs, and who wishes to save other people from his fate, is not dangerous, but on the contrary, is a valuable aid in teaching the important facts relating to tuberculosis. On the other hand, the wilfully [sic] ignorant and criminally careless consumptives spread their disease widely and are more dangerous than mad dogs. In the interest of public welfare, we recommend legislation which will effectually restrain the criminally ignorant and criminally careless consumptives.¹

Personal responsibility became a way to dodge blame for the more pernicious, systemic issues at play; doctors seemed unable to imagine how disease was related to class, environment, and health.² Instead, it was the untrained, uneducated subject who was to blame for their own disease, and then it was the willful refusal of that subject to be made docile that led to the spread of the disease.

Virginia’s sanatorium, and the rhetoric which supported its creation, corresponded to broader governmental and juridical shifts around this same period. Germ theory and the rise of public health brought with it the surveilling gaze of various public actors (1.3.4) and larger scale maneuvers to combat contagious disease. This project often normalized western, white familial and cultural practices by depicting them as clean and safe. As Nayan Shah argues, that public health as it operated on newly established class norms, measured and maintained

a new way of thinking about persons and their lives in the environment and in society. . . . Steadfast regulation of the body, conduct, and living environment became an increasingly crucial practice in guarding against the infiltration of disease. Voluntary associations and local government in the nineteenth century promoted hygienic care and sanitary management as essential to the modern project of ensuring human longevity, maintaining health, and managing the vitality of the population. Nineteenth-century bourgeois economic classes particularly valued the health benefits of self-care and contrasted their enlightened conduct and consciousness with the legions of the working poor and traditional agriculturalists. Their models of proper conduct employed new categories of normal and deviant, which were dramatically defined and invigorated by punitive race and class differences.³

Systems of public health often leveraged judgemental, individualist modes of control and regulation. If the patient could not conform to the regiments of the charity sanatorium, they were either asked to leave or would leave themselves (1.3.4).⁴ If patients used provided charity in a way that was unexpected or seemed otherwise ungrateful, they were chastised. The gaze which is produced in this context is a kind of projection: an imagined pollutant in the form of an uncontrolled body must be disciplined in particular ways to protect the broader public.⁵

There is a slippage here regarding the docile subject and the modes of resistance that are beyond the scope of the current project.⁶ The discourses that surround hygienic thinking implicitly leverage a eugenicist ideology; the people who were blamed for their sickness and for spreading the disease were not the wealthy white subjects who could escape for an idyllic rest cure. Those who were denied care were implicitly blamed for their own deaths, and equally blamed for the deaths they caused by ignoring the guidelines of doctors (1.3.4). The creation of a docile subject, a hygienic subject, a healthy subject, meant the construction of a counter-subject which could be vilified, and through that vilification allowed to die.⁷

This denial of care for tuberculosis patients is a covert eugenicist necropolitics: the unhygienic subject can be allowed to die becaus they endanger the larger white society. I frame it in this way to negotiate Achille Mbembe’s notion of necropolitics—a theoretical framework that examines how undesired populations are made to die through structural negligence (2.2.4)—and link it to the overtly biopolitical framing of eugenics. Biopolitics, as derived from Michel Foucault’s work, stresses the ways the biological body became a political actor in modern societies.⁸ Eugenics as a scientific method born out of evolution is an exemplary example of biopolitical control. Coined by Francis Galton from the Greek work eugenes, or “well-born”, eugenics responded to a series of Gregor Mendell-influenced studies in the ways traits were passed in human reproduction. Harriet Washington gives a succinct summary:

Galton first formulated the desirability of using selective procreation to refine the human race while conquering social dysfunction. This goal was widely embraced on both scientific and popular levels by the 1930s, not only in the United States, but also abroad, and eugenic yardsticks were applied to not only populations but to individuals. Eugenicists proposed that society use medical information about disease and trait inheritance to end social ills by encouraging the birth of children with good, healthy, and beautiful traits.⁹

Eugenicists viewed non-white peoples as being genetically inferior, owing to higher rates of disease like syphilis and tuberculosis, and saw the procreation of supposedly inferior subjects as detrimental to the body politic.¹⁰ The forced sterilization campaigns, born from eugenicist frameworks of human society, were the overt practice of a biopolitical operation.¹¹ The necropolitical valence of these practices plays out in the aesthetics around who is deemed a good patient, and who is denied care because they do not fit that aesthetic ideal.¹²

Important for tuberculosis in the period of this study, was that the undercurrent of the discourses around the disease were centered around the protection of certain populations, be they working laborers or the white ruling class. Returning to Virginia’s 1915 report, this logic can seen explicitly. The authors write,

Since the greatest number of deaths and the greatest number of living cases occur among the negro race, since the relations between the two races are so intimate that a communicable disease affecting the negro must in a grave measure affect the white, since there is not a bed maintained by the State at present for a negro consumptive except in the State Asylum and Penitentiary, we would respectfully urge, for both humanitarian and economic reasons, that a sum of not less than $40,000 be appropriated for the immediate construction of a State sanatorium for the negro consumptive.¹³

Hygiene and public health, as they are constructed in this report, are used to protect a specific race of subjects separate from the Black patients they sought to institutionalize. In the example images shown in the preceding sections (1.3.1; 1.3.2; 1.3.4), the hygienic gaze was one that expressed anxiety over the supposedly unwashed nonwhite, lower-class subject that endangered the lives of the hygienic upperclass by their very proximity. Establishing sickness as a moral failure was a means to give an excuse to why the lower class may be allowed to die.¹⁴ Designating who is clean and unclean, healthy and unhealthy works into an imagined idealization of the subject¹⁵ but there is a secondary engineering at play: the moralization of how one is allowed to live or die. Necropower, as Mbembe writes, functions as such: ”the new technologies of destruction are less concerned with inscribing bodies within disciplinary apparatuses than with inscribing them, when the time comes, within the order of the maximal economy now represented by the ‘massacre.’”¹⁶

The aesthetics of hygiene, and the hygienic gaze articulated in this section, proliferates a deeply eugenicist idea: some patients should be left to die because they are, in the parlance of racist and classist rhetoric, ‘uncivilized’ and thus a threat to the broader social order.