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Federal Intervention in Health Care is Old News but Not Always Good News

It was the antecedent, the organization that “placed federal officials for the first time in U.S. history in direct and intimate contact with the bodies of ordinary people.” And it was a disaster, a years-long horror show that led to enormous numbers of ghastly deaths.

In an extraordinary work of scholarship published last year called Sick From Freedom: African-American Illness and Suffering During the Civil War and Reconstruction, Connecticut College historian Jim Downs describes the unexpected results of the great accident of American emancipation in the Confederate states, an event ordered as policy, directly caused by military action, and unanticipated as a practical human concern.

In 1865, the federal government created the Freedmen’s Bureau to deal with the mass of emancipated slaves. And it did deal with them as a mass—particularly in the case of the bureau’s Medical Division, which created “the first federal system of medical care,” but left records that describe treating sick freedmen as a problem of economic and military resources rather than a disaster of human suffering. “The government became interested in the health conditions of freed slaves,” Downs argues, “because it wanted to create a healthy labor force.” Holding freedmen for labor assignments, army officials found a useful facility: “antebellum slave pens.”

“When members of Congress and the president considered the possibility that the war would lead to emancipation,” Downs writes, “they discussed it in terms of the economic, legal, political, and social consequences—paying little, if any, attention to the human consequences of emancipation. Where were slaves to live? How would they find adequate food or clean drinking water? What would happen if they became sick or injured?”

Those questions remained largely unanswered in the face of a growing body of refugees. Starving, freezing, inadequately clothed, and ravaged by rampant disease, newly freed slaves left slavery for agony. Per Downs, “tens of thousands of freed slaves became sick and died.” Buy this book and read for yourself about, for instance, the experience of the escaped slave Joseph Miller and his family, who made it to the shelter of the Union army only to find little comfort—I won’t describe it here, and you won’t forget it.

Downs has done something significant for two reasons. First, he has uncovered a vitally important missing piece of a broader historical topic that has been studied extensively, a narrative-smashing act that feels like a miracle of scholarship whenever anyone manages to pull it off.

But Downs has also examined the causes of a stunning piece of human cruelty. The politics of the moment militated against an acknowledgement of suffering and death among freedmen. To give just one example, former slaveowners pointed to the deaths of freed slaves as proof that they shouldn’t have been freed in the first place, in an iteration of the long argument for “Negro incapacity” that saw Scarlett O’Hara telling the freedmen of Tara that they didn’t actually need to starve to death.

To speak urgently about mass death among freed slaves was to arm the defeated South with a useful narrative: See, this emancipation thing really was a bad idea, and so was the war that made it happen. Seeing this narrative as a threat, federal officials tried to conceal it. They minimized reports of mass starvation and fatal disease because they shed light on a bad story, on unfortunate politics.

Several things broke this cycle of misery and death—gradually—and the first is a direct answer to the long-rebuked Dunningite historians, who didn’t live long enough to see it revealed: freedmen organized and petitioned for help, persistently and effectively bringing their condition to the attention of government officials.

“Before the organized crusades for suffrage, freedpeople’s activism focused on access to food, clothing, shelter, medicine, and burials for their family and kin,” Downs concludes.

Former abolitionists joined their effort, amplifying their voices. Freedmen’s Bureau officials pushed relief efforts out and down and gave responsibility to newly reestablished Southern states and communities.

It would be too easy to draw direct, simple parallels between the medical crises of Reconstruction and other incipient crises in federal healthcare management, just in case any incipient federal crises in healthcare management come to mind, but the behavior of governments in the face of crisis is familiar and patterned. See Seeing Like a State: How Certain Schemes to Improve the Human Condition Have Failed for more examples; the immediate needs of real human beings have often fallen behind the curtain of aggregated evaluations and politically loaded considerations.

In the course of formulating and initiating policy, major actors have a disproportionate and distorting influence. But over time, civil society turns the state. Organization amplifies diminished voices. Persistence in speaking moderates institutional stubbornness. Change is a process, not an event.