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Southern Spaces
A journal about real and imagined spaces and places of the US South and their global connections

Putting the Hospital into Southern Hospitality

Duke University
Published October 10, 2011


Peter H. Wood reviews Peter McCandless's Slavery, Disease, and Suffering in the Southern Lowcountry (Cambridge: Cambridge University Press, 2011).


Slavery, Disease, and Suffering in the Southern Lowcountry, Cambridge University Press, 2011.
Slavery, Disease, and Suffering in the Southern Lowcountry, Cambridge University Press, 2011.

In a few days, well before the first mosquito-killing frost reaches the South Carolina Lowcountry, I’ll head to Charleston for a conference. I look forward to the visit, and I expect to return home in good health. As medical historian Peter McCandless comments reassuringly about the region, “It is now, as it once was, a relatively healthy place.”

Six centuries ago, well before the Columbian Exchange began, small bands of indigenous inhabitants enjoyed the bounty of the Sea Island region. Safely isolated from such Old World sicknesses as influenza, smallpox, malaria, and yellow fever, they migrated seasonally to take full advantage of the coastal abundance. Nowadays, other seasonal migrants, the tourists who step ashore at Charleston’s Union Pier Terminal, are more likely to become sick aboard their crowded cruise ship than when they stroll down Meeting Street.

It is the troubled generations between the pre-Columbian past and the post-Pasteur present that occupy McCandless, who taught history at the College of Charleston from 1974 until his retirement in 2008. His well-written and suggestive new book, Slavery, Disease, and Suffering in the Southern Lowcountry, is as engrossing as it is grim. He argues convincingly that during the eighteenth and nineteenth centuries the Lowcountry proved “the deadliest disease region on the North American mainland,” especially in the summer and fall. “Carolina is in the spring a paradise,” commented a German visitor, “in the summer a hell, and in the autumn a hospital.” As an Atlantic proverb put it: “Those who want to die quickly, go to Carolina.”

“Having lived in Charleston for many years,” McCandless writes at the outset, “I was vaguely aware that the Lowcountry had once been an unhealthy place. But only immersing myself in the eighteenth- and nineteenth-century sources brought home to me just how unhealthy it had been.” In turn, he brings that realization home vividly to his readers. He puts “hospital” back into the traditional notion of South Carolina hospitality, since colonial Charleston proved so welcoming to new maladies. The busy port soon became, in the author’s apt image, “a convention center for diseases of the tropical and temperate world.”

Map of Charleston, South Carolina and the South Carolina Lowcountry, 2011.
Map showing Charleston and the South Carolina Lowcountry, 2011.

Indeed, his dilemma becomes which stars to feature at this crowded convention. Malaria and smallpox earn extensive and informative chapters. Cholera, in contrast, receives no such spotlight, since it “did not arrive in the region until very late in the story, in the 1830s, and did not have the impact it had on highly industrialized and urbanized regions.” Other menaces, such as typhoid, typhus, measles, diphtheria, mumps, scarlet fever, and whooping cough “were no more common in the Lowcountry than in other parts of America,” so they remain off stage for the most part, “although they formed a part of the overall disease matrix.”

With yellow fever, on the other hand, a good case can be made that it first earned its name in South Carolina before 1750, and McCandless gives it a keynote role at the convention. When yellow fever receded from northern port cities after 1800, “Charleston proved to be a better host than those places,” McCandless quips, “in part because it was warmer and closer to centers of endemic yellow fever in the Caribbean. No other disease,” he adds, “became so identified with the city and so influenced its lifestyle, image, and culture.”

But McCandless does more than provide sound and accessible medical history. He adds an important social and economic twist. The knot that he deftly ties between slavery, disease, and the Lowcountry environment has devastating and lasting implications that stretch far beyond South Carolina. McCandless is quick to absorb and ponder the irony that the continent’s least healthy place swiftly became its wealthiest. Rice, indigo, and then cotton yielded huge profits to a tiny minority of intermarried merchant and planter families, while “most of the population experienced pestilence without prosperity.”

The implications would be disastrous, and we are finally attaining enough distance and perspective to begin to fathom the full enormity of the devastating chain of events. The proprietary colony of Carolina, chartered in 1663, had its immediate origins in the counter-revolutionary and deeply conservative English Restoration. Its initial plan for government, the Fundamental Constitutions, endorsed slavery and feudal hierarchy. Moreover, several of the original proprietors had a direct stake the Royal Africa Company, a new monopoly granted by the financially and morally challenged Stuart monarch, Charles II, to make money buying and deporting enslaved Africans.

This initial mix proved fatal, both literally and figuratively. Within a generation, the West African rice growing skills documented by such scholars as Daniel Littlefield, Walter Hawthorne, Judith Carney, and Edda L. Fields-Black had taken hold in the coastal swamps near Charleston. Fortuitously for some and disastrously for others, this enormously profitable staple took hold during the so-called “Terrible Transformation,” the decades before and after 1700 when racial slavery went from being a marginal practice in Britain’s New World colonies to a thoroughly codified and sanctioned way of life.

But the same enslaved Africans who introduced rice culture brought with them a virulent strain of falciparum malaria, and as they cleared swamps for expanded rice production they expanded the breeding grounds for the mosquitoes that spread the disease. The colony had an enslaved black majority by 1708. In a vicious downward spiral, greater rice profits led to more African slaves, who were obliged to open up more stump-filled and mosquito-infested swamplands.

James Gathany, A female Aedes aegypti mosquito plays a key role as a vector for the Flavivirus, "yellow fever," a disease that left its mark on Charleston. Courtesy of the CDC Public Health Image Library, #9256.
James Gathany, A female Aedes aegypti mosquito plays a key role as a vector for the Flavivirus, "yellow fever," a disease that left its mark on Charleston. Courtesy of the CDC Public Health Image Library, #9256.

Ironically, these African workers had a comparative resistance to falciparum malaria, as McCandless explains succinctly, due both to inheritance of the sickle cell (Hemoglobin S) gene and the limited but important malarial immunity that comes from frequent exposure. Europeans, migrating from a different disease zone outside the tropics, suffered more than Africans from malaria. The wealthiest white elite, who could afford to escape the sickly summer and fall seasons, soon learned to relocate annually—escaping first by sea to healthier, cooler Rhode Island and later vacationing inland or at coastal estates where ocean breezes limited the presence of mosquitoes.

But these same capitalists also learned to dissemble, to themselves and others, about health conditions in South Carolina. Better than any predecessor, McCandless lays out this litany of subtle self-deception. To induce migration, foster trade, and maintain morale, publicists and doctors downplayed the region’s sickliness, convinced that high mortality was worthwhile, at least for the few in control, since the economic profits could be so enormous.

McCandless infers that as this unhealthy combination of economic greed and denial of medical realities became an ingrained perspective, the myopia regarding medical sickness increasingly bled into denial about the savage abuses and injustice of race slavery itself. By the 1850s, South Carolina’s pro-slavery “fire-eaters” in Congress proved so uncompromising that (not unlike present-day ideologues) they would be willing to tear the Union apart to defend their cherished beliefs and “way of life.”

The stool that McCandless has constructed so convincingly rests on three strong legs. He would be the first to acknowledge that four decades ago, when he arrived in Charleston, little was known about

  1. early South Carolina slavery,
  2. epidemic disease in the region, and
  3. the distinctive environment of the Lowcountry.

In those days, black South Carolinians, enslaved or free, played little role in the state’s official past, and medical history, there and elsewhere, was too often written as the story of venerable and clever white practitioners.

At least in these two fields—slavery studies and medical history—there was a long trail of prior commentary that could be examined and reworked. Granted, much of it fell far short, but some earlier projects had made suggestive contributions. (McCandless rightly acknowledges, for example, the perceptive study on malaria in early South Carolina written by a pioneering Charlestonian, St. Julien Ravenel Childs, in 1940.) But the same cannot be said for the third field, environmental history. Granted, in 1929 historian Ulrich B. Phillips started Life and Labor in the Old South with the comment: “Let us begin with the weather, for that has been the chief agency in making the South distinctive.” But it would take more than half a century to rise from that truism to Albert E. Cowdrey’s seminal regional survey, This Land, This South: An Environmental History, published in 1983.

Current students of southern history continue to wonder why the growth of environmental awareness has taken so long, and why many southerners still seem so slow to acknowledge the centrality of the environment in shaping the past, present, and future of human affairs, both locally and globally. As far back as the early sixteenth century, the Italian-born French explorer Verrazano marveled at “la ‘mousse espagnole’” hanging in tree branches along the Carolina coast. But it has taken almost five hundred years for serious environmental scholarship to take hold in the American South. The first contribution of this emerging environmental historiography has been to underscore that wide area’s obvious ecological diversity. Numerous distinctive ecological regions compose the broader section of the nation known as the South, as this study of South Carolina’s coastal parishes illustrates. Each one—from the Virginia Tidewater and the Florida Keys to the mountains of North Georgia and the Balcones Fault in East Texas—has its own complex past.

In short, much has changed over the last forty years to make possible McCandless’ vivid book. The many scholars who appear in his detailed footnotes have, collectively, pushed forward these three fields, and nudged them closer together. But until now, few authors have been able to intertwine the economic, medical, and environmental threads so successfully. One recent exception who managed to set the bar high is William Dusinberre, author of another fine Lowcountry study entitled Them Dark Days: Slavery in the American Rice Swamps (New York: Oxford University Press, 1996). McCandless has cleared that same bar with apparent ease. We can only hope that their impressive works inspire more such compelling interdisciplinary studies, for the Lowcountry and beyond.