BIOPOLITICS AND THE INFLUENZA PANDEMICS OF 1918 AND 2009 IN THE UNITED STATES: POWER, IMMUNITY, AND THE LAW by Alina B. Baciu Master of Public Health, 1996, Loma Linda University Bachelor of Arts, 1993, Pacific Union College A Dissertation submitted to The Faculty of Columbian College of Arts and Sciences of The George Washington University in partial fulfillment of the requirements for the degree of Doctor of Philosophy August 31, 2010 Dissertation directed by Andrew Zimmerman Associate Professor of History and International Affairs The Columbian College of Arts and Sciences of The George Washington University certifies that Alina Beatrice Baciu has passed the Final Examination for the degree of Doctor of Philosophy as of May 3, 2010. This is the final and approved form of the dissertation. BIOPOLITICS AND THE INFLUENZA PANDEMICS OF 1918 AND 2009 IN THE UNITED STATES: POWER, IMMUNITY, AND THE LAW Alina B. Baciu Dissertation Research Committee: Andrew Zimmerman, Associate Professor of History and International Affairs, Dissertation Director Sara Rosenbaum, Harold and Jane Hirsh Professor of Health Law and Policy, Committee Member Joel C. Kuipers, Professor of Anthropology, Committee Member ii © Copyright 2010 by Alina B. Baciu All rights reserved iii Acknowledgments I have been a public health policy researcher at the Institute of Medicine (IOM) of the National Academy of Sciences since 2001, and have benefited not only from the Academy’s financial support for continuing education, but also from the intellectual processes used in the course of my work. While writing the dissertation, some disadvantages of being a non-traditional student were at least partially ameliorated by a professional milieu that requires deeply researched and analytical writing, and rigorous processes of external peer review. I am grateful to my IOM division director, Rose Marie Martinez, and to Kathleen Stratton and other colleagues whose unwavering support, friendship, and sympathetic understanding for my sometimes irregular work schedule and competing demands on my time were important contributors to my ability to finish this dissertation. Scholars Elena Nightingale, Ronald Bayer, Josef Gregory Mahoney, and Howard Markel provided valuable guidance and constructive criticism at various points in the writing of my dissertation. My dissertation director, Andrew Zimmerman, offered ongoing intellectual support and wise advice, and was instrumental in helping me to return to the dissertation after a leave of absence and to bring the dissertation to the level of a more fully realized work. I was fortunate to have a terrific interdisciplinary committee and outside readers, and I thank Sara Rosenbaum, Joel C. Kuipers, Amir A. Afkhami, and Ellen K. Feder for their thoughtful and thought-provoking comments and suggestions. The blending of expertise and perspectives in philosophy, public health law, iv history, and anthropology strengthened and enriched my understanding of and engagement with my research topic. I thank my family, especially my parents and mother-in-law, for their love, patience, and faith in me. I have been inspired by my father’s life-long pursuit of knowledge and my mother’s achievements in her second career. Finally, I owe a debt of gratitude to Bill Buchman, who lived the dissertation-writing process with me, and to our three-year-old daughter who once said: “Mommy, come! Computer will wait.” v Abstract of Dissertation Biopolitics and the Influenza Pandemics of 1918 and 2009 in the United States: Power, Immunity, and the Law There is a point at the furthest reaches of the hypothetical pandemic influenza spectrum that is marked by a combination of greatest scarcity of medical resources and maximum disease severity. A severe pandemic was one of the two scenarios considered by U.S. federal government planners in their 2005 pandemic influenza plans, and it was modeled on the conditions of the 1918 pandemic and especially the experience of cities like Philadelphia, where hospital morgues ran out of room and bodies were stacked in hallways. Bruno Latour has shown that the line that distinguishes great epidemics and wars is vanishingly fine. And this is not simply due to their existential weight, but also due to the discourses, power effects, politics, and societal responses they generate. “Can war really provide a valid analysis of power relations, and can it act as a matrix for techniques and domination?” Although acknowledging that power relations cannot be confused with the relations of war, Foucault answered his own question affirmatively in his January 21, 1976, lecture at the Collège de France. “[W]ar,” he asserted, “can be regarded as the point of maximum tension, or as force-relations laid bare.” This dissertation represents a partial genealogy of the “clinical gaze” of public health (or social medicine, as Foucault called the field) at two points in the history of humanity’s perpetual war against microbes and in the history of modern biopolitics: the 1918 and 2009 influenza pandemics. The vi pandemics are my two central case studies, though the broader context matters greatly— World War I in the case of the first pandemic, and decades of public health ‘preparedness’ for bioterrorism (inflicted by either humans or Mother Nature) in the case of the second pandemic. I use a range of sources, from archival correspondence and letters, to the medical and scientific literature of the respective periods to inform me about the functioning of the biopolitical apparatus, i.e., the American public health system, during the pandemics. The theoretical framework for the dissertation consists of three related concepts from the works of Michel Foucault, Giorgio Agamben, and Roberto Esposito that enable an analysis of the biopolitics (the calculated management of life) in contemporary American society. War, military and medical, is the common thread that runs through both pandemics—war as an immune or even autoimmune reaction of the body, the political body, and the State against its microbial or human Others (immigrants, the poor); war as the impetus for the state of exception that suspends the rule of law (e.g., of civil liberties, of separation between civilian and military elements); and war as a power effect of increasingly penetrating and multi-layered knowledge about the population and the internal and external threats to its health. Given the hybrid provenance of the public health field, I draw on a dense matrix of disciplines: on the one hand, law, ethics, microbiology, and epidemiology, and on the other hand, philosophy, history, and the human sciences approach to analyzing the public health field, its discourses, and its functioning. vii Table of Contents Acknowledgments........................................................................................................ iv Abstract of Dissertation ............................................................................................... vi Table of Contents ....................................................................................................... viii List of Figures .............................................................................................................. ix List of Tables .................................................................................................................x Chapter 1: Introduction ..................................................................................................1 Chapter 2: Theory ........................................................................................................37 Chapter 3: Public Health and the 1918 Influenza Pandemic .....................................109 Chapter 4: War on Two Fronts: Epidemics and the Military.....................................197 Chapter 5: The Twenty-First Century Influenza Pandemic .......................................251 Chapter 6: Conclusion................................................................................................304 Bibliography ..............................................................................................................313 Appendix A: Sources and Archival Research ............................................................334 Appendix B: Contemporary Pandemic Definitions ...................................................342 viii List of Figures Figure 2.1 …..................................................................................................................... 74 ix List of Tables Table 3.1 ….................................................................................................................... 113 Table 3.2 ….................................................................................................................... 117 Table 5.1 ….................................................................................................................... 276 Table B.1 …....................................................................................................................343 x Chapter 1: Introduction The term biopolitics has been used by Michel Foucault and others to denote the calculated management of human, or more precisely, biological life. This phenomenon is decidedly modern, but draws on an ancient dialectic—the power interchange between the Sovereign (first a monarch, later the State) and his subjects in matters related to life, health, and corporeality, whether individual or collective. 1 Although the State began to concern itself with demographic and mortality data