In Slavery, Disease, and Suffering in the Southern Lowcountry, Peter McCandless offers a well-researched account of the ways in which the wholesale adoption of African slavery and European settlement earned the southern lowcountry a reputation as one of the wealthiest and deadliest regions in North America. McCandless fixes his historical gaze on the impact of malaria, yellow fever and smallpox – ‘epidemiological consequences’ that shaped the social and cultural destiny of the region from the seventeenth century to the antebellum period. Adding to scholarship that addresses slavery, the Atlantic World, and the Old South, McCandless assiduously employs sources from planters, religious missionaries, physicians, colonial elites and foreign visitors to the region, to reveal the diversity in perspectives on disease and suffering as they shaped settlement patterns, medical practice, race relations and economic prosperity in the southern lowcountry.

In Part I, ‘Talk About Suffering’, McCandless presents a compelling case against colonial proprietors who deceptively painted the lowcountry as a paradise to lure white settlers. Only after their arrival were settlers confronted with the realities of the Carolina climate, topography and disease environment. Southern American colonies, as well as the West Indies, earned reputations as places that brought wealth and early death to those who settled there, and as McCandless demonstrates, the Carolinas were no exception. While persuasive in his contention that colonial boosterism led many to an early death (p. 30), he misses the opportunity to link patterns of settlement across British colonial holdings in the West Indies that might have shed further light on the cultural, demographic and epidemiological ties between the whites who settled both regions. The West Indies had already garnered a reputation as a ‘white man’s grave’ and the omission seems odd given that McCandless himself refers to the Carolinas as the ‘northern rim of the Caribbean’ (p. 7).

In Part II, ‘Combating Pestilence’, McCandless excels at presenting the mechanisms employed by physicians and other healers to counteract the increasingly unhealthy environment of the southern lowcountry. He explores the development of Charleston’s medical community and the various ways in which the public grew to understand disease, by drawing attention to the influx of Scottish-trained physicians to the region, professional squabbles over medical treatments waged in South Carolina’s newspapers, and public attitudes towards medical therapies in the face of epidemics. Equally impressive is his discussion of the relationships between white practitioners and enslaved healers and the ways in which residents coped with epidemics – through flight, prayer, ambivalence and resolve. McCandless is persuasive in demonstrating the wide scope of suffering from fevers by situating their effects on white merchants, slave traders, soldiers, Native Americans, missionaries and enslaved Africans. He notes that, though different in their social destinies, few were immune to the ravages of disease.

The strength of this work is its source material. However, there are a few moments interspersed with presentist evaluations of the eighteenth- and nineteenth-century medical armamentarium and standards of care. McCandless’s engagement with the evolution of medical ideas about black and white disease susceptibility is surprisingly limited, considering the vast array of medical sources he uses in his narrative. He argues that whites were convinced of innate constitutional differences between the races, and such beliefs were bolstered by observations of the differential mortality between blacks and whites. However, he does not go any further in exploring the complex ways physicians read constitution, climate and race as factors that interacted with each other in cases of sickness (p. 133). Drawing tighter links between climate and disease environment would have sharpened his discussion of the ways in which the alleged ability of blacks to withstand the climate of the southern lowcountry transformed from a physiological advantage to a medical justification for slavery. While he utilises commentary from sources that noted blacks’ predisposition to ‘pleurisies and peripneumonies’ (p. 126) he does not place those observations within the existing medical framework of the nineteenth century – particularly the belief that blacks were more susceptible to lung diseases than whites. Finally, a critical engagement with the broader nineteenth-century southern medical context and white commentaries on black suffering would have strengthened his claims that racial dynamics mediated perceptions of sickness and health (pp. 128–129). These criticisms aside, McCandless provides an accessible, well-crafted, and much needed perspective on how disease shaped the development of the southern lowcountry’s social landscape.