HIST 234: Epidemics in Western Society Since 1600
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Epidemics in Western Society Since 1600
HIST 234 - Lecture 11 - The Sanitary Movement and the "Filth Theory of Disease"
Chapter 1. The Sanitary Movement [00:00:00]
Professor Frank Snowden: This morning we’ll take up one of the themes — that is to say, we’ve described how the course is about specific diseases, but it’s also about a number of overarching themes, and one of those is the development of various public health strategies. So far, as you’ll remember, we’ve dealt with three public health strategies. One was the system of plague measures: sanitary cordons, lazarettos, quarantine, and all the rest of it. We’ve dealt with vaccination as a public health strategy, with regard to smallpox in particular. And we’ve talked about a third policy, if we want to dignify it in that way, and this was the strategy of concealment.
This morning I want to talk about a fourth approach to public health, and this was what’s called commonly the sanitary movement. This was pioneered in Britain in the 1830s and ’40s, and it was then exported to the continent in North America, assuming particular forms in France and Italy, with the actual rebuilding of cities in accord with sanitary principles. Now, the sanitary movement was the first to define itself as a public health movement, and it had two essential meanings for its term. The first was the prevention of infectious epidemic diseases, and the second was the removal of filth. So, it’s based, in a sense, on the relationship of filth and disease. Indeed, many people talk about the filth theory of disease as lying at the basis of the sanitary movement. Its focus, therefore, was on the towns and cities that had sprung up with urbanization and the industrial revolution.
Epidemic diseases disproportionately claimed their victims in the cities, and correspondingly the legacy of lasting effects was especially pronounced in urban areas, and the sanitary movement is one of those lasting legacies. Now, there is a theory that we may as well look at, just for a second, developed by the British physician and demographer, Thomas McKeown — and it’s often called his thesis — where he was dealing with the demographic fact of what he called a mortality revolution; a demographic transition in which cities, for the first time, become places that are dependent for their expansion not only on inward migration to the towns, but on the fact that the longevity and the birthrate come to exceed the death rate; which was something new, a real demographic revolution.
And why was this achieved? Many people have thought and postulated that it was due to medical science, to conscious policy and those sorts of explanations. McKeown instead stresses two factors. He sees this as largely unplanned and due to improved nutrition, but also — and that’s the point this morning — to the role of sanitation. In other words, the population explosion, the demographic revolution, is something that he postulates was due to, not to medical science, but rather to the sanitary movement, and also to nutrition.
Chapter 2. Background [00:04:13]
Well, what was the background to the sanitary movement? We’ve seen and mentioned that there really was a tremendous challenge to health in this period of the industrial revolution in European history. There were tremendous changes afoot in British society. There was the rise of a modern commercial agriculture, and with it enclosure, the driving of peasants off the land. We know about the major demographic growth that was underway by this period, supported by the new agriculture and the fading of the threat of famine and the fading of the threat of plague. There was the rise of manufacture, and then the factory system, especially the textile industry, and the associated and unregulated horrors of things such as long hours, low wages, child labor. You know, too, that across Europe, urban populations doubled in the first half of the nineteenth century, and in so doing overwhelmed the infrastructure of available jobs, the housing stock, sanitary arrangements, and all the rest, so that we see the rise of tenement slums, sweatshops.
There was a mass movement of population from countryside to town, and with that went psychological adjustments. There was a breakdown of older notions of social relations based on paternalism, of the customary notion of a moral economy based on moral obligation. And we see instead the rise of the principles of impersonal relations, of a free-market economy, and laissez-faire, epitomized in the new discipline of political economy, with such figures, of course, as Adam Smith, Ricardo, Jeremy Bentham, Thomas Malthus. The result, along with those transformations, was a rise of new social tensions. We’ve talked about the nineteenth century as the rebellious century.
Now, in Britain, there were no social and political revolutions, nothing comparable to 1789 in France, or to what happened on the continent in 1830, and in 1848 and ‘49. But contemporaries weren’t certain at all that this was going to be a lasting fortune for Britain, and indeed Britain did have a number of signs of severe social tension as well. There were large-scale riots. One could mention the Chartist Movement, and in the countryside the movement known as Captain Swing.
So, urban and industrial centers, also in Britain, were perceived as dangerous, politically, for fear of the so-called dangerous classes who rioted, perhaps committed crime, threatened revolution, and were dangerous medically, as well; that is, they were infected with cholera and other diseases. And it was cholera in particular that was a real prod to action, this new and most feared disease of the nineteenth century. It’s not by chance, then, that the sanitary movement begins in the 1830s and ’40s in Britain, after, that is to say, the first pandemic and the second of Asiatic cholera. And it lasts intermittently down through the First World War.
And this really was a vast movement. It was nothing less than the retrofitting of the urban centers of the nation, with the specific goal of removing filth, because filth was held to be the cause of disease. So, we’re talking about one of the great public works projects of modern history: the establishment of sewer systems, a whole infrastructure of water mains, of waste removal, street cleansing, improved and less crowded housing, the creation of parks and public spaces. We can see that Victorian Britain truly was preoccupied with that combination of excrement and water.
All of this, of course, presupposed as well the emergence of a modern state. It was state power that alone provided the wealth and organizational structures that were needed to carry out this enormous project. And in turn we can see the causal chain working in both ways, because the sanitary movement was a very important factor in reinforcing state power. Its implementation meant that the state now invaded areas of life formerly regarded as private, and appropriated for itself enormous new powers. And the reformers were supported by Protestant and especially evangelical Christian churches.
Chapter 3. Sir Edwin Chadwick [00:10:15]
Well, who were the leaders of this movement? I think we should turn first of all to this man, Sir Edwin Chadwick. This is Edwin, Sir Edwin, in his younger days. This may be a slightly more familiar picture of him, I guess maybe at my age. In any case, Sir Edwin wrote a major work collaboratively — he produced it, let us say — which was called “The Report on the Sanitary Condition of the Labouring Population of Great Britain of 1842.” Now, Chadwick wasn’t a physician at all, and this is part of the background perhaps to the thesis I was mentioning earlier. He was instead a lawyer by training from Manchester. And he was already well known, in particular for his reform of welfare provisions in Britain; that is, he was responsible in large part, for the passage, from the old poor law, which had provided relief as the birthright of every citizen in distress; that is, the right to some form of assistance or aid in time of distress.
Chadwick’s idea was to economize, to minimize the cost of payments, to discourage the poor from applying for relief. He wanted to make the experience of receiving relief more painful than the experience of distress itself, a principle that was dubbed “the principle of least eligibility.” The workhouse, in other words, was to be a place of punishment, of pain and of suffering. So, work should be, in the workhouse, more unpleasant than any to be found in the labor market. And the diet should be intentionally made to be loathsome, more so than what could be found by the poor outside. The poor law bureaucracy was also invoked, and was an essential foundation of the information on which Chadwick relied for the sanitary report of the laboring population of Great Britain.
This was the man who was the same in both faces, with the new poor law and with the sanitary report. The sanitary reform was also a stark assertion of state power as a means of social control. The intention was to discipline and civilize the working classes in the interests of social stability. Following in the wake of the report was the establishment of a Public Health Act of 1848 in Britain, and a general Board of Health, and such champions of sanitary reform as John Simon, Thomas Southwood Smith and Neil Arnott.
Now, let’s talk for a minute about this man’s ideology and his intentions. This was a class-based movement. It was top-down and centralizing. In Chadwick’s mind, the poor were largely responsible for their own plight. They weren’t innocent, and they certainly weren’t harmless. His mission was to cleanse and civilize the dangerous classes. As I said, he wasn’t a physician, and his reforms were not based on any new medical discoveries, on scientific experimentation or observation to determine what measures were most effective by determining the causes of disease. His reform measures, enormous as they were, were based more on what was the commonsense of the period and a priori assumptions.
Public health, in this way, was separate from the development of medical science. His view — and this was widely accepted — was that medicine was about private persons, not so much public policy. And his idea was to use public policy to cleanse the urban environment, but not to deal with other social and economic determinants of disease. We’ll talk about that in a moment. We need to think about not only about what Chadwick wanted to do, but we also need to think about what he decided not to do, what wasn’t important to him. And so we should see this as progress, yes, but progress that came at a cost, and we want to know about that as well.
Now, an influence on Chadwick’s thinking was “The Essay on Population” of Thomas Malthus, who believed that there was a law that in every society population pressure sooner or later pressed against the limits of subsistence. So, real improvement for the poor was likely to be illusory, short-term, and perhaps counter-productive. In the long run, really significant improvement couldn’t occur, according to Malthus. It might even be self-defeating, leading to disease, starvation and war, those great positive checks on population increase. That idea of the limited nature of possible improvement was in Chadwick’s mind; the poor will always be with us.
There was also, as I said, the filth theory of disease. We know it. We’ve talked about miasma and its long history in European thought. Well, filth now was associated very closely with smell. And if you are to read the report at some point, you would notice that smells constitute an important part of the report. The report is filled with descriptions of stench. The authorities consulted by Chadwick frequently used phrases such as, “I was assailed by a most disagreeable smell, and it was clear to me that the air was full of most injurious malaria.” By malaria, that’s another word that occurs throughout the report. And we should note that before malaria came to mean a specific disease, it meant “bad air,” from the Italian mal’ aria, bad air.
And, so, this report, in Britain in the 1840s, is filled with descriptions of what they called malaria. Let me give you an example from the town in the West Country of Truro. Reporting to Chadwick, the reporting official said, “Passing into St. Mary’s Parish, the proportion of sickness and deaths is as great as any part of Truro. But there’s no mystery at all in the causation. Ill-constructed houses with decomposing refuse, clothes upon their doors and windows, open drains, bring the oozings of pigsties and filth to stagnate at the foot of the walls. Such are a few of the sources of disease, which even the breezes from the hills cannot dissipate.”
Everywhere the reports discovered disease, and they correlated the disease with such findings as poisonous vapor, morbific effluvia, filth, obnoxious effluvia, poisonous exhalations, miasma and malaria. The moral of the texts of those conditions also preoccupied those who took part in the report. Vice, alcohol, intemperance, and then more poverty, and still worse, more filth. Poverty was partly the result of depravity and improvidence, and those in turn reinforced more poverty and more filth.
Well, there was a political aim behind the sanitary reform, and I think we might call this a transformation that Chadwick was aiming at in the demographic composition of the British population. In Chadwick’s mind, trade unions, which he abhorred, demonstrations, strikes, the Chartist Movement, and all the rest, were called by Chadwick “wild and dangerous assemblages.” But he noted that they were mainly led by the young. Older, experienced workmen, with family responsibilities, he found to be moderate and temperate, and not to take part in strikes and social unrest. Therefore a high early death rate, and poor sanitary conditions, were actually politically destabilizing, at least in his mind, because they led to the early death of workmen, and hence to an overrepresentation of the dangerous young, and an under-representation of moderating older workmen.
If we want to understand and explain this view, perhaps we could invoke an anachronism, to make an analogy. And we could use the analogy of a nuclear reactor, and compare social unrest to a meltdown of the reactor core, with disastrous consequences. Well, in terms of the reactor, to prevent such events reactors make use, as you know, of boron control rods that are inserted to control the rate of fission of uranium and plutonium, and to limit chain reactions. In this way, what Chadwick wanted to do, by analogy, was to use older people like control rods that would have the calming effect of preventing social meltdown and social revolution. But to do that you had to do something about infectious diseases, to achieve this demographic transformation of the population.
So, if infectious disease was destabilizing for the state and political order, a population subject to infectious disease moreover is unlikely to be educated and to be open to the moral influence of the clergy. And the absence of cleansing in towns, Chadwick felt, would lead also to demoralization and further depravity. Now, in all of this thinking, let’s remember too at what was lost. A striking feature of Chadwick’s view was the narrowness of its focus. The cause of ill health in Victorian Britain — I think we should say not the cause — the causes were undoubtedly multiple, and one could think about low wages, unregulated factories, inadequate diet, poor clothing, lack of education, working conditions in sweatshops, mines and factories, child labor, overcrowded housing. These I would call social and economic determinants of disease. And there were voices, particularly on the continent, for an alternative public health that would address precisely such broad interests.
Chapter 4. Social Medicine [00:23:27]
There was an older tradition of what was called a “medical police” on the continent, and a current of thought of what was called “social medicine”, whose most prominent figure was this man, Rudolph Virchow, a Prussian physician who lived from 1821 to 1902, and was one of the great figures of nineteenth century medicine; a physician, anthropologist, biologist and radical politician. Now, his view was that disease was not simply a biological event, but a socially driven phenomenon. And his meaning of the term “social medicine” was that physicians should treat not just individual patients but entire societies, and that they should pay great attention to matters of the economy, to diet, wages, housing, child labor, working conditions.
Virchow was, in a sense, the anti-Chadwick. Chadwick’s intention instead was to focus on the narrow issue of filth and water, and his attention was confined to the working classes and the filth in which they lived. At stake was the issue of how broad should a public health movement be? And perhaps one could say that one of the sad features of the period was the triumph of the narrowest gauge vision of public health. The solution, in Chadwick’s hands — and this was a major event in public health, there’s no doubt about it. I’m trying to say — not that this was unfortunate — it was only unfortunately narrow. Chadwick’s solution involved technological measures, all good in themselves: drains, sewers, water pipes. But they didn’t include social, economic and educational reform. And the reforms all came from above, and reinforced a centralizing state, rather than finding ways to empower ordinary people to participate in defending their own health.
Let me give you an example of a simple technological improvement. It might be hard to recognize when you first look at it but — and I’m talking about some very humble movements that have enormous political and medical consequences. What we’re looking at is a sewer main, and these were established under the soil of cities in this period, and one of the technological inventions was to make the sewers egg shaped, so that you would maximize the flow and they would be self-cleaning and they would drain most efficiently. So, technological innovations of that sort were part of it.
Now, the victory of Chadwick’s vision of public health wasn’t simply automatic, and so it was worth to keep alternatives in mind. His side was the winning side in a debate of the early nineteenth century, and a wider view, like that of Virchow, was present, but lost the debate. Let’s be clear in summation. I’d argue that Chadwick’s vision of public health was highly successful, that it was a crucial part of the mortality revolution of nineteenth century Europe, but that at the same time something was lost, a broad vision of the causes of disease, and those causes weren’t addressed.
Although what Chadwick achieved was a major and positive advance, it perhaps fell short of what might have been, and it demonstrates the practical and positive impact of miasmatic theory. And public health, a theory — and this is perhaps something we ought to bear in mind — that a theory that is by now rejected — that is miasmatism, the filth theory of disease — did operate in such a way as to promote major and positive health results. And one of the causes of this movement was the epidemic disease that we dealt with the last couple of times, and that is Asiatic cholera. We might note there was a sidelight that may be of interest as well; that this sanitary movement, the literal sanitary movement, was accompanied in some places by what we might call a figurative sanitary movement, and that is moral sanitation. And one of those was particularly notable in France where there was a great fear of another disease, that we’ll be talking about slightly later in the course, and that is syphilis.
Remember, the early nineteenth century, we’re dealing with the period in the wake of the Napoleonic wars. And with those wars, as always happens — or happened — there was a major upsurge in socially transmitted diseases, and in particular syphilis. And so this sanitary movement was accompanied by the movement for moral sanitation through the registration and surveillance of prostitutes. And in France those responsible for moral sanitation actually made the link explicit; that is to say that they compared brothels with sewers, and said that they, the brothels, should become the target of sanitation. So this was a form of moral sanitation that was an offshoot of the literal sanitary movement that is our main theme.
Chapter 5. Rebuilding Cities and Urban Planning: Paris [00:30:25]
The sanitary worldview led also on the continent to further offshoots, and that — I want to talk now about a continental form of the sanitary movement, the rebuilding of cities in their entirety. This was actually much more comprehensive and systematic. It means urban planning. It’s more comprehensive than what happened in Britain, which was the retrofitting of cities with sewers and drains and sanitary provisions. It entailed the actual leveling of whole cities, or neighborhoods within them, to start afresh, in accordance with a comprehensive plan.
There were a number of prototypes. In France, Paris, Lyon and Marseilles. In Belgium, Brussels. In Naples — that is in Italy, there was Naples, as you know, but also Florence, La Spezia, and other places. But let’s begin in Paris, because that established the pattern. Here again we see the influence of epidemic cholera, which ravaged Paris in the 1830s and again in 1849. And this caused an enormous psychological shock, the idea that civilization was no sure-fire protection against sudden and agonizing disease. There was an unbearable contradiction that a city, that is Paris, that prided itself at being at the heart of European intellectual life, at being the leading city in the arts and culture, a world center, as you now know, of scientific medicine, could nevertheless be devastated by a disease that was associated with poverty, with filth, and with the colonial world.
Well, after the revolutions of 1848 to ‘49, we have a reactionary and authoritarian regime established by Louis Napoleon Bonaparte, or Napoleon III, that soon became the Second Empire, that lasted from 1851 ‘til 1870. There’s Napoleon III. He undertook a major movement to rebuild Paris. And I want to argue that this had enormous sanitary consequences, intentionally so, and that the experience of epidemic cholera was very important in the establishment of that. But I don’t want to say that the rebuilding of Paris was solely designed as a health measure, and solely to prevent the return of cholera. There were other gains as well.
Napoleon III wanted imperial splendor. He wanted a city that would be worthy of the role of France in the world, that would be a showcase for his new political regime. He too was thinking about social control. So, there was a political aim; that was, to destroy the working class slums that had been the sites of rebellion. The idea was to use urban renewal to remove workers from the center of the city to distant suburbs, and in the center to construct wide boulevards that could not be defended by barricades, and that the troops could use to move quickly across the cities, and cannonballs could fire down the boulevards to demolish barricades. In other words, Paris was to be made revolution-proof, or at least that was the goal.
It was also a project of public works; that is, it was a means of enormous patronage. It would provide employment and would defuse social tensions as well. So, Paris, under Napoleon III, became a vast public works project, enormous shovel-ready projects. The workers of Paris then would be employed and therefore largely pacified. It was thought that this would also have an economic role. The new boulevards, the wide spaces, would facilitate the movement of goods and assist free trade and commerce. And then there was the public health objective: to improve health, to prevent the return of infectious epidemics.
The task was entrusted to this man, Georges Haussmann, the Prefect of the Seine. And often what was accomplished is referred to as the “Haussmannization” of Paris, with the so-called great works, or grands travaux, that were undertaken from 1852 until 1870. Now, this project was authoritarian. The rights of individuals were disregarded. The population was not consulted about being moved, and it was an operation of colossal complexity. All of the affairs of one of the greatest cities in France, the great city in France, were gathered into a single pair of hands: finance, administration, transport, sanitation, engineering, architecture, evictions, expropriation of land by eminent domain, slum clearance, gas fixtures and lighting, sewers. All of this was an enormous assertion, then, of state power. The means were broad intersecting boulevards.
Let me show you the sorts of plans — were to have the great boulevards of Paris, that you can see today — such as the Rue de Rivoli, Boulevard de Strasbourg, Sébastopol, the Boulevard Saint-Michel. The average size width of a street in Paris was to be doubled, and underneath the streets there were to be sewers and drains. There was to be water supply, and there were to be broad parks and public spaces, such as the Bois de Boulogne. The aesthetics were the aesthetics of the straight line. We can see that there. We can see it also here. And you can see the intersection of these broad boulevards, and you can see how these were multi-purpose and would allow not only — part of the idea was the miasmatic one, that they would allow air and light to sweep through the city and remove the noxious smells, and purify and cleanse the city. And you can see as well that they would be good for commerce and for social control.
So, Paris, after Haussmann, was clearly much healthier as a city than before, and cholera did not return thereafter to the city center. But there is an irony here, that cholera did return, less vehemently than before. But in the 1890s it did return, but not to the center of the city. In other words, part of the sanitary problem of Paris was not entirely solved, but was exported to the suburbs, and it was the suburbs that experienced the return of cholera in 1892. We have to see this as an enormous sanitary success, but one that we ought to qualify. Let me look at — let’s look — this is a map — a picture of the demolition, to convince you of what a major undertaking this was. And there’s a view of the new open spaces, cleansed with light and air, and germ free. And also in Napoleon III’s mind, it would be also — make revolution much more difficult. Well there was — the political success, as well as the sanitary — was a success but one that needs to be qualified.
There was an enormous resentment among the working people of Paris at Haussmann’s project, and there was an enormous history from that time down to nearly our own of hostility of the suburbs. Paris becomes, not by chance, surrounded by a red belt of concluding hostility to the regime, and this exploded in the spring of 1871 in the Paris Commune that brought down the regime and led to the establishment of a republic. So, there are also political qualifications.
Chapter 6. Naples [00:40:51]
Well, I’ll move then to another example very quickly, and one that is in the reading, and that is the Italian version, and in particular the risanamento of Naples, which was Italy’s largest city.
As you know, there was a massive epidemic in the city — this is the plan of risanamento in Naples — and as you know, it led to the idea — and here is something that is actually unique; that is to say that we’ve talked about the retrofitting of British cities and also American ones. We’ve talked about the rebuilding of Paris. Those were associated with a variety of disease experiences, and they had purposes other than a single disease. One can’t see the retrofitting of British cities as due solely to epidemic cholera, nor the rebuilding of Paris. Here in Naples we have something that’s unusual and probably unique, which is the actual rebuilding of a major European city for the specific purpose of preventing the return of cholera. And the way that the plan was developed reflected the specific medical understanding of the time of the cause of cholera. And we see here too a form of the filth theory of disease.
The rebuilding of Naples was for this single purpose, and the medical theory behind the rebuilding project was specifically the miasmatic theory of this physician from Bavaria, Munich in particular, who is Max von Pettenkofer, who had an enormous influence on public health. And one aspect of his influence was that his theory lay at the basis of the rebuilding of Naples. He developed the most sophisticated of miasmatic theories in the nineteenth century and was aimed — the aim then behind the rebuilding of Naples was to thin out the population. Overcrowding was a cause of disease, and poisonous vapors arising from underneath the city poisoned the air, people breathed in the poison and succumbed to cholera, in Max Pettenkofer’s view.
The purpose of risanamento then was first of all to raise the level of the streets; that is to say, the danger and the miasma was, if we like, fermenting beneath the streets of the city. So, you want to place a greater distance between the population living above and the poisonous effluvia arising from below. And, so, the aspiration was to raise the level of the streets to the second storey of the houses. And there would be, if you like, then a massive cushion, including the mortar of the streets themselves, between the population of the city and the danger lurking in the groundwater beneath the soil.
In addition, the idea was that you would have Naples — there’s a picture of the old city that’s — in various aspects — that’s been demolished; and here what I wanted to show was this, the great access at the center; and then there were various cross streets. The great boulevard at the center was in the direction of the prevailing wind, and it was called a bellows of fresh air that would allow the wind to rush through the city, drying up the effluvia and blowing away the stenches and allowing the sunlight to reach ground level, and then it would be crossed by a series of wide boulevards as well. And then under the — if this happened above ground, there would also be work going on beneath, and you would have a whole sewage mains being built under the city.
So, risanamento, this enormous project, both above and below ground, was related — it was a cousin of the sanitary movement in Britain. It was a first-cousin of the rebuilding of Paris and Lyon. But it was distinctive too, because it’s the only example of a project conducted exclusively for the purpose of defeating a single disease, and that was cholera. Was it a success? Well, Naples was rebuilt. And there’s no doubt that the health of the city thereafter was greater than it had been before. But unfortunately there too there were qualifications. The rebuilding was marred, marred perhaps partly by the flaws in its conception from the outset, but marred also by the fact of corruption and the misuse of the funds that were used to carry it out.
And, so, we see thereafter that although Naples was rebuilt in the aftermath of 1884, that there was a return of cholera, a major epidemic again, in 1911. And there was even a small coda to that, which is another outbreak, even in 1973. So, the irony and conclusion. The sanitary movement in Britain, retrofitting of cities, the rebuilding of cities in France, therisanamento in Naples, did achieve major success. But it’s worth remembering that they often weren’t based on a medical theory that was to endure. And indeed in the case of Naples, it was a medical theory that very soon after the rebuilding was to be discarded.
No sooner had Naples been rebuilt than the theories of Pettenkofer were overturned, with the coming of the germ theory of disease. So, when we’re — one of the questions we ask, then, was the lasting impact of epidemic diseases. And I would argue that one of the senses of lasting impact is one that’s embodied in bricks and mortar, in urban planning. And if you visit these cities, then you can see the lasting legacy of epidemic disease in the urban landscape itself.
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