WEBVTT

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Prof: This morning we'll
take up one of the themes--

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that is to say,
we've described how the course

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is about specific diseases,
but it's also about a number of

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overarching themes,
and one of those is the

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development of various public
health strategies.

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So far, as you'll remember,
we've dealt with three public

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health strategies.

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One was the system of plague
measures: sanitary cordons,

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lazarettos, quarantine,
and all the rest of it.

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We've dealt with vaccination as
a public health strategy,

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with regard to smallpox in
particular.

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And we've talked about a third
policy, if we want to dignify it

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in that way, and this was the
strategy of concealment.

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This morning I want to talk
about a fourth approach to

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public health,
and this was what's called

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commonly the sanitary movement.

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This was pioneered in Britain
in the 1830s and '40s,

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and it was then exported to the
continent in North America,

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assuming particular forms in
France and Italy,

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with the actual rebuilding of
cities in accord with sanitary

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principles.

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Now, the sanitary movement was
the first to define itself as a

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public health movement,
and it had two essential

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meanings for its term.

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The first was the prevention of
infectious epidemic diseases,

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and the second was the removal
of filth.

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So, it's based,
in a sense, on the relationship

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of filth and disease.

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Indeed, many people talk about
the filth theory of disease as

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lying at the basis of the
sanitary movement.

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Its focus, therefore,
was on the towns and cities

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that had sprung up with
urbanization and the industrial

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revolution.

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Epidemic diseases
disproportionately claimed their

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victims in the cities,
and correspondingly the legacy

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of lasting effects was
especially pronounced in urban

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areas,
and the sanitary movement is

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one of those lasting legacies.

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Now, there is a theory that we
may as well look at,

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just for a second,
developed by the British

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physician and demographer,
Thomas McKeown--and it's often

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called his thesis--
where he was dealing with the

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demographic fact of what he
called a mortality revolution;

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a demographic transition in
which cities,

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for the first time,
become places that are

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dependent for their expansion
not only on inward migration to

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the towns,
but on the fact that the

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longevity and the birthrate come
to exceed the death rate;

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which was something new,
a real demographic revolution.

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And why was this achieved?

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Many people have thought and
postulated that it was due to

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medical science,
to conscious policy and those

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sorts of explanations.

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McKeown instead stresses two
factors.

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He sees this as largely
unplanned and due to improved

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nutrition, but also--and that's
the point this morning--to the

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role of sanitation.

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In other words,
the population explosion,

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the demographic revolution,
is something that he postulates

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was due to,
not to medical science,

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but rather to the sanitary
movement,

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and also to nutrition.

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Well, what was the background
to the sanitary movement?

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We've seen and mentioned that
there really was a tremendous

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challenge to health in this
period of the industrial

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revolution in European history.

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There were tremendous changes
afoot in British society.

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There was the rise of a modern
commercial agriculture,

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and with it enclosure,
the driving of peasants off the

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land.

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We know about the major
demographic growth that was

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underway by this period,
supported by the new

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agriculture and the fading of
the threat of famine and the

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fading of the threat of plague.

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There was the rise of
manufacture,

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and then the factory system,
especially the textile

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industry,
and the associated and

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unregulated horrors of things
such as long hours,

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low wages, child labor.

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You know, too,
that across Europe,

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urban populations doubled in
the first half of the nineteenth

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century,
and in so doing overwhelmed the

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infrastructure of available
jobs,

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the housing stock,
sanitary arrangements,

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and all the rest,
so that we see the rise of

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tenement slums,
sweatshops.

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There was a mass movement of
population from countryside to

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town, and with that went
psychological adjustments.

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There was a breakdown of older
notions of social relations

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based on paternalism,
of the customary notion of a

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moral economy based on moral
obligation.

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And we see instead the rise of
the principles of impersonal

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relations,
of a free-market economy,

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and laissez-faire,
epitomized in the new

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discipline of political economy,
with such figures,

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of course, as Adam Smith,
Ricardo, Jeremy Bentham,

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Thomas Malthus.

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The result, along with those
transformations,

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was a rise of new social
tensions.

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We've talked about the
nineteenth century as the

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rebellious century.

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Now, in Britain,
there were no social and

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political revolutions,
nothing comparable to 1789 in

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France,
or to what happened on the

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continent in 1830,
and in 1848 and '49.

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But contemporaries weren't
certain at all that this was

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going to be a lasting fortune
for Britain,

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and indeed Britain did have a
number of signs of severe social

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tension as well.

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There were large-scale riots.

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One could mention the Chartist
Movement, and in the countryside

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the movement known as Captain
Swing.

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So, urban and industrial
centers, also in Britain,

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were perceived as dangerous,
politically,

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for fear of the so-called
dangerous classes who rioted,

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perhaps committed crime,
threatened revolution,

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and were dangerous medically,
as well;

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that is, they were infected
with cholera and other diseases.

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And it was cholera in
particular that was a real prod

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to action, this new and most
feared disease of the nineteenth

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century.

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It's not by chance,
then, that the sanitary

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movement begins in the 1830s and
'40s in Britain,

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after, that is to say,
the first pandemic and the

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second of Asiatic cholera.

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And it lasts intermittently
down through the First World

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War.

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And this really was a vast
movement.

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It was nothing less than the
retrofitting of the urban

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centers of the nation,
with the specific goal of

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removing filth,
because filth was held to be

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the cause of disease.

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So, we're talking about one of
the great public works projects

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of modern history:
the establishment of sewer

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systems,
a whole infrastructure of water

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mains,
of waste removal,

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street cleansing,
improved and less crowded

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housing, the creation of parks
and public spaces.

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We can see that Victorian
Britain truly was preoccupied

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with that combination of
excrement and water.

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All of this,
of course, presupposed as well

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the emergence of a modern state.

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It was state power that alone
provided the wealth and

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organizational structures that
were needed to carry out this

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enormous project.

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And in turn we can see the
causal chain working in both

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ways, because the sanitary
movement was a very important

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factor in reinforcing state
power.

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Its implementation meant that
the state now invaded areas of

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life formerly regarded as
private, and appropriated for

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itself enormous new powers.

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And the reformers were
supported by Protestant and

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especially evangelical Christian
churches.

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Well, who were the leaders of
this movement?

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I think we should turn first of
all to this man,

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Sir Edwin Chadwick.

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This is Edwin,
Sir Edwin, in his younger days.

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This may be a slightly more
familiar picture of him,

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I guess maybe at my age.

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In any case,
Sir Edwin wrote a major work

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collaboratively--
he produced it,

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let us say--which was called
"The Report on the Sanitary

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Condition of the Labouring
Population of Great Britain of

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1842."

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Now, Chadwick wasn't a
physician at all,

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and this is part of the
background perhaps to the thesis

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I was mentioning earlier.

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He was instead a lawyer by
training from Manchester.

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And he was already well known,
in particular for his reform of

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welfare provisions in Britain;
that is, he was responsible in

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large part,
for the passage,

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from the old poor law,
which had provided relief as

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the birthright of every citizen
in distress;

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that is, the right to some form
of assistance or aid in time of

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distress.

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Chadwick's idea was to
economize, to minimize the cost

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of payments, to discourage the
poor from applying for relief.

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He wanted to make the
experience of receiving relief

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more painful than the experience
of distress itself,

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a principle that was dubbed
"the principle of least

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eligibility."

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The workhouse,
in other words,

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was to be a place of
punishment, of pain and of

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suffering.

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So, work should be,
in the workhouse,

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more unpleasant than any to be
found in the labor market.

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And the diet should be
intentionally made to be

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loathsome, more so than what
could be found by the poor

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outside.

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The poor law bureaucracy was
also invoked,

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and was an essential foundation
of the information on which

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Chadwick relied for the sanitary
report of the laboring

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population of Great Britain.

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This was the man who was the
same in both faces,

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with the new poor law and with
the sanitary report.

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The sanitary reform was also a
stark assertion of state power

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as a means of social control.

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The intention was to discipline
and civilize the working classes

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in the interests of social
stability.

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Following in the wake of the
report was the establishment of

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a Public Health Act of 1848 in
Britain,

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and a general Board of Health,
and such champions of sanitary

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reform as John Simon,
Thomas Southwood Smith and Neil

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Arnott.

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Now, let's talk for a minute
about this man's ideology and

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his intentions.

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This was a class-based movement.

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It was top-down and
centralizing.

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In Chadwick's mind,
the poor were largely

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responsible for their own
plight.

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They weren't innocent,
and they certainly weren't

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harmless.

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His mission was to cleanse and
civilize the dangerous classes.

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As I said, he wasn't a
physician, and his reforms were

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not based on any new medical
discoveries,

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on scientific experimentation
or observation to determine what

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measures were most effective by
determining the causes of

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disease.

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His reform measures,
enormous as they were,

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were based more on what was the
commonsense of the period and a

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priori assumptions.

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Public health,
in this way,

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was separate from the
development of medical science.

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His view--and this was widely
accepted--was that medicine was

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about private persons,
not so much public policy.

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And his idea was to use public
policy to cleanse the urban

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environment, but not to deal
with other social and economic

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determinants of disease.

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We'll talk about that in a
moment.

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We need to think about not only
about what Chadwick wanted to

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do,
but we also need to think about

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what he decided not to do,
what wasn't important to him.

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And so we should see this as
progress, yes,

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but progress that came at a
cost, and we want to know about

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that as well.

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Now, an influence on Chadwick's
thinking was "The Essay on

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Population"
of Thomas Malthus,

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who believed that there was a
law that in every society

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population pressure sooner or
later pressed against the limits

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of subsistence.

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So, real improvement for the
poor was likely to be illusory,

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short-term, and perhaps
counter-productive.

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In the long run,
really significant improvement

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couldn't occur,
according to Malthus.

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It might even be
self-defeating,

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leading to disease,
starvation and war,

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those great positive checks on
population increase.

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That idea of the limited nature
of possible improvement was in

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Chadwick's mind;
the poor will always be with us.

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There was also,
as I said, the filth theory of

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disease.

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We know it.

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We've talked about miasma and
its long history in European

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thought.

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Well, filth now was associated
very closely with smell.

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And if you are to read the
report at some point,

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you would notice that smells
constitute an important part of

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the report.

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The report is filled with
descriptions of stench.

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The authorities consulted by
Chadwick frequently used phrases

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such as,
"I was assailed by a most

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disagreeable smell,
and it was clear to me that the

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air was full of most injurious
malaria."

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By malaria, that's another word
that occurs throughout the

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report.

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And we should note that before
malaria came to mean a specific

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disease,
it meant "bad air,"

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from the Italian mal'
aria,

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bad air.

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And, so, this report,
in Britain in the 1840s,

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is filled with descriptions of
what they called malaria.

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Let me give you an example from
the town in the West Country of

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Truro.

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Reporting to Chadwick,
the reporting official said,

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"Passing into St.

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Mary's Parish,
the proportion of sickness and

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deaths is as great as any part
of Truro.

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But there's no mystery at all
in the causation.

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Ill-constructed houses with
decomposing refuse,

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clothes upon their doors and
windows,

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open drains,
bring the oozings of pigsties

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and filth to stagnate at the
foot of the walls.

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Such are a few of the sources
of disease, which even the

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breezes from the hills cannot
dissipate."

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Everywhere the reports
discovered disease,

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and they correlated the disease
with such findings as poisonous

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vapor,
morbific effluvia,

18:54.356 --> 19:01.236
filth, obnoxious effluvia,
poisonous exhalations,

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miasma and malaria.

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The moral of the texts of those
conditions also preoccupied

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those who took part in the
report.

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Vice, alcohol,
intemperance,

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and then more poverty,
and still worse,

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more filth.

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Poverty was partly the result
of depravity and improvidence,

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and those in turn reinforced
more poverty and more filth.

19:30.858 --> 19:35.448
Well, there was a political aim
behind the sanitary reform,

19:35.450 --> 19:40.570
and I think we might call this
a transformation that Chadwick

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was aiming at in the demographic
composition of the British

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population.

19:46.788 --> 19:50.118
In Chadwick's mind,
trade unions,

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which he abhorred,
demonstrations,

19:53.650 --> 19:58.120
strikes, the Chartist Movement,
and all the rest,

19:58.118 --> 20:02.268
were called by Chadwick
"wild and dangerous

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assemblages."

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But he noted that they were
mainly led by the young.

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Older, experienced workmen,
with family responsibilities,

20:15.101 --> 20:21.241
he found to be moderate and
temperate, and not to take part

20:21.243 --> 20:24.743
in strikes and social unrest.

20:24.740 --> 20:29.430
Therefore a high early death
rate,

20:29.430 --> 20:33.980
and poor sanitary conditions,
were actually politically

20:33.984 --> 20:37.144
destabilizing,
at least in his mind,

20:37.144 --> 20:41.174
because they led to the early
death of workmen,

20:41.170 --> 20:44.650
and hence to an
overrepresentation of the

20:44.646 --> 20:49.556
dangerous young,
and an under-representation of

20:49.557 --> 20:52.377
moderating older workmen.

20:52.380 --> 20:56.410
If we want to understand and
explain this view,

20:56.412 --> 21:01.762
perhaps we could invoke an
anachronism, to make an analogy.

21:01.759 --> 21:06.359
And we could use the analogy of
a nuclear reactor,

21:06.364 --> 21:11.914
and compare social unrest to a
meltdown of the reactor core,

21:11.907 --> 21:15.007
with disastrous consequences.

21:15.009 --> 21:19.599
Well, in terms of the reactor,
to prevent such events reactors

21:19.596 --> 21:21.546
make use,
as you know,

21:21.545 --> 21:26.855
of boron control rods that are
inserted to control the rate of

21:26.856 --> 21:30.076
fission of uranium and
plutonium,

21:30.079 --> 21:33.769
and to limit chain reactions.

21:33.769 --> 21:37.039
In this way,
what Chadwick wanted to do,

21:37.038 --> 21:42.418
by analogy, was to use older
people like control rods that

21:42.423 --> 21:48.283
would have the calming effect of
preventing social meltdown and

21:48.280 --> 21:50.360
social revolution.

21:50.358 --> 21:54.768
But to do that you had to do
something about infectious

21:54.772 --> 21:59.192
diseases, to achieve this
demographic transformation of

21:59.186 --> 22:00.736
the population.

22:00.740 --> 22:06.000
So, if infectious disease was
destabilizing for the state and

22:06.002 --> 22:09.862
political order,
a population subject to

22:09.862 --> 22:15.582
infectious disease moreover is
unlikely to be educated and to

22:15.583 --> 22:20.163
be open to the moral influence
of the clergy.

22:20.160 --> 22:25.480
And the absence of cleansing in
towns, Chadwick felt,

22:25.481 --> 22:29.991
would lead also to
demoralization and further

22:29.986 --> 22:31.416
depravity.

22:31.420 --> 22:37.180
Now, in all of this thinking,
let's remember too at what was

22:37.175 --> 22:37.855
lost.

22:37.858 --> 22:43.328
A striking feature of
Chadwick's view was the

22:43.327 --> 22:46.557
narrowness of its focus.

22:46.558 --> 22:50.438
The cause of ill health in
Victorian Britain--

22:50.440 --> 22:52.370
I think we should say not the
cause--

22:52.368 --> 22:55.358
the causes were undoubtedly
multiple,

22:55.358 --> 22:57.748
and one could think about low
wages,

22:57.750 --> 23:01.540
unregulated factories,
inadequate diet,

23:01.538 --> 23:04.408
poor clothing,
lack of education,

23:04.414 --> 23:07.654
working conditions in
sweatshops,

23:07.650 --> 23:10.240
mines and factories,
child labor,

23:10.239 --> 23:12.019
overcrowded housing.

23:12.019 --> 23:16.449
These I would call social and
economic determinants of

23:16.452 --> 23:17.292
disease.

23:17.288 --> 23:21.228
And there were voices,
particularly on the continent,

23:21.229 --> 23:25.019
for an alternative public
health that would address

23:25.018 --> 23:27.668
precisely such broad interests.

23:27.670 --> 23:31.510
There was an older tradition of
what was called a "medical

23:31.512 --> 23:35.212
police" on the continent,
and a current of thought of

23:35.212 --> 23:38.032
what was called "social
medicine",

23:38.029 --> 23:42.899
whose most prominent figure was
this man,

23:42.900 --> 23:48.690
Rudolph Virchow,
a Prussian physician who lived

23:48.686 --> 23:52.826
from 1821 to 1902,
and was one of the great

23:52.833 --> 23:55.343
figures of nineteenth century
medicine;

23:55.338 --> 23:58.398
a physician,
anthropologist,

23:58.396 --> 24:02.356
biologist and radical
politician.

24:02.358 --> 24:06.538
Now, his view was that disease
was not simply a biological

24:06.538 --> 24:09.618
event, but a socially driven
phenomenon.

24:09.618 --> 24:13.188
And his meaning of the term
"social medicine"

24:13.194 --> 24:16.574
was that physicians should
treat not just individual

24:16.571 --> 24:21.821
patients but entire societies,
and that they should pay great

24:21.815 --> 24:25.515
attention to matters of the
economy,

24:25.519 --> 24:29.509
to diet, wages,
housing, child labor,

24:29.509 --> 24:32.149
working conditions.

24:32.150 --> 24:37.480
Virchow was,
in a sense, the anti-Chadwick.

24:37.480 --> 24:45.070
Chadwick's intention instead
was to focus on the narrow issue

24:45.067 --> 24:50.657
of filth and water,
and his attention was confined

24:50.664 --> 24:56.114
to the working classes and the
filth in which they lived.

24:56.108 --> 25:01.798
At stake was the issue of how
broad should a public health

25:01.800 --> 25:03.200
movement be?

25:03.200 --> 25:08.290
And perhaps one could say that
one of the sad features of the

25:08.289 --> 25:13.469
period was the triumph of the
narrowest gauge vision of public

25:13.465 --> 25:14.395
health.

25:14.400 --> 25:18.150
The solution,
in Chadwick's hands--and this

25:18.152 --> 25:23.242
was a major event in public
health, there's no doubt about

25:23.243 --> 25:23.873
it.

25:23.868 --> 25:28.168
I'm trying to say--not that
this was unfortunate--it was

25:28.170 --> 25:30.360
only unfortunately narrow.

25:30.358 --> 25:36.118
Chadwick's solution involved
technological measures,

25:36.115 --> 25:40.395
all good in themselves:
drains, sewers,

25:40.404 --> 25:42.214
water pipes.

25:42.210 --> 25:46.780
But they didn't include social,
economic and educational

25:46.780 --> 25:47.530
reform.

25:47.529 --> 25:50.649
And the reforms all came from
above,

25:50.650 --> 25:54.270
and reinforced a centralizing
state,

25:54.269 --> 25:58.679
rather than finding ways to
empower ordinary people to

25:58.679 --> 26:02.339
participate in defending their
own health.

26:02.338 --> 26:05.818
Let me give you an example of a
simple technological

26:05.815 --> 26:06.765
improvement.

26:06.769 --> 26:11.009
It might be hard to recognize
when you first look at it but--

26:11.009 --> 26:15.899
and I'm talking about some very
humble movements that have

26:15.895 --> 26:19.835
enormous political and medical
consequences.

26:19.838 --> 26:22.878
What we're looking at is a
sewer main,

26:22.880 --> 26:28.870
and these were established
under the soil of cities in this

26:28.866 --> 26:31.736
period,
and one of the technological

26:31.743 --> 26:34.843
inventions was to make the
sewers egg shaped,

26:34.838 --> 26:39.778
so that you would maximize the
flow and they would be

26:39.779 --> 26:44.909
self-cleaning and they would
drain most efficiently.

26:44.910 --> 26:50.560
So, technological innovations
of that sort were part of it.

26:50.558 --> 26:56.248
Now, the victory of Chadwick's
vision of public health wasn't

26:56.252 --> 27:00.432
simply automatic,
and so it was worth to keep

27:00.426 --> 27:02.796
alternatives in mind.

27:02.798 --> 27:07.528
His side was the winning side
in a debate of the early

27:07.529 --> 27:10.739
nineteenth century,
and a wider view,

27:10.742 --> 27:13.692
like that of Virchow,
was present,

27:13.689 --> 27:16.009
but lost the debate.

27:16.009 --> 27:22.029
Let's be clear in summation.

27:22.028 --> 27:26.828
I'd argue that Chadwick's
vision of public health was

27:26.830 --> 27:31.110
highly successful,
that it was a crucial part of

27:31.113 --> 27:35.643
the mortality revolution of
nineteenth century Europe,

27:35.640 --> 27:39.180
but that at the same time
something was lost,

27:39.180 --> 27:42.870
a broad vision of the causes of
disease,

27:42.868 --> 27:46.978
and those causes weren't
addressed.

27:46.980 --> 27:51.310
Although what Chadwick achieved
was a major and positive

27:51.313 --> 27:54.783
advance,
it perhaps fell short of what

27:54.777 --> 27:58.477
might have been,
and it demonstrates the

27:58.480 --> 28:03.120
practical and positive impact of
miasmatic theory.

28:03.118 --> 28:06.248
And public health,
a theory--and this is perhaps

28:06.249 --> 28:08.779
something we ought to bear in
mind--

28:08.778 --> 28:14.278
that a theory that is by now
rejected--

28:14.278 --> 28:18.938
that is miasmatism,
the filth theory of disease--

28:18.940 --> 28:25.260
did operate in such a way as to
promote major and positive

28:25.256 --> 28:27.136
health results.

28:27.140 --> 28:31.780
And one of the causes of this
movement was the epidemic

28:31.782 --> 28:36.172
disease that we dealt with the
last couple of times,

28:36.167 --> 28:38.917
and that is Asiatic cholera.

28:38.920 --> 28:44.090
We might note there was a
sidelight that may be of

28:44.093 --> 28:48.443
interest as well;
that this sanitary movement,

28:48.438 --> 28:53.978
the literal sanitary movement,
was accompanied in some places

28:53.979 --> 28:59.239
by what we might call a
figurative sanitary movement,

28:59.240 --> 29:04.770
and that is moral sanitation.

29:04.769 --> 29:09.059
And one of those was
particularly notable in France

29:09.061 --> 29:13.441
where there was a great fear of
another disease,

29:13.440 --> 29:16.690
that we'll be talking about
slightly later in the course,

29:16.690 --> 29:19.000
and that is syphilis.

29:19.000 --> 29:24.390
Remember, the early nineteenth
century, we're dealing with the

29:24.391 --> 29:28.281
period in the wake of the
Napoleonic wars.

29:28.278 --> 29:33.048
And with those wars,
as always happens--or

29:33.047 --> 29:39.787
happened--there was a major
upsurge in socially transmitted

29:39.791 --> 29:44.561
diseases, and in particular
syphilis.

29:44.558 --> 29:49.268
And so this sanitary movement
was accompanied by the movement

29:49.273 --> 29:54.303
for moral sanitation through the
registration and surveillance of

29:54.301 --> 29:55.561
prostitutes.

29:55.558 --> 30:01.548
And in France those responsible
for moral sanitation actually

30:01.551 --> 30:06.201
made the link explicit;
that is to say that they

30:06.200 --> 30:10.590
compared brothels with sewers,
and said that they,

30:10.590 --> 30:14.180
the brothels,
should become the target of

30:14.175 --> 30:15.605
sanitation.

30:15.608 --> 30:20.968
So this was a form of moral
sanitation that was an offshoot

30:20.973 --> 30:26.343
of the literal sanitary movement
that is our main theme.

30:26.338 --> 30:33.438
The sanitary worldview led also
on the continent to further

30:33.438 --> 30:38.088
offshoots,
and that--I want to talk now

30:38.087 --> 30:43.767
about a continental form of the
sanitary movement,

30:43.769 --> 30:48.009
the rebuilding of cities in
their entirety.

30:48.009 --> 30:52.579
This was actually much more
comprehensive and systematic.

30:52.579 --> 30:55.849
It means urban planning.

30:55.848 --> 31:00.358
It's more comprehensive than
what happened in Britain,

31:00.364 --> 31:05.304
which was the retrofitting of
cities with sewers and drains

31:05.304 --> 31:07.694
and sanitary provisions.

31:07.690 --> 31:11.830
It entailed the actual leveling
of whole cities,

31:11.829 --> 31:15.789
or neighborhoods within them,
to start afresh,

31:15.794 --> 31:19.674
in accordance with a
comprehensive plan.

31:19.670 --> 31:22.030
There were a number of
prototypes.

31:22.028 --> 31:27.328
In France, Paris,
Lyon and Marseilles.

31:27.329 --> 31:29.819
In Belgium, Brussels.

31:29.818 --> 31:32.908
In Naples--that is in Italy,
there was Naples,

31:32.911 --> 31:34.971
as you know,
but also Florence,

31:34.971 --> 31:37.171
La Spezia, and other places.

31:37.170 --> 31:43.000
But let's begin in Paris,
because that established the

31:43.000 --> 31:44.100
pattern.

31:44.098 --> 31:50.528
Here again we see the influence
of epidemic cholera,

31:50.532 --> 31:57.222
which ravaged Paris in the
1830s and again in 1849.

31:57.220 --> 32:02.190
And this caused an enormous
psychological shock,

32:02.192 --> 32:08.652
the idea that civilization was
no sure-fire protection against

32:08.647 --> 32:12.137
sudden and agonizing disease.

32:12.140 --> 32:16.560
There was an unbearable
contradiction that a city,

32:16.558 --> 32:20.538
that is Paris,
that prided itself at being at

32:20.539 --> 32:24.429
the heart of European
intellectual life,

32:24.430 --> 32:29.080
at being the leading city in
the arts and culture,

32:29.078 --> 32:31.738
a world center,
as you now know,

32:31.739 --> 32:35.779
of scientific medicine,
could nevertheless be

32:35.780 --> 32:40.870
devastated by a disease that was
associated with poverty,

32:40.868 --> 32:46.788
with filth, and with the
colonial world.

32:46.788 --> 32:51.748
Well, after the revolutions of
1848 to '49,

32:51.750 --> 32:57.900
we have a reactionary and
authoritarian regime established

32:57.903 --> 33:03.453
by Louis Napoleon Bonaparte,
or Napoleon III,

33:03.452 --> 33:08.552
that soon became the Second
Empire,

33:08.549 --> 33:13.749
that lasted from 1851 'til 1870.

33:13.750 --> 33:16.000
There's Napoleon III.

33:16.000 --> 33:20.420
He undertook a major movement
to rebuild Paris.

33:20.420 --> 33:24.270
And I want to argue that this
had enormous sanitary

33:24.268 --> 33:26.828
consequences,
intentionally so,

33:26.827 --> 33:30.807
and that the experience of
epidemic cholera was very

33:30.809 --> 33:34.089
important in the establishment
of that.

33:34.088 --> 33:39.038
But I don't want to say that
the rebuilding of Paris was

33:39.042 --> 33:44.182
solely designed as a health
measure, and solely to prevent

33:44.178 --> 33:46.518
the return of cholera.

33:46.519 --> 33:49.109
There were other gains as well.

33:49.108 --> 33:54.028
Napoleon III wanted imperial
splendor.

33:54.029 --> 33:59.389
He wanted a city that would be
worthy of the role of France in

33:59.385 --> 34:04.295
the world, that would be a
showcase for his new political

34:04.304 --> 34:05.274
regime.

34:05.269 --> 34:09.389
He too was thinking about
social control.

34:09.389 --> 34:13.939
So, there was a political aim;
that was, to destroy the

34:13.938 --> 34:20.098
working class slums that had
been the sites of rebellion.

34:20.099 --> 34:25.619
The idea was to use urban
renewal to remove workers from

34:25.615 --> 34:30.125
the center of the city to
distant suburbs,

34:30.130 --> 34:35.920
and in the center to construct
wide boulevards that could not

34:35.920 --> 34:40.970
be defended by barricades,
and that the troops could use

34:40.972 --> 34:43.772
to move quickly across the
cities,

34:43.768 --> 34:48.268
and cannonballs could fire down
the boulevards to demolish

34:48.273 --> 34:49.303
barricades.

34:49.300 --> 34:52.840
In other words,
Paris was to be made

34:52.840 --> 34:57.900
revolution-proof,
or at least that was the goal.

34:57.900 --> 35:01.530
It was also a project of public
works;

35:01.530 --> 35:05.430
that is, it was a means of
enormous patronage.

35:05.429 --> 35:09.949
It would provide employment and
would defuse social tensions as

35:09.949 --> 35:10.459
well.

35:10.460 --> 35:16.550
So, Paris, under Napoleon III,
became a vast public works

35:16.550 --> 35:21.120
project, enormous shovel-ready
projects.

35:21.119 --> 35:26.139
The workers of Paris then would
be employed and therefore

35:26.144 --> 35:27.854
largely pacified.

35:27.849 --> 35:31.959
It was thought that this would
also have an economic role.

35:31.960 --> 35:34.960
The new boulevards,
the wide spaces,

35:34.958 --> 35:40.008
would facilitate the movement
of goods and assist free trade

35:40.012 --> 35:41.472
and commerce.

35:41.469 --> 35:45.989
And then there was the public
health objective:

35:45.987 --> 35:50.107
to improve health,
to prevent the return of

35:50.114 --> 35:52.574
infectious epidemics.

35:52.570 --> 35:58.450
The task was entrusted to this
man, Georges Haussmann,

35:58.445 --> 36:01.435
the Prefect of the Seine.

36:01.440 --> 36:05.420
And often what was accomplished
is referred to as the

36:05.420 --> 36:08.560
"Haussmannization"
of Paris,

36:08.559 --> 36:12.629
with the so-called great works,
or grands travaux,

36:12.630 --> 36:18.280
that were undertaken from 1852
until 1870.

36:18.280 --> 36:22.590
Now, this project was
authoritarian.

36:22.590 --> 36:25.940
The rights of individuals were
disregarded.

36:25.940 --> 36:30.380
The population was not
consulted about being moved,

36:30.378 --> 36:34.728
and it was an operation of
colossal complexity.

36:34.730 --> 36:40.290
All of the affairs of one of
the greatest cities in France,

36:40.289 --> 36:45.719
the great city in France,
were gathered into a single

36:45.715 --> 36:48.425
pair of hands:
finance,

36:48.429 --> 36:52.349
administration,
transport, sanitation,

36:52.349 --> 36:55.009
engineering,
architecture,

36:55.014 --> 36:58.894
evictions,
expropriation of land by

36:58.893 --> 37:02.273
eminent domain,
slum clearance,

37:02.268 --> 37:06.338
gas fixtures and lighting,
sewers.

37:06.340 --> 37:11.390
All of this was an enormous
assertion, then,

37:11.391 --> 37:13.391
of state power.

37:13.389 --> 37:17.739
The means were broad
intersecting boulevards.

37:17.739 --> 37:21.389
Let me show you the sorts of
plans--

37:21.389 --> 37:25.619
were to have the great
boulevards of Paris,

37:25.619 --> 37:32.279
that you can see today--such as
the Rue de Rivoli,

37:32.280 --> 37:35.130
Boulevard de Strasbourg,
S�bastopol,

37:35.130 --> 37:36.690
the Boulevard Saint-Michel.

37:36.690 --> 37:40.750
The average size width of a
street in Paris was to be

37:40.746 --> 37:45.266
doubled, and underneath the
streets there were to be sewers

37:45.268 --> 37:46.438
and drains.

37:46.440 --> 37:50.410
There was to be water supply,
and there were to be broad

37:50.413 --> 37:54.463
parks and public spaces,
such as the Bois de Boulogne.

37:54.460 --> 37:59.450
The aesthetics were the
aesthetics of the straight line.

37:59.449 --> 38:00.889
We can see that there.

38:00.889 --> 38:03.569
We can see it also here.

38:03.570 --> 38:06.510
And you can see the
intersection of these broad

38:06.514 --> 38:09.994
boulevards,
and you can see how these were

38:09.994 --> 38:13.534
multi-purpose and would allow
not only--

38:13.530 --> 38:17.360
part of the idea was the
miasmatic one,

38:17.360 --> 38:22.330
that they would allow air and
light to sweep through the city

38:22.327 --> 38:28.857
and remove the noxious smells,
and purify and cleanse the city.

38:28.860 --> 38:34.910
And you can see as well that
they would be good for commerce

38:34.914 --> 38:37.484
and for social control.

38:37.480 --> 38:43.680
So, Paris, after Haussmann,
was clearly much healthier as a

38:43.682 --> 38:48.282
city than before,
and cholera did not return

38:48.282 --> 38:51.922
thereafter to the city center.

38:51.920 --> 38:57.620
But there is an irony here,
that cholera did return,

38:57.617 --> 39:00.967
less vehemently than before.

39:00.969 --> 39:05.729
But in the 1890s it did return,
but not to the center of the

39:05.733 --> 39:06.303
city.

39:06.300 --> 39:10.170
In other words,
part of the sanitary problem of

39:10.172 --> 39:14.732
Paris was not entirely solved,
but was exported to the

39:14.731 --> 39:19.461
suburbs, and it was the suburbs
that experienced the return of

39:19.456 --> 39:20.926
cholera in 1892.

39:20.929 --> 39:25.579
We have to see this as an
enormous sanitary success,

39:25.579 --> 39:28.769
but one that we ought to
qualify.

39:28.768 --> 39:33.888
Let me look at--let's
look--this is a map--a picture

39:33.889 --> 39:38.809
of the demolition,
to convince you of what a major

39:38.809 --> 39:41.319
undertaking this was.

39:41.320 --> 39:48.460
And there's a view of the new
open spaces, cleansed with light

39:48.461 --> 39:51.391
and air, and germ free.

39:51.389 --> 39:57.499
And also in Napoleon III's
mind, it would be also--make

39:57.503 --> 40:01.243
revolution much more difficult.

40:01.239 --> 40:05.749
Well there was--the political
success, as well as the

40:05.753 --> 40:11.053
sanitary--was a success but one
that needs to be qualified.

40:11.050 --> 40:15.450
There was an enormous
resentment among the working

40:15.454 --> 40:19.234
people of Paris at Haussmann's
project,

40:19.230 --> 40:24.150
and there was an enormous
history from that time down to

40:24.152 --> 40:28.182
nearly our own of hostility of
the suburbs.

40:28.179 --> 40:30.749
Paris becomes,
not by chance,

40:30.750 --> 40:35.710
surrounded by a red belt of
concluding hostility to the

40:35.708 --> 40:39.418
regime,
and this exploded in the spring

40:39.420 --> 40:44.470
of 1871 in the Paris Commune
that brought down the regime and

40:44.472 --> 40:48.012
led to the establishment of a
republic.

40:48.010 --> 40:52.180
So, there are also political
qualifications.

40:52.179 --> 40:56.409
Well, I'll move then to another
example very quickly,

40:56.409 --> 41:01.979
and one that is in the reading,
and that is the Italian

41:01.983 --> 41:05.613
version,
and in particular the

41:05.606 --> 41:11.946
risanamento of Naples,
which was Italy's largest city.

41:11.949 --> 41:15.759
As you know,
there was a massive epidemic in

41:15.764 --> 41:19.944
the city--
this is the plan of

41:19.942 --> 41:27.012
risanamento in Naples--
and as you know,

41:27.012 --> 41:32.102
it led to the idea--
and here is something that is

41:32.101 --> 41:35.601
actually unique;
that is to say that we've

41:35.603 --> 41:40.863
talked about the retrofitting of
British cities and also American

41:40.862 --> 41:41.522
ones.

41:41.518 --> 41:45.088
We've talked about the
rebuilding of Paris.

41:45.090 --> 41:50.650
Those were associated with a
variety of disease experiences,

41:50.648 --> 41:55.548
and they had purposes other
than a single disease.

41:55.550 --> 42:01.770
One can't see the retrofitting
of British cities as due solely

42:01.768 --> 42:06.968
to epidemic cholera,
nor the rebuilding of Paris.

42:06.969 --> 42:11.549
Here in Naples we have
something that's unusual and

42:11.548 --> 42:16.298
probably unique,
which is the actual rebuilding

42:16.304 --> 42:22.544
of a major European city for the
specific purpose of preventing

42:22.536 --> 42:25.046
the return of cholera.

42:25.050 --> 42:30.570
And the way that the plan was
developed reflected the specific

42:30.574 --> 42:36.014
medical understanding of the
time of the cause of cholera.

42:36.010 --> 42:42.920
And we see here too a form of
the filth theory of disease.

42:42.920 --> 42:46.740
The rebuilding of Naples was
for this single purpose,

42:46.739 --> 42:52.849
and the medical theory behind
the rebuilding project was

42:52.847 --> 42:58.957
specifically the miasmatic
theory of this physician from

42:58.956 --> 43:02.096
Bavaria,
Munich in particular,

43:02.101 --> 43:07.821
who is Max von Pettenkofer,
who had an enormous influence

43:07.818 --> 43:09.908
on public health.

43:09.909 --> 43:15.709
And one aspect of his influence
was that his theory lay at the

43:15.713 --> 43:19.143
basis of the rebuilding of
Naples.

43:19.139 --> 43:22.819
He developed the most
sophisticated of miasmatic

43:22.818 --> 43:26.888
theories in the nineteenth
century and was aimed--

43:26.889 --> 43:32.209
the aim then behind the
rebuilding of Naples was to thin

43:32.208 --> 43:34.238
out the population.

43:34.239 --> 43:39.429
Overcrowding was a cause of
disease,

43:39.429 --> 43:45.109
and poisonous vapors arising
from underneath the city

43:45.106 --> 43:50.116
poisoned the air,
people breathed in the poison

43:50.117 --> 43:56.617
and succumbed to cholera,
in Max Pettenkofer's view.

43:56.619 --> 44:00.859
The purpose of
risanamento then was

44:00.860 --> 44:05.930
first of all to raise the level
of the streets;

44:05.929 --> 44:10.249
that is to say,
the danger and the miasma was,

44:10.248 --> 44:15.718
if we like, fermenting beneath
the streets of the city.

44:15.719 --> 44:21.279
So, you want to place a greater
distance between the population

44:21.278 --> 44:26.748
living above and the poisonous
effluvia arising from below.

44:26.750 --> 44:31.920
And, so, the aspiration was to
raise the level of the streets

44:31.920 --> 44:35.110
to the second storey of the
houses.

44:35.110 --> 44:37.670
And there would be,
if you like,

44:37.666 --> 44:42.296
then a massive cushion,
including the mortar of the

44:42.295 --> 44:46.995
streets themselves,
between the population of the

44:46.996 --> 44:52.436
city and the danger lurking in
the groundwater beneath the

44:52.436 --> 44:53.196
soil.

44:53.199 --> 44:57.259
In addition,
the idea was that you would

44:57.259 --> 45:03.089
have Naples--there's a picture
of the old city that's--in

45:03.088 --> 45:07.668
various aspects--that's been
demolished;

45:07.670 --> 45:12.030
and here what I wanted to show
was this, the great access at

45:12.028 --> 45:14.968
the center;
and then there were various

45:14.969 --> 45:16.069
cross streets.

45:16.070 --> 45:20.980
The great boulevard at the
center was in the direction of

45:20.981 --> 45:25.221
the prevailing wind,
and it was called a bellows of

45:25.222 --> 45:29.892
fresh air that would allow the
wind to rush through the city,

45:29.889 --> 45:36.179
drying up the effluvia and
blowing away the stenches and

45:36.177 --> 45:41.547
allowing the sunlight to reach
ground level,

45:41.550 --> 45:46.150
and then it would be crossed by
a series of wide boulevards as

45:46.150 --> 45:46.680
well.

45:46.679 --> 45:50.199
And then under the--if this
happened above ground,

45:50.199 --> 45:53.249
there would also be work going
on beneath,

45:53.250 --> 45:59.270
and you would have a whole
sewage mains being built under

45:59.266 --> 46:00.446
the city.

46:00.449 --> 46:04.189
So, risanamento,
this enormous project,

46:04.186 --> 46:08.916
both above and below ground,
was related-- it was a cousin

46:08.918 --> 46:12.238
of the sanitary movement in
Britain.

46:12.239 --> 46:17.799
It was a first-cousin of the
rebuilding of Paris and Lyon.

46:17.800 --> 46:21.880
But it was distinctive too,
because it's the only example

46:21.876 --> 46:25.656
of a project conducted
exclusively for the purpose of

46:25.659 --> 46:30.549
defeating a single disease,
and that was cholera.

46:30.550 --> 46:32.750
Was it a success?

46:32.750 --> 46:35.610
Well, Naples was rebuilt.

46:35.610 --> 46:39.730
And there's no doubt that the
health of the city thereafter

46:39.730 --> 46:42.430
was greater than it had been
before.

46:42.429 --> 46:48.529
But unfortunately there too
there were qualifications.

46:48.530 --> 46:53.510
The rebuilding was marred,
marred perhaps partly by the

46:53.512 --> 46:57.482
flaws in its conception from the
outset,

46:57.480 --> 47:03.940
but marred also by the fact of
corruption and the misuse of the

47:03.936 --> 47:07.996
funds that were used to carry it
out.

47:08.000 --> 47:13.800
And, so, we see thereafter that
although Naples was rebuilt in

47:13.802 --> 47:18.952
the aftermath of 1884,
that there was a return of

47:18.945 --> 47:25.535
cholera,
a major epidemic again, in 1911.

47:25.539 --> 47:32.179
And there was even a small coda
to that, which is another

47:32.182 --> 47:35.152
outbreak, even in 1973.

47:35.150 --> 47:37.790
So, the irony and conclusion.

47:37.789 --> 47:45.799
The sanitary movement in
Britain, retrofitting of cities,

47:45.800 --> 47:48.840
the rebuilding of cities in
France,

47:48.840 --> 47:53.930
the risanamento in
Naples, did achieve major

47:53.931 --> 47:54.951
success.

47:54.949 --> 48:00.159
But it's worth remembering that
they often weren't based on a

48:00.155 --> 48:03.275
medical theory that was to
endure.

48:03.280 --> 48:07.370
And indeed in the case of
Naples, it was a medical theory

48:07.367 --> 48:11.597
that very soon after the
rebuilding was to be discarded.

48:11.599 --> 48:16.249
No sooner had Naples been
rebuilt than the theories of

48:16.246 --> 48:21.066
Pettenkofer were overturned,
with the coming of the germ

48:21.070 --> 48:23.000
theory of disease.

48:23.000 --> 48:26.900
So, when we're--one of the
questions we ask,

48:26.896 --> 48:31.606
then, was the lasting impact of
epidemic diseases.

48:31.610 --> 48:37.390
And I would argue that one of
the senses of lasting impact is

48:37.393 --> 48:43.373
one that's embodied in bricks
and mortar, in urban planning.

48:43.369 --> 48:49.729
And if you visit these cities,
then you can see the lasting

48:49.730 --> 48:56.200
legacy of epidemic disease in
the urban landscape itself.

48:56.199 --> 49:00.999