This book was recommended by Dave Pell at The Next Draft. I have yet to read a Pell recommendation that wasn't fantastic, including this book, which tells of the London Cholera outbreak of the 1840s and 1850s, along with the scientific investigation by John Snow (who, in this case, does know something), and Henry Whitehead.
I enjoyed this book and, given the current pandemic, strongly recommend it. In it, we learn about the cholera epidemic, about just how grateful we should be for and how amazing is indoor plumbing with modern sewer systems that take human excrement away from us for processing (household cesspools and cellars with foot deep shit in them were the norm back in Victorian England and wow, ugh, no thank you). We learn about how short of a time we have had the germ theory of illness (hello, 1850s), and how our biases adversely affect our thinking when confronted with overwhelming evidence our beliefs are inaccurate (hello incredible denyings, ignorings, and twisting of facts to fit our views). We learn about inadvertent consequences of mundane actions (hello tea as the culturally predominant drink, which incidentally boils water and kills bacteria that cause illnesses, there by reducing infection rates). And we learn about how knowing community means more than power when fixing said communities.
I did so much enjoy this book. It is a quick read. The conclusion and epilogue seemed out of place, like a story continuing after the denouement, but are still interesting - read them as two separate essays included after the cholera tale told.
For the record, the way to survive cholera is lots of clean water, don't over do it, boil the crap out of it first.
WASTE RECYCLING IS USUALLY ASSUMED TO BE AN INVENTION of the environmental movement, as modern as the blue plastic bags we now fill with detergent bottles and soda cans. But it is an ancient art. Composting pits were used by the citizens of Knossos in Crete four thousand years ago. Much of medieval Rome was built out of materials pilfered from the crumbling ruins of the imperial city. (Before it was a tourist landmark, the Colosseum served as a de facto quarry.)
Of course we think we're special. All of this has happened before.
There is something remarkable about the minutiae of all these ordinary lives in a seemingly ordinary week persisting in the human record for almost two centuries.
Sometime on Wednesday, it’s likely that the tailor at 40 Broad, Mr. G, began to feel an odd sense of unease, accompanied by a slightly upset stomach. The initial symptoms themselves would be entirely indistinguishable from a mild case of food poisoning. But layered over those physical symptoms would be a deeper sense of foreboding. Imagine if every time you experienced a slight upset stomach you knew that there was an entirely reasonable chance you’d be dead in forty-eight hours. Remember, too, that the diet and sanitary conditions of the day—no refrigeration; impure water supplies; excessive consumption of beer, spirits, and coffee—created a breeding ground for digestive ailments, even when they didn’t lead to cholera.
Imagine living with that sword of Damocles hovering above your head—every stomach pain or watery stool a potential harbinger of imminent doom.
One of cholera’s distinctive curses is that its sufferers remain mentally alert until the very last stages of the disease, fully conscious both of the pain that the disease has brought them and the sudden, shocking contraction of their life expectancy.
Good lord, horrible.
Dying of dehydration is, in a sense, an abomination against the very origins of life on earth. Our ancestors evolved first in the oceans of the young planet, and while some organisms managed to adapt to life on the land, our bodies retain a genetic memory of their watery origin. Fertilization for all animals takes place in some form of water; embryos float in the womb; human blood has almost the same concentration of salts as seawater.
When Prince Albert first announced his idea for a Great Exhibition, his speech included these utopian lines: “We are living at a period of most wonderful transition, which tends rapidly to accomplish that great era to which, indeed, all history points: the realisation of the unity of mankind.” Mankind was no doubt becoming more unified, but the results were often far from wonderful. The sanitary conditions of Delhi could directly affect the conditions of London and Paris. It wasn’t just mankind that was being unified; it was also mankind’s small intestine.
But not all the locals had succumbed to abject fear. As he made his rounds, Whitehead found himself musing on an old saying that invariably surfaced during plague times: “Whilst pestilence slays its thousands, fear slays its tens of thousands.”
But if cowardice somehow made one more vulnerable to the ravages of the disease, Whitehead had seen no evidence of it. “The brave and the timid [were] indiscriminately dying and indiscriminately surviving,” he would later write. For every terrified soul who fell victim to the cholera, there was another equally frightened survivor.
From our vantage point, more than a century later, it is hard to tell how heavily that fear weighed upon the minds of individual Victorians. As a matter of practical reality, the threat of sudden devastation—your entire extended family wiped out in a matter of days—was far more immediate than the terror threats of today. At the height of a nineteenth-century cholera outbreak, a thousand Londoners would often die of the disease in a matter of weeks—out of a population that was a quarter the size of modern New York. Imagine the terror and panic if a biological attack killed four thousand otherwise healthy New Yorkers over a twenty-day period. Living amid cholera in 1854 was like living in a world where urban tragedies on that scale happened week after week, year after year. A world where it was not at all out of the ordinary for an entire family to die in the space of forty-eight hours, children suffering alone in the arsenic-lit dark next to the corpses of their parents.
The literature—both public and private—of the nineteenth century is filled with many dark emotions: misery, humiliation, drudgery, rage. But terror does not quite play the role that one might expect, given the body count. Far more prevalent was another feeling: that things could not continue at this pace for long. The city was headed toward some kind of climactic breaking point that would likely undo the tremendous growth of the preceding century.
I'm not sure that feeling has ever really disappeared.
Most of us accept without debate the long-term viability of human settlements with populations in the millions, or tens of millions. We know it can be done. We just haven’t figured out how to ensure that it is done well.
There is a lovely symmetry that comes from telling the story this way, because a city and a bacterium are each situated at the very extreme boundaries of the shapes that life takes on earth. Viewed from space, the only recurring evidence of man’s presence on this planet are the cities we build. And in the night view of the planet, cities are the only thing going at all, geologic or biologic. (Think of those pulsing clusters of streetlights, arranged in the chaotic, but still recognizable patterns of real human settlement patterns, and not the clean, imperial geometry of political borders.) With the exception of the earth’s atmosphere, the city is life’s largest footprint. And microbes are its smallest. As you zoom in past the scale of the bacterium and the virus, you travel from the regime of biology to the regime of chemistry: from organisms with a pattern of growth and development, life and death, to mere molecules. It is a great testimony to the connectedness of life on earth that the fates of the largest and the tiniest life should be so closely dependent on each other.
The scientific establishment was equally anchored in the miasma theory. In September 1849, the Times ran a series of articles that surveyed the existing theories about cholera: “How is the cholera generated?—how spread? what is its modus operandi on the human frame? These questions are in every mouth,” the paper observed, before taking a decidedly pessimistic stance on the question of whether they would ever be answered:
These problems are, and will probably ever remain, among the
inscrutable secrets of nature. They belong to a class of questions
radically inaccessible to the human intelligence. What the forces
are which generate phenomena we cannot tell. We know as little
of the vital force itself as of the poison-forces which have the
power to disturb or suppress it.
So often what is lacking in many of these explanations and prescriptions is some measure of humility, some sense that the theory being put forward is still unproven. It’s not just that the authorities of the day were wrong about miasma; it’s the tenacious, unquestioning way they went about being wrong. An investigator looking for holes in the theory could find them everywhere, even in the writings of the miasmatists themselves. The canary in the miasma coal mine should have been the sewer-hunters, who spent their waking hours exposed to the most noxious—sometimes even explosive—air imaginable. And yet, bizarrely, the canary seemed to be doing just fine, and Mayhew admits as much in one slightly puzzled passage in London Labour and the London Poor.
All of which begs the central question: Why was the miasma theory so persuasive? Why did so many brilliant minds cling to it, despite the mounting evidence that suggested it was false? This kind of question leads one to a kind of mirror-image version of intellectual history: not the history of breakthroughs and eureka moments, but instead the history of canards and false leads, the history of being wrong. Whenever smart people cling to an outlandishly incorrect idea despite substantial evidence to the contrary, something interesting is at work.
Miasma theories were eminently compatible with religious tradition as well. As one might expect from a man of the cloth, Henry Whitehead believed that the Golden Square outbreak was God’s will, but he supplemented his theological explanation with a miasmatic one; he believed that “the atmosphere, all over the world, is at this time favourable to the production of a most formidable plague.” To reconcile this hideous reality with the idea of a beneficent Creator, Whitehead had settled on what might later have been termed an ingeniously Darwinian explanation: that plagues were God’s way of adapting the human body to global changes in the atmosphere, killing off thousands or millions, but in the process creating generations that could thrive in the new environment.
The sense of smell is often described as the most primitive of the senses, provoking powerful feelings of lust or repulsion, triggering mémoires involontaires.
And not having a sense of smell sucks.
Modern brain-imaging technology has revealed the intimate physiological connection between the olfactory system and the brain’s emotional centers.
So went Thomas Sydenham’s internal-constitution theory of the epidemic, an eccentric hybrid of weather forecasting and medieval humorology. Certain atmospheric conditions were likely to spawn epidemic disease, but the nature of the diseases that emerged depended partly on a kind of preexisting condition, a constitutional susceptibility to smallpox, or influenza, or cholera. The distinction was often defined as one between exciting and predisposing causes. The exciting cause was the atmospheric condition that encouraged a certain kind of disease: a specific weather pattern that might lead to yellow fever, or cholera. The predisposing cause lay in the bodies of the sufferers themselves. That constitutional failing was invariably linked to moral or social failing: poverty, alcohol abuse, unsanitary living.
HEY! Blame the victims! A millennial old tradition.
People were more likely to die of cholera at lower elevations, but not for the reasons Farr imagined. And the poor did have higher rates of contagion than the well-to-do, but not because they were morally debauched.
Chadwick and Nightingale and Dickens were hardly bigots where the working classes were concerned. Miasma, for them, was not a public sign of the underclasses’ moral failing; it was a sign of the deplorable conditions in which the underclasses had been forced to live. It seemed only logical that subjecting such an immense number of people to such deplorable living environments would have a detrimental effect on their health, and of course, the liberal miasmatists were entirely right in those basic assumptions. Where they went wrong was in assuming that the primary culprit lay in the air.
Yes, the path of science works within regimes of agreement and convention, and history is littered with past regimes that were overthrown. But some regimes are better than others, and the general tendency in science is for explanatory models to be overthrown in the name of better models. Oftentimes because their success sows the seeds of their destruction.
Jane Jacobs observed many years ago that one of the paradoxical effects of metropolitan life is that huge cities create environments where small niches can flourish. A store sellin nothing but buttons most likely won’t be able to find a market in a town of 50,000 people, but in New York City, there’s an entire button-store district. Subcultures thrive in big cities for this reason as well: if you have idiosyncratic tastes, you’re much more likely to find someone who shares those tastes in a city of 9 million.
Increase the knowledge that the government has of its constituents’ problems, and increase the constituents’ knowledge of the solutions offered for those problems, and you have a recipe for civic health that goes far beyond the superficial appeal of “quality of life” campaigns.
The most profound impact may be closer to home: keeping a neighborhood safe and clean and quiet, connecting city dwellers to the immense array of programs offered by their government, creating a sense that individuals can contribute to their community’s overall health, just by dialing three numbers on a phone.
Indeed, it is the peculiar nature of epidemic disease to create terrible urban carnage and leave almost no trace in the infrastructure of the city. The other great catastrophes that afflict cities—fires, earthquakes, hurricanes, bombs—almost invariably inflict vast architectural damage alongside the human body count. In fact, that’s how they tend to do their killing: by destroying human shelter. Plagues are more insidious. The microbes don’t care about buildings, because the buildings don’t help them reproduce. So the buildings get to continue standing. It’s the bodies that fall.
So why are health officials in London and Washington and Rome worried about poultry workers in Thailand? Why, indeed, are these officials worried about avian flu in the first place? Because microbial life has an uncanny knack for mutation and innovation. All the world needs is for a single strain of H5N1 to somehow mutate into a form that is transmissible between humans, and that virus could unleash a pandemic that could easily rival the 1918 influenza pandemic, which killed as many as 100 million people worldwide.
Right now we’re in an arms race with the microbes, because, effectively, we’re operating on the same scale that they are. The viruses are both our enemy and our arms manufacturer.