Germs and the City

Two centuries of success against infectious disease have left us complacent—and vulnerable.

by Peter W. Huber (Spring, 2007)

[...] Germs are never in fact defeated completely. If they retire for a while, it’s only to search, in their ingeniously stupid and methodically random way, for a bold new strategy. They’ve also contrived, of late, to get human sociopaths to add thought and order to the search. The germs will return. We won’t be ready.

Microbes discovered the joys of socialism long before Marx did, and in matters of health, they made communists of us all. Since the dawn of civilization, infectious disease has been the great equalizer, with the city serving as septic womb, colony, and mortuary. Epidemic—“upon the people”—is the democracy of rich and poor incinerated indiscriminately by the same fever, or dying indistinguishably in puddles of their own excrement.

The Mao of microbes was smallpox, which killed 300 million people in the twentieth century alone. Sometimes called the first urban virus, it probably jumped from animals to humans in Egypt, Mesopotamia, or the Indus River Valley, at about the same time that the rise of agriculture began drawing people together in towns and cities. Smallpox has also been called nature’s cruelest antidote to human vanity. Princes broke out in the same pustules as paupers, reeked as foully of rotting flesh, and oozed the same black blood from all their orifices. Alongside millions of nameless dead lie kings of France and Spain, queens of England and Sweden, one Austrian and two Japanese emperors, and a czar of Russia.

While the germs reigned, there wasn’t much rest-of-medicine to speak of: infections eclipsed every other cause of illness but malnutrition. And when monarchs were dying, too, language and politics honestly tracked medical reality. The “social” in “social disease” reflected an epidemiological fact. It also pointed to a practical, collective solution. Disease arose and spread when people converged to create societies. It was caused by invisible agents that individuals could not control on their own. It could be eradicated only by social means—public sanitation, slum clearance, education, and, above all, a robust, germ-hating culture. It took a city to erase a cholera.

This was the overarching insight that crystallized in the public consciousness in the first half of the nineteenth century. “In the Victorian version of the Puritan ethic,” Himmelfarb writes, “cleanliness was, if not next to godliness, at least next to industriousness and temperance.” For Dickens, as Himmelfarb and others have observed, the filth in the Thames symbolized the city’s insidious taint, its ubiquitous, effluvial corruption. What social historians often fail to note, however, is that by the time Dickens was placing the Thames at the center of London’s many ills, a new science had emerged to move the river far beyond metaphor.

Epidemiology—the rigorous science of public health—was born with physician William Farr’s appointment as controller of London’s General Register Office in 1838. Directed to do something about the cholera epidemic, Farr began systematically recording who was dying and where. The most important things he discovered were negative. Wealth didn’t protect you from cholera. Neither did occupation, or residing close to the sea. What mattered was how high above the Thames you lived. Farr concluded that the river’s horrendous stench caused the disease. Another English doctor, John Snow, made the right connection in 1853: London’s sewers emptied into the Thames, so the farther down-sewer you lived, the more likely you were to drink foul water. A year later, Snow saved countless lives by persuading parish authorities to remove the handle from the Broad Street pump in Soho.

The rest is history. By pinning down the waterborne pathway of contagion, Farr and Snow had transformed a devastating public disease into a routine exercise in civil engineering. In 1858, Parliament passed legislation, proposed by then-chancellor of the exchequer Benjamin Disraeli, to finance new drains. Charles Dickens published his last novel—Our Mutual Friend, in which the main character is the pestilential Thames—in 1864. London suffered its last cholera epidemic in 1866.

This wasn’t the end of great plagues in the city, or even the beginning of the end, but it was the end of the beginning. In 1872, Disraeli rallied his Tory Party around what his Liberal opponents derided as a “policy of sewage”—reforms involving housing, sanitation, factory conditions, food, and the water supply—and while he served as prime minister, these policies became law. For the next 50 years or so, in the United States as in Britain, public health depended on city bureaucrats above all. They wasted little time with sick patients, other than sometimes ordering them to lock their doors and die alone. They focused instead on eradicating germs before they reached the patient, and that meant attending to the water, sewage, trash, and rats.

In a recent British Medical Journal survey, public sanitation was voted the most important medical advance since the journal was established in 1840. If we don’t think of public sanitation as “medical” any more, it’s only because the municipal bureaucrats who followed Farr cleaned things up so well. (read more)