The Pandemic

Pandemania: Or, a Brief History of the Medicalisation of Life

One of the many curious features of the declaration of the coronavirus pandemic in March 2020 was the belief that the outbreak was unprecedented. The mainstream Western media not only assumed its global impact unique, they also anticipated its consequences in a rhetoric that mixed the mawkish with the morbid and the apocalyptic. In an atmosphere of media hysteria, governments reinforced the sense of impending doom, embracing an epidemiological prediction of death rates of 1 per cent of the West’s population unless they locked down the economy, quarantined households and suspended all non-essential activity.

This essay appears in the latest Quadrant.
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A rationalist preoccupation with a very short view of the past and a much longer view of the future, informs this perverse neglect of past pandemic events and the manner in which Western governments and society have historically responded to them. Ironically, this nescience is one of the few things that is unprecedented about the current crisis. How, we might wonder, have societies reacted to pandemics in the past, and are there psychological, social, political and economic responses in the past that repeat themselves in the present—or, alternatively, might past practice offer insight into our current predicament?

 

Disease in history

To the extent that the media takes account of past pandemics it is to invoke a vicarious sense of horror. Newspapers and periodicals have recalled inter alia the epidemic described by Thucydides in his History of the Peloponnesian Wars that did so much to undermine the Athenian war effort in the early years of its campaign against Sparta, the Black Death (1348 to 1350), the London plague of 1665, vividly described by Daniel Defoe in his Journal of the Plague Year (1720) and, more recently, the Spanish influenza outbreak (1918 to 1920), the little understood pandemic that at the end of the First World War may have killed between 40 million and 100 million people. Journalists recall these pandemics and their traumatic psychological effect upon popular consciousness to show the disruption and death they caused to societies with limited knowledge of micro-organisms, their transmission or control.

Treating these epidemics as discrete infectious events nevertheless leads to some broad and perhaps questionable inferences. The Black Death, the most frequently cited pandemic event, was responsible for the death of between a third and a half of the European population between 1348 and 1350. It affected, like all the epidemics we are discussing, the poor and labouring classes disproportionally. The high death rate amongst the rural peasantry and urban poor led to the decline of the manorial system and a fall in agricultural rents, particularly in England and France. Labour shortages, despite measures like the Statue of Labourers (1352) to restrict their movement, eventually led to a general increase in wages. To infer that a similar effect might be generated from the current pandemic, given its relatively low case fatality rate (CFR) however, is highly debatable. Similarly, to the extent the media analyses the impact of the Spanish flu pandemic, it is to show that although the lockdown as well as the death rate, especially in the US, was initially severe, the economy and the labour market recovered rapidly as the 1920s roared.

One of the more impressive studies by economists from the Bank of San Francisco and the University of California that attempted to assess the comparative effects of pandemics over time found that between 1348 and 2009 pandemics with a death rate in excess of 100,000 had a depressing effect on real rates of return on interest and a “somewhat elevated” effect on wages.[1] Moreover, the pandemics’ depressing effect on investment took decades to work through the economy. Are there similar comparative social, political and psychological impacts that can be adduced from pandemic events over the longer run?

 

The historiography of disease

Historians of medicine and disease have conducted broad and, in Roy Porter’s case, finely detailed studies of diseases and their scientific, social and political effects over time. As Porter observed in his encyclopaedic study of the history of medicine, The Greatest Benefit of Mankind, “illness is not just biological but social. Concepts of the body and its sickness draw upon powerful dichotomies: nature and culture; the sacred and the profane.” Sick bodies possess “eloquent messages for society”. [2]

Indeed, conceptions of the body shaped that most enduring of political metaphors, the body politic, found in Plato’s Republic, Aristotle’s Politics, and John of Salisbury’s Policraticon. The nineteenth-century “father of modern pathology” and leader of the German Progressive Party after 1872, Rudolf Virchow, pathologised this metaphor when he wrote, “medicine is a social science and politics nothing more than social science on a grand scale”.[3]

From this perspective, A.H. McNeill in Plagues and Peoples (1975) considered human history evincing “a precarious equilibrium between the micro parasitism of disease organisms and the macro parasitism of large bodied predators, chief of which have been other human beings”[4]. In his best-selling Guns, Germs and Steel, Jared Diamond presents human development as a Darwinian struggle shaped by conquest, epidemics and genocide, in which the transmission of germs by conquering armies, notably the Conquistadores, during the unequal Columbian exchange between South America and Europe, played a determining and little-understood role in the rise and fall of civilisations.[5] Eurasian germs killed far more native peoples than European guns and steel. Less sensationally, the French Annales school historian, Emmanuel Leroy Ladurie, in his quantitative examination of mortality statistics in Europe, demonstrated how infectious diseases, notably the great plague pandemics of Justinian (541 AD that swept Merovingian Europe and the Middle East), the Black Death (from 1330 when it first emerged in China to 1350), the impact of smallpox visited upon the Inca and Aztec empires of South America by the Spanish after 1492, as well as successive cholera outbreaks in the nineteenth century have unified the globe through disease. “A large part of the human populations of the world, especially in Europe and America,” Ladurie writes, “perished between 1348–1600, in the flames of a microbial holocaust, causing loss of life on a scale serious in Europe, devastating in mainland America, and total, or near total, in the Caribbean”. Moreover, Ledurie concludes, “the spread of cholera in the nineteenth century is proof that the era of microbial unification is not yet over”.[6]

Not only has the macro historical impact of infectious diseases been neglected in the post-historical aftermath of the Cold War, so too have the recurring themes that distinctive infectious diseases from leprosy in the Old Testament, to plague in the fourteenth to the seventeenth century and cholera and tuberculosis in the nineteenth, have evoked in the social imagination and the political responses to them.

The most predictable and enduring reaction to pandemic disease from Moses to Albert Camus’s Father Paneloux in The Plague is to consider it either a religious judgment on a wicked people or a test that the righteous must suffer and endure. According to Habbakuk, the Lord travels with “pestilence” before him.[7] In the Book of Exodus, the Lord tells Moses that He will pass over the congregation of Israel but smite their Egyptian hosts with plague.[8] Psalm 91 reveals that “the Lord is my refuge and my fortress”, trusting in him will “deliver thee from the snare of the fowler, and from the noisome pestilence”. Consequently, “thou shalt not be afraid for the terror by night; nor for the arrow that flieth by day, nor for the pestilence that walketh at night, nor for the destruction that wasteth at noonday”.[9] Finding his Bible open at this psalm, the narrator of Daniel Defoe’s Journal of the Plague Year decides to remain in London and keep a record of the great plague that devastated the city in the summer of 1665, leaving grass growing in the locked-down streets around Bishopsgate and killing a fifth of the population.[10]

The conventional response to epidemic disease was a heightened preoccupation with sin and salvation. Defoe observed this in London in 1665, Boccaccio and Machiavelli in the plagues of Florence in 1348 and 1527, and Camus in his fictional Oran in 1947. Not only did sinners flock to church and more especially to shrines dedicated to the plague saints Sebastian and Roch, but also to join new fanatical movements like the Brotherhood of the Cross, the flagellant sect that appeared in Germany in the summer of 1348. The sect engaged in ritual flagellation in marketplaces across Northern Europe and called upon the people to abandon their sinful lives and follow the Cross. The movement’s chiliastic attachment to the more apocalyptic passages in the Book of Revelation that foresaw Christ coming down to rule for a thousand years over the saved made them an object of political concern. The Papacy declared the sect heretical in 1349. Religious enthusiasm also encouraged scapegoating, particularly of Jews widely accused of poisoning the population. Attacks on Jewish communities were, somewhat unsurprisingly, most common in Germany.[11]

The rapid and shocking mortality rate of infectious disease also encouraged a preoccupation with Death, the pale rider of the Book of Revelation. An iconography of Death dominated the later Middle Ages celebrated in murals depicting the Triumph of Death and Death’s Dance. The iconography endured and was vividly recalled in Bergman’s Cold War masterpiece The Seventh Seal (1956).

Fatalism could also engender psychological crisis denying God and a recourse to anarchic self-indulgence. Boccaccio found some Florentines believed “that to carouse and make merry and go about singing and frolicking and satisfy the appetite in everything possible and laugh and scoff at whatever befell was [one] very certain remedy for such an ill”. [12] Describing the plague that devastated the city two hundred years later, Machiavelli observed:

Florence, at the present, resembles a city that has been sacked by the infidels and afterwards abandoned. Some of the inhabitants … have retired to country villas to escape the deadly plague; some are dead and others are approaching death; so that the while present circumstances offend us, the future threatens us; so as one struggles with death, one fears for one’s life … The neat and beautiful streets, which used to be bursting with rich and noble citizens, are now stinking, ugly and swarming with the poor … The shops are locked, the businesses closed, the courts and the lawyers dragged away, prostrating the laws. Now one hears of this theft, now of that murder: the piazzas and markets, where the citizens used to be in the habit of gathering frequently, are now made into communal graves, and vile dens of thieves.[13]

One hundred and fifty years on from Machiavelli, Daniel Defoe found that whilst “the better sort first took alarm hurrying themselves” out of London, as “if all the city was running away” to self-isolate on their country estates, some who remained, like “the dreadful set of fellows” who frequented the Pye Tavern in Houndsditch, behaved “with all the revelling and roaring extravagances as is usual for such people”:

They sat generally in a room next the street; and, as they always kept late hours, so when the dead-cart came across the street end to go into Houndsditch, which was in view of the tavern windows, they would frequently open the windows, as soon as they heard the bell, and look out at them; and, as they might often hear sad lamentations of people in the streets, or at their windows, as the carts went along, they would make their impudent mocks and jeers at them, especially if they heard the poor people call upon God to have mercy upon them.[14]

Boccaccio concluded that “the sore affliction and misery” of epidemic disease undermined “the reverend authority of the laws both human and divine”.[15] Those who survived the Black Death gave themselves up to a “more shameful and disordered life”.[16] Boccaccio, like Machiavelli, Defoe and Camus after him, tried to extract lessons from the popular response to plague for posterity. In this they followed the example initially set by Thucydides, who first attempted to inform future generations of what to expect when an epidemic overwhelms a city state like Athens (430 BC).

Thucydides described in fine detail “what sort of thing it was”, specifying its symptoms and analysing the process by which it spread. Thucydides observed, as did Boccaccio, Machiavelli and Defoe, “the despair into which people fell, when they realised that they had caught the plague, for they would immediately adopt an attitude of utter hopelessness”. The catastrophe “was so overwhelming that men not knowing what would happen next to them, became indifferent to every rule of religion or of law”. Funeral ceremonies whether in ancient Athens or medieval Florence and early modern London “became disorganised”.[17] Whilst the Athenians resorted to throwing bodies onto funeral pyres, the magistrates of medieval Florence and seventeenth-century London consigned the dead to plague pits like the one Defoe describes in Aldgate.

 

Reason, medicine and epidemics

However, it was Thucydides who “with greater precision than the medical profession would achieve for nearly two millennia thereafter”, identified for the first time “two processes of profound importance: person-to-person transmission and specific acquired immunity”.[18] His realistic precision not only informed his politics and statecraft, it also reflected a distinctively Greek approach to knowledge of the healthy physical, as well as social, body, its humours and its balance. Hippocrates (460–377), a contemporary of Thucydides, developed in his collection of cases a patient-centred healing system founded upon natural philosophy and reason independent of magic or supernatural speculation.[19] The Corpus Hippocraticum included seven books devoted to epidemics (epi demos). Hippocrates not only coined this term for those diseases that fall upon a people or circulate within a country, and that invariably, like the Athenian pestilence or later bubonic plagues arrive from outside, he also described the environmental and temperamental factors that determined their outcome.[20]

Subsequently, Galen, the most prolific Roman clinician, “perfected” Hippocrates, rendering the corpus more logical, scholastic and anatomical. He contributed a new emphasis on the pulse and blood-letting to restore the bodily humours to equilibrium. This corpus was adapted to the Muslim world from the eighth century through the contributions of Averroes, al Razi (Rhazes) and Avicenna, which also developed the use of drugs (a word of Arabic coinage). This Galenic worldview, amplified by astrology, astronomy and Thomist scholasticism, informed the medieval and early modern plague doctor’s diagnostic approach to bubonic plague as well as other endemic diseases like yaws and leprosy. One of the pilgrims accompanying Chaucer to Canterbury a few decades after the black death included a:

Doctour of Phisyk,
In al this world ne was ther noon him lyk
To speke of phisik and of surgerye;
For he was grounded in astronomy …
He knew the cause of everich maladye,
ere it of hoot or cold, or moiste or drye,
And where engendred, and of what humour,
He was a verrey parfit practisour.[21]

“Parfit practisours”, however, were not much use in controlling the spread of infectious diseases like the plague. Marginally more effective perhaps were the religious orders that had founded hospices and hospitals for the poor, the sick and the needy. Crusading orders like the Knights of St John established foundations catering for pilgrims en route to Jerusalem in the twelfth century. By the late thirteenth century Paris had its Hotel de Dieu and London its St Bartholomew’s and St Thomas’s hospitals.

During the plague era, which lasted in Europe until 1720, hospitals could be turned into lazarettos or pest houses, catering for those suffering from what came to be recognised as contagious diseases carried along trade routes to European port cities like Venice, Genoa, London, Amsterdam and Marseilles. It was the wealthy trading city-states of Renaissance Italy that first developed public health commissions comprised of nobles and public officials to address “the culture of poverty, dirt, promiscuity” and over-population in which plague thrived, or what Ledurie described as that fatal medieval “menage a trois” between the black rat (Rattus rattus), the flea (Pulex irritans) and man.[22]

Venice and Florence established boards of health as early as 1348. By the early fifteenth century, Milan had developed a permanent magistracy monitoring and regulating civic health. These developments followed the growing recognition that disease came from the outside and along trade routes. The first isolation of shipping occurred in the Venetian Adriatic colony of Ragusa in 1377, and the quarantine of suspect maritime commerce developed from there.[23] In 1374 Milan and Mantua also introduced controls on overland commerce, the beginning of more rigid border regulation and cordons sanitaires in the following centuries. In 1374, in Milan again, the contacts of those infected, as well as the sick themselves, were isolated, and between 1450 and 1470 many of the city-states of northern Italy set up isolation hospitals, lazzaretti, in further attempts to prevent contagion. By the seventeenth century, an administrative program was in place in most large cities which could be adapted for use against an epidemic threat. Defoe comments favourably on the Lord Mayor’s efficiently organised lockdown of the City of London and isolation of the sick in July 1665. The city quickly appointed [24]examiners for every parish and appointed two watchmen to each “infected house”.

The administrative attack on contagion developed, then, from the late fifteenth century in Western Europe. It owed much to the association of plague with poverty and it may also have owed something to the observation of subsequent epidemics, like typhus and smallpox and, in the nineteenth century, tuberculosis and cholera. As Paul Slack observed, the public-health model of government “came late, and as the result of a learning process”. [25]

 

The state of disease and early modern statecraft

It was during this learning process that medicine and science broke decisively with the Galenic and scholastic tradition, applying the new empirical science and the resoluto-compositive method promoted by Bacon, Galileo and Gassendi to the understanding of the body. However, it was raison d’état and the new political science associated with Machiavelli, Bodin and Hobbes, rather than new medical knowledge, that drove administrative campaigns against epidemic diseases, as well as other forms of internal and external threat.

Sovereign states, with pretensions to absolute power, emerged from the disintegrating cocoon of Christendom in the era of religious enthusiasm and confessional strife that beset much of Europe from 1517 to 1648.[26] By the mid-seventeenth century, plague, typhus, syphilis and smallpox were endemic, the population in decline and trade in disarray. Historians have for several decades debated whether a little ice age devastated the economy causing a global crisis, or whether Europe suffered from a distinctive “general crisis”.[27] Whatever else, the century witnessed European warfare on a continental scale, famine, poverty and, of course, epidemic disease. Bubonic plague followed in the train of Wallenstein’s imperial troops. War disrupted trade, and displaced people carried infection. Peter Wilson’s comprehensive overview of the human and material costs of the Thirty Years War concluded that “disease was the main killer”. The first major plague epidemic occurred in Bavaria in 1622-23. Three others followed between 1625 and 1650. Typhus and typhoid fevers also appeared. Bubonic plague, however, was “responsible for most of the mortality”. Wilson writes, “The frequency and scale of outbreaks after 1618 suggests a pandemic where the infection ebbed but never completely disappeared.” By 1650, the population of Munich had fallen from 22,000 in 1618 to 14,000.[28]

Jan Vries, evaluating the European economic collapse of the seventeenth century, argues that rather than “a crisis provoked by endogenous processes, unique to the technologies, institutions, and reproductive practices of particular societies, the seventeenth-century demographic crisis appears to have had a proximate cause that was exogenous—infectious-disease vectors possessing a history of their own, and before which societies stood powerless”.[29] The process, he maintains, decentred and recentred the European and world economies. It saw the decline of the Mediterranean world and the rise of the maritime Atlantic trading states, the Dutch Republic and England as well as absolute monarchies dominating continental Europe, from France to Tsarist Russia.

 

The pathological gaze and the birth of the clinic

Significantly, enlightened despots like Frederick of Prussia and the Hapsburg Emperor Joseph II promoted rational administration to improve the hygiene and health of their people. Physicians became state functionaries. Frederick created a medical police to administer everyday life and states across Europe sought to control the movement of people seen as disease carriers. The last European plague outbreak occurred in Marseilles in 1720. A cordon sanitaire along the Hapsburg border with the Ottoman empire halted its spread later in the century. By contrast, Muslim passive acceptance of the “great annihilation” caused by endemic plague hastened Ottoman decline.

The new European rationalism achieved a major medical breakthrough in the eighteenth century, first with inoculation and then Edward Jenner’s new vaccination against smallpox. Napoleon vaccinated his grande armée, although it was still devastated by typhus during its retreat from Moscow.

Enlightenment, war and revolution encouraged a new scientific medicine undertaken by state-appointed physicians. Napoleonic France led the way. The church lost its oversight of hospitals and public hospitals like the Hotel de Dieu and Salpêtrière now served the nation. A new cadre of professional physicians like Xavier Bichat and René Laennec pioneered the clinic, the medical gaze and a new attention to disease-centred medicine. Laennec invented the stethoscope and developed a radical diagnostic insight into internal diseases like tuberculosis, the “white plague”.[30] The new pathology considered death and disease the essence of medical inquiry. Life, wrote Bichat, was merely “the sum of all functions by which death is prevented”.[31] The patient was a thing, subjected to the clinician’s objective gaze. Clinical observation of disease and death preoccupied the Paris school. It influenced medical teaching across Europe.

As Roy Porter explains, “the pathological gaze penetrating the diseased body” and the new microscopy practised later in the century in the laboratories run by Pasteur, Virchow and Robert Koch, applied rigorous scientific method to the whole medical enterprise.[32] In George Eliot’s Middlemarch, set in the 1830s, the ambitious Paris-trained doctor Tertius Lydgate arrives in town advocating Bichat’s approach to diagnosis to sceptical locals. Elsewhere in the UK new teaching hospitals like University College and King’s College trained a generation of practitioners in scientific medicine. The Royal Colleges licensed them. Journals like the Lancet (1823) kept them informed. Eventually, the British Medical Association (1855) and General Medical Council (1858) standardised professional practice. There were 15,000 doctors in 1859 and six times that number a century later.

 

Choleraphobia and the public health state

Notwithstanding the expansion and standardisation of medical science and practice in the nineteenth century, the new profession had negligible impact, smallpox apart, on infectious diseases like tuberculosis, typhus, typhoid and, from the 1830s, cholera. The industrial revolution first in England and then across Western Europe and the United States not only generated wealth and a rapid growth in population, it also spawned industrial slums. A population explosion brought with it, as Thomas Malthus wrote in his Essay on Population (1796) the renewed threat of famine, pestilence and war. The more populous future, the parson prognosticated, promised successive subsistence and health crises.

By the 1850s the majority of the UK population lived in towns. Social novelists like Gaskell and Dickens described their filth, poverty and squalor. The dangerous and perishing classes that inhabited them became an object of concern not only for science but also for the developing administrative state, both as a political threat, and also as a source of infectious disease. Dickens’s description in Bleak House of the slum hard by Chancery Lane captures the amorphous character of the fear:

Jo lives—that is to say, Jo has not yet died—in a ruinous place known to the like of him by the name of Tom-All-Alone’s … There is not a drop of Tom’s corrupted blood but propagates infection and contagion somewhere … There is not an atom of Tom’s slime, not a cubic inch of any pestilential gas in which he lives, not one obscenity or degradation about him, not an ignorance, not a wickedness, not a brutality of his committing, but shall work its retribution through every order of society up to the proudest of the proud and the highest of the high.[33]

Dickens accepted the prevailing scientific thinking of the time that infectious disease spread through environmental factors. Miasmas and pestilential gases emanating from the industrial slums bred the “putrid fevers” typhoid, measles and mumps. Fevers colonised the new conurbations but also brought new and disturbing invaders like cholera. Previously endemic to the Indian sub-continent, cholera went global on the wings of British trade in the nineteenth century. It moved rapidly along the railways, which were the main arteries of the rapidly expanding commerce. As it arrived in the mushrooming towns and cities of a society in the throes of rapid urbanisation, it took advantage of overcrowded housing, poor hygiene and insanitary water supplies with a vigour that suggested these conditions might almost have been designed for it.

Cholera might also have been designed to achieve maximum political as well as medical impact. There could be few more violent affronts to Victorian amour propre than the grossly physical symptoms of a cholera attack. At a time when European high culture from the Pre-Raphaelites to Thomas Mann celebrated “the beautiful death”, with diseases like tuberculosis accorded a transforming influence on their victims, whether the poet Keats or Mimi in La Boheme, here was an affliction that killed rapidly and with symptoms that could only be seen as degrading.

The disease spread in a series of pandemics. Between 1826 and 1837 cholera swept across Europe and North Africa and over the Atlantic to the eastern seaboard of North America. It returned in a series of waves of declining intensity in 1841–59, 1863–75, and 1881–96. When it arrived on the European continent, most regimes dusted off their files on bubonic plague and put traditional policing measures into operation: military cordons sanitaires, quarantine, fumigation, disinfection, isolation.

The resources at the state’s disposal were now more powerful than they had been a century before, and their impact on the population far greater. Moreover, decades of war, the impact of the French Revolution and the rise of radical democratic political movements had all left a mark on popular consciousness. During the first cholera pandemic, Prussian and Russian peasants attacked cordons sanitaires, murdering those trying to set them up.

Military cordons and the restriction of movement not only prevented people from escaping the scene of the epidemic, they also interfered with their livelihood: interrupting the flow of goods and produce to and from local markets. Above all they cut off or drastically reduced the supply of food and essential goods to urban populations. In Konigsberg in East Prussia in July 1831, disturbances broke out after food prices rose dramatically following the imposition of a military cordon sanitaire.

Cholera crystallised the bitter scientific controversy about the origins of infectious disease. Radical anti-contagionists like Edwin Chadwick and James Kay Shuttleworth maintained that local environments were decisive in an epidemic outbreak, not the presence of a causative agent which could be transmitted from one place to another. An English reform-minded, free-trading radicalism facilitated the anti-contagionist perspective. It shared an affinity with “advanced”, physiological accounts of disease processes. It also provided a means by which liberals could reject reactionary quarantine measures and other military or quasi-military interventions by European autocrats. Anti-contagionism in Britain assumed the characteristics of a social movement. By the time cholera arrived in Europe, anti-quarantinists condemned quarantine as useless, a nuisance to trade and obnoxious to growth.

In its first phase cholera defined administrative extremes. On the one hand, Russia, Austria and Prussia imposed strict quarantine practices (sealing borders, isolating travellers, sequestering the sick and seeking to break chains of transmission in the manner traditionally employed against the plague); on the other, the new sanitationist approach adopted in Britain and France.

Cholera, a “revolutionary infection” next swept across Europe in the revolutionary year of 1848. The French political scientist Andre Siegfried argued that epidemics and ideologies spread in the same way. Faced with cholera riots and the threat of revolution, most European states abandoned military cordons, quarantine and other policing measures. Fear of popular disturbances, rather than disease, played a major role in this change of heart.

As early as 1831, the Prussian authorities conceded that military cordons caused economic difficulty. The fear of what cholera might do to trade increasingly affected state policy. In relaxing lockdowns, European authorities also gave way to pressure from merchants, traders and manufacturers, who in turn were not slow to raise the spectre of “the labouring classes” deprived of a living and driven to desperation. Where mercantile interests were paramount, the state withdrew almost entirely from the fight against cholera.

Nineteenth-century radical social reformers recognised that the state required effective public health measures, but not the crude recourse to quarantine and cordons, stopping trade. Disease defined the modern liberal approach to public health and sanitation. Utilitarians like Edwin Chadwick and Southwood Smith, who drove government thinking on urban policy during the 1840s, assumed that sickness bred poverty. Drains, cesspools, refuse and slaughter-houses arose independently of the intemperate habits of the poor. They were public matters that could be targeted for political action. From the sanitationist perspective, epidemic disease was the product of dirt and decomposing matter. It was concentrated in towns and especially in their least sanitary districts. In London in 1849 and 1853-54, cholera mortality rates in the poor districts of Bermondsey and Rotherhithe were between six and twelve times as high as they were in wealthier areas such as Kensington and Westminster.

It could be remedied primarily by public health policy and civil engineering. The new poor law combined with public health and education in Kay Shuttleworth’s recommendations for improvement in his book The Moral and Physical Condition of the Working Classes (1832). The social cost of illness converted Chadwick to “the sanitary idea” and the creation of a central public health authority directing local boards of health in the provision of drains, drinking water and sanitary regulation. Chadwick’s report on the sanitary condition of the labouring population of Great Britain in 1842 led to the first British public health act in 1848. In other words, the new sanitary ideas, associated with anti-contagionism, produced an effective program for government action.

In Germany two decades later, Virchow, following English utility, argued that epidemics were symptoms of a general malaise. The answer was “political medicine”, the improvement of social conditions. Only democracy, the leading German pathologist argued, could prevent epidemics.

Interestingly, utilitarian public health advocates rejected the findings of early epidemiologists and statisticians like John Snow and William Farr. In 1854, Snow had traced an outbreak of cholera in Soho to a water pump in Broad Street. He argued in evidence given to House of Commons select committee that cholera was a water-borne contagion, not a local environmental miasma. Parliament rejected his advice. In an 1858 report to the General Board of Health, the architect of the UK’s public health system, Sir John Simon, dismissed Snow’s “peculiar doctrine as to the contagiousness of cholera … Dr Snow’s illustrations are very far from proving his doctrine: but they are valuable evidence of the danger of drinking faecal water.”[34]

Thus the new sanitary infrastructure that improved the living and working conditions of London and the industrial towns was a triumph of civil engineering, not epidemiological modelling. By the 1870s the UK had developed a comprehensive regulatory infrastructure overseeing public health and infectious disease. Ironically, the utility-influenced governments of Peel and later Gladstone got the right public health outcome for the economy for the wrong scientific reasons.

Sanitationist views also prevailed in the first attempts to organise an international response to the cholera pandemics. Cholera was an international problem in an era of global trade. The disease travelled at speed along the new networks of communication without respecting borders. Yet, what Western governments found particularly irksome were quarantines and cordons and their “often disastrous hindrances to international commerce”. It was this concern that prompted European governments to meet to discuss “to what extent these onerous restrictions could be lifted without undue risk to the health of their populations”.[35] If cholera and its prevention were international concerns, they required an international solution.[36] The first international sanitation conference convened in Paris in 1851. Fourteen international conferences were held before 1938 and they formed the background to the formation of the World Health Organisation and its remit to assess infectious disease and declare pandemic threats.

It was only at the seventh conference in 1885 that a scientific consensus emerged. In 1884, Robert Koch had identified and isolated the distinctive cholera comma bacillus. Withdrawal of the state from the medical policing of epidemics that characterised the half-century after the arrival of cholera on the European continent ended with the rise of bacteriology and the discovery, by Koch in Berlin and Louis Pasteur in France, of the microorganisms that spread infectious disease. Under Koch’s influence, European governments, drawing on previous administrative practice but now acting under medical instruction, instituted massive preventive campaigns of quarantine, disinfection and the isolation of victims. Resistance to the new interventionism, like that offered in Hamburg before the cholera epidemic of 1892, was swept aside. The creation of professional police forces in the aftermath of the 1848 revolutions, the general process of centralisation that had taken place over the nineteenth century, the growth of rapid communications in the form of railway networks, and the general increase in the resources available to the European state, meant that such measures were infinitely more effective in the 1890s than they had been sixty years earlier.

 

Modernity, the microbe and the medicalisation of life

In 1880, the Liberal MP and scientist Lyon Playfair predicted that society would in time “become a well-behaved patient and public health a great field open to growing medical men”.[37] The twentieth century witnessed its ambiguous realisation. The bacteriological revolution pioneered in the laboratories of Pasteur and Koch that isolated the anthrax, rabies, smallpox, cholera, tuberculosis and, in 1894, the plague bacilli announced a new era of scientific progress and the potential for medical control of infectious disease. It endowed medical science with a new authority, access to government funding and bequests from charities like the Rockefeller Foundation and the Wellcome Trust. Prestigious research institutes like the Pasteur Institute in France, the Robert Koch Institute in Germany, the Imperial College of Science and Technology in the UK and Johns Hopkins University in the United States developed and refined scientific laboratory practice. By the early twentieth century scientists had also isolated the polio and mumps viruses, although the virus, which the Nobel Prize-winner Peter Medawar described as “a strip of nucleic acid surrounded by bad news”, remained something of a mystery.

Meanwhile, the pharmacological revolution that Alexander Fleming’s discovery of penicillin announced and the subsequent mass manufacture of antibiotics by drug companies after 1945 seemed to presage the end of infection. By the 1950s, medicine’s triumph over infectious disease was increasingly taken for granted. The Conquest series of UK medical texts included such titles as The Conquest of Tuberculosis, The Conquest of Disease and even The Conquest of the Unknown. In the century from Koch to mass-produced antibiotics one of the ancient dreams of medicine had come true. Reliable knowledge of what caused epidemics facilitated their prevention and cure. In the general euphoria some hard truths about the evolution of micro-organisms, viruses and their human hosts were too easily forgotten. In retrospect, the period between Pasteur and Fleming may one day be nostalgically recalled as an anomalous exception to medicine’s Sisyphean labour.[38]

After 1945 WHO programs of disease eradication reinforced the authority of science and the medicalisation of life. Modern democracies assumed the health and welfare of the people integral to the post-war social contract, an incontrovertible good that appealed to all the electorate. After 1945, the National Health Service provided universal health care for all UK citizens. Developing and developed states embraced various forms of health care insurance. Medical health became central to the new therapeutic bureaucracies that managed the population in depth and detail.

By the 1980s, however, a medical establishment had evolved into an unwieldy Leviathan comparable to the civil service. Medical power lies in the hands of Nobel Prize-winning researchers, presidents of prestigious medical schools and the boards of multi-billion-dollar hospital conglomerates and pharmaceutical companies. In many states, health became the largest single employer, incompletely incorporated in the public domain. The politics of medicine became a governmental priority. As a result of what Sir William Osler in 1900 termed its “singular beneficence”, health care laid claim to a privileged autonomy. Yet its anxious protection of its status concealed its dependence as an institution on the market and the state for its funding.

With the birth of the clinic, scientific medicine first reduced the sick person to a patient, a pathological body beset with disease. This disappearing act of the autonomous self continued over the next two centuries, reducing the patient in the process to an element in equations dominated by economics, diagnostic technology, systems analysis, epidemiological modelling and most recently the elusive R factor.

Medical expertise intervened in all branches of life. A growing preoccupation with chronic disease meant doctors increasingly exercised a new ability to prolong life. The good death, the ars moriendi as a stage in the life process, yielded to the new medical priesthood. The health professional could render the infertile fertile, prevent pregnancy, abort life and revive the dead.

 

Conclusion

The medicalisation of life in the last hundred years is one of the most remarkable features of our post-historical world. Until the twentieth century the role of clinical medicine in the improvement of health was minute. Whether populations grew or shrank had little to do with medicine, despite its best efforts. That changed utterly after 1945, and in not very well understood ways. But if medicine expanded almost beyond the bounds of imagination, the euphoria of the age of penicillin and the pill has turned since the end of the Cold War to dependence and anxious insecurity. The medicalisation of life has transformed society and rendered it iatrogenic. Despite being healthier and living longer, there is, as Roy Porter wrote in 1997, “a pervasive sense that our well-being is imperilled by ‘threats’ all around, from the air we breathe to the food in the shops”.[39] In a media addicted to scare-mongering, today’s headlines are more likely to be about a new cholera epidemic or an unknown virus emerging from a Chinese wet market. The age of infectious disease gave way to the era of chronic disorder. Longer life means inactive frailty in a care home and medicine is more open to criticism. National health has become a hollow achievement.

Medical confidence, moreover, has been increasingly shaken by the unexpected. Influenza pandemics like the one that swept the world with unsurpassed virulence between 1918 and 1920 have proved difficult to anticipate or contain in an era of globalisation. Since the 1980s infectious diseases from Aids to Ebola, SARS and now COVID-19 have shaken faith in scientific omniscience, yet they are what a Darwinian and Malthusian struggle for survival would anticipate.

Medicine has conquered many ailments and provided relief from suffering for many but its mandate, as the current medical and government response to the coronavirus demonstrates, has become confused. Is its prime duty and that of the medical surveillance state to keep people alive whatever the circumstances and cost? In Gulliver’s Travels Jonathan Swift satirised the folly of pursuing immortality, depicting the misery of the demented Struldbrugs of Luggnagg who never die but age remorselessly. Modern medical science governments and the Big Tech companies that treat death as the last disease are addicted to the power of life. They might benefit from reading Swift.

Paradoxically, the healthier society becomes the more treatment it craves. The patient/consumer regards it as both a right and a duty. The root of the problem is structural. It is endemic to a system in which an ever-expanding health establishment is driven to medicalise normal events like menopause or death, or a low-mortality pandemic, converting risk into disease. Boris Johnson captured the folly of our iatrogenic polity when he informed a locked-down people that the government’s decision to end the ruinous quarantine “will be driven not by mere hope or by economic necessity. We are going to be driven by the science, the data and public health.” The medical model of the state has reached a new contagionist apotheosis that nineteenth-century liberal sanitationists would deplore for its economic illiteracy, social damage and political danger.

A correspondent of Adam Smith after the British defeat at the battle of Saratoga wrote, “If we go on at this rate, the nation must be ruined.” Smith answered, “Be assured, my young friend, that there is a great deal of ruin in a nation.” Smith, however, would not be reassured by the recent conduct of either the British or Australian governments and their obeisance to a dangerous valetudinarianism.[40]

David Martin Jones is a Visiting Professor in War Studies at King’s College London

 

[1] Jordà, Òscar, Sanjay R. Singh, Alan M. Taylor. 2020. “Longer-Run Economic Consequences of Pandemics,” Federal Reserve Bank of San Francisco Working Paper 2020-09. https://doi.org/10.24148/wp2020-09

[2] Roy Porter, The Greatest Benefit of Mankind A Medical History of HUmanity from Antiquity to the Present. London 1997

[3] Peter Baldwin Contagion and the State in Europe 1830-1930 Cambridge University Press 2004

[4] A. McNeill Plagues and Peoples Anchor Books 1998 p.48

[5] The Europeans exchanged, amongst other things, smallpox for syphilis or “the pox’.

[6] Emmanuel Leroy Ledurie, “A Concept: the unification of the world by disease’ in The Mind and Method of the Historian The Harvester Press, 1981, p.82.

[7] Habbakuk 3,5 The Bible Authorized King James version with apocrypha Oxford University Press, 2008, p.1018

[8] Exodus 12,23 Ibid p.79

[9] Psalm 91 2-6 Ibid p.691

[10] Daniel Defoe, Journal of the Plague Year London, 1720, Longmans 1896 p. 16.

[11] See Phillip Ziegler The Black Death Allen and Lane

[12] Giovanni Bocaccio The Decameron or Ten Days Entertainment The World Library 1947 p.28

[13] See Landon, William J. Lorenzo Di Filippo Strozzi and Niccolo Machiavelli: Patron, Client, and the Pistola Fatta per La Peste/An Epistle Written Concerning the Plague. University of Toronto Press, 2013. Accessed May 8, 2020. www.jstor.org/stable/10.3138/j.ctt5hjtpc.

[14] Daniel Defoe, Journal of the Plague Year (1720) Longmans 1896, p.62.

[15] Bocaccio Ibid p.28

[16] Zeigler The Black Death

[17] Thucydides History of the Peloponnesian War London 1974 pp,154-5

[18] Paul Rahe What the Great Historian Thucydides saw in Athens Plague and our own’, The Federalist April 2020 https://thefederalist.com/2020/04/08/what-the-great-historian-thucydides-saw-in-athens-plague-and-our-own/

[19] Roy Porter, The Greatest Benefit of Mankind Fontana 1999 p.56.

[20] It is not clear why Hippocrates chose the term, rather than the more conventional nosos (disease) to apply to his collection of medical casec. Thucydides had used polemos epidemios to describe a civil war circulating in a country. Epidemics 1 (circa 400BC) gives a detailed description of an outbreak of deadly mumps in Thasos. See W.H.S Jones De Morbis Popularibus Cambridge 1896http://www.perseus.tufts.edu/hopper/text?doc=Perseus%3Atext%3A1999.01.0251%3Atext%3DEpid.%3Abook%3D1%3Achapter%3D1%3Asection%3D1

[21] Porter Ibid pp.115-116

[22] Ledurie Ibid p.50

[23] The word derived from the Italian quarrantino or the forty day isolation that Venice imposed upon trading vessels. See Brian Pullan, “Plague and Perceptions of the Poor in early Modern Italy’, in Terence Ranger & Paul Slack (eds) Epidemics and Ideas Essays on the historical perception of pestilence Cambridge, 1992 pp.101-25

[24] Defoe Ibid p.40.

[25] Paul Slack Ibid p.16.

[26] Mark Greengrass Christendom Destroyed Europe 1517-1648 London 2015. As Greengrass notes protestants increasingly used the term Europe rather than Christendom in the sixteenth century, p29.

[27] See inter alia Hugh Trevor Roper The Crisis of the Seventeenth Century Indianapolis 1967 especially chapter 2; H.G. Koenigsberger Politicians and Virtuosi Essays in Early Modern History (London , 1986) and Geoffrey Parker Global Crisis War Climate Change and Catastrophe in the Seventeenth Century (Yale, 2017)

[28] Peter Wilson, Europe’s Tragedy A New History of the Thirty Years War (London, 2010) pp.791-792.

[29] Jan de Vries, “The Economic Crisis of the Seventeenth Century after fifty years’, The Journal of Interdisciplinary History xl:2(Autumn) 2009 pp 151-94. See also Fernand Braudel, Civilization and Capitalism, 15th–18th Century. III. The Perspective on the World (New York, 1981).

[30] Outlined in his Essais sur les medecines et les lesions organiques du coeur et des gros vaisseaux (1806). Laennec succumbed to the disease shortly after.

[31] Porter, p.306

[32] Ibid p.341

[33] Charles Dickens Bleak House London 1853

[34] Norman Howard Jones, The Scientific Background of the International Sanitary Conferences 1851-1938 WHO 1975 p.15

[35] Ibid p.17

[36] V. Huber, “The unification of the globe by disease ? The international sanitary conferences on cholera 1851-94’. The Historical Journal, 49:2 (2006) p. 457

[37] Porter p.416

[38] Porter p.461

[39] Ibid p.3.

[40] Sir John Sinclair, The Correspondence of Sir John Sinclair vol 1 London 1831 p.391

2 comments
  • IainC

    Statistically, in all of recorded history (who knows how Edenic our lives were before we started writing it down?) we have never been safer, healthier or longer lived. The urge to nevertheless find an existential threat every few years is so widespread that it must be innate in human psychology. Perhaps “fear of destruction” is part of what makes mankind so innovative in creating more and more wonders of technology and civilization – it’s all to give us the chance to sit on the back porch smoking a pipe knowing that there are vast armies of professional soldiers, physicians, police and farmers out there to ensure that we are not taken away by one of the Four Horsemen.
    (On a lighter note, relieved to receive my paper copy of Quadrant today: I half expected the supply chains to have been disrupted – although it surely is classified as an Essential Service.)

  • [email protected]

    Ian McDonald, oh so very wrong again and then the temerity to reference a typically falsely lunatical Guardian article. Good grief!!

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