The Transformation of the World (40 page)

In general, late developers had to bear lower biological costs. As soon as new knowledge about epidemics and ways of combating them became available, big cities shed their “excess mortality” and became healthier places to live in than the countryside. It has been possible to demonstrate this for Germany as well as for colonies such as India, where Calcutta, Bombay, and Madras, for example, acquired at least some of the sanitary improvements of British cities. In both cases the new trend began in the 1870s.
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The spread of medical and hygienic knowledge and of sewer and water supply technology was, at least in Europe, a “transnational” process; innovations took only a few years to pass across frontiers. For example, a modern water supply was being constructed by British firms in Berlin from 1853 and in Warsaw from 1880. Britain pioneered legislation on public health but took quite a long time to implement it. Germany, on the other hand, the industrial latecomer, swiftly adopted new sanitary measures, even before adequate legal provision had been made for them. Here the authorities applied their traditional right to intervene. The high administrative competence of Prussian governments proved to be an advantage, whereas in England powerful middle-class ratepayers were reluctant to take on extra costs, and weak municipal authorities were for a long time unable to stand up to them.
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The introduction of health systems had a profound impact all around the world. The new turn was palpable even in countries where indigenous arts of healing were well tried and recognized and enjoyed the confidence of the majority of the population. Traditional medicine—in Africa or Latin America, for instance—was strongly individualist, in the sense that it was bound up with the virtues and capacities of particular charismatic healers. There were three prerequisites for the introduction of public health systems: (1) a new definition of the tasks of the state and the will to commit resources to them; (2) the presence of biomedical knowledge, including its practical implications; and (3) an expectation on the part of citizens that the state should concern itself with health matters.

Intellectually the microbe theory developed by Louis Pasteur, which gained acceptance throughout Europe from the 1880s on, gave a scientific foundation to the observations of practical men such as John Snow, raising policies to promote public hygiene above the party-political fray. The earliest initiatives, though
“well meant,” rested on shaky premises and did not lead to generalizable conclusions. Only the theory of microbes established cleanliness as the highest priority, making
Homo hygienicus
the creation of bacteriology. Scientists such as Pasteur and Robert Koch became cultural heroes of the age. Disease was detached from its familiar ecological, social, political, and religious contexts, and health was proclaimed to be a supreme value. The middle classes, and more and more people from other strata of society, internalized this attitude.
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Improved sanitation probably played a greater role in reducing mortality in Europe and North America than elsewhere in the world, where attempts are still being made to achieve comparable results with simpler and cheaper technology. The universality of ends was not matched by a universalization of means. The influence of the West, then, was differentiated.

Major public investment in hospital coverage became worldwide only in the twentieth century. The Allgemeine Krankenhaus in Vienna, founded in 1784 on the orders of Emperor Joseph II, was the first great modern hospital. In Britain the eighteenth century was the breakthrough age: hospitals were to be found by 1800 in all the large cities of England and Scotland, with a whole series of specialist centers already operating in London. Britain was the world pioneer; things took considerably longer to develop in the United States. All these early hospitals were private foundations—unlike in continental Europe.
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In the German Reich, a growing number of hospitals were built after 1870, with the result that there was a surplus of beds on the eve of the First World War. The hospitals of the late nineteenth century were rather different from the care institutions of the early modern age. Geared to the new knowledge of hygiene, they mainly served the purposes of short-term medical treatment, the training of doctors, and the development of the art and science of medicine. The importance of these tasks increased with the advance of specialization (in Germany from the 1880s onward).
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So long as there was a fear of epidemic outbreaks, it was a major task of hospitals to care for patients with acute illnesses—but for a long time no one could be sure that they increased rather than lowered the chances of survival.
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The universalization of the Western-style clinic is a phenomenon of more recent times, closely bound up with new types of health funding.

The (Relatively) Healthy Slaves of Jamaica

The average state of health of a social group depends on numerous factors: adaptation to the local climate, quantity and quality of food, physical and mental stresses of work, risk-lowering behavior (such as personal hygiene), access to medical care, and so on. The information available for the nineteenth century allows a reasonably complete health profile to be drawn up for only a few groups, most of them in Europe. We still know little, for example, about the situation in the most populous country in the world, China. But there are exceptions to this rule. One is the slave population of the British Caribbean, between the end of the African trade in 1808 and the abolition of slavery in the British Empire
in 1833. During that period it would have been foolish for even an unscrupulous and sadistic plantation owner to work his slaves to death; black laborers had become a commodity that was no longer so easy to replace. Most planters employed European doctors, or Creoles who had studied medicine in England or Scotland. Medical stations were not a rare sight on the large plantations. Of course it was in the logic of the exploitative system to care quite well for young and strong slaves, while neglecting older ones or even driving them from the plantation. All in all, however, medical facilities for slaves were not much worse than for English industrial workers at that time. The main limits to health care—in Europe as in the Caribbean—lay in the defective state of knowledge, which in the early nineteenth century still had not identified the causes of many diseases, especially those prevalent in the tropics. Many slaves wisely refrained from placing their trust in European medicine, often preferring to consult black healers who practiced a folk medicine unavailable to the European industrial proletariat.
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3 Medical Fears and Prevention

Major Trends

A second factor that helped to lower mortality wherever theory found practical application was the new knowledge of disease prevention. Like the “demographic transition,” an epidemiological transition made itself felt at different times in various parts of the world. Generally speaking, the chances of succumbing to a mass outbreak of disease—what demographers call a mortality crisis—decreased over the course of the nineteenth century. For northwestern Europe the following sequence has been described: In a first phase that began in 1600 and reached its peak between 1670 and 1750, diseases such as bubonic plague and typhus lost their importance. In a second phase deadly infectious diseases such as scarlet fever, diphtheria, and whooping cough receded. In a third phase that began around 1850, respiratory diseases apart from tuberculosis gradually declined in significance. Finally, the twentieth century saw the gradual emergence of the mortality profile that is familiar today in all European societies: heart and circulation disorders and cancer as the main causes of death.
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For each region of the world, a particular balance sheet of old and new diseases might be drawn up.

Tuberculosis was among the afflictions of the epoch that was thought of as new. Since it was recognized as a uniform disease pattern only in the early nineteenth century, little that is precise can be said about its appearance in earlier times. It was undoubtedly more common than the historical documents suggest. We can be sure that it was endemic in various parts of Eurasia and North Africa, and probably also in the “pre-Columbian” Americas. But its spectacular spread in the nineteenth century made it a token of the age, not only in the new working-class suburbs but also in the drawing-rooms of high society. The
courtesan Marie Duplessis, immortalized as the “Dame aux Camélias” in Alexandre Dumas's eponymous novel (1848) and as Violetta in Giuseppe Verdi's opera
La Traviata
(1853), was one of its most famous victims. In the first half of the century, it doubled in frequency as a cause of death in France. It was still one of the great social calamities after the First World War, against which health policies fought with disappointing results. There were no drugs to treat it until 1944, and the truly effective ones became available only in 1966. Since tuberculosis was thought to be hereditary, it was often covered up in the families of the bourgeoisie. But silence was not possible in the case of prominent figures who succumbed to it—from John Keats (1821) to Frédéric Chopin (1849), from Robert Louis Stevenson (1894) to Anton Chekhov (1904) and Franz Kafka (1924).
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The cures that the rich began to seek in the 1880s, in a new archipelago of mountain sanatoriums, resulted in a special kind of international semipublic sphere. Here they were by themselves, but not alone, as they rested, ate healthily, shed the stresses of the big city, and willingly subjected themselves to the tyranny of the staff.
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Thomas Mann's novel
The Magic Mountain
(1924), set in an Alpine sanatorium in the years before the First World War, depicts one of these characteristic institutions that sprang up even as far as Korea, where a fifth of the population was infected.
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In Japan too, the number of tubercular patients rose dramatically after the turn of the century, to fall again only after 1919. Japanese scientists thoroughly studied new Western discoveries about the disease, but for that reason it sometimes took them a long time to act on them. Not until several decades after Robert Koch's simple and empirical identification of the tuberculosis bacillus (1882)—an effective vaccine followed in the 1890s—was the Japanese medical profession prepared to accept a clinical picture of it as a single infectious disease. But that was not the end of the story, since, as in Europe, there continued to be a divergence between popular and scientific perceptions. The majority of the Japanese population held on to the belief that “TB” was a hereditary disease that should be concealed as much as possible, whereas medical officials wanted to record as many cases as they could. Factory owners were also fond of the inheritance theory, since it relieved them of the need to improve conditions at the workplace. For the largest group of carriers in Japan were female workers in the silk and cotton industry, who subsequently spread the disease to their native villages.
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Some completely new diseases also appeared in the nineteenth century. One of these, first recorded among young people in Geneva in 1805, was meningitis, which in one out of two cases led to death within a few days. Soldiers on the move from one garrison to another seem to have been the most frequent carriers in France. Eventually the whole of France and Algeria were affected. At the peak of its virulence, between 1837 and 1857, the disease claimed several tens of thousands of lives, almost exclusively of people under the age of thirty. Poliomyelitis was another scourge of the nineteenth century. For a long time medical knowledge of it had been extremely vague, but in the last quarter of the century new
conditions in France and other European countries caused it to assume epidemic proportions. A vaccine did not become available until 1953. Polio has never been a disease of poverty attributable to unhygienic surroundings: indeed, it first appeared in countries such as Sweden that had the most developed hygiene in the world. Other illnesses were rife among clearly defined risk groups: for example, the dreadful and incurable distemper, in principle an equine disease, spread to consumers of infected horsemeat and to coachmen or soldiers who had to deal with horses professionally.

In terms of global history, the nineteenth century saw a tension develop between easier transmission of diseases and more successful campaigns against them. On the one hand, migration and modern means of transportation proved effective conduits for the global spread of infections. The Black Death of the fourteenth century had already gripped most of the known world, by no means only Europe, and killed a third of the population of Egypt.
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Now epidemics spread much more quickly across regions. The worst by far was the global influenza pandemic of 1918, which struck even remote islands in the South Seas, and is estimated to have killed between 50 and 100 million people—more than the total number of deaths in the recently ended First World War. Especially hard hit were Italy, which lost 1 percent of its population, and Mexico, where the figure reached 4 percent.
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On the other hand, advances in medicine and disease control made it possible to combat some of the greatest epidemics that history had yet seen, not eliminating them altogether but breaking their power. The chronologies and spatial patterns of this counteroffensive provide information about global processes. The nineteenth century was the first epoch in which worldwide campaigns were systematically waged against medical scourges. In order to be successful they had to combine adequate biomedical knowledge with the idea of a public health policy. Here are a few examples.

The Preventive War against Smallpox

The primal story, later repeated elsewhere in modified forms, was the war against smallpox. It began, at least in Europe, with the English country-doctor Edward Jenner's successful vaccination trials in 1796, but there had been a prehistory to the campaign outside Europe. China had been practicing inoculation or “variolation” since the late seventeenth century, and the practice was common in India and the Ottoman Empire too. In this method, pathogens from a smallpox patient were directly applied to the skin of a healthy person to trigger an immunizing reaction. At the beginning of the eighteenth century, Lady Mary Wortley Montagu, a diplomat's wife and well-known travel writer, observed this immunizing effect among both peasant women and the wealthy upper classes of Turkey, and she reported it to her learned friends in London. In fact, inoculation had many advocates in England, Germany, and France in the last third of the eighteenth century, but failure to isolate the subjects properly at the stage when they were highly infectious often resulted in an epidemic outbreak. Before
Edward Jenner, who discovered the protective effect for humans of the much weaker cowpox pathogen, no one had found a risk-free way of guarding whole populations against smallpox. In 1798, after two years of experiments, Jenner presented his pathbreaking results to the public. A safe and inexpensive alternative to inoculation had been found in the shape of vaccination.