The Plague Cycle

by Charles Kenny

  The new religion, Christianity, didn’t help.7 Christian observance was enforced in the Roman Empire by an edict in 350. But early Christianity was a dirty religion, one that militated against humans’ natural desire to be clean. St. Jerome, who translated the Bible into Latin, typified the problem. As a hermit, he avoided bathing. And he also objected to women engaging in the practice:

  I wholly disapprove of baths for a virgin of full age. Such a one should blush and feel overcome at the idea of seeing herself undressed. By vigils and fasts she mortifies her body and brings it into subjection. By a cold chastity she seeks to put out the flame of lust and to quench the hot desires of youth. And by a deliberate squalor she makes haste to spoil her natural good looks.8

  A number of other saints clearly felt the same way: St. Benedict had warned against the risks of baths, St. Agnes took none at all in her thirteen years of life, and Catherine of Siena also followed the same routine.9 The phrase “Cleanliness is next to Godliness” only emerged in the late eighteenth century.

  The problem of urban sanitation waxed and waned with the size of cities. Historian John Kelly notes that in fourteenth-century Europe there were at least five Parisian streets named after excrement (rue Merdiere, for example), as well as the rue du Pipi. As long as a person shouted, “Look out below, look out below, look out below!” first, many European towns were fine with throwing the contents of chamber pots out of the window into the street. And continual warfare kept people densely enclosed behind city walls for safety. That was why, in the fifteenth century, life expectancy was a third lower in European towns than in the countryside (the reverse of China’s health pattern at the time).10

  Official complaint about the state of public sanitation became shriller when plague was linked with bad air. King Edward III wrote to the City of London to rail against “human feces and other obnoxious filth lying about in the streets and lanes, where it was cast from the houses both by day and by night, so that the air of the city was polluted with foul odours to the great peril of citizens during that time of prevailing sickness.”11 By 1385, London had a sergeant of the channels on patrol with city rakers who collected filth from the streets and piled it on dumps by the river, where it was collected by dung boats. Officially, fines were imposed for throwing dung onto the road. But the remaining piles of ordure and the few people fined suggest enforcement was lax.12

  And as London expanded in the Middle Ages, carting dung through congested streets to urban plots or the countryside became more complex. In 1411, Henry Ivory, a London privy-cleaner, earned sixty-five shillings for digging out and carting away 3,675 gallons of ordure—about seventy bathtubs’ worth. Each year, he’d remove about three times that total.13 But not everyone paid for privy-cleaning services, and urban areas were eventually buried in excrement from human inhabitants, alongside dung from horses, cows, and other animals housed with them.

  In response, the power of public officials over sanitation continued to expand: in 1486, Venice had an elected Public Health Commission of three noblemen who inspected wine, fish, meat, and water supplies, monitored sewage, and regulated burials to control the threat of miasma. In 1504, they were given the power to arrest and torture people to ensure ordinances were followed.14 These ideas spread: England’s Cardinal Wolsey and Thomas More, both lord chancellors to Henry VIII, introduced plague orders in the second decade of the 1500s that copied many features of the Italian model.15 Some cities added more controls: London massacred dogs in 1563, while Edinburgh banned leeks, chives, and onions two years after.16

  Despite a growing role for the state, London’s average life expectancy remained only around twenty-eight years, thanks in part to poor sanitation. The increasing piles of animal and human excrement, rubbish, and corpses would have been a direct affront to the senses and created a disgust instinctively associated with disease. By the 1780s, suggests historian J. N. Hays, “air had become the health issue, the nose was the diagnostic tool, and clean water was the solution to the filthy atmosphere that bred disease.”17 The foundations for a sanitation revolution were in place.

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  In the early 1800s, one in five of the English people lived in towns with a population of more than five thousand. Less than fifty years later, as the Industrial Revolution took hold, that proportion had risen to one-half. Between 1800 and 1850, Birmingham tripled in size while Manchester and Liverpool more than quadrupled.18 And, by 1870, London was home to 3 million people.19

  These packed and dirty cities teemed with infections ancient and modern. For many infected by tuberculosis, a disease thousands of years old, the immune response is rapid and effective. The body creates a holding pen for the organism—the tubercle—which stops further damage. But for others, the barrier doesn’t hold, and tuberculosis spreads. If it reaches the lungs, victims suffer consumption—a deathly pallor, with coughing fits of bloody sputum.

  Tuberculosis had an apparent penchant for striking the suffering artist—in the three years from 1847 to 1849 alone, consumption carried off Felix Mendelssohn, Emily and Anne Brontë, Edgar Allan Poe, and Frederic Chopin. But the efficacy of people’s immune response and their ability to live with the disease appear to be related to a range of factors, including general health, nutrition, and stress.20 And that meant tuberculosis was most lethal among poor, malnourished people packed into growing slums. In the middle of the nineteenth century, it was killing fifty thousand people in England and Wales each year, with rates that varied by orders of magnitude between wealthy and poor parts of the same city.21

  A new affliction was cholera. The first cholera pandemic emerged in 1817, spreading rapidly thanks to globalization and poor sanitation. Cholera is a bacterial infection that passes from the end extremity of the digestive system of a host to the start of the digestive system of a new victim, also known as the fecal-oral route. It can do so explosively thanks to cholera’s symptoms. If someone swallows enough of the microbe, these symptoms can start within hours of infection. Diarrhea develops into “rice water stools”—milky water that is expelled in volumes as much as five liters a day. As the victim’s body rapidly dehydrates, the person suffers muscle cramps, plummeting blood pressure, a slowed heart rate, and coma. Death from renal failure and circulatory collapse can be so rapid that even treatment by antibiotics is ineffective.22

  The first cholera pandemic spread through India with the help of war. The British general the Marquess of Hastings reported death striking victims in as little as a few hours and that hundreds of troops were dying each day. That is to say nothing of those who were unfortunate to live in the path of the various armies. Not everyone was saddened by the losses—the Calcutta Medical Board, loyal Malthusians to a man, suggested that the consequences of the outbreak “may in the present instance have been beneficial, correcting the influence of an overcrowded population.”23

  By 1820, the outbreak had reached China, the Philippines, and (thanks to a British expeditionary force) the Persian Gulf. Two years later cholera was killing people in Japan. Russia and Egypt both imposed quarantines that may have worked at least in the short term—and the disease retreated for a few years. But it roared back: by 1831, it had reached Britain, and in 1832, it evaded North American quarantines and spread along waterways through Canada and the United States.

  Over the course of the nineteenth century through the First World War, India lost as many as 25 million people to the disease.24 In Europe it was no Black Death—mortality was only in the tens of thousands in major cities, killing off one in twenty or one in ten, not one in three or one in two. Nonetheless, it was a sign that growing globalization could produce threats not just to the newly conquered but the conquerors. And the disease came as a rude shock according to R. S. Bray, author of Armies of Pestilence:

  Western Europe had been free of plague for over one hundred years, smallpox was on the retreat and yellow fever was but an infrequent visitor. It was only the lesser races which suffered great epidemics in the opinion of nineteenth-ce
ntury Western Europe. Cholera came as a very nasty surprise indeed and Europe was in thrall to it. It struck terror into the hearts of a civilization which had thought that the external world was softening towards it.25

  Cholera spread misery and fear.26 The overwhelmingly poor victims of the infection focused their wrath on the establishment—in Russia, riots erupted around the idea that the aristocracy was using cholera to kill off workers, while in the UK the rioters were convinced doctors spread the disease to increase the number of cadavers available for dissection.27 Given that the wealthy shared Malthus’s concern with the teeming masses, it wasn’t implausible they’d welcome or even enable a disease that would thin populations.

  In the 1830s and ’40s, William Farr, compiler of abstracts of the Registrar General’s Office, used the new UK register of births, deaths, and marriages to confirm that death rates were higher where poor people were packed together. He felt sure that unsanitary conditions lay behind the correlation.28

  Farr’s friend Edwin Chadwick had reason to agree with him. Chadwick was a lawyer and essayist turned social reformer who’d implemented Britain’s Poor Law. The legislation herded those desperate enough to ask for relief into locked and sex-segregated poorhouses, where they wore uniforms and were denied alcohol, tobacco, or reading material besides the Bible. Chadwick argued that these unpleasant conditions would ensure only those who really needed support, rather than the merely lazy, would apply for relief. It was an attitude toward people that fit with his personality: headstrong, impatient, dogmatic, convinced of his infallibility, and utterly humorless. He demonstrated his attitude toward the majority of his countrymen in a letter attached to a set of deficient cutlery he was returning to a silversmith: “My new experience in household matters has brought so much annoyance from the carelessness of workingmen of every class… I intend to make these experiences of the indolence and inattention of workmen the subject of some remarks on popular education.”29

  But Chadwick did accept that some of those left destitute were disadvantaged by ill health in increasingly foul industrial towns up and down the country. His poorhouses had surely removed the problem of poverty causing ill health because they provided sustenance and shelter to those people who really needed them. Something else must be driving the spread of ill health that itself caused greater poverty. Chadwick’s Report on the Sanitary Condition of the Labouring Population of Great Britain noted: “The annual loss of life… is greater than the loss from death or wounds in any wars in which the country has been engaged in modern times.” He suggested the direct cause was “filth and bad ventilation.”30

  In 1846, Chadwick convinced a parliamentary committee that “all smell is, if it be intense, immediate and acute disease.”31 In response, he promoted what he labeled “the sanitary idea”: a national and local bureaucracy to provide for clean water and drainage, paved streets, and proper housing together with the control of “noxious trades” like abattoirs.32 His first step, backed up by an 1847 law: close the cesspits that were the receptacles of the city’s human waste and direct excrement through pipes from backyard privies into storm sewers, taking the smells with them. In a period of just six years, thirty thousand cesspits were dismantled and many of the 2 million Londoners began flushing their waste into sewers that led to the River Thames.33

  Chadwick’s priorities, according to the London Times, were “the complete purification of the dwelling house, next of the street and lastly of the river.”34 His report suggested that, eventually, intercepting sewers should be constructed on the banks of the Thames to take waste away from the river to be used as agricultural fertilizer. But the priority was to get smelly ordure away from houses.

  Chadwick’s solution, if fully implemented, would have carried waterborne bacteria like cholera far from London’s inhabitants, breaking the chain of infection. But leaving the river to be dealt with sometime later was a fatal problem: the Thames was the source of much of the city’s drinking water. The new sewage system helped ensure that cholera microbes could be piped almost directly from sufferer to new victim. Chadwick’s half solution was part responsible for a particularly virulent epidemic of cholera in 1848–49 that killed more than eighteen thousand Londoners.

  By 1849, water companies, their customers, and the press were all crying out for a solution to the foul water and stinking river. That was the year that engineer Joseph Bazalgette returned to the capital where he had been born three decades before.

  As a twelve-year-old, Joseph had witnessed the first cases of cholera reaching London. He’d left the city to work on land drainage projects in Ireland and railway projects in the north of England. But in the aftermath of the latest cholera epidemic, Bazalgette was appointed assistant surveyor to the London Metropolitan Commission of Sewers. Six years later, he became chief engineer of the newly created Metropolitan Board of Works. And over that time, Bazalgette created a plan for radically overhauling the capital’s sewage system with a set of intercepting pipes that would collect the rainwater and ordure from existing sewers and transport it out of London downstream, toward the English coast, where it would be pumped into the river.

  Bazalgette, too, was a miasmist. The sewage system he constructed was to complement Chadwick’s earlier work. But the plan was expensive, and opposition was considerable from those who thought the scheme an unnecessary luxury or—like Chadwick—a waste of fertilizer. In the meantime, an 1854 epidemic of cholera came and went, with twenty thousand more deaths.

  Members of the British Parliament were finally motivated to act in 1858 by the smell that wafted through Parliament’s riverside windows during the “Great Stink” of that year. The Thames turned almost solid with the output of the sewers. If intense smell was acute disease, the Great Stink was a direct threat to Britain’s ruling elite as they worked.35 The government passed an act to authorize the intercepting sewage system.

  The feats of engineering undertaken by Bazalgette involved six main sewers, with a combined length of 100 miles, and 450 miles of new interceptor sewers that connected existing sewage lines. Bazalgette estimated the project took 318 million bricks and nearly a million cubic yards of concrete.36 And the whole system had to be constructed with constant gradients that ensured available water flow could flush the pipes clear. Along with mastering the complexity of a system that always had to slope downward, it was necessary to acquire a deep knowledge of rainfall patterns, water supply, and usage by the city’s residents. Bazalgette noted that the habits of the population were reflected in sewage flow: “the maximum flow in the more fashionable districts of the West end being two or three hours later than from the East end.”37

  For all its complexity and cost—4.1 million pounds in mid-century money, worth perhaps more than half a billion dollars today—the system worked brilliantly. The city’s excrement was piped and pumped downriver, past the intakes for water supply. And London’s last cholera epidemic would take place in 1866.

  Most of Bazalgette’s network of sewers is still in use today. Other cities across Britain, the rest of Europe, and America followed with similar solutions over the next half century, with significant impact on health.

  The sanitation revolution wasn’t just about build-out of sewage and water systems, it was also and crucially about changing attitudes toward their use. In the 1710s, total soap consumption in England was less than 0.2 ounces a day—allocated to washing not just bodies, but also clothes, utensils, and everything else.38 Until the 1800s, the young man or woman seeking advice on etiquette would be told of the importance of clean hands, face, and hair—with nothing said of the necessity of cleaning the rest of the body.39 But, over the course of the nineteenth century, with industrializing Britain in the lead, full-bodied cleanliness became a necessity of polite company.

  By 1849, when William Makepeace Thackeray described “the great unwashed,” it was clear that cleanliness was an aspirational good. Britain’s Baths and Washhouses Act of three years earlier had encouraged local governments across
the country to open public baths where the poorest would have to pay no more than two pence for clean water and a towel. (These baths were signs of slow progress: as late as 1914, when most houses still lacked their own bath, attendance at big-city baths once a year or more ranged between a fifth and four-fifths of the citizens.)40 And in the 1870s, the Housing and Crowding Acts led to a slew of building regulations that reduced overcrowding and enforced access to clean water.41

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  The extent of the sanitation victory is clear from what goes on in modern-day global cities. Take, for example, Per Se, a restaurant in New York City, located just off the southwest corner of Central Park. Fox News declared the eatery, which serves a combination of New American and French cuisine, one of the three most expensive in the world in 2014.42 With a trio of Michelin stars and starters that include a “pastrami” of Hudson Valley moulard duck foie gras alongside the inevitable ossetra caviar, the tasting menu cost $325 a diner (drinks not included).43 But a 2014 inspection by New York City health inspectors revealed that Per Se had no hand-washing facility or soap in the food-prep area. Additionally, the inspectors reported hot and cold items held in improper temperatures. New York City forces restaurants to post their health inspection grades in front of the restaurant—and given its violations, Per Se was awarded a barely passing C grade.44

  The city’s health inspectors are a small part of a massive urban public health and sanitation operation. The New York City Department of Sanitation, founded in 1881, today has nine thousand staff and a $1.4 billion budget—most of which is spent on garbage collection, street cleaning, and “waste export” (a euphemistic phrase for paying other places to take Gotham’s trash).45 To get rid of liquid waste—sewage—the Bureau of Wastewater Treatment manages six thousand miles of sewer pipes linked to fourteen treatment plants that process and discharge 1.4 billion gallons of water a day. The bureau has nineteen hundred staff and a $376 million budget.46