Politics of a Plague

Asiatic cholera, one of humanity’s greatest scourges in the modern period, came to Europe for the first time in the years after 1817, traveling by ship and caravan route from the banks of the Ganges, where it was endemic, to the Persian Gulf, Mesopotamia and Iran, the Caspian Sea and southern Russia, and then—thanks to troop movements occasioned by Russia’s wars against Persia and Turkey in the late 1820s and its suppression of the revolt in Poland in 1830–1831—to the shores of the Baltic Sea. From there its spread westward was swift and devastating, and before the end of 1833 it had ravaged the German states, France, and the British Isles and passed on to Canada, the western and southern parts of the United States, and Mexico.

Statistics for morbidity and mortality in this first great cholera epidemic are unreliable, for there was generally no means of collecting and tabulating them on a large scale, but on the basis of what we have it appears that Russia suffered over 100,000 deaths in 1830–1831 and that, in Germany, Berlin alone had 2,000 deaths out of a population of 230,000, while in France there were 39,000 cases of cholera in Paris, with 18,000 deaths, a mortality rate of 21.8 per thousand of population. In Great Britain, the Black Country was particularly affected, with heavy death rates in towns like Bilston, Manchester, and Liverpool, while Glasgow and Dublin had mortality rates of 15 and 30 to the thousand respectively. In Canada one in every thirteen inhabitants of Montreal died in 1832, and in the United States there were 5,000 cases in New Orleans. Nor was this the end of the matter, for the disease returned in 1848–1849, when there were 668,000 deaths in Russia and heavy losses in Italy and France; in 1854, when there were 5,000 deaths in Liverpool; in 1866–1867; in 1873, when half a million Hungarians died of the disease; in 1884; and in 1892.

Cholera was by no means the greatest of the killer diseases of the nineteenth century; tuberculosis had a far higher incidence and claimed nearly four million victims in England and Wales alone between 1851 and 1910, and typhoid, smallpox, and measles had higher mortality rates. But there is no doubt that its psychological impact was unequaled. William H. McNeill has written that the cholera bacillus produced

violent and dramatic symptoms—diarrhea, vomiting, fever and death—often within a few hours of the first signs of illness. The speed with which cholera killed was profoundly alarming, since perfectly healthy people could never feel safe from sudden death when the infection was anywhere near. In addition, the symptoms were peculiarly horrible: radical dehydration meant that a victim shrank into a wizened caricature of his former self within a few hours, while ruptured capillaries discolored the skin, turning it black and blue. The effect was to make mortality uniquely visible: patterns of bodily decay were exacerbated and accelerated, as in a time-lapse motion picture, to remind all who saw it of death’s ugly horror and utter inevitability.^*

Nor did the disease respect class or degree. It struck down the prominent as well as the humble—among its victims in 1831 were the French prime minister Casimir-Perier, the German philosopher Hegel, Napoleon’s great antagonist August Neithardt von Gneisenau, the military theorist Clausewitz, the Russian grand duke Constantine, and the commander who suppressed the Polish revolt, General Diebitsch. It also had the power to undermine the foundations of apparently stable regimes, as it did in the canton of Zurich in 1867, when an unforeseen outbreak of cholera, which affected the poorer districts of the city most grievously, raised a storm of indignation that helped to overthrow the government and ended the liberal era that had lasted since 1830. It was no accident that preoccupation with the disease affected literature and supplied both the pulpit and the language of politics with new analogies and symbols. When Bismarck said that preventive war was like committing suicide because you are afraid to die, he was thinking of an old lady in Berlin during the epidemic of 1831 who had done precisely that. When Theodor Mommsen sought an effective way of describing his feelings about anti-Semitism, his mind turned in the same direction, and he said, “It is a horrible epidemic like cholera—one can neither explain nor cure it. One must patiently wait until the poison consumes itself and loses its virulence.”

In an influential article in Past and Present in April 1961, Asa Briggs called upon historians to turn their attention to cholera’s deadly nineteenth-century progress, which they had until then largely neglected. He insisted that when they did so they would have to undertake far more than a mere exercise in medical epidemiology, for cholera was a disease of society in the most profound sense:

It hit the poor particularly ruthlessly, thriving on the kind of conditions in which they lived. Whenever it threatened European countries, it quickened social apprehensions. Wherever it appeared, it tested the efficiency and resilience of local administrative structures. It exposed relentlessly political, social and moral shortcomings. It prompted rumours, suspicions and at times violent social conflicts.

Richard Evans’s new book, which concentrates on the cholera epidemic in Hamburg in 1892, is precisely the kind of study that Briggs had in mind. A brilliantly written work of great analytical penetration, which is based on very extensive reading, it is not a mere description of the Hamburg epidemic of 1892 (which, even with its 17,000 cases and 8,600 deaths and its mortality rate of 13.4 per thousand, was far less severe than the epidemics in Montreal in 1832 or in Hungary in 1873), but rather an investigation of why the harbor city on the Elbe, alone of the great European cities, suffered a major outbreak in that year. Evans finds the answer to that question in the peculiar combination of political, economic, social, and medical circumstances that prevailed in Hamburg at the time, which not only explained the failure to take preventive action before the crisis came but also determined the nature of the response to it and the corrective measures taken after it was over.

The epidemic itself is not really the center of Evans’s story, but it was, as he says, “one of those events that, as Lenin once put it, may perhaps be ultimately insignificant in themselves, but nevertheless, as in a flash of lightning, illuminate a whole historical landscape, throwing even the obscurest features into sharp and dramatic relief.” More graphically than other epidemics, it demonstrated the helplessness of traditional patterns of authority to meet the challenge posed by the social and environmental consequences of rapid industrial and urban growth, while revealing the structures of social inequality, the operations of political power, and the attitudes and habits of mind of different classes and groups in society with a cold and pitiless clarity.

At the end of the nineteenth century, Hamburg was governed by an eighteen-member Senate and a Citizens’ Assembly of 160 members. Both bodies were representative of the population only in the most limited sense, for the Senate, whose members served for life and could not be replaced, filled its vacancies by a process of appointment in which the Citizens’ Assembly collaborated, and the latter body was elected half by the tax-paying citizens, who also had to pay a substantial annual citizen’s fee, and half by the property owners and the “notables” or citizens serving in civic positions. As Evans writes, “Property thus in a very real sense formed the foundation of direct political power.” The wealthiest of the city’s merchants, bankers, and lawyers, bound together by familial and social ties, reserved to themselves the executive power in the Senate. The middling bourgeoisie of lesser merchants, doctors, apothecaries, lawyers, and teachers, and those members of the lower middle class who owned rentable property, made their influence felt through the Citizens’ Assembly, the Chamber of Commerce, the Property-Owners’ Association, the Citizens’ Clubs, and other organizations.

This was a form of government that worked through leisurely consultation and informal agreement and compromise, but it was at a grave disadvantage when it came to coping with emergency situations or even with the kind of problems that are inevitable in expanding urban conglomerations—public works, communications, housing, and hygiene and sanitation. Unlike the bordering Kingdom of Prussia, it had no professional civil service, the very idea of which was offensive to its tradition of particularism and its liberal philosophy. Almost all of the city’s higher administrative work was carried out by the so-called Deputations, of which there were thirty-four, each responsible for a particular aspect of government and each composed of prominent citizens, elected by the Citizens’ Assembly and serving without pay under the leadership of one or more senators. Inevitably the work of these bodies was characterized by duplication of effort, conflict over jurisdiction, and, since all senators were not equally competent or energetic, inefficiency and procrastination.

Given the social complexion of the Deputations, and their lack of technical advisers, they were also affected by a baleful myopia when confronted with problems like environmental pollution, to which Hamburg was increasingly prone as it became more industrialized. They were inclined to regard this as a direct physical consequence not of capitalist expansion but of the dirtiness and unhygienic habits of the lower classes, a fixation from which much tragedy was to come. In general, there was no doubt about the civic conscience that animated the political system, but the philosophy underlying this was one of “common sense,” which meant doing nothing that violated tradition, or involved needless and costly change—above all nothing that would jeopardize Hamburg’s trade, the promotion of which was universally regarded as the end of all policy, even by such outsiders as the Social Democrats (this helps to explain the reformism of that party in Hamburg, despite its revolutionary pronouncements elsewhere in the country).

These institutional weaknesses and habits of mind might have had less tragic results during the crisis of 1892 if there had been a determined and united medical profession capable of making the government face up to realities. But the doctors were slow in winning the confidence of the ruling classes in Hamburg, who were suspicious of their claim to a monopoly in the health market and their attempt to strengthen hygienic and sanitary regulations, and who were in any case, as one doctor wrote in 1863, prone to “a scarcely believable ignorance and indifference…with regard to what one might call public health care.”

Typical of the disregard of medical advice is the fact that decades after the introduction of compulsory vaccination against smallpox in the rest of Germany, Hamburg’s government continued to rely on voluntary methods of prevention, and when the medical profession pressed for legislation on the subject in the 1860s, and again in 1871, this was rejected by the Citizens’ Assembly, with the argument on the latter occasion that compulsory vaccination “encroaches upon personal freedom and liberty, and upon the most basic right of the individual, that of the freedom to dispose of his body as he wishes.” Later in the year, soldiers returning from the war against France brought the smallpox virus with them. Four thousand and fifty-three inhabitants of Hamburg died of the disease, more victims than in any local outbreak of typhoid or cholera in the nineteenth century, including the epidemic of 1892.

In the case of cholera, effective pressure for remedial action was made impossible because the medical profession was badly divided on the question of the causes of the disease. The English doctor John Snow had demonstrated that all cases of cholera that occurred in a district of central London during the outbreak of 1854 could be traced to a single contaminated source of drinking water. But his report was regarded as circumstantial and attracted little attention in Germany, where the prevailing theory was that of Dr. Max von Pettenkofer, a flamboyant and stubborn Bavarian advocate of the miasmatic theory, which held that sudden outbreaks of the disease were caused by a miasma that was exuded by corpses and other rotting matter in the earth and was particularly infectious to constitutions weakened by their living conditions or manner of life.

This theory remained unchallenged until 1883, when Robert Koch, the discoverer of the tuberculosis bacillus, claimed to have found a new bacillus responsible for cholera. This discovery was hailed throughout Germany, perhaps more for political than for scientific reasons, for it seemed to be proof of the scientific eminence of the new German Reich, but for the same reasons it had less resonance in particularistic Hamburg, which feared the kind of bureaucratic controls that the contagionist theory would require in time of epidemic. On the other hand, Pettenkofer’s views were entirely congenial to Hamburg’s liberal philosophy of government, for he declared roundly that prevention by hygienic measures to provide cleanliness, fresh air, and rational diet was the only effective way of coping with cholera, and that, once an epidemic had broken out, nothing could be done by quarantine or special hospitals or the closing of markets and fairs or the compulsory boiling of water to check its progress. His theory of cholera was reassuring because it seemed a guarantee against excessive expenditures and the disruption of trade, and also, as Evans writes, because

his emphasis on sanitation…[was] more than welcome to the German middle classes at a time when the urban environment was rapidly deteriorating, and when bourgeois consciousness of the presence of dirt and excrement, noxious vapours, and polluted or adulterated food was growing stronger. The stress he laid on temperance and regularity accorded strongly with bourgeois values, as did the belief he expressed that hygienic improvement depended above all on the individual.

Morever, since Pettenkofer was a sound scientist who offered a synthesis of many previous studies and linked his theory to the established scientific principle of fermentation, he persuaded a large part of the medical profession that his views were correct and left others undecided, and hence doubtful of the validity of the contagion theory of Snow and Koch. In the intermittent debate on the construction of a new water and sewage disposal system for Hamburg, which began after the epidemic of 1873 and continued without issue for the next seventeen years, there was no really persistent pressure from the medical profession, even after Koch’s discovery increased the advisability of such construction. The doctors do not seem to have protested when new port facilities and a grandiose new town hall were given precedence over a water filtration system, which was not indeed approved until 1890 and was still unfinished when the epidemic came in 1892.

The first part of Evans’s discussion of the epidemic itself is aptly called “From Concealment to Catastrophe,” and it is a sad story of administrative failure and individual incompetence. Throughout the summer of 1892, local authorities were aware that a new epidemic was threatening their city, and they had been warned by the Imperial Health Office, which by now had completely accepted Koch’s views, to institute all of the measures that had been anathema to Pettenkofer: disinfection and quarantine, strict control of the river traffic, the boiling of all water, and the plentiful use of carbolic. But when the first cases appeared, doctors were reluctant to take the responsibility for diagnosing them as cholera Asiatica, and were subjected to pressure to prevent them from doing so. The city’s chief medical officer, Johann Caspar Kraus, Evans says, followed an ” ‘absolutely definite plan’…of not taking cognizance of individual cases.”

Kraus and his superior, Senator Gerhard Hachmann, were so dilatory in responding to accumulating evidence of the mounting danger that it was not until August 24, nine days after the appearance of the first case, that the Senate met to consider what measures might be taken, and even then its members seemed more worried about the quarantine measures that foreign ports might impose upon Hamburg shipping if the news got out than about the danger confronting the people of Hamburg. It was by then already too late to prevent the epidemic. It had been a hot summer, and the Elbe was so low that the tide was pushing further upstream than usual, and carrying rapidly multiplying cholera bacilli and excreta from the river’s traffic past and into the main intake of the city’s unfiltered central water supply, whence it passed into reservoirs and was pumped directly into the city’s houses. By August 23 every section of the city was affected and thousands of people were experiencing the first symptoms of the disease. When Robert Koch arrived in the city and inspected its hospitals on August 25, he wrote to his mistress:

I felt as if I was walking across a battlefield. Everywhere, people who had still been bursting with health a few hours before and had begun the day full of joie de vivre were now lying stretched out in long rows, shot down by invisible bullets, some with the characteristic rigid stare of the cholera victim, others with broken eyes, others already dead: no lamentations were to be heard, only here and there a sign or a death-rattle.

Koch was appalled by the delays and confusion and lack of energy that he found in government offices, by the evasiveness and disingenuousness of the city’s medical authorities, and by the failure to implement measures long recommended and now proving their worth in Bremen and Altona, which experienced cholera in 1892 but not in epidemic proportions, Bremen suffering only six deaths. Most of all, he was shaken by the conditions of overcrowding, lack of effective sewage disposal, narrow alleys, insanitary courtyards, and stinking waterways that he discovered in a tour of the Alley Quarters in the inner city; and it was here that he made the remark that, Evans says, did more than any other single statement “to discredit the government of Hamburg, its social policy, and the political system on which it rested.” “Gentlemen,” Koch said, “I forget that I am in Europe.”

And yet after the epidemic had run its course, the system was able to survive, with only cosmetic changes, and in Evans’s opinion “the power of mercantile, banking, and industrial interests in the city continued undiminished, and even increased.” One of the few genuine reforms that can be attributed to the epidemic was the law of November 1896, which broadened the suffrage by abolishing the citizen’s fee, but even here income requirements were included to prevent the extension of the voting right beyond the respectable working class. The reform of 1896 also established a higher civil service in Hamburg with a career structure like the Prussian system, which weakened the element of self-government by citizen participation and tended to strengthen the authority of the Senate, as did the granting of new powers to the police “to protect persons and property against emergencies and dangers,” a provision intended to guard against any possible threat from the lower and still disenfranchised classes.

The pressure from Berlin for elaborate reform in the sphere of public health was only partially successful. A Hygienic Institute was established to carry on testing of food and drink and eliminate adulteration; the sewage system was greatly improved, but it was many years before a full treatment process was instituted; new medical regulations were written, designed among other things to increase the medical profession’s numerical superiority on the medical boards, although these did not come into effect until 1900. These reforms and the institution of an effective water filtration system in 1893 doubtless improved the health of the population in the years before the war. The basic social and political realities in the city, however, remained unchanged.

Given Hamburg’s bourgeois-liberal tradition and its opposition to centralization and bureaucratization, which in some part determined the inefficiency of its authorities in 1892, one might think that it would have been strongly opposed to National Socialism. In reality, before 1933 the Nazis received the support not only of its resentful lower middle class, the chief victims of the financial misfortunes of the Weimar Republic, but a significant proportion of the votes of the middle and upper bourgeoisie as well. During the Third Reich, Hamburg was a Nazi stronghold often visited by Hitler and a place where the sterilization and extermination policies of the regime proved easier to carry out than in other parts of Germany. Evans believes that in part this was a reflection of attitudes toward the poor and vulnerable classes of society that had become almost automatic during the epidemics of the nineteenth century, when the well-to-do came, quite illogically, to regard them as the cause of all of society’s misfortunes, including epidemic disease. It was, he says,

the culmination of the fear and contempt with which the state, the bourgeoisie, and increasingly the apparatus of the Social Democratic Party had come to regard people such as the denizens of the Alley Quarters—the last parts of which were pulled down in the Third Reich—until they were ultimately disqualified as human beings altogether.

About the contemporary relevance of this book there can be no question, confronted as we are with an epidemic of yet unknown, but surely staggering, proportions. Current public attitudes toward AIDS are not dissimilar to those that were elicited by the great cholera epidemics of the last century. Today too, as Evans correctly points out, there has been a tendency to blame stigmatized groups, and governments waver between coercion and indifference. Medical opinion sometimes seems as widely divided about the crisis as it was in the nineteenth century; nor has it been immune to political pressure. Governments have been as reluctant to commit the resources that the threat requires as the Hamburg Senate of 1892 showed itself to be. The same lack of energy in grappling with the problem is everywhere evident. The price of such attitudes is clearly written in the historical record. If cholera has disappeared from our society, the mistakes made by governments in dealing with it in the nineteenth century still have something to teach us.