They say history never repeats, but it rhymes: The Eradication of Cholera in Victorian Britain
The contrast between metropolitan London and England’s ancient second city, York, in their steps towards cholera eradication suggests that, when the current pandemic subsides, authorities should invest in large-scale, long-term planning, the better to manage epidemic infectious disease in future, writes Ann-Marie Akehurst.
From 1831, England succumbed to the Asiatic cholera pandemic (1826–1837), transmitted through faecal-contaminated foods and river water. Britain’s Boards of Health followed the ancient miasma theory that disease was transmitted by miasmata: air-borne particles from foul-smelling, dirty and decomposing matter. Anticipating epidemic, authorities ordered upholstery burnt, disinfection and airing. Cholera entered Britain in north-eastern England and quickly spread to York, where the rivers were silted up with sewage and polluted with factory effluent upstream from the waterworks. Cholera victims came largely – though not exclusively – from flood-prone areas. John Snow, of whom more later, was born next to York’s river, and in 1832 encountered cholera as a medical student in Newcastle.
The medieval parish remained England’s unit of administration at the time, causing tensions between parish and civic interests that resulted in confused management and governance. York took a short-term, literally parochial view of public health. Primed for the outbreak, York’s Medical Society delivered lectures, while the Board of Health levied a parish rate for whitewashing houses, for removing detritus, and for medicines, nurses and attendants for a temporary cholera hospital. As a cheaper alternative to enlarging the Country Hospital fever ward, they rented an isolated house and identified a burial ground.
Wenceslaus Hollar, A new and exact map of Great Britannie &c., 1667. Credit: Q,6.113 © Trustees of the British Museum, Released under Creative Commons Attribution - NonCommercial - ShareAlike 4.0 International (CC BY-NC-SA 4.0) license
John Varley, The Ouse Bridge, York. T09396 © Tate, released under Creative Commons CC-BY-NC-ND (3.0 Unported)
But public-health management was problematic. York lacked clear medical leadership, and cholera’s cause and progress weren’t well-understood – opinion divided between miasma and contagion theories. Local partisanship stymied decision-making: there was a row about the burial ground and the controversial route taken towards it. The epidemic occurred amidst national hysteria surrounding Resurrectionists, focused on the execution of murderer William Burke, who had supplied anatomists in Edinburgh with cadavers. Conspiracy theorists suspected York authorities of sacrificing poor people as corpses for dissection. The epidemic’s scale surprised authorities: the tiny cholera hospital was overwhelmed, requiring supplementary accommodation so, despite preparations, 185 died, most of whom lived in riverside locations. Afterwards, the Board of Health was dissolved, but drains laid at the time were subsequently deemed cheap and insufficient, and the unanimous 1831 decision to build washhouses and public baths remained unexecuted over a decade later.
Three factors eventually aligned to eradicate cholera in England: persuasive knowledge production, long-term, large-scale planning and generous resources. John Snow moved to London in 1836 and observed its cholera outbreaks. He related infected households to contaminated water, arguing ingestion was the cause and acted to prevent it. Since his pamphlet On the Mode of Communication of Cholera (1849) received little interest, he innovatively allied statistical analysis with cartography, permitting visualisation of evidence supporting his theory. With William Farr, he studied 300,000 London deaths, demonstrating that using water from the Southwark & Vauxhall Water Company made cholera deaths fourteen times more likely than that from the Lambeth Water Company, which withdrew its water miles upstream of the polluted city. Snow’s work is a microcosm of the debates over sanitation because his negotiations – as now – involved balancing public health against personal liberty.
George Cruickshank, Salus Populi Supreme Lex Esto, 1832. © The Trustees of the British Museum.
Secondly, building on ongoing political pressure from social reformer Edwin Chadwick for sanitary reform, and finally escaping short-term parish planning, the Metropolitan Board of Works was established in 1855 as the first city-wide body in England to pursue integrated sanitation. Its chief engineer – appointed the following year – was the brilliant surveyor Joseph Bazalgette.
Extensive change often needs political will committed to releasing immense resources, galvanised by crisis and self-interest. In 1858, the contaminated Thames issued a suffocating stench from overflowing cesspits and night-soil, exacerbated by water closets disgorging into the main drain, which received the waste of two million people. The ‘Great Stink’ was a call to action, concentrating minds wonderfully in the shiny new, riverside Palace of Westminster, suggesting that immediate action was essential. Bazalgette displayed immense breath of vision: for two decades he, his assistants and innumerable navvies built more than 1,500 miles of sewers costing £6.5 million – Britain’s largest single peace-time expenditure to that date.
Despite being founded on incomplete epidemiology, one consequence of the removal of contamination was to eliminate cholera from the water system and reduce the incidence of typhus and typhoid. Additionally, Bazalgette’s ‘cathedral thinking’ over-specified the sewers’ diameter, future-proofing the system by allowing for increases in population density, while also creating such temples to sanitation as Crossness Pumping Station.
John Mayhew Williams, The Engine-House, Crossness and the Outfall of the Metropolitan Sewerage, 1865. © Wellcome Collection. Attribution 4.0 International (CC BY 4.0).
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In 2016, a pandemic simulation, Operation Cygnus, demonstrated that Britain would, in the words of the Daily Telegraph be ‘quickly overwhelmed … amid a shortage of critical care beds, morgue capacity and …PPE’. But, preoccupied with Brexit, the government suppressed these findings, preferring to pursue lean management systems and complex, just-in-time supply lines. These doctrines took priority over the arguments of epidemiologists advocating research in epidemic progress and cytokine storms – the hubristic assumption in government circles was that epidemics were history.
But knowing the past helps us imagine alternative futures. While provincial York’s lack of effective, unambiguous ‘command and control’ management generated confusion and anxiety, local boy Snow’s mapping demonstrated that local knowledge and hotspot location were key to epidemic control. The example of Bazalgette in London shows that eradication requires resilient cathedral-thinking, with visionary architectural and infrastructural interventions, investment in heroic, decades-long projects, and the toleration of flexibility and redundancy.
Like the Great Stink, the wake-up call provided by COVID-19 triggered the creation of London’s 4,000-bed Nightingale field hospital, demonstrating that ambitious planning is still possible where the will exists, but that it is now considered temporary, unlike Bazalgette’s sewers. Rather than upcoming elections consistently shaping policy, politicians should embrace this cultural moment and remember that public health is government’s principal responsibility. In the current fog of confusion, with its myriad of unknowns, even conservative governments should become creative and interventionist, supporting grands projets to match the ‘catalytic philanthropy’ of such private enterprises as the Bill & Melinda Gates Foundation. In the world of architecture, it is possible to imagine a wide range of important, if often expensive, interventions, such as the following:
Reimagining hospital architecture in the light of aerosol transmission, and in particular reconsidering the role of HEPA (high-efficiency particulate air) ventilation systems.
Radically upgrading Britain’s run-down railways, permitting socially distanced travel both across the country and on to Europe.
Researching the therapeutic effects of intensive-care gardens, as called for by the 83-year-old explorer Robin Hanbury-Tenison after his seven-week hospitalisation with COVID.
And, crucially, redressing the country’s health inequalities, which have been so greatly exacerbated by decades of austerity policies. In particular, building high-quality social housing is vital – just as with the cholera epidemics, those in poor-quality housing are far more vulnerable to infective diseases.
This paper was first delivered at the online symposium Epidemic Urbanism: Reflections on History on 28 and 29 May 2020, which considered epidemics from all periods and places, with the intention of deriving lessons from history that might be applied to the current situation.