Blue Funk and Yellow Peril

29 January 2013

Blue Funk and Yellow Peril

Professor Sir Richard Evans

Cholera, despite some argument amongst medical historians of the kind we’ve become used to during this lecture series, is generally agreed to have been an entirely new disease in the nineteenth century, at least new to Europe and the Americas.  It had been endemic to Bengal since ancient times and had been observed both by ancient Greek authors familiar with India and by European travellers. But it only came to Europe as a result of the opening up of new trade routes through Afghanistan and Persia following the British conquest of North India, escaping from its reservoir in Bengal in 1817 and making its way westwards initially with troop movements and then with trade. It was thus to begin with very much the product of empire, of Europe and particularly Britain’s newly achieved dominance over the rest of the world, built in the late eighteenth and early nineteenth centuries by the advent of industrialization and the rapid development of military technology and naval superiority in the French Revolutionary and Napoleonic Wars and afterwards.

In the mid-1820s it was halted, possibly by a military cordon sanitaire set up by the Russian authorities but trade continued to grow in the region and by 1827 cholera was in Persia again, moving along the Don and Volga rivers to Russia, then St Petersburg and thence to Germany in 1831 and Britain and France the following year. Cholera spread to Europe because Europe’s strategic power was spreading across Asia. Soon christened ‘Asiatic cholera’, the disease was widely understood as Asia’s revenge: a deadly invasion from the supposedly backward and uncivilized East, launched just as western civilization, in the eyes of many Europeans, was reaching the height of its progress and achievements.

Once it had arrived in Europe, cholera quickly battened on to another central aspect of Europe’s nineteenth-century expansion and growth. Industrialization helped move cholera rapidly from place to place, first along the rivers and canals which were the main arteries of transport in the 1820s and 1830s then even more rapidly along the railway lines that began to be built across Europe from the 1840s onwards, a fact rrecognized in this French cartoon from the epidemic of 1884, drawn after the discovery of the causative bacillus and portraying it as a kind of blue monster (I’ll come back to the colour in a moment). But it also ensured the disease could be transmitted easily from person to person in the overcrowded and insanitary towns and seaports of the new industrial society, passed on either through contaminated water supplies and foodstuffs or through direct human contact.

Cholera is spread by a bacillus, which if ingested through the mouth causes extremely severe vomiting and diarrhoea, with rapid and extreme dehydration, agonizing stomach cramps, and in effect such a drastic draining of fluid from the body that the blood, as it were, almost coagulates in the veins, giving the skin a co-called corrugated effect and turning the patient blue: psychologically it caused extreme anxiety amounting to terror: hence the expression ‘blue funk’. Contemporary cartoonists attempted to convey with more or less success what it felt like to be a victim: it felt as if a thousand devils were pulling at one’s innardsor perhaps sawing one’s body in half at the same time. The death rate, averaging fifty per cent of those affected, was only one of the terrifying aspects of the disease. Almost as important for nineteenth-century bourgeois sensibilities was the fact that its onset and progress were sudden, often running from the first symptoms to death within twenty-four hours, giving no time to prepare for death, quite unlike TB; and the symptoms themselves were grossly physical and degrading, a shock to Victorian prudery and concealment of bodily functions. Death from cholera was the antithesis of a beautiful death.

Cholera killed millions in Asia and Europe in the 1820s and early 1830s; it returned in 1848-9, spreading again from east to west; and reaching the United States of America by ship across the Atlantic; it came back again in the mid-1860s, again crossing the Atlantic, and once more in the 1880s, in a series of epidemics lasting until the early 1890s. The map here of the mid-century pandemic shows clearly how trade and European emigration to the Americas carried it over the seas, across to the Pacific coast and then down by ships again into South America. In between the great pandemics cholera was effectively absent from Europe; the bacillus survives only in relatively warm temperatures, and a hard winter is enough to kill it off, which is why it hardly ever moved into northern Russia or China or Canada.

The coincidence of these major epidemics with periods of war, upheaval and revolution is too obvious to ignore and was noted in a variety of ways by contemporaries. It was brought westwards by Russian troops suppressing a Polish national uprising in 1830, as cartoonists portrayed the blind fury of the Russian giant belabouring Polish patriots as cholera, represented by the figure of death, followed him at his shoulder. ‘Ah! – Dear July Revolution!’ the caption has the vagabond figure of cholera exclaiming: ‘without you I would have stayed in the north of Russia, it’s you who made me come to this unhappy country by revolutionizing Poland’; on the ground, two men are suffering an attack of the disease, or by implication, the revolutionary ideas that have spread from Paris to Poland – in exactly the opposite direction in fact to that taken by the disease itself.In 1848-49 it followed the forces of order, including once more Russian troops, as they put down the Europe-wide revolutions of that year.  The coincidence was not lost on contemporaries, as they likened the great clean-up of Europe after the epidemic with the sweeping back of the revolutionary tide by the forces of reaction, led by Prussia and Austria.The epidemic of 1854-6, which in similar fashion swept across Europe from Russia to the West, was also the only one that spread across Europe from West to East, carried to Turkey, Bulgaria and the Middle East by British and French troops fighting in the Crimean War. The epidemics of 1866 and 1871 were spread by Bismarck’s wars of German unification. In 1892 cholera came westwards to Central Europe with a wave of migrants fleeing persecution, particularly anti-Semitic persecution, in Russia and looking for a new home in America, via the German seaport of Hamburg.Once more, therefore, as in the case of the Black Death, war as well as trade carried disease to new victims.

Medical opinion, crucially, was divided on the causes of cholera. The failure of quarantine measures and cordons sanitairesafter the 1820s convinced many that it was not a directly infectious disease, but spread through the atmosphere in a miasma,an invisible vapour, which in time-honoured fashion local authorities sought to dispel by making a noise, ringing bells, As late as 1911, it may be recalled from Thomas Mann’s Death in Venive and the film of that name directed by Lucino Visconti, town councils were placing slow-burning aromatic fires in the streets to ward off the disease, though it was a far more common measure earlier on in the century, as here, in an illustration from France in 1865. By the 1870s scientists led by Max von Pettenkofer in Munich were arguing that cholera rose from the ground-water under certain climatic conditions. This belief appealed particularly of course to liberal opinion at the time, while authoritarian states on the European Continent instinctively resorted to the same measures they had mobilized in earlier times against the plague, restricting movement from place to place, forcibly quarantining or hospitalizing victims, and imposing quarantines on seaports and towns affected by the disease.

It wasn’t the case that the miasmatists opposed any kind of state intervention out of a dogmatic belief in laissez-faire liberalism; a reformer like Edwin Chadwick in England, for example, combined miasmatism with support for sanitary reform, and even Pettenkofer, who declared roundly that cholera could not be passed from person to person or transmitted through water, urged the clean-up of slums and the improvement of waste disposal in his native Munich to prevent dangerous miasmas. On a personal level people tried to keep themselves healthy by caryring sweet-smelling herbs, as in this satirical illustration from the 1840s of a woman who has taken every possible measure to prevent herself from catching cholera. Other medical advice focused on maintaining a moderate and regular lifestyle, avoiding excess, and in general remaining calm. There was no shortage of patent remedies on offer, including, as here on the left, piling bedclothes on top of patients to try and warm them up, or, on the right, rubbing them vigorously with electrically charged magnets to try and get circulation going again; both are likely to have done more harm than good. The most common reaction, as in earlier epidemics back as far as the Black Death, was flight, but these people leaving the city of Marseilles in 1831 are likely to have spread the disease further rather than escaping it altogether.

Miasmatism or anti-contagionism, as it was known, naturally appealed to the interests of any state that was particularly concerned about the economic effects of quarantine, and none more so than the self-governing city-state of Hamburg in north Germany, the largest seaport on the European Continent and the biggest and richest in the world after London, Liverpool and New York. It was controlled by an oligarchy of wealthy merchants, who dominated the city’s administration and appointed all its senior officials including medical and public health officers. The merchants believed strongly in a minimalist state, refusing for many years to appoint a professional municipal civil service, rejecting costly initiatives for the construction of a sand-filtered water supply and failing to spend money on adequate sewage and waste disposal systems, leaving the tidal canals that criss-crossed the city filled with detritus and excrement.

Hamburg’s Medical Board, under the powerful influence of the merchant families, ensured throughout the 1870s and 1880s that no medical officer was appointed to an official position unless he was an adherent of Pettenkofer’s miasmatist theory of the disease and its transmission. But they were challenged in the following decade by the publicity given to the claim of Robert Koch, whom we have already met in connection with TB, to have discovered the cholera bacillus – in fact identified some years before by an Italian scientist, but now trumpeted as a triumph of German medical science by a national government in Berlin eager to put up a rival to the Frenchman Pasteur. Koch had gone to Egypt then India itself in the epidemic of 1883-4 and beaten a French team to it in identifying the bacillus as the cause of the disease. He insisted it was carried in contaminated water, a point already made by the English doctor John Snow in his investigation of the Broad Street Pump in the cholera epidemic of 1854 but largely ignored by the overwhelmingly miasmatist medical profession and ingested through the mouth in contaminated liquids and foodstuffs. It could be killed by acid but on the other hand was easily spread from person to person, or through shared toilet facilities, of which there were many in the poorer areas of Europe’s towns and cities.

By 1890 Koch’s views had conquered the Imperial Health Office, reflecting the turn of the German government from 1879 onwards to greater intervention in economy and society, and Berlin was officially backing the contagionist theory of cholera, putting in place plans for quarantines and disinfection measures should the disease break out anywhere in Germany. But the powers of central government over the federated states were limited. Berlin could not force Hamburg to accept its views. In August 1892 the disease arrived in Hamburg from Russia on a trainload of migrants. Convinced that cholera could only break out in consequence of local climatic conditions, and refusing to believe it could be carried in water, the medical authorities in the city took no action. The hot weather and brackish water of the tidal Elbe river provided ideal breeding grounds for the bacillus, which entered the river from the cheap lodging houses and primitive, insanitary barracks where the migrants were housed, and was swept upstream by the tide, which was unusually strong because the prolonged drought of the summer had lowered the normal levels of the river-water. It soon reached the city’s water intake point, spread through the unfiltered reservoirs and was pumped into homes and houses across the city before the medical authorities had taken steps to diagnose the disease in its first victims or take any measures to deal with it or warn people of its presence. Soon victims were being collected in their thousands from infected homes and taken to hospital, in 50% of cases never to return.

Altogether some 10,000 people died in the city in the space of little more than six weeks. Hamburg was the only city in Western or Central Europe to suffer an epidemic on this scale in 1892. Death rates were highest amongst the very young (underestimated in the official statistics) and the elderly and old; death rates were already high among these groups for a variety of reasons unconnected with cholera, including TB for example; but what was particularly striking to contemporaries was the fact that normally young, fit and healthy people died in large numbers, boosting excess mortality rates in these age-groups, especially among women whose job it was to clean the household and prepare the food. Thus cholera made much more of a difference to the young adult population than it did to the rest.

The legitimacy of Hamburg’s state administration was severely damaged by the epidemic. Koch was sent by the national government sent to Hamburg to impose quarantine, disinfection and other measures including the distribution of free, uncontaminated water and instructions to citizens to boil all water before they used it - measures that eventually had some influence in bringing the epidemic to an end. The disease hit the poorest most severely, living as they did in overcrowded and unhygienic dwellings, sharing toilet facilities and unable to take precautions such as boiling water before drinking it as Koch advised; here the columns of cholera morbidity and mortality are highest among the lowest income groups, on the left, and decrease as average income increases with each group moving to the right. Surveying the slum quarters by the harbour where the impact of the disease was greatest, and remembering the squalid dwellings he had seen in Egypt and India, Koch turned to his team and said: “Gentlemen, I forget that I am in Europe”. In the age of imperialism it was hard to think of a more damning verdict. Hamburg was forced eventually to reform its system of administration and appoint contagionists to key posts in the medical service.

In a last-ditch attempt to rescue his miasmatic theory of the disease, Max von Pettenkofer obtained a sample of the bacillus culture from Hamburg and swallowed it, though in the true style of the German professor he also made his assistant do the same immediately afterwards, in the presence of a hundred onlookers. Both survived, largely because, it seems, the doctor in Hamburg from whom Pettenkofer had ordered the sample had a shrewd idea of what he intended to do with it and so sent him a diluted culture. It took some time for Koch’s contagionism to triumph everywhere, and miasmatism still had its champions even after the turn of the century, but the 1892 epidemic was the major turning-point in the debate.

It was remarkable in 1892 that ordinary people in Hamburg raised no objection to the measures taken by Koch. At least 40,000 people fled the city, many of them by rail, as these statistics suggest; there were reports of mass drunkenness, and the churches were crowded with unusually large numbers of people praying for deliverance. But the working classes in the city overwhelmingly supported the Social Democratic Party, which as a progressive political movement believed in the legitimacy of modern medical science, and co-operated fully with the authorities in combating the epidemic. German society had begun a process of mass medicalization in the 1870s, implemented first of all in a national compulsory vaccination law passed in 1874, and Koch had particularly high prestige because of the publicity given to his discoveries by the national press. The political effects of the epidemic were found not in protests against medical intervention but in the Social Democrats’ use of the disaster to pillory the state administration for serving the interests of a rich minority and neglecting the health and safety of the mass of ordinary people. In the 1893 national elections all the city’s Reichstag seats fell to the Social Democrats, and they made such gains in local elections that in 1906 the city’s ruling Senate changed the voting qualifications to reduce the chances of a Social Democratic takeover.

The situation was very different in the only other part of Europe affected by epidemic cholera in 1892, namely Russia. When cholera had first struck Europe at the beginning of the 1830s, there had been popular disturbances in many areas; in Russia, peasants and townspeople massacred physicians, local administrators and medical teams who came to the stricken areas to lend help, in the belief that the government was trying to poison the people to reduce their burden on the state; Tsar Nicholas I was forced to appear in person to quell the unrest, as seen in this commemorative relief; in the Habsburg Monarchy angry mobs sacked castles and slaughtered quarantine officers; in Prussian towns crowds broke into isolation hospitals and forcibly removed the patients, stormed officials’ houses and resisted attempts to take victims to hospital; in Britain people rioted against the doctors, accusing them of trying to poison them in order to get bodies for the anatomy schools, along the lines of the Burke and Hare murders in Edinburgh.

The reduction of state intervention in subsequent epidemics, partly as a result of the spread of miasmatic theories of the disease, partly in consequence of the realization that quarantine and isolation had not stopped the spread of cholera, helped prevent the recurrence of cholera riots after the 1830s; and by the 1890s the prestige of medicine in western and central Europe was such that doctors and medical officials met with a high degree of acceptance and trust. But this was still not the case in Russia. In the same epidemic that spread to Hamburg in 1892, the city of Saratov, on the Volga, was overrun by people fleeing the disease, and when the first cases broke out, the Tsarist authorities closed down food shops, heavily restricted the sale of vegetables, banned markets, and enforced quarantine, hospitalization and isolation not through the medical services, which were minimal in the city, but by the police. Notices of instruction posted up in public places by the authorities were meaningless to most people in the city, who were illiterate and unable to read them. The hospitals and hastily constructed barracks where the sick were taken were unhygienic, overcrowded, poorly equipped and understaffed. The dead were not given up to their families but disposed of in mass graves.

Deprived of their livelihood, or of the means of feeding themselves properly, a large crowd of tradesmen, shopkeepers and craftsmen gathered in the city’s most prosperous district and began a manhunt for doctors and policemen, stoning and assaulting anyone in a white coat, attacked the town hospital and released the sick, then set the building on fire. They broke into pharmacies and doctors’ homes and ransacked the contents. Eventually troops arrived, opened fire and dispersed the crowd. Similar disturbances took place in Astrakhan, shown in the illustration. Commentators quickly ascribed the riot to the ignorance and superstition of the populace, but in fact they were acting rationally to the heavy-handed and largely futile measures imposed by the authorities. Provoked by these disturbances, the Tsarist authorities undertook major reforms of the medical services, inaugurating a partial medicalization of society in the town and indeed more generally; but they did little to bring about real sanitary reform, and cholera returned in 1910, by which time the medical profession in the city was strong and well organized and clashed seriously with the local and regional authorities, who grasped for the same, traditional policing measures as before; a significant moment in the alienation of the middle classes from the Tsarist regime.

The epidemic of 1910 also hit the southern Italian city of Naples, returning in a more severe epidemic the following year. During the previous cholera outbreak in the city, in 1884, the state mobilized military force to repulse the migrants and outsiders whom it accused of bringing the disease to the city. Quarantines were imposed by the military, and victims were forcibly taken off to the hospitals, where they were subjected to painful treatments including the administration of electric shocks and the purging of the intestines with strychnine – not surprisingly, death rates in the poorly organized and badly equipped hospitals were very high. The municipal authorities were notoriously corrupt and in league with local crime syndicates; the mass of the inhabitants of the city’s poorer districts, were illiterate, uneducated, and mistrustful of the local government, especially when it restricted food supplies and closed down markets.

Here as in Hamburg and Saratov, cholera hit the poorest parts of the city hardest, reflecting insanitary and overcrowded living conditions and poor, usually shared water supplies; here too, as in all cholera epidemics, the usual pattern of mortality was reversed, with normally healthy age groups in their late teens, twenties and thirties being severely affected, so that excess mortality rates among these groups were extremely high; cholera made little difference to death rates among the very young and the old, but it made a huge difference to the youthful and the middle-aged, further stoking suspicions of poisoning among the poorer parts of the population. Crowds forcibly freed victims being taken off to hospitals, attacked doctors, stretcher-bearers and policemen, pelting them with stones, chairs and even tables and benches, and even stopped workmen from lighting fumigation bonfires because they filled the streets with swarms of sewer rats. For most people, religious processions through the streets were the most persuasive way of fighting the disease.

By 1910-11, however, the Neapolitan and national Italian authorities had learned the lesson of the 1884 disturbances. Instead of coercive policing measures, they formed sanitary squads consisting mainly of working men from the areas in which they operated, instructed them to use courtesy and persuasion and not force, and avoided alarming publicity. The sale of food on the streets was banned, wells and cisterns were sealed, sewers were disinfected, the water supply was monitored, swimming in the harbour was stopped, the streets were swept, the homes of victims were cleaned and their clothes destroyed; but a huge effort was made to win public trust through persuasion and education, and indeed after some initial resistance, there was widespread popular acceptance of these measures, as there had been in Hamburg in 1892. Unfortunately the rehydration therapy used with some success by the English physician Leonard Rogers in a hospital in Palermo could have no effect in Naples because the Italian authorities banned him from the mainland fearing it would result in knowledge of the epidemic spreading to the rest of the world.

Cholera riots and disturbances and attacks on physicians and medical teams were thus not simply the product of ignorance and illiteracy, though these clearly played a part, as in this cartoon, where one child is saying to another: ‘I say Tommy, I’m blow’d if there isn’t a man turning on the cholera!’ They were also an expression of popular fear and distrust of the medical profession and the state, and this fear and distrust was at least to some extent not only understandable but even justified. Crudely authoritarian policing measures carried out on behalf of a remote or notoriously corrupt state imply intensified the fear and panic already affecting the population. State authorities could increase the likelihood of panic by concealing the presence of the disease, leading to the spread of rumours as the number of unexplained deaths among the normally healthy population in a city began to multiply, particularly among the poorer classes, a fact that aroused suspicion in itself. Quarantine, isolation, forcible hospitalization and police restrictions on trade and movement all deepened the panic among those affected either directly or indirectly. Medical discoveries like those of Koch were not immediately accepted, since they were linked not only to particular views of the world – in his case a heavy, “Prussian” dose of state intervention in society – but also to particular interests, most notably in Hamburg, where medical theories denying the need for quarantine spoke clearly to the interests of the mercantile elite. As the example of the Naples epidemic in 1910-11 showed, public health measures had to be undertaken in a way that did not affect people’s sensitivities.

How far did cholera act as a motor of sanitary reform in the nineteenth century? Certainly the need to prevent a recurrence of cholera was frequently cited by sanitary reformers and referred to by contemporary cartoonists, often using it as a metaphor for political reform as well. But the historical reality was far more complex than this simple ‘challenge-and-response’ model suggests. To begin with, since the medical understanding of the disease was dominated until the late 1880s by the miasmatic model of its transmission, sanitary reform frequently neglected such vital issues as the purification of the water supply under the influence of hygienists like Pettenkofer, who declared that cholera could not be transmitted in water. For a long time the state in Europe fought shy of quarantines and cordons sanitaires since they had not only failed in the 1830s but also aroused hostile public reactions. Reform could often be short-lived, as in Paris in the early 1830s, when the bourgeoisie drew the lesson that their own relative immunity from the disease showed their superiority over the dirty and disorderly masses, and recommended the improvement of working-class morality rather than increased state expenditure on sanitation. New sewers became sources of civic pride and even objects of tourism, but in Paris they affected mainly the centre of cities, leaving poor outlying districts still using more primitive means of waste disposal. In Belgium radical liberals used cholera to force through sanitary reform in 1848-9, but reform slowed down in the reactionary 1850s. Slum clearance could be one course taken to improve living conditions but it was also motivated by the perceived need to remove centres of political unrest and social deviance. Urban pride in a capital city like Berlin could be more important as a motor of sanitary reform than the occurrence of epidemic disease.

It was not until the age of bacteriology that sanitary reform could be directed more precisely to cholera prevention. After 1892, border controls, the disinfection of railway travellers and other similar measures were remarkably effective in preventing this from happening. The disinfection of travellers during epidemics became the norm even in poor Balkan states like Serbia. Throughout most of the nineteenth century, bordedrs were relatively open; travellers did not need international passports; and national citizenship was a nebulous concept, particularly in view of the lack of individual citizens’ rights such as the vote in most parts of Europe. By 1900 all this had changed. The age of imperialism had hardened concepts of national identity, while the growth of state power had enabled armies and police forces to mount effective controls on the movement of people between one country and another. In the USA the previously open attitude to immigrants had changed to a growing climate of nativism, built partly on hostility to European migrants as carriers of disease. Quarantines were increasingly imposed when epidemics raged in Europe, as in 1892 or later, during the Italian epidemic of 1911, which took place when Italian emigration to the USA was at its height. There was a darker side to these developments too; for they also signified the deterioration of international relations in Europe by the end of the nineteenth century. The scientific, industrial and technological progress that had one expression in the conquest of epidemic disease found another in the rapid development of new and ever more deadly weapons of war. Satiated by its manifold triumphs and conquests overseas, European imperialism now turned inwards. Cholera itself became a potent symbol of the fears and anxieties of one nation about the character and ambition of another, as Germans for example associated its continued presence in Russia not only with what they increasingly thought of as the backward and uncivilized nature of the Slavic East but also with the permanent threat of invasion and contagion that they imagined it posed. As the borders closed, so too did people’s minds, and many of the lives saved by the creation of effective controls over the spread of disease were to be lost in the vast conflagration of the First World War.

In the course of the following decades simple but effective measures were developed to treat cholera victims, largely by rehydration; this had been tried in the nineteenth century but not with the right balance of salts and electrolytes in the solution, and seldom in enough quantities. Inoculation has a limited effect because the disease is located in the digestive system not in the bloodstream. More than almost any other disease, prevention is a matter of public hygiene and personal cleanliness. It’s as a result of Koch’s campaign that sand-filtration of water supplies was introduced where it didn’t previously exist, that we now wash our hands after going to the toilet, that we disinfect kitchen surfaces, and also, since the discovery that the disease flourishes particularly in molluscs and other creatures feeding round the detritus that gathers at sewage outlets in rivers and harbours, that we disinfect prawns and other seafood with lemon juice before we eat it.

Public health measures require a well organized state, a medicalized population and an effective enforcement of public health policy. These are notoriously absent in times of war and political upheaval. Cholera epidemics occur and spread not least because of the crisis or disorganization of the state. The major epidemics of the twentieth century fall into this category, though a mutation of the bacillus first discovered in the Egyptian port of El Tor reduced the fatality rate among victims, a change that we’ve seen in other diseases as well. In China the age of the warlords after the fall of the Qing dynasty in 1911 spread cholera to many parts of the country, and although the need for disinfection was by then well known, the state was in no position to apply it comprehensively. Epidemics broke out again during the civil war that ended with the victory of Mao Zedong after 1945, and the Communists used their triumph in 1951 to educate people about how to recognize the symptoms and how to avoid impure water and contaminated food. The mass starvation, intercommunal violence and precipitate flight and migration of millions of people that accompanied the chaotic end of British rule in India in the mid-1940s generated a cholera epidemic thought to have killed over a million people. More recently, the violent guerilla movement of the “Shining Path” that drove thousands of Peruvians from their mountain homes down to makeshift and unhygienic camps on the coast in the early 1990s, from where cholera spread to other parts of Latin America, though it was quickly contained.

It’s no surprise therefore that the most recent major epidemic should have occurred in Haiti, where the state is weak and disorganized, the population poor, educational standards low, and a major earthquake early in 2010 followed by a devastating hurricane had left one and a half million people homeless.  A major cholera epidemic broke out in October 2010, the first for more than a century. By February 2011 over 120,000 people had been hospitalized with the disease, which had affected nearly a quarter of a million people, with more than 4,500 deaths. Morbidity was running cumulatively at 23.5 per 1,000 inhabitants, reaching nearly 40 per 1000 in some districts. The spread of the disease was intensified by poor sanitation in the camps set up for earthquake victims, only around half of which (600 out of 1,152) had latrines.Water supplies were inadequate or unhygienic and the resources and organization to provide clean water and proper waste removal facilities were lacking, with the result that the epidemic continued in 2012. By January 2013 there had been a total of 640,000 cases and 8,000 deaths, a cumulative fatality of 1.2 per cent of the population, and the epidemic is continuing; the vast majority of cholera cases in the world since 2010 have been in Haiti.

Familiar patterns of behaviour have re-emerged during the current Haitian epidemic. In November 2010 the news that the strain of cholera found in Haiti was familiar in South Asia but unknown in Latin America led to attacks on UN troops, especially from Nepal, who were blamed for bringing the disease to Haiti. There had been around 12,000 UN peacekeeping forces in the country since 2004, following violence accompanying elections and the effective disbanding of the country’s army and police. The UN’s stabilization mission or ‘Minustah’ was engaged in training up a local police force and maintaining security but had little contact with the population and played little or no role in dealing with the consequences of the earthquake. It was widely seen as propping up a generally hated government and the belief that it had brought cholera to Haiti was another expression of the widespread popular distrust of the force. As the political temperature heated up with approaching elections, crowds threw stones at the UN mission, burned tyres and blockaded roads, preventing cholera medication from coming in to affected areas. UN aid workers were attacked because of their association with the stabilization force, which was seen by some sectors of the population as an occupying army. The riots eventually died down, but they provided another example of how popular disturbances could be triggered by an insensitive approach to a desperate local situation. While the UN initially denied any responsibility, genome sequencing of the Haitian strain of cholera has shown that it is an exact match for the strain of cholera in Nepal. 5,000 plaintiffs are now represented in a claass action for bilions of dollars in compensation filed against the United Nations in New York. In December 2012 the UN finally recognized its responsibility and voted $2 billion in aid to Haiti to help eradicate the disease and bring sanitation and water supplies up to acceptable standards.

By the time of the Haiti epidemic, cholera had been known to medical science for 120 years and there was general agreement about its causes, prevention and treatment. For much of the nineteenth century, however, as I’ve pointed out, medical opinion was divided and there was no effective prevention and treatment. Nineteenth-century medical science got very good at working out what caused diseases, but it had little success in working out how to cure them. For this reason, its popular legitimacy wasn’t very high. By the late twentieth century, the public prestige of medicine had grown substantially. Yet health care remained an eminently political issue, especially where some political movements identified the medical profession for historical reasons with colonialism, with multinational drug companies, or with the long history of an oppressive regime that denied adequate health care to the majority of citizens on racial grounds. Epidemic diseases are spread more rapidly and over greater distances than ever now in the age of cheap air travel. A disease like cholera is closely bound up with human politics and society, with class conflict and inequality; and the connections are even closer, as we’ll see in the next lecture in the series, in the case of another great scourge of modern society, typhus.

© Professor Sir Richard Evans 2013