Source of book: Borrowed from the Library
I have wanted to read this book for some time, but, you know me, I have a list of “books I want to read” that grows ever longer despite my best attempts to catch up. As the author of Ecclesiastes once said, “Of the writing of books, there is no end…” If only he had seen the 21st Century!
In the annals of human development, there have been many watershed moments. The discovery of antibiotics, for example, or of vaccinations. The discovery of fire if you want to go really far back.
But it is pretty hard to argue against the development of germ theory and the realization that contaminated water was the cause of some of humanity’s worst diseases.
This book tells of the pivotal moment in this realization - one that led to a revolution in sanitation and city planning.
The story itself is fascination. Cholera was a scourge of the Victorian Era, killing vast numbers of people. It’s pretty hard to truly understand the terror these days, when a few dozen killed by terrorists leads to mass hysteria. Back then, your entire extended family could - and often would - be wiped out completely in a matter of days. Half your neighborhood could be dead in a week. And (adjusting for population), it would be a common occurrence in New York City for the number that died on the September 11 attacks succumb to disease in a few weeks. Over and over. All the time.
And some outbreaks were even worse. The one described in this book killed 10% of a neighborhood before it was stopped. And one of the last outbreaks of cholera and typhoid in a major city in the United States occurred in Chicago in 1885. Ten Percent of the population died.
In modern numbers, imagine if within a few weeks, one million people died in the greater Los Angeles area. Imagine the panic and horror.
That is how life in major metropolises was a mere 150 years ago. Yet, despite the exponential growth of cities, these plagues are unheard of today.
What caused this problem, and how was it solved?
Cholera itself is believed to have originated in India, where it infected plankton in the Ganges delta. Two things contributed to its evolution into a devastating human disease. The first was that a strain arose which had deadly effects on humans, killing them quickly. The second was that humans began to congregate in cities, which had water systems which were capable of transmitting the germs to many new hosts. After all, a disease that kills quickly often dies out, because victims are unable to transmit the infection, enabling the organism to reproduce. But the close spacing and poor sanitation of cities made transmission easy.
Cities had grown up by chance, rather than planning. People migrated for the usual reasons: opportunity, a diminished need for farm labor, and access to markets. While urbanization accelerated in the aftermath of the agricultural and industrial revolutions, city planning did keep pace. By 1854, the time of the outbreak described in this book, London was, to quote the author, “a Victorian metropolis trying to make do with an Elizabethan public infrastructure.”
If you want an all-too-realistic portrayal of London in the Elizabethan era, C. J. Sansom captures it pretty well in his murder mystery, Dark Fire, which I read recently. For that matter, the state of the city in the 1850s is described pretty well in Dodger by Terry Pratchett: the title character is one of the waste recyclers that the city depended on.
Many of the problems faced, of course, still trouble us today, from the ills of industrialization, predatory capitalists, collective bargaining, and urban poverty. Many of the philosophical and political ideas we discuss today date from this era. But there is one problem that tends to be forgotten by most people.
It’s true enough that the Victorians were grappling with heady issues like utilitarianism and class consciousness. But the finest minds of the era were also devoted to an equally pressing question: What are we going to do with all of this shit?
The Ghost Map spends a good bit of the early part of the book describing all of this, from the urban recycling which was being strained to the limit, to the depressing statistics. Once upon a time, not that long ago, life expectancy was a good bit lower in the city than in the countryside. This is now reversed, as city dwellers have better access to lifesaving medical treatment. Driving the high death rates were the deaths of small children - 62% of all deaths were those under age 5. Life was hard.
It was against this background that the central drama of the book played out.
Prior to our modern understanding of germ theory, there were a number of competing theories as to what caused disease. Some of these had significant merit. For example, malnutrition and overwork do indeed make one more vulnerable to a variety of illnesses. Likewise, rotten food can make you sick, as humans have known for millennia. Likewise, there is a strong taboo on the eating of excrement.
Other theories were not quite as useful. The chief of these also happened to be the one that most dominated the scientific minds of the time: the “miasma” theory of disease. Essentially, this was the idea that “bad, malodorous air” caused disease. This wasn’t completely wrong, of course. It is true that many bacteria and viruses are transmitted through the air. But it wasn’t the smell, but the germs themselves.
The problems this erroneous idea presented were manifold. On a scientific level, of course, chasing the wrong culprit allowed the right culprit to go undetected longer than it should have. But sociologically, it was even worse. Bad smells were, naturally, associated with bad neighborhoods. (The rich could afford to live further away from the smells.) And bad neighborhoods were (in the view of many) caused by the badness of poor people. Hey, we still love to engage in a lot of class snobbery! For some, this led to efforts to improve the lot of the poor. (See Charles Dickens and especially Henry Mayhew) For others, it just led to moralizing. “If they wouldn’t live like animals, they wouldn’t die so much.”
I’ll just give a summary of the events. I doubt I am playing the spoiler, because this is history that everyone should know.
The SoHo neighborhood of London, then a mostly rough and lower class area, experienced a horrific outbreak of cholera. Within a couple of weeks, a tenth of the residents were dead, and many more would have died if not for the efforts of a doctor, John Snow, who managed to convince the neighborhood board to remove the handle of a well pump on Broad Street.
Snow would already have been a man remembered by history for his remarkable work with anesthesia. He took a procedure which was more art and guesswork than anything else, and made it a scientific discipline, going so far as to invent and build devices to standardize the administration of ether and other substances. Probably it was this fame that enabled him to gain a hearing at this crucial time.
Snow had speculated for several years that cholera was spread by contaminated water, but he had never had an opportunity to do a real experiment. He lived just a few blocks from SoHo, and sprang into action as soon as the outbreak was reported. Using a combination of maps and old-fashioned investigation, he concluded that the source of the outbreak was the pump. After the pump was shut down, the outbreak stopped. And the rest is, as they say, history.
John Snow's famous map.
But the story neither began nor ended there. Snow’s theories were largely disregarded before this event - and were dismissed even after he showed the results of his investigation. In fact, the official report of the incident disregards Snow’s theory completely. Snow himself would die before the revolution he predicted came to pass.
It was another man who would play a crucial role in both the investigation and the aftermath who would live to see the acceptance of water-transmission as the explanation for cholera. That man was Henry Whitehead, a clergyman who served the SoHo area, and knew its residents well.
Whitehead was an interesting character. He was a truly admirable curate, choosing to work among the poor, and well beloved by everyone. He knew just about everyone in the neighborhood, and knew more about their lives than anyone else.
The real breakthrough in this case came when Snow and Whitehead joined forces. I find it fascinating how that happened. Snow’s publication was widely circulated (and also widely mocked), and it came to the attention of Whitehead, who instinctively rejected Snow’s ideas. He felt they were like the miasma theory, based as much on prejudice as on fact. The problem was, when Whitehead started doing his own investigation, he came to the inescapable conclusion that Snow was right: the Broad Street pump was indeed the one thing the victims had in common.
Furthermore, Whitehead put the final piece of the puzzle together. Snow had a compelling statistical case, based on the mapping of the deaths, and his interviews of people who had escaped the plague. But he had no “patient zero,” the first victim who spread the cholera to the well.
Whitehead found her: an infant girl that somehow had survived for a week after first becoming ill. She had been missed, because nobody lived that long, let alone an impoverished infant. But she did. And once Whitehead realized that her house abutted the Broad Street well, he and Snow knew they had found the answer. The well was mere feet from a cesspool in the basement of the apartment block, and the mother had thrown the water used to wash the linens of the infant into that cesspool. The old bricks had crumbled, and the contaminated water had a clear shot into the well.
This was the final piece needed to solve the case. It didn’t happen immediately, but inexorably, public - and more importantly, official - opinion shifted. A couple of years later, the “Big Stink,” a heat wave caused city-wide miasma, failed to produce an epidemic of cholera. The resulting statistics were the final straw for the miasma theory, and Snow’s ideas took hold.
There are many amazing projects of the Victorian Era that thrill us today, from great buildings to the Eiffel Tower and more. But one project that is little known and less appreciated is the great London sewer system designed and built by engineer Joseph Bazalgette. It was this project, which removed the sewage of London from the Thames and the groundwater which ended the recurring cholera outbreaks - and made the city smell nicer too. It is hard to believe, but central London is still served by the 150 year old infrastructure.
It was a final incident that occurred shortly before the completion of the sewer that provided incontrovertible evidence that John Snow was right. An outbreak of cholera - the last major outbreak in London - was unmistakably traced to a particular water company. Which just happened to serve the area that had not quite yet been connected to the sewer system. Supposedly, the water was filtered by a state-of-the-art system. While it is debateable that the filters would have purged the cholera germs, there is no doubt that the filters were, um, not working optimally: customers reported finding live eels in the tap water. (Then as now, profit tended to take precedence over public safety…)
The sewer project was a success. With its success came an important idea, which we tend to take for granted today: public health is a public problem, and requires the investment and power of a strong government. Edwin Chadwick, although he never quite accepted Snow’s theory, and retired before the outbreak in this book, he built the government infrastructure at the General Board of Health, which was really the birth of a vital part of the public sector worldwide.
Chadwick helped solidify, if not outright invent, an ensemble of categories that we now take for granted: that the state should directly engage in protecting the health and well-being of its citizens, particularly the poorest among them; that a centralized bureaucracy of experts can solve societal problems that free markets either exacerbate or ignore; that public-health issues often require massive state investment in infrastructure or prevention...Most of us today accept that the broad movements of Chadwick’s campaigns were ultimately positive ones. You have to be a committed libertarian or anarchist to think that the government shouldn’t be building sewers or funding the Centers for Disease Control or monitoring the public water supply.
Just a few minutes ago, I turned on my tap, and I drank a glass of water. And I knew that it was free from cholera. And from other contaminants. How could I know that? Well, because it is something that I can take for granted here in 21st Century America. (Well, most of the time - see note below.) That didn’t come about easily, though. The infrastructure that provides that water makes it possible. The sewer systems which keep my neighbor’s shit from getting in my water. The multiple sterilization and filtration systems that my water company uses. The government agency that tests the water regularly. The regulations that force the water company to remove the arsenic from the water. And so on.
The strength of this book isn’t just in the storytelling - although Steven Johnson is a good writer. It is in the way he brings together so much relevant background facts and stories to make sense of the greater picture. The chapter at the end on the nuclear and bioterrorist threats to modern cities - and the ways that we can evolve to meet them - is a good one too.
I highly recommend this book (with one caveat below), and have put several other books by the author on my list for the future.
One caveat: While the research in this book is generally very good, there is one false note. As usual, this occurs, not in the main story of the book, but in a bit of “dicta,” as we lawyers say. (For those who didn’t go to law school, this is the part of a court opinion where the judge or justice talks about something outside the facts of the case at hand - such remarks are “dicta,” meaning they are non-binding and not necessarily relevant to the case or other future cases.) In this case, there is a remark during an otherwise interesting discussion of the role of alcohol in ensuring safe water. Johnson remarks that aboriginal groups lack the gene to process alcohol like other (read: white) societies. This idea has been debunked, due to the lack of evidence of differences in drinking rate or a genetic difference related to the processing of alcohol. We all process alcohol the same way, and populations tend to binge drink at the same rates. The evidence does strongly suggest, however, that addictions of all kinds are far higher in persons who have suffered trauma.
Flint Michigan: You knew I would bring this up. Just as in the case of the East London Water Company, the water company for Flint made a decision based on money that endangered those who depended on the water. After being warned that switching to water from the Flint River would corrode the old lead pipes, leading to lead poisoning, the decision makers decided to do it anyway, then faked the tests to show the water was “safe.” Recently, there have been criminal charges brought against a number of those involved. You can read a pretty good summary from NPR here. On the plus side, it is good to see real consequences for those involved. On the bad side, it is awful to see people so calloused toward a deeply impoverished population.
Haiti: Speaking of cover ups, a really recent incident occurred in Haiti. Remember the earthquake and its aftermath? Well, one of the causes of death afterward was our old friend cholera. And anyone with a knowledge of the same investigative procedures used by John Snow and Henry Whitehead can figure out where the epidemic started, which was the UN peacekeeper camp - specifically the Nepali division. You can read a bit about this here, which, coincidentally is the place I first heard about this book. You want a reliable source for the underlying claim? Here is the study from European journal, Clinical Microbiology and Infection.
Some other cholera stories:
Tchaikovsky: The famous Russian composer, Pyotr Ilyich Tchaikovsky (of Nutcracker fame) died under mysterious circumstances. He was prone to bouts of depression, and during one of these, he drank unboiled water during a known cholera outbreak. Was it suicide? Recklessness? Or just carelessness? Who knows for sure? But if you want to think of famous cholera victims, his name has to be near the top. (Also Hegel and U.S. President James Polk.)
W.E.B. Du Bois: I read his best-known work, The Souls of Black Folk, a few years back. (Highly recommended!) By far the hardest part of the book to read was Du Bois’ description of the death of his young son from cholera. Johnson gives a pretty harrowing description in The Ghost Map, but it is even worse when told from the perspective of a father watching his son slowly dehydrate and die. My hands were shaking after I read that chapter.
The worst part was, this boy did not have to die. By that time, they knew that it quite possible to survive cholera, as long as the fluids and electrolytes were replaced as fast as they were depleted by the diarrhea. The problem was, DuBois couldn’t obtain medical care for his son. Why not? Because he was Black. There were very few African American physicians at the time - medical schools generally wouldn’t take them - and not a single White doctor within possible travel distance would accept a Black patient. And so a little boy died.
Remember that whenever you read about current and proposed laws intended to allow doctors to refuse to treat LGBTQ people and their children…
What else? The lacerating finale movement of Tchaikovsky’s final symphony, the Pathetique.