The Transformation of the World (44 page)

Finally, there was epidemic typhus, sometimes known as jail fever, quite devoid of glamour, or even of the frisson caused by the “democratic” horseman of the apocalypse who levels the highest and the lowest in society. It was a disease of poverty in a cold climate, the complete opposite of a tropical disease. Carried by lice, it tended to appear where poor sanitary conditions and fuel poverty meant that people living closely together did not change and wash their clothes often enough. Typhus, together with typhoid fever and dysentery, is a classic disease of war. Until the First World War it accompanied every modern conflict in Europe. The decimation of Napoleon's Grande Armée resulted more from dysentery and typhus than from the operations of all its other adversaries.

The Beginning of the End of the Medical Ancien Régime

In many respects, the medical history of the nineteenth century belongs to the ancien régime. There were still distinctive risk groups, the chief one being soldiers of every nation. The wars to conquer New Zealand were possibly the only ones in the century in which more European soldiers died in battle or from accidents than as a result of disease. The opposite extreme was the campaign in Madagascar in 1895, when some 6,000 French soldiers died of malaria and only 20 in military action.
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A new era dawned outside Europe with the Russo-Japanese war of 1904–5, when the Japanese, thanks to meticulous vaccination and medical facilities, managed to keep their losses through disease to a quarter of the numbers killed in battle.
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From a position of weakness, the emergent military state could hope for victory only if it carefully husbanded and deployed
its scarce resources in personnel and material. But the nineteenth century also witnessed the beginning of the end for the medical ancien régime—something that, despite all the jolts and discontinuities, should not be denied the name progress. This transition had, roughly speaking, three aspects, which may be arranged in sequence.

The first aspect covers the global retreat of smallpox in the face of Jennerinspired vaccination and the prevention and treatment of malaria with alkaloids obtained and developed from cinchona bark. After 1840 or thereabouts, and especially after 1854, deaths from malaria began to decline at least among Europeans in the tropics—an essential for military conquests in southern latitudes.
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These were the only two effective medical breakthroughs until the emergence of microbiology.

The second aspect was the rise of laboratory medicine, associated with the names of Louis Pasteur and Robert Koch, which was one of the great innovations of the age. After its first major successes in the 1870s, it established itself in the following decade as an independent field of science, although it took a while before preventive strategies or even mass treatments could be deployed against the various diseases whose causes were now identified. Moreover, the idea that medical research had to take place in the laboratory remained controversial for a long time for the Western public. Such doubts were often expressed in the form of opposition to experiments with animals (“vivisection”).
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Between these two breakthroughs (the Jenner and Pasteur moments in medical history, as it were), an intermediary aspect or third phase involved a triumph for practice rather than for theory. It is associated more with the names of social reformers and medical-sanitary practitioners than with researchers bent over a microscope.
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The movement for improved sanitation that began in mid-century in Western Europe and North America soon had at least a sporadic impact in many other parts of the world. Long before causalities had been scientifically established, experience showed that it was healthier to live in cities with clean water, proper sewers, and organized garbage disposal and street cleaning (which, unlike today, was mainly a question of removing organic matter such as ash and horse dung). Medical people knew this even before they were in a position to classify clean water bacteriologically.

This third aspect concerns a change in attitudes, which in principle was possible on various cultural foundations and did not depend on a correct understanding of the latest scientific theories from Europe. Societies that could find the will and resources to make their cities healthier and to care better for their soldiers gained a mortality dividend, enhanced their military capability, and raised their general energy level. Experiences in handling epidemic disease could translate into a changed international weight for the countries concerned. The global “hygiene revolution” was one of the great breakthroughs of the nineteenth century. It began after 1850 in western and northern Europe and has continued down to the present day. It was soon taken up in parts of India, later in east-central
Europe and Russia, and from the 1930s in countries such as Brazil, Iran, and Egypt.
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It would be too simple to interpret this global process as a straightforward result of the Industrial Revolution, or even of the new scientific discoveries of the age. National income growth and new expertise did not
directly
translate into gains right across society in health, life expectancy, and the quality of life. There also had to be a certain normative change, so that epidemics were no longer seen as divine retribution or a consequence of evil individual or collective behavior; morality had to be taken out of the medical understanding of the world. As it became clear that epidemics responded to social intervention, support grew for state-run programs to construct public health systems. The decisive innovation, in which cities such as London and New York took the lead, was probably the creation of local health authorities under central control but with the leeway to respond to conditions in their area. People now expected clean tap water and regular collection of the garbage they had recently learned to fear and loathe. And consumers were ready to pay for facilities that were beneficial to their health.

In the nineteenth century, tropical diseases endemic in latitudes close to the equator were less successfully combated than some of the great scourges that affected Europe.
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Nonurban environments were often more difficult and more costly than cities to keep clean, especially in tropical climes. The disparity was due to a number of factors: to the fairly limited reach of colonial medicine, which, despite many successes (e.g., in the fight against sleeping sickness), did not have the means to root out endemic diseases at the source; to the fact that neither the regions concerned nor the colonial tax system could meet the exceptionally high cost of removing contributory causes such as swamps (insect bites were definitely established as a conduit of infection only in 1879); and to a vicious circle of malnutrition and defective resistance to disease, which Europe and North America mostly escaped. There is much evidence that in the worldwide retreat of fatal diseases, the biological and economic pressures declined faster in the temperate zones of the earth than in the tropics. Climate does not explain economic performance directly or override social and political factors, but it should not be overlooked that the health burdens in tropical zones were and are greater than those in temperate latitudes. This has contributed to an environmental fatalism in hot countries that acts as a dampener on hopes of development.
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Whether tropical medicine was a tool of medical imperialism is a question that does not admit of a single straightforward answer. In some respects (e.g., malaria) it gave Europeans and North Americans the medical assurance with which to conduct further conquests, but it did not do this in other respects (e.g., yellow fever). On the one hand, important medical discoveries were made in the colonies; on the other hand, experiments were conducted with new treatments and drugs that could not be tried out on Europeans. The main goal of colonial medicine and sanitary services was to improve living conditions for the colonizers. But in many colonies efforts were also made to raise the working
capacity of the colonized and to strengthen the legitimacy of colonial rule by means of reforms. Confronting potentially global scourges such as the plague in their non-European places of origin was a new approach that complemented the older strategies of protective shielding. The fight against disease was recognized in the nineteenth century as an international task. In the twentieth century it became one of the main areas of coordinated crisis control and prevention.

5 Natural Disasters

Apart from epidemics, there was no lack of other apocalyptic horsemen in the nineteenth century. Natural disasters seem to break into history from the outside; they are antihistorical free agents and independent variables. The most disturbing are those for which people are unprepared and against which human action is ineffectual. These include earthquakes. There is a history of earthquakes—as there is of spring floods or volcanic eruptions—but it can never be a history of progress. Only in the second half of the twentieth century did geology and meteorology, together with new measurement techniques, create some scope for disaster prophylaxis. Warnings are possible, and there is also a minimum, but nothing more than that, of preparation for the worst. Natural disasters are no peculiarity of the nineteenth century, but a portrait of the age would be incomplete without this ever-present menace to the routines of ordinary life. At times, certain spots of the earth were afflicted by a whole array of calamities. “In the first decade of the nineteenth century,” reports a historian of Oceania, “Fiji experienced a total eclipse of the sun in 1803, the passage of a comet across the heavens in either 1805 or 1807, an epidemic of dysentery, a hurricane, and the inundation of many coastal areas as a result of either a tsunami or cyclonic storm waves.”
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Earthquakes and Volcanoes

No event in nineteenth-century Europe had an impact on people's minds comparable to that of the Lisbon earthquake in 1755, whose horror still resounded thirty years later in the
terremoto
at the end of Joseph Haydn's
Seven Last Words of Christ on the Cross
. Heinrich von Kleist used a real case from 1647 as the basis for his novella
The Earthquake in Chile
(1807). But if any earthquake comes close to the one in Lisbon, it is the great tremor that shook San Francisco on 18 April 1906 at five o'clock in the morning. Many of the Victorian houses in the city collapsed, no thought having been given in their construction to the possibility that the earth would one day move. The social order itself was stretched to the limits as looters roamed the streets and the mayor called in the army to help. Fires blazed for several days and destroyed a large part of the city. Tens of thousands were rescued from the sea at the height of the crisis, in what was probably the largest maritime evacuation before Dunkirk in 1940. The most pessimistic estimates put the total loss of life at 3,000 and the number rendered
homeless at 225,000;
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early concrete structures, which were more resilient than masonry, kept those figures from being even higher. The quake of 1906 was exceptional not because of the scale of the losses (far below the 100,000 deaths or more in Japan following the Kanto earthquake of 1923) but for a different reason: like the earthquake in 1891 on the main Japanese island of Honshu, which had left 7,300 dead, destroyed buildings with a mainly European design, and fueled criticism of exaggerated Westernization—it seemed to embody a new type of “national” disaster, in which nature attacked the nation at its weak point but at the same time gave it an opportunity to display solidarity and ingenuity in the work of relief and reconstruction. This was a general trend in response to natural disasters. In the 1870s, when huge swarms of Rocky Mountain locusts devastated large areas in the American Midwest, the creatures were declared a national enemy and the army was mobilized, under the leadership of an old Civil War general and Indian campaigner, to get aid through to small farmers. In the winter of 1874–75 two million food rations were distributed in the states of Colorado, Dakota, Iowa, Kansas, Minnesota, and Nebraska. It was one of the logistically most elaborate operations conducted by the government since the end of the Civil War in 1865.
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Volcanic events too are sudden and localized, but their effects may stretch over a wide geographical area. The eruption of Krakatau on August 27, 1883, in the Sunda Strait in what is now Indonesia, threw up an ash cloud that spread all around the world. A tsunami triggered by the eruption claimed approximately 36,000 lives along the coasts of Southeast Asia, and the already quite advanced instruments of the time measured seismic waves on every continent. A local natural disaster thus became a global scientific event.
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Back in April 1815 the eruption of Tambora on the small Indonesian island of Sumbawa, more powerful and more devastating in its consequences (117,000 killed in the area), had not yet caught the attention of the international public. A large part of the Indonesian archipelago was covered in darkness for three whole days; people heard the volcanic explosions at a distance of several hundred kilometers, often mistaking them for cannon fire, and troops were put on a war footing in Makassar and Jogjakarta. A thick deposit of ash and rock settled over the export-oriented island, which lost most of its forest and saw its rice fields along the coast flooded with seawater. The eruption reduced the height of Mount Tambora from 4,200 to 2,800 meters. Sumbawa became virtually uninhabitable. There was no medical care for the often seriously injured survivors; food supplies were destroyed and drinking water contaminated; the island became completely dependent on imports. This situation lasted for several months until the colonial authorities and the outside world realized the full extent of what had happened. There could be no talk of speedy emergency relief. The neighboring islands of Bali and Lombok were covered with twenty to thirty centimeters of ash, and there too, the destruction of the standing rice crop led to outbreaks of famine. Agriculture in Bali—which suffered 25,000 deaths—was still seriously
affected in 1821, but in the late 1820s the island began to reap the benefit of the fertile volcanic deposits. This was one of the reasons for the modern rise in its farm output.