Urban Epidemics

A vital tool that was used by epidemiologists to convey findings in regards to social conditions is statistics. In Victorian Social Medicine: The Ideas and Methods of William Farr, four major components of statistics are listed. These divisions are: economic, political, medical and moral. All of which can be used to explain the filthy conditions of the impoverished in England.

As both of the leads pointed out, urbanization of society lead to the deteriorating conditions, as Engels described in he Conditions of the Working Class in England. The focus of the nascent science was on the conditions of England. In Victorian Social Medicine: The Ideas and Methods of William Farr, statistics was described as a method to find the solutions for England’s state of destitute. This social science could be used as a method to make conclusions regarding certain legislations and acts. The most important fact was that bias and political tampering must be avoided.

The creators of the Statistical Society of London point out the benefits of Statistics: “… we arrive at a knowledge of the physiology of societies, and comprehend the paroxysms of disease which they sometimes exhibit in a state of violence or the exhilaration of health… Empirical treatment of symptoms, without this knowledge, must be vain in it effects upon the body politic as upon the human frame…” This quote stresses the importance of statistics by saying that this type of social science would allow the accurate depiction of conditions of society, and without this data, it would be realistically impossible to improve Public Health.

William Farr helped improve living conditions of society because of his major contributions to statistics. One of his views was that the horrendous conditions in which the poor lived in were at large caused by “physical defects” in societal cities. As Megan pointed out, many of the middle class men viewed “sturdy beggars” as scurrilous individuals. William Farr did not show sympathy with these paupers and supported the Poor Law as a temporary solution. Farr did show great sympathy for the people who were suffering due to urbanization and societal conditions. Many of his writings described his shock as to the conditions in which the poor live in.

Farr believed that reform in public health was possible and was a strong advocator of self- help.  As many other health practitioners, Farr believed that statistics could be used to depict the conditions of life and epidemic disease. He saw it as a method of ameliorating medical knowledge that would as a result improve overall Public Health. Farr believed that this social science would discover certain relationships in medicine, social conditions, and other fields. He was able to promote certain laws due to observations. Farr proposed certain relationships between food prices and mortality. He then drew conclusions between population density and life expectancy. All of these inferences were made possible due to his use of statistical methods.  Farr was able to create many life tables that depicted the rate of mortality and age. He was able to explain how outside factors were able to influence life expectancy. Overall, Farr was able to use statistics as an impetus for the improvement of public health due to its social findings.

Jesse Geisler

August 29, 12

Seminar III

With Professor Oppenheimer

Urbanization, Industrialization and Population: Mobilizing for the Public’s Health

            This week’s readings focused on the ill health effects wrought by rapid industrialization. All of the readings suggest that the main determinant of disease is one’s socio-economic status. Frederick Engels quotes evidence showing that poorly kept streets, those in which the most obvious sanitary conditions were ignored, had rates of mortality four times those of richer neighborhoods (Engels). The readings do not patronize the poor and imply that they are dirty from ignorance, or lacking in bourgeoisie etiquette and hygiene. They suggest instead that the working class poor at that time, the “proletariat,” were thrust into a position of radically changing economic, political, and class interactions that led to crippling conditions of squalor and destitution. With these conditions came epidemics, specifically cholera. The devastating effects of such diseases became symbolic of the cost of unprecedented, unregulated, and uncontrolled industrial growth (Porter D).

In the book Civilization and the State by Porter D, he explores the physical conditions working class people in 19^th century England endured daily and their connection to disease. Porter also chronicles some of the symptoms and nature of cholera and typhus. Porter cites sources claiming that in the first half of the 19^th century epidemics and infant mortality were the number one causes of death. He also states or assumes that the majority of English urban poor were well fed enough to be above the level of malnutrition at which the integrity of ones immune system is compromised, and susceptibility to diseases common. Therefore death from starvation/famine was not so much an ill of 19^th century England, however the quality of food and exposure to contaminants may have compounded citizens susceptibility to disease. After 1870 deaths from infectious diseases declined abruptly due to improved sanitation and temporary school closings in districts with infected children (Porter D).

The book also explores differing opinions regarding how best to respond to epidemics. Some researchers at that time were what were called “contagionists,” believing that human-to-human contact was the sole source of disease and those afflicted must be immediately segregated. Anti-contagionists believed diseases were present in the environment, some belching from the bowels of the earth, and opinions varied as to why they infected some and not others. Many believed morality was linked to a weak constitution, and therefore sinners were more susceptible to epidemics. Anti-contagionists also pointed out that the problem with the theory that disease traveled only by human-to-human contact was that the same epidemic could break out in geographically distant isolated pockets. Moreover, another significant problem with contagionism was the political climate at that time. Quarintine practices used since medieval times—closed down public meeting places and sealed off cities and towns—which were ordinances enforced by the military, caused outrage in newer generations more in tune with social unrest.

This lead to civil disobedience and the murder of bureaucrats and doctors throughout Europe. Doctors were targeted because of their use of cadavers for research, and rumors circulated that cholera was a plot hatched by medical professionals who wanted more bodies to dissect. A central question that Porter raises is whether or not disease causes social unrest or if social unrest and the fragmentation of society create conditions ripe for disease. Porter does not draw a conclusion but essentially notes that the two situations may not be mutually exclusive, and a distinction regarding causation may be difficult. However Porter states that urban stress—conditions he defines as “hardship from political and economic conflict, strikes and lockouts, and homelessness and overcrowding resulting from slum clearance”—does consistently seem to precede the outbreak of a dangerous epidemic such as typhus or cholera.

Porter describes the symptoms of cholera as such: it begins with violent vomiting and diarrhea, which quickly leads to severe dehydration and pale bluesh tint of the skin that characterizes the disease. This is followed by debilitating cramps and muscular spasms, which lead quickly to death. Research seems to show the acidity or alkalinity of ones stomach can effect survival rates, and this is corroborated by alcoholics susceptibility to the disease—alcoholism is associated with a high PH stomach. Today when adequate resources are available cholera is no longer considered a deadly disease and can be treated with high doses of a potent antibiotic cocktail. It is now understood that the disease is transmitted primarily through feces, which explained the rampant spread in London slums. English country traditions regarding waste disposal involved essentially pooling all waste and runoff into a cesspit. However when this practice was employed in the vastly overcrowded slums of London, the cesspits became overrun swamps that almost invariably contaminated nearby drinking water. This lead to the rapid spread of the disease.

The cholera bacterium, if it survives the acidic conditions of the stomach, lodges itself in the walls of the small intestine and produces cell byproducts that are toxic to its host. This leads to the symptoms of vomiting and diarrhea. Typhus, the other major killer in 19^th century England, uses lice as a host. When the victim is bit by lice, and the resulting welts are scratched, the typhus bacterium enter through the open sore quickly infecting the person. Today typhus can also be treated with antibiotics, but in 19^th century England it was often deadly. Porter sinisterly notes that sometimes outbreaks of these deadly diseases were hidden and responses delayed because of public officials or private interest groups fears of the effects quarantine would have on revenue streams.

The devastation of these epidemics lead to the creation of public health systems. Initially, The expansion of Britain’s public health system was justified partly by the belief that conditions of society would effect the market health of the economy and in turn greater British society—namely the wealthy class, those with the power to yea or nay such public health campaigns. Therefore investing in the health of the lower classes was worthy because not doing so would essentially be bad for business (Porter D).

This belief was backed partly by the calculation by state architects that a surefire way to reduce the cost of the poor on the state was to ensure the health of the urban poor’s “breadwinners” (Porter D). As Engels noted in his The Conditions of the Working Class in England, the primary worker in a family was always the one most likely to be afflicted by a disease, and also the one a family could least afford to lose. This was probably because of stress on the job and exposure to more people and contaminants at work. Although Porter acknowledges that some held the view that government apathy was the cause of overcrowded slums and squalor, he does not like Engels entirely blame the government.

Tied into the vast overcrowding of the slums and subsistence level living that made death from famine unlikely but death from epidemics related to overcrowding common was the allowance system. The allowance system allocated enough money to poor families to supplement their wages just to subsistence levels in accordance with the price of bread (Porter D). Intense overcrowding in urban environments led to extreme situations of filth—animal and human waste, excrement, and refuse—that seeped into water supplies causing illness. The unbearable stench associated with such urban environments at that time likely led to the numerous theories of atmospheric contagions that randomly and intermittently spewed out of the earth to infect sinful townspeople.

However many within the British elite believed the allowance program was smothering the free market economy and increasing the price of labor, by dulling the “fear of hunger” in the poor. Still others believed the epidemics were necessary to curb wild population growth that if continued to grow unchecked would threaten industry and lead to instability (Porter D).

Edwin Chadwick and Dr. Henry Rumsey both became pioneers in English public health by creating reports that criticized the current state of affairs. Chadwick’s report essentially documented the terrible living conditions and complete disregard for sanitary practices in most of the slums. Chadwick, similarly to Engels, noted that the chronic diseases affecting the working class from infancy never allowed a generation to get truly ahead, leading to a chronic cycle of subsistence living. He essentially tied the elimination of poverty to proper healthcare. Rumsey published a report bemoaning the fact that the English General Board of Health was run by bureaucrats with zero medical knowledge and no advice from doctors. This in many ways is the beginning of an ongoing argument to this day between public health officials and doctors as to who should advise who and how the two professions should interact. As Porter stated, “Rumsey noted that preventive and palliative (treating symptoms not underlying causes) care needed to be integrated in some way” (Porter D). Another important figure within public health was Dr. William Farr, who pioneered the International Classification of Diseases (ICD) system. Farr also created many public health systems, and developed a national statistics initiative to aid doctors with data collection. Farr’s extensive implementation of statistics changed healthcare and social sciences (Eyler J).

Engel’s take on the abhorrent conditions in slums leading to epidemics is different from Porter’s in that he places specific blame on the government. He states that the government’s attitude towards slums and the squalor that proletariat Britain’s dwell in is one of such indifference that it constitutes manslaughter. Engels believes that the sheer density of people living in London leads to a lack of oxygen and that “carbonic acid gas” engineered by industry is spewed into the streets and because of the oppressive and cramped building style hovers close to the ground endangering peoples lungs. Again Engels as with many other critics of living conditions and their effect on health believed that much of the ills associated with city life came from unclean air. In fact he often mentions the stench associated with London, and as with others correlates it to ill health—not entirely without basis, as foul smells often indicate the presence of something harmful. In relation to Chadwick’s perception of the correlation between poverty and healthcare Engels notes the chronic illnesses beginning in children bring a perpetuating “enfeeblement upon the entire race of workers” (Engels).

Engels emphasizes indigestion as a constant ailment plaguing the working man, the result of old or contaminated food. Workers complain constantly of dull aching stomach pains in addition to their bleak environment, all of which they blunt with alcohol, a meager comfort that only compounds their ailments. He also addresses the rampant phenomenon of quack medicine, that is, various pills or elixirs that promise the world to the working class but do nothing but rob them of their menial pay or poison further bodies wracked with ills (Engels).

The thrust of Engel’s paper The Conditions of the Working Class in England seems to imply that the “property holding classes” have vested interest in sustaining and maintaining this state of affairs for the purpose of cheap labor, and are responsible for the sky high mortality rates among the working poor (Engels). Engels also addresses the education system in Britain for the poor, stating that it is essentially useless and staffed by unknowledgeable people and zero counseling or advice for upward mobility. The Conditions of the Working Class in England is filled with vivid descriptions and accusatory political rhetoric and serves its point. One cannot help but feel that the working classes are caught within a vicious cycle out of their control leaving them subject to the bacterial and viral ravages of nature.

In the midst of the British Industrial Revolution, demand for labor sparked a march of opportunistic proletariats into industrial areas, with rapid urbanization leading to less than adequate living conditions for the working poor. Those higher up on the food chain, the economically stable British bourgeoisie, sought to keep populations impoverished for cheap labor. But this want created a cycle of malaise: the central and prevailing idea of this week’s assigned texts seems to incarnate a direct correlation between socio-economic status and health, specifically in that the poorer and more destitute an individual the more susceptible to illness he would be. That being said, a clash of theories regarding the cause of disease served to help sustain the economic status quo, and thus keep populations in conditions that contributed to their poor health.

As F. Engels points out in The Conditions of the Working Class in England, rapid urbanization had adverse outcomes, such as cramped living areas, lack of infrastructure such as ventilation and drainage, and unsanitary conditions. Along with bad diet, these factors led to poor health for the poor working class. And because the poor barely had enough funds for subsistence, they could not afford actual doctors. As such, the proletariat was to rely on quack medicine, most of which caused more harm than good. According to a study by Dr. P.H. Holland in Manchester, the mortality rate of the third class (the poorest) was 78% greater than the first class (the richest) in a grouping of streets. This statistic points to the poor’s susceptibility to disease, which is greater than the rich.

Victorian sentiments powered the British bourgeoisie’s view of the poor, especially in a moral way; the upper class saw those capable yet unwilling to work as the gunk on the bottom of a shoe, and condemned pauperism. The English New Poor Law, which reduced the group mentioned previously to an inferior race, served as a harsh deterrent for such behavior. The problem was that it did not allow for relief outside of workhouses, places where the out of work may find shelter and food. The industrial north of Britain experienced cyclical unemployment from sporadic recessions, but unemployed workers were unwilling to enter the workhouses.

As such, it could be said that the New Poor Law failed in its vision of reducing the number of poor. But Edwin Chadwick, chief commissioner of the Poor Law Commission, refused to accept the inadequacy of the statute. His obsession with the miasmatic theory of disease causation (in which agents of disease are created by decaying organic material) exists as a last but feeble attempt to pin disease on social factors, rather than economic factors. Chadwick and followers blamed illness purely on unsanitary environment disregarding the multitude of other factors such as poor diet and incapacitating working conditions.

However, men of medicine often prescribed food for ailing patients. This decision was fueled by money: doctors had to pay for medicine out of their own pockets but food was covered by medical unions (Mutton Medicine). Chadwick and the Poor Law Commission saw this action as preposterous, believing that hunger drove the poor to work, so by prescribing food the doctors were encouraging pauperism. Also, the PLC’s goal was to link disease to filth and not destitution. The act of prescribing food alluded to a relationship between an aspect of destitution (poor diet) and fever. British bourgeoisie supported Chadwick’s belief, because a continuous flow of cheap labor equated to higher profitability.

The PLC quickly clamped down on any contrasting information regarding its organization and used intimidation to extend their funding. For example it forbid people with medical credentials from Scotland and Ireland passage into English medical unions. This was because Scots wanted support from the English poor law establishment in creating a foundation for similar systems in Scotland; doing so however revealed contradictions in the English New Poor Law. That these conflicting studies were to be taken as fact would render the deterrent practice (in which the poor are left hungry so they would work and not be a drain on society) as unreliable and worthless. With that, it was not until Chadwick stepped down and John Simon took the position that science and not just speculation was used in public health reform.