70 Books & arts The EconomistAugust 1st 2020
21Quarantine aside, day-to-day life in the late Middle
Ages remained a mucky affair. People ate with un-
washed hands from shared plates. They crowded to-
gether in close proximity to household refuse and hu-
man waste. In homes with earthen floors, residents
would often urinate on the ground. Spitting was com-
mon; people blew their noses into their hands.
Habits changed slowly—though improvements
were rarely responses to concerns about health or dis-
ease. Instead, conducting oneself in a manner intend-
ed not to cause offence to others became a mark of re-
finement, and a means of distinguishing a class from
the literally unwashed masses. Norbert Elias, a Ger-
man sociologist, described the centuries-long accu-
mulation of hygienic habits as the construction of an
“invisible wall of affects” which activates “at the mere
approach of something that has been in contact with
the mouth or hands of someone else”.
Consider the use of forks, which slowly spread
across Western Europe during the late Middle Ages.
These provided a more hygienic means of moving food
to the mouth than fingers. But their power as a status
symbol derived more from the dainty, dexterous han-
dling required by the utensil. In the absence of a germ
theory, fashion could only take society so far. Giovanni
Della Casa, an Italian poet and authority on 16th-cen-
tury etiquette, discouraged his readers from hand-
washing after using the privy, “as the reason for...wash-
ing will arouse disagreeable thoughts in people”.A bar of faith and hope
By the 18th century the first stirrings of a more system-
atic approach to public health began to appear. Larger
cities established public bodies charged with deter-
mining when and how to conduct quarantines in re-
sponse to outbreaks of diseases like smallpox. Many
set up hospitals to care for the ill. But it was the begin-
ning of industrialisation, and the associated growth of
cities, that proved the most consequential health de-
velopment of the century.
London’s population roughly doubled in the 18th
century, to about 1m inhabitants. It then rose nearly
sevenfold in the 19th. That of New York City grew from
about 30,000 people to 3.5m between 1790 and 1900.
Manufacturing centres across Europe and North
America transformed from modest villages to swelling
metropolises in the space of a lifetime.
The consequences for public health were devastat-
ing. Factories pumped smoke into the air. Sewers emp-
tied waste into rivers and lakes used for drinking wa-
ter. Epidemics of water-borne diseases like cholera and
typhoid killed thousands of people. As a result, death
rates in cities were substantially higher than those in
rural areas. They were also higher than the urban birth
rate. In the early 19th century, as many as half of the
children born to the working class in London died by
the age of five. Only the steady flow of people migrating
from the countryside kept cities from shrinking.
The hardship of city life during the first century of
industrialisation fed the deep discontent with capital-
ism brewing among the working classes. Friedrich
Engels, in his writing on “The Condition of the Work-
ing Class in England” (1845), made much of the state of
sanitation in the districts occupied by poor labourers,
like St Giles in London, where “heaps of garbage and
ashes lie in all directions, and the foul liquids emptied
before the doors gather in stinking pools.”
But dirt posed a greater threat to the sustainabilityof capitalist growth than socialist thinkers did. High
urban mortality rates placed a ceiling on the extent to
which early industrial societies could urbanise, of
about 30%—or roughly the share of the population of
the Netherlands considered urban in the 18th century.
The deadliness of industrial cities became a bottleneck
to modern economic growth.
Such terrible conditions slowly moved people to
demand action. Nascent studies on chronic infectious
disease made clear that cities themselves were delete-
rious to health, though the best minds of the day could
not be certain precisely why. This was no small pro-
blem. The rapid pace of change within cities, and the
sheer number of sources of nastiness which might
contribute to ill health, made the problem of spurious
correlation nearly insurmountable.
Some 18th-century scholars speculated that ail-
ments might pass from person to person through the
movement of unknown microscopic particles. In the
absence of the equipment and know-how needed to
detect such particles, empirically serious scholars dis-
missed the notion in favour of the idea that miasma, or
foul air, was the cause of infectious disease. The theory
found further favour with businessmen who disliked
the trade-interrupting effects of quarantines and re-
formers keen to clean up the cities.
In the 19th century scores of public-minded indi-
viduals began pitching schemes to clean up cities. Ed-
win Chadwick, a British lawyer who contributed to the
reform of the English Poor Laws, oversaw the drafting
of a scathing report on sanitary conditions in Britain,
published in 1842, which documented that the average
age of death for tradesmen in London was just 22, and
for labourers just 16. Chadwick cited miasma as the
chief contributor to infectious illness and called for
large-scale public investments in drainage and sewage
systems. Similar figures across the industrialising
world sought to build support for policies to clean up
deadly cities. Dickens was one of them.
It was not easy. Despite reports such as Chadwick’s,
scientific understanding remained scant. In 1849 The
Economistdeclared that:The belief in contagion, like the belief in astrology and
witchcraft, seems destined to die out; and as we have got
rid of all regulations for consulting the starts or attend-
ing to omens before we begin any undertakings, and of
all the laws against feeding evil spirits and punishing
witches, so we shall no doubt in time get rid of the quar-
antine regulations that were established from the old be-
lief in contagion.So too did stubborn citizens grow weary of the lectur-
ing of muckraking do-gooders. By 1854, outbreaks of
infectious disease had killed thousands of Londoners
of all classes, and yet an editorial in The Timeshuffed,
“We prefer to take our chance of cholera and the rest
rather than be bullied into health.”
Instead the concept of a collective responsibility to
invest in public goods had to be cultivated. As Johan
Goudsblom, a Dutch sociologist, noted: “Increasingly,
it dawned upon the rich that they could not ignore the
plight of the poor; the proximity of gold coast and slum
was too close.” Governments at all levels began to take
on direct responsibility for tidying up large cities. Re-
moval of household waste, cleaning of streets, provi-
sion of fresh running water and universal connection
to sewage slowly became the norm.
The effects of this sanitary revolution were dramat-In the absence
of a germ theory,
fashion could
only take society
so far