Knowledge in the Time of Cholera

by Owen Whooley

  Sanitary Surveys—The normal death rate supplied an abstract, rough numerical indicator of the pernicious effect of poor sanitation on health. It quantified disease abnormality but did so via abstraction from the reality on the ground. Behind this abstraction, however, was the mundane activity of data collection. To create dot maps and to calculate normal death rates, reformers had to acquire hard data on local conditions that would explain the variation in mortality rates and the patterns observable on dot maps, to pinpoint the conditions of filth that lead to nonnormal death. Sanitarians conducted sanitary surveys that not only provided important information but also became their most effective rhetorical tool.

  Sanitary surveys required good old-fashion “shoe-leather” research to gather local intelligence. Indeed, America’s most important contribution to medical cartography was the idea that the local conditions of disease could not be gleaned through correspondence or from decontextualized statistical tables. Researchers had to go to the place to understand the relationship between disease and place (Barrett 1996). To produce their sanitary surveys, sanitarians divided a geographic locale into discrete sections and then sent surveyors to note the conditions on the ground and take inventory of a plethora of environmental factors. The comprehensiveness of the sanitary surveys reflected sanitarians’ desire to reconstruct the total environment of a specific locale, because the total environment might be relevant to the prevalence of disease. These diverse conditions were then correlated with “prevailing sickness and disease” in all the specific locales that when amassed provided a comprehensive sanitary picture of the city. The most famous of these surveys was the Report of the Council of Hygiene and Public Health of the Citizens’ Association of New York upon the Sanitary Condition of the City (1866), which would a play key role in securing a permanent board of health in New York City.

  Sanitary surveys provided a “ground level” view of local conditions. In a sense they rendered the city legible, as they were the primary instrument by which sanitarians transformed sensory observations into first, systematic data and second, visual dot maps that spatialized the data of disease. Such a “thorough and systematic sanitary inspection by competent experts” (Citizens’ Association of New York 1866, xxii) would confirm:

  what reason should have taught every person, however uneducated, that filth, overcrowding, bad drainage, excessive humidity, imperfect supply of air and sunlight, neglect of excrementitious and decaying material, and the putrid exhalations from sinks, sewers, gutters, and dirty streets, will both produce and perpetuate disease; and that whatever sickness occurs in such localities will be more virulent and destructive than the same or similar maladies when occurring in places where such conditions do not prevail. (Citizens’ Association of New York 1866, lxiii)

  Through the sanitary surveys, local knowledge and anecdotal observations were systematically amassed so as to transform them into the generalized, abstract representations of dot maps and normal morality ratios.

  The combined effect of dot maps, normal mortality ratios, and sanitary surveys was to produce an understanding of cholera as filth, linking the disease to place in an understanding that was inherently ecological. This was no more evident than in their identification of “cholera nests.” Cholera nests, also referred to as “cholera fields” (New York Times July 19, 1866, 2), “diarrheal fields” (Metropolitan Board of Health, 1867: 150), “fever nests” (Citizens’ Association of New York 1866, 35), and “plague spots” (New York Times July 19, 1866, 2), were those “special centres” (Metropolitan Board of Health 1866, 38) that possessed multiple factors “from whence emanate the most dreaded diseases that find their way to the more favored districts of the city” (Citizens’ Association of New York 1866, xxxiv). The Metropolitan Board of Health (1866, 13) described one of these cholera nests:

  The streets were uncleaned; manure heaps, containing thousands of tons, occupied piers and vacant lots; sewers were obstructed; houses were crowded, and badly ventilated, and lighted; privies were unconnected with the sewers, and overflowing; stables and yards were filled with stagnant water, and many dark and damp cellars were inhabited. The streets were obstructed, and the wharves and piers were filthy and dangerous from dilapidation; cattle were driven through the streets at all hours of the day in large numbers, and endangered the lives of the people; slaughter-houses were open to the streets, and were offensive with accumulated offal and blood, or filled the sewers with decomposing animal substances. Gas companies, shell-burners, and fat-boilers, pursued their occupations without regard to the public health or comfort, and filled the air with disgusting odors.

  Cholera’s “favorite haunts” (Newman 1856, 441) were breeding grounds for all types of disease and, as such, were a menace, not only to their inhabitants but also to the rest of the city. Because cholera “will be epidemically propagated only where and when certain conditions of putrescence in the earth, the atmosphere, or the potable water are present” (Metropolitan Board of Health 1867, 150), the areas in which these “localizing conditions of disease” (Citizens’ Association of New York 1866, lxiii) were rife needed to be cleaned to prevent an epidemic. As cholera became rooted in place, those responsible for filthy places (i.e., landlords) were put on watch as culpable purveyors of disease.

  The relationship between cholera and filth remained vague and, therefore, could accommodate divergent viewpoints regarding the etiology of diease. On the surface, it seemed to confirm the views of noncontagionists at the expense of contagionists. After all, it focused on local conditions in accounting for disease. Many historians have taken this as a sign that non-contagionism was dominant (e.g., Rosen 1993). But while it is true that non-contagionism was gaining adherents, the idea of cholera as filth had more ambiguous effects. The flexibility in the understanding of the relationship between filth and cholera enabled contagionists and noncontagionists, homeopaths and regulars, to unite in the common goal of cleaning the city. Contagionists bought into sanitation by viewing the local conditions essentially as intervening variables in the spread of the disease, a common position during the period called “contingent contagionism,” which held that cholera needed a ripe environment to prosper and grow (Hamlin 2009). Local factors were necessary but not sufficient for the spread of cholera. As for strict contagionists, the focus on sanitation could not hurt, provided it did not detract from quarantines and the search for the etiological cause of cholera.

  Even diverse medical sects converged on a common ground of cholera as filth, as elements of the argument resonated with their different epistemological systems. Homeopaths, long amenable to the type of statistical rhetoric being proffered by sanitary reformers, were convinced of the association between filth and disease. In a speech on cholera before the American Institute of Homeopathy, Horace Paine (1866, 142–143) outlined the homeopathic position:

  Whatever opinion may be entertained as to the cause of cholera or the mode of its propagation (and on these points physicians are still much divided), it is certain that foul and confined air, putrid and decaying vegetable and animal deposits, and damp, crowded, and ill-ventilated apartments, offer the greatest encouragement to its development and increase its virulence. Consequently, cleanliness of towns, dwellings, and persons, is of the first importance; and would, if fully accomplished, be more effectual than any quarantine arrangements in preventing its invasion.

  For their part, regulars could support the link between cholera and filth, even though their persistent suspicion of statistics made them unlikely to accept the normal mortality ratio. The link conformed to their clinical observations of cholera’s tendency to cluster in certain neighborhoods. And the shoe-leather data of the sanitary surveys resonated with allopathy’s commitment to radical empiricism and sensory observation. Provided sanitarians’ claims remained rooted in these observations, regulars were willing to sign on.

  Therefore, while medical debates about the nature of cholera endured, they were mitigated by a growing focus on prevention. Elisha Ha
rris (1869, 122), a longtime sanitary reformer and commissioner for the national Sanitary Commission, reporting to the New York Academy of Medicine in 1866, stressed “that physicians and sanitary authorities should promptly act upon all practical questions relating to this duty without waiting the adjustment of theories, remembering that it is the first duty to prevent or control the earliest outbreaks of the disease” (emphasis added). Because the association of cholera with filth did not require the commitment to a causal understanding of the relationship, it united strange bedfellows. As the New York Times (July 1, 1866, 4 emphasis added) pointed out in discussing the New York Academy’s support of sanitary reforms in New York City,

  The camps of the medical world are divided on this disease, as on many others, into two hostile parties, for and against contagion; but the truly scientific, like the members of the Academy, are waiting patiently for facts before they proclaim a theory. Thus far, in the approach of this epidemic, the facts are sufficiently confusing. . . . The Academy, wisely, do not commit themselves for or against any theory of contagion; they only urge the practical course of cleansing and disinfection as “absolutely necessary.”

  The ambiguity and flexibility in the understanding of the relationship between filth and disease made it hard to reject whatever one’s particular theory of disease. All could agree on some generic sanitary reforms.

  INTELLECTUAL ECUMENISM AND EPISTEMIC TRUSTWORTHINESS

  The localization of cholera necessitated locational responses. Unified under a broad banner of sanitary science, reformers of diverse backgrounds formed a coalition to advocate for the cleaning up of the city. This coalition sought to harness a wide array of technical knowledge and community energy to conquer disease by creating permanent, independent boards of health. But, in doing so, they faced stiff resistance from local political machines. The existing sanitary regimes were bastions of corruption and political patronage. To bring about the independent boards, sanitarians had to convince legislatures of their superiority over the existing boards. They had to convince legislatures that they possessed better knowledge and, in turn, better protection against cholera.

  To justify their epistemic authority, sanitarians adopted a position rooted in their disinterested position and the accompanying trustworthiness of the knowledge that emanated from such a position. This strategy was born of the particular configuration of the reform movement. The diverse knowledge that sanitarians valued precluded them from claiming epistemic authority in terms of possession of any one type of specialized knowledge. Nor could the sanitarians claims special technical acumen in producing dot maps, statistical data, and sanitary surveys, for politicians used similar techniques to make contradictory arguments. Rather, they argued that existing boards of health and sanitary policies of the city were unsalvageable because of political corruption. Sanitary contracts were “managed in the interest of partisan greed” (Agnew 1874, 4), doled out as patronage by urban political machines in exchange for political support. Streets went uncleaned, inspections unconducted, and water unpurified, all because city inhabitants “stupidly permit[ted] the conditions of their health to be controlled by politicians” (Nation January 11, 1866, 40). Politicians were not just ignorant; they lacked the proper motivation to honestly carry out their duties. “The doctrine that ‘to the victors belong the spoils’ may be food for politicians and a fair rule of practice in the general affairs of State,” a sanitarian later echoed, “but when positions of public trust are to be filled whose duty requires technical ability and special adaptation, then it becomes highly expedient that politicians be requested to keep hands off” (Halley 1887, 241). Reduced to political transactions, sanitary activities were not taken seriously, nor was there any incentive to produce accurate knowledge of sanitary conditions.

  Instead, sanitarians stressed the disinterested and apolitical nature of their motivations. Sanitarians were uncorrupted by political calculations and driven by purer motives of civic responsibility. They wanted to see the streets cleaned and wanted to figure out the best means to do so. Their knowledge was unsullied by the kickbacks and graft that accompanied machine politics. Thus, it was disinterested knowledge, not technical acumen, which they offered as the antidote to political corruption, local filth, and epidemic disease. In other words, sanitarians sought to win back public trust through a particular ethos of disinterestedness toward sanitary knowledge. This ethos was joined with new technologies—accurate cholera maps, comprehensive sanitary surveys, and troubling mortality statistics—that sought to render knowledge of disease visible and transparent to the public. Transparent sanitary knowledge was opposed to the backroom dealings of politicians. It promised both more accountability and better accuracy.

  Sanitarians argued that boards of health needed to be insulated from politics, staffed by officers who would not abuse the public trust for political gain and who would apply the proper reforms based on trustworthy knowledge. This argument was not a claim to objectivity per se, as it is commonly understood today. It did not rest on an ideal of aperspectival knowledge, a “view from nowhere,” which argues for privilege based on having eliminated (or at the very least, greatly minimized) potential biases and corrupting influences of particular perspectives (Novick 1988)—a claim to trust based on a negation. Sanitarians had no pretensions of purging the positionality of the knower from the production of knowledge. To the contrary, positionality and the character of the knower determined the epistemic validity of knowledge claims. Sanitarians’ trustworthiness was based on their standing as responsible citizens in the community unbiased by crass politics. Their epistemic authority was inextricably tied to who they were and where they stood vis-à-vis city politics. This was an argument for epistemic authority that was, in an important sense, ad hominem. By virtue of who they were sanitarians could produce accurate and honest sanitary knowledge that would rid the city of filth.

  The First Permanent Board of Health

  The struggle for sanitary reform in New York City offers insights into the way in which reformers advocated for and won important reforms by framing their epistemic authority in terms of disinterested, apolitical knowledge. Sanitarians in New York not only secured the first permanent, depoliticized municipal board of health in the United States; their efforts became the model for sanitary reformers in other contexts.

  New York, like many other U.S. cities, had established temporary boards of health during prior epidemics to disseminate information and coordinate measures to prevent the spread of the epidemic. These temporary boards typically consisted of little more than the mayor and alderman, with some input from a few well-regarded physicians who sat on hastily thrown together special medical councils. There would be a period of porous quarantines and cosmetic cleanings, but once the epidemics passed, the sanitary situation would return to its pre-epidemic condition. Lingering sanitary practices, like street cleaning, were doled out as patronage to supporters by city political machines, resulting in a hodgepodge of municipal organizations working independently of one another, more interested in advancing their political agendas than cleaning the streets (Duffy 1990).

  The initial call for reforming New York’s municipal health was led by the allopathic medical profession itself. While rank-and-file regulars tended to be ambivalent toward public health, a handful of elite physicians, driven by a sense of civic duty, prodded the New York Academy of Medicine (NYAM) into advocating for a more permanent solution to sanitation in 1857. They supported legislation that would depoliticize sanitation. Within allopathy, this spurred internal debate as to the relevance of public health, as well as concerns that putting energy into sanitary reforms was misguided. Still, even the skeptical rank and file, less encumbered by civic duty, could see the potential professional benefits of reform, provided that public health remained under allopathic control. The president of the Medical Society of the State of New York, Fordyce Barker (1860, 8), made the case for allopathic control:

  And I say further, that it is the absolute
duty of the citizen, and the duty of the legislator, to accept as final our decisions in all scientific hygienic matters, and to act upon such decisions. As the decisions of a court of last resort furnish a final interpretation of written and shape the unwritten law for the legislator and the citizen, so should the expressed convictions of this scientific body be received and accepted by all, and be the basis of all action had in sanitary matters. Knowledge on this subject can only be had from medical men.

  In arguing for allopathic control, sanitary-minded physicians aligned the calls for reform with the professional goals of the society, and thereby gained NYAM’s endorsement.

  These early reforms received a boost from newspaper exposés that blamed the poor sanitary condition of the city on political corruption. The New York Times (June 25, 1856, 3), in an editorial provocatively entitled “Killing Off Our Children—By Authority,” drew the link between patronage and needless death: “Thousands of lives are lost, and thousands that live are demoralized and broken in constitution—all because our mock sanitary officers have not the intelligence or the enterprise to fill up these sunken lots, and drain these poisoned valleys.” The not-so-subtle moral of this editorial was clear: the greed of politicians was responsible for the fever nests that killed children. Exposés like this focused public attention on the harms caused by lax sanitation and placed culpability for filth squarely on the shoulders of unresponsive city officials.

  NYAM, however, was not able to translate this support into tangible reforms. Its plans were derailed by the city’s machine politics, as the Democratic political machine of Tammany Hall persuaded the state assembly to reject the proposed legislation. The legislative failure gave those within the allopathic profession initially skeptical of reforms fodder for backing out of future reform efforts. They dismissed any further forays into public health reform as a waste of time and resources, given their political unlikelihood and marginal payoff. Consequently, after this brief flirtation with sanitary reform, NYAM, and regulars in general, remained content to sit on the sidelines as others took up the fight against entrenched political interests (Duffy 1968). Physicians were free to support the cause individually, but without the support from the medical society.