Over the last decade, the role of modern water supply and sewage disposal infrastructure in the West’s 19th and early 20th century urban mortality transition has attracted renewed attention among economic historians and development economists (Harris and Helgertz, 2019). A robust conclusion of this literature is that access to tap water and sanitary sewers was crucial in turning cities from hotspots of infectious diseases to evermore healthy places. However, the causal mechanisms linking patterns of declining mortality and expanding access to modern water infrastructure are still poorly understood. In particular, should the emergence of urban sanitation be seen as a rational, indeed inevitable reaction to the 19th century’s recurrent epidemic shocks and elevated urban mortality rates, an idea that Christopher Hamlin (2009) termed “cholera forcing”?
In a recent EHES working paper, I retrace Berlin’s long and bumpy road to safe water conditions, challenging popular narratives that interpret modern water infrastructure as an efficient, scientifically motivated answer to Europe’s recurrent cholera epidemics since 1831. To the contrary, Berlin’s experience suggests a highly complicated relationship between urban epidemics, their statistical, proto-epidemiological examination, and water management reform. Far from serving as “our old ally”, an attribute later assigned by urban hygienist Robert Koch, cholera turned out not only a weak motivator, but in fact an ambiguous one.
“The Great World Pestilence” in Berlin
Quite representative in the Western European context, 19th century Berlin suffered from a characteristic “urban mortality penalty”, partly fuelled by periodic outbreaks of epidemic diseases. Cholera was not the most fatal, but arguably the scariest and most unpredictable member of Berlin’s disease panorama, amounting to almost 19,000 documented deaths in between 1831 and 1873.
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Figure 1a and 1b: Cholera incidence and Crude Death Rates in Berlin, 1830-1880
In hindsight, it is not hard to understand why cholera raged in a repeated, yet seemingly erratic fashion. Berlin had experienced rapid population growth since the 1850s, bringing about the typical problems of increasing density, pollution, congestion and the consequent spread of infectious diseases. Commercial travelers repeatedly carried vibrio cholerae from the East and introduced the bacillus into the local cesspools, which in turn contaminated the water of nearby wells, spreading the diseases among the population. Berlin’s international connections, dense living conditions and inadequate sanitary conditions rendered the city an ideal transitional habitat.
On Unwanted Tap Water and Miasmatic Plague Tubes
Roughly 25 years after its first acquaintance with cholera, Berlin began a lengthy path to safe water conditions, substituting an essentially medieval infrastructure based on pump wells, cesspits, open gutters and the river Spree’s natural absorption capabilities by relatively clean tap water and sanitary sewers that disposed waste in the rural hinterlands.
Initially, recurrent epidemic shocks played hardly any motivating role. By the 1850s, it was aesthetic rather than sanitary concerns that brought the construction of a modern tap water network on the municipal agenda. However, a combination of misaligned economic incentives, low public demand, conflict over fiscal and administrative responsibilities, and, crucially, a lack of understanding of cholera’s fecal-oral transmission route ensured that the spatial expansion of the network was slow, reaching full coverage only by the 1890s. Moreover, there is evidence that failure to understand the adverse repercussions that an ample tap water supply would have on an urban water cycle still lacking safe sewage disposal contributed to the urban health crisis and cholera’s incidence in particular, as suggested by the disease’s forceful comeback in 1866.
It took another 25 years until the issue of complementary sewers would be tackled. Analysis of contemporary discourse reveals that, while cholera’s continued appearance clearly motivated some sanitary reform, physicians, public health advocates, urban planners, and the general public for a long time disagreed on the shape that such reforms should take on. Were sewers preferable to manual disposal via containers and haulers? Was the strict separation of liquid waste from excrement and other organic waste preferable to mixed sewers that promised dilution of the contaminated material? Should waste be left to the river’s natural cleaning capabilities or were sediments and the soil’s microorganisms a more reliable disinfector? And what about dangerous, disease-ridden “sewer gases” that could spread via underground plague tubes? Far from suggesting a straight road to a unique sanitary solution, prevailing miasmatic theories were vague enough to levy arguments for competing solutions to the mounting urban health crises.
The Data Did Not Speak
In hindsight, it is tempting to interpret this lengthy transition phase as a result of technical, financial and political hurdles counteracting the inevitable triumph of rational approaches to the problems of cholera and infectious disease. However, a closer look at the epistemological struggles of contemporary Berlin’s health officers and medical statisticians suggests that the relationship between the extensive proto-epidemiological analysis of infectious diseases and efficient sanitary reform was highly ambiguous.
Not only did the collection of ever larger amounts of data fail to yield any compelling reasons to rely on clean drinking water and sanitary sewers, as opposed to a myriad of competing policy recommendation focussing on ventilation, cleansing of the soil or quarantine. Moreover, the lack of adequate mathematical and statistical tools proved fatal for the proto-epidemiological approach to unraveling cholera’s complex properties. Well into the 1880s, Berlin’s health statisticians were forced to retreat to the role of mere documenters as prevailing miasma theories proved too blunt an instrument to cut through the jungle of cholera’s complex spatiotemporal patterns. The “myth of John Snow” (McLeod, 2000) notwithstanding, Berlin’s experience suggests that observational data and inductive logic did not suffice to set the urban health community on the right track and induce crucial investments into the urban water infrastructure. To the contrary, unable to free itself from the vagueness of miasma theory, proto-epidemiology turned out more an obstacle, rather than a driver of knowledge generation.
“Cholera Forcing”: Tales, Realities, and Implications
What lessons does a careful reinterpretation of the Western urban sanitation transition promise? Of course, there is no immediate danger of history repeating itself, as comprehension of both cholera’s etiology and the importance of safe water systems dramatically improved. Still, the absence of any automatisms in the Western cholera-sanitation-nexus at the least suggests a cautious interpretation of the disease’s potential to induce change.
Powerful narratives of the West’s past struggle are highly consequential regarding the attitudes, recommendation, and modes of assistance that today’s developing world receives (Konteh, 2009). While it originates from a misleading backward extrapolation of modern technocratic approaches and scientific knowledge to the past, the real danger of the “cholera forcing” narrative arises when extrapolation of an imagined Western past serves as the basis for present policy recommendations.
Hamlin, Christopher, 2009: “Cholera Forcing”. The Myth of the Good Epidemic and the Coming of Good Water, American Journal of Public Health 99(11), 1946-1954, doi: 10.2105/AJPH.2009.165688
Harris, Bernard & Jonas Helgertz, 2019: Urban Sanitation and the Decline of Mortality, The History of the Family 24(2), 207-226, doi: 10.1080/1081602X.2019.1605923
Kappner, Kalle, 2019: “Cholera Forcing” and the Urban Water Infrastructure: Lessons from Historical Berlin, EHES Working Paper 167
Konteh, Frederick Hassan, 2009: Urban Sanitation and Health in the Developing World: Reminiscing the Nineteenth Century Industrial Nations, Health & Place 15(1), 69-78, doi: 10.1016/j.healthplace.2008.02.003
McLeod, Kari S., 2000: Our Sense of Snow: The Myth of John Snow in Medical Geography, Social Science & Medicine 50(7-8), 923-935, doi: 10.1016/S0277-9536(99)00345-7