A water-borne illness induced by the bacterium Vibrio cholerae, cholera is now principally a disease of the indigent throughout the developing countries—a disease attributable to the lack of clean water and adequate sanitary infrastructure. Historically, however, cholera exhibited significant negative effects on prosperity and governance in the core states of Europe (particularly in regard to the evolution of health governance at the level of the state). It is thought to have caused the death of such philosophical and artistic luminaries as Hegel, Clausewitz,100 and Tchaikovsky.101 During the nineteenth century, cholera generated 130,000 deaths in the United Kingdom, while India lost approximately 25 million people to Vibrio.101 Significant problems in the analysis of the historic impact of cholera emanate from the mortality data, as many who perished would have not been registered as victims of cholera, owing to the stigmatization of dying a "dog's death."103 Further, until the German biologist Robert Koch identified the pathogen in 1884, there was no empirical means of accurate diagnosis. Thus, certain individuals who appeared to succumb to cholera may have in fact died of illnesses displaying similar symptoms (such as dysentery).104
The historian Richard Evans has argued that the novelty of the pathogen and its Eastern origins produced psychological trauma among afflicted European populations and undermined their assumptions of biological superiority. "All this," Evans writes, "made (cholera) into an object of peculiar terror and revulsion to the contemporary imagination, and further contributed to the shock effect it had on nineteenth-century society."105 As the pathogen proliferated throughout Europe, the disease was viewed by the lower classes as a deliberate attempt by malign elites to poison them, fulfilling the Malthusian dictates of a draconian form of population control. As cholera swept across France in 1832, the historian Francois Delaporte notes, "the poor all over Europe shared the same fears and identified the same enemy, for the simple reason that cholera struck the poor first. People could not understand how a disease that attacked only the lower classes could be anything but intentional."106 The uncertainty surrounding both the origins and vectors of transmission of cholera generated profound fear and anxiety, induced the perception and construction of elites as enemies, exacerbated mistrust between classes, and thereby augmented the potential for conflict between social factions. Such tensions often exploded into overt civil violence. Delaporte explains the "construction" of such a deliberate threat by the impassioned (and fearful) working class as a draconian solution to the problem of masses of poor, uneducated, and unproductive people.107 The psychological demonization of "the other," and consequent manifestations of social tensions in the form of inter-class violence, often bedeviled European societies. The historian Frank Snowden shares these conclusions. "As at Naples in 1884," he writes, "cholera epidemics gave rise in many countries to serious social tensions, leading to riots, mass flight, and assaults on doctors and officials."108
Evans characterizes cholera's march across Europe during the 1830s as "marked by a string of riots and disturbances in almost every country it affected. Riots, massacres and the destruction of property took place across Russia, swept through the Hapsburg Empire, broke out in Königsberg, Stettin and Memel in 1831 and spread to Britain the next year."109 Fear of contagion (and the poisoning hypothesis) led to pathos, to scapegoating of "the other," and to intra-state violence. According to Roderick McGrew, "the hysteria focused on particular scapegoats. The most popular villains were Polish agents and foreigners in general, though both physicians and government officials were also included. By midsummer a mass phobia had set in which affected the educated and the illiterate alike. . . . For the masses a spirit of evil had entered the land, and no one was immune. The poison scare played a part in the Petersburg cholera revolt, in the risings in the Novogorod military colonies, in the riots which occurred in Staraia Russia. . . ."110
Fearing massive disease-induced mortality and severe internal disruption, Czar Nicholas I adopted contagionist tactics, imposed a quarantine, and ordered that those infected be isolated. Such tactics failed to stem the spread of the pathogen and led to increasing social destabilization as the people reacted to the draconian measures of the state, with particularly serious riots in St. Petersburg in 1831.111
The British cholera epidemic of 1831 also incited riots, notably in Manchester. During the spring of that year, the public ascertained that the cadavers of cholera victims were being harvested by unscrupulous hospital authorities and sold to schools of anatomy. Furious citizens rose up in Manchester, among other cities, and demanded that their dead be treated with dignity.112 Such riots in Britain were chronicled by the historian Michael Durey, who counted thirty cholera-induced riots in the United Kingdom between February and November 1832.113 The appearance of cholera was also associated with the flight, or mass exodus, of citizens from affected regions, adding an additional dimension to the chaos that the illness generated. This phenomenon of contagion-induced refugees facilitated the expansion of the epidemic into naive populations.114
During this era, cholera infection also became associated with "immorality" (sex and drinking, specifically), providing the impetus for a legal crackdown by the state on such "unhealthy" habits.115 As cholera-induced mortality mounted in Britain, the elites decided that segregation of the poor into "union houses" (also known as poorhouses ) would be the most effective means of containing transmission. Parliament enacted the Poor Law Amendment Act of 1834, which entailed the creation of poorhouses based on parish. The conditions in these poorhouses were atrocious. According to Sheldon Watts, "the response of ordinary men and women was to dub the union poor-houses 'bastilles' and to keep clear of them. Within a generation, the idea that it was degrading, dishonorable, and depraved to allow oneself to be carted away to the poorhouse had become central to laboring people's system of values. The alternative—starvation or suicide at home—was seen as preferable."116 Thus, cholera worsened the social stratification of British society and intensified the antipathy of one class toward the other. And through the closure of markets and the stagnation of business, not to mention the debilitation and/or destruction of human capital, cholera was instrumental in eroding the economic prosperity of affected regions.117 After the international cholera control meetings held in Istanbul in 1866, trade was further constrained by London's imposition of exceptionally strict quarantine regulations on foreign vessels harboring infected persons.118 The extreme contagionist measures undermined citizens' perceptions of the legitimacy of state institutions and of certain elites associated with the state (namely physicians), and it promoted violence against ethnic groups who were seen as carriers.119 Thus, acute social tensions and manifestations of violence were rampant during the first waves of epidemic cholera to strike Europe. Advances in public health and biology (courtesy of John Snow and Robert Koch) reduced uncertainty about the nature and source of the pathogen and about its vectors of transmission, and thereby resulted in a corresponding decline in fear and violence.
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