“The medicalisation of life in the last hundred years is one of the most remarkable features of our post-historical world. Until the 20th century the role of clinical medicine in the improvement of health was minute. Whether populations grew or shrank had little to do with medicine, despite its best efforts. That changed utterly after 1945, and in not very well understood ways. But if medicine expanded almost beyond the bounds of imagination, the euphoria of the age of penicillin and the pill has turned, since the end of the Cold War, into dependence and anxious insecurity.”
THE PATHOLOGICAL GAZE AND THE BIRTH OF THE CLINIC
It was during the Enlightenment that the modern European state developed the capacity to administer its subject populations in growing depth and detail. Significantly, despots like Frederick of Prussia and the Habsburg Emperor Joseph II promoted rational administration to improve the hygiene and health of their people. Physicians became state functionaries. Frederick created a medical police to administer everyday life and states across Europe sought to control the movement of people seen as disease carriers. The last European plague outbreak occurred in Marseilles in 1720. A cordon sanitaire along the Habsburg border with the Ottoman empire halted its spread later in the century. Conversely, Muslim passive acceptance of the “great annihilation”, that accompanied endemic plague, hastened Ottoman decline.
Enlightenment rationalism, by contrast, achieved a major medical breakthrough in the 18th century first with inoculation and then Edward Jenner’s new vaccination against smallpox. Napoleon vaccinated his Grande Armée. This, however, failed to prevent typhus decimating its ranks during its retreat from Moscow (1812).
Rationalism, war and revolution encouraged a new scientific medicine undertaken by state-appointed physicians. Napoleonic France led the way. The Church lost its oversight of hospitals and public hospitals like the Hôtel-Dieu and Salpêtrière now served the nation. A new cadre of professional physicians like Xavier Bichat and René Laënnec pioneered the clinic, the medical gaze and a new attention to disease-centred medicine. Laënnec invented the stethoscope and developed a radical diagnostic insight into internal diseases like tuberculosis or consumption – the white plague.1 The new pathology considered death and disease the essence of medical enquiry. “Life”, wrote Bichat, was merely “the sum of all functions by which death is prevented.”2 The patient was “a thing” subjected to the clinician’s objective gaze. Clinical observation of disease and death preoccupied the Paris school. It influenced medical teaching across Europe.
As Roy Porter explains, “the pathological gaze penetrating the diseased body” and the new microscopy practiced later in the century in the laboratories run by Pasteur, Virchow and Robert Koch applied rigorous scientific method to the whole medical enterprise.3 In George Eliot’s Middlemarch, set in the 1830s, the ambitious, Paris-trained doctor, Tertius Lydgate, arrives in town advocating Bichat’s approach to diagnosis to sceptical locals. Elsewhere in the UK new teaching hospitals like University College and King’s College trained a generation of practitioners in scientific medicine. The Royal Colleges licensed them. Journals like The Lancet (1823) kept them informed. Eventually, the British Medical Association (1855) and General Medical Council (1858) standardised professional practice. There were 15,000 doctors in 1859 and six times that number a century later.
CHOLERAPHOBIA AND THE PUBLIC HEALTH STATE
Notwithstanding the expansion and standardisation of medical science and practice in the 19th century, the new profession had negligible impact, smallpox apart, on infectious diseases like tuberculosis, typhus, typhoid and, from the 1830s, cholera. The Industrial Revolution, first in England and then across Western Europe and the United States, not only generated wealth and a rapid growth in population, it also spawned industrial slums. A population explosion brought with it, as Thomas Malthus wrote in his Essay on Population (1796), the renewed threat of famine, pestilence and war. The more populous future, the parson prognosticated, promised successive subsistence and health crises.4
By the 1850s, the majority of the UK population lived in towns. Social novelists like Gaskell and Dickens described their filth, poverty and squalor. The dangerous and perishing classes that inhabited them became an object of concern not only for science but also for the developing administrative state, both as a political threat and as a source of infectious disease. Dickens’s description of the slum by Chancery Lane captures the amorphous character of the fear:
Jo lives – that is to say, Jo has not yet died – in a ruinous place known to the like of him by the name of Tom-All-Alone’s… There is not a drop of Tom’s corrupted blood but propagates infection and contagion somewhere… There is not an atom of Tom’s slime, not a cubic inch of any pestilential gas in which he lives, not one obscenity or degradation about him, not an ignorance, not a wickedness not a brutality of his committing, but shall work its retribution through every order of society up to the proudest of the proud and the highest of the high.5
Dickens accepted the prevailing scientific thinking of the time that infectious disease spread through environmental factors. Miasmas and pestilential gases emanating from the industrial slums bred the “putrid fevers”, typhoid, measles and mumps. Fevers colonised the new conurbations but also brought new and disturbing invaders like cholera. Endemic to the Indian sub-continent, cholera went global on the wings of British trade in the 19th century.6
It moved rapidly along the railways, which were the main arteries of the rapidly expanding commerce of the 19th century. As it arrived in the mushrooming towns and cities of a society in the throes of rapid urbanisation, it took advantage of overcrowded housing conditions, poor hygiene and insanitary water supplies with a vigour that suggested these conditions might almost have been designed for it.
Cholera might also have been designed to achieve maximum political as well as medical impact. There could be few more violent affronts to Victorian amour-propre than the grossly physical symptoms of a cholera attack. At a time when European high culture from the Pre-Raphaelites to Thomas Mann celebrated “the beautiful death”, with diseases like typhoid or tuberculosis, accorded a transforming influence on their victims whether it was the poet Keats or Mimi in La Bohème, cholera was an affliction that killed rapidly and with symptoms that could only be seen as degrading.7
The disease spread in a series of pandemics. The period 1826 to 1837 saw cholera sweep across Europe and North Africa and over the Atlantic to the eastern seaboard of North America. It returned in a series of waves of declining intensity in 1841– 1859, 1863–1875 and 1881–1896. When it reached the European continent, most regimes dusted off their files on bubonic plague and put traditional policing measures into operation: military cordons sanitaires, quarantine, fumigation, disinfection, isolation.
The resources at the state’s disposal were now more powerful than they had been a century before, and their impact on the population far greater. Moreover, decades of war, the impact of the French Revolution and the rise of radical democratic political movements had all left a mark on popular consciousness. During the first cholera pandemic, Prussian and Russian peasants attacked cordons sanitaires murdering those trying to set them up.8
Military cordons and the restriction of movement not only prevented people from escaping the scene of the epidemic, they also interfered with their livelihood: interrupting the flow of goods and produce to and from local markets. Above all they cut off or drastically reduced the supply of food and essential goods to urban populations. In Königsberg in East Prussia in July 1831, disturbances broke out after food prices rose dramatically following the imposition of a military cordon sanitaire.
Cholera crystallised the bitter scientific controversy about the origins of infectious disease. Radical anti-contagionists like Edwin Chadwick and James Kay Shuttleworth maintained that the decisive element in any epidemic outbreak was the local environment, not the presence of a causative agent which could be transmitted from one place to another. In England, a reform-minded, free trading radicalism facilitated the anti-contagionist perspective. It shared an affinity with “advanced”, physiological, accounts of disease processes. It also provided a means by which liberals could reject reactionary quarantine measures and other military or quasi-military interventions by European autocrats. Anti-contagionism in Britain assumed the characteristics of a social movement. By the time cholera arrived in Europe, anti-quarantinists were condemning quarantine as useless, a nuisance to trade, and obnoxious to growth.9
In its first phase cholera defined political extremes. On the one hand, Russia, Austria and Prussia imposed the strict quarantine practices (sealing borders, isolating travellers, sequestering the sick and seeking to break chains of transmission in the way traditionally employed against the plague). On the other, the new sanitationist approach in Britain and France adopted a less authoritarian sanitary approach to urban politics.
Cholera, a “revolutionary infection” swept across Europe again in the revolutionary year of 1848. The French political scientist André Siegfried even argued that epidemics and ideologies spread in the same way. Faced with cholera riots and the threat of revolution, most European states abandoned military cordons, quarantine and other policing measures. Fear of popular disturbances, rather than disease, played a major role in this change of heart.10
As early as 1831, the Prussian authorities conceded that military cordons caused economic difficulty. The fear of what cholera might do to trade increasingly affected state policy. In relaxing lockdowns, European authorities also gave way to pressure from merchants, traders and manufacturers. These in turn were not slow to raise the spectre of “the labouring classes” deprived of a living and driven to desperation. Where mercantile interests were paramount, the state withdrew almost entirely from the fight against cholera.
19th-century radical social reformers, in particular, recognised that the state required effective public health measures, but not the crude recourse to quarantines and trade-disrupting cordons. Disease defined the modern liberal approach to public health and sanitation. Utilitarians like Edwin Chadwick and Southwood Smith, who drove government thinking on urban policy during the 1840s, assumed sickness bred in poverty. Drains, cesspools, refuse and slaughter-houses arose independently of the intemperate habits of the poor. They were public matters that could be targeted for political action. From the sanitationist perspective epidemic disease was the product of dirt and decomposing matter. It was concentrated in towns and especially in their least sanitary districts. In London in 1849 and 1853–1854, cholera mortality rates in the poor districts of Bermondsey and Rotherhithe were between six and twelve times as high as they were in wealthier areas such as Kensington and Westminster.
It could be remedied, utilitarians argued, by public health policy and civil engineering. The new Poor Law combined with public health and education provoked Kay Shuttleworth’s recommendations for improving The Moral and Physical Condition of the Working Class (1832). The social cost of ill health converted Chadwick to “the sanitary idea” and the creation of a central public health authority directing local boards of health in the provision of drains, drinking water and sanitary regulation. Chadwick’s report on the sanitary condition of the labouring population of Great Britain in 1842 led to the first British public health act (1848). In other words, the new sanitary ideas, associated with anti-contagionism, produced an effective programme for government action.11
In Germany, two decades later, Virchow, following English utility, claimed that epidemics were symptoms of a general malaise. The answer was “political medicine”, the improvement of social conditions. Only democracy, the leading German pathologist argued, could prevent epidemics.12
Interestingly, utilitarian public health advocates rejected the findings of early epidemiologists and statisticians like John Snow and William Farr. In 1854, Snow had traced an outbreak of cholera in Soho to a water pump in Broad Street. He argued in evidence given to a House of Commons select committee that cholera was a waterborne contagion and not a local environmental miasma. Parliament rejected his modelling. In an 1858 report to the General Board of Health, the architect of the UK’s public health system, Sir John Simon, dismissed Snow’s “peculiar doctrine as to the contagiousness of cholera. […] Dr Snow’s illustrations are very far from proving his doctrine: but they are valuable evidence of the danger of drinking faecal water.”13
Thus the new sanitary infrastructure that improved the living and working conditions of London and the industrial towns was a triumph of civil engineering, not epidemiological modelling. By the 1870s the UK had developed a comprehensive regulatory infrastructure overseeing public health and infectious disease. Ironically, the utility-influenced governments of Peel and later Gladstone got the right public health outcome for the economy for the wrong scientific reasons.
Sanitationist views also prevailed in the first attempts to organise an international response to the cholera pandemics. Cholera was an international problem in an era of global trade. The disease travelled at speed along the new networks of communication without respecting borders. Yet, what governments found particularly irksome were quarantines and cordons and their “often disastrous hindrances to international commerce”. It was this concern that prompted European governments to meet to discuss “to what extent these onerous restrictions could be lifted without undue risk to the health of their populations”.14 If cholera and its prevention were international concerns, they required an international solution.15 The first International Sanitary Conference convened in Paris in 1851. Fourteen international conferences were held before 1938 and they formed the background to the formation of the World Health Organisation in 1945 and its remit to assess infectious disease and declare pandemic threats.
It was only at the seventh conference in 1885 that a scientific consensus emerged. In 1884, Robert Koch had identified and isolated the distinctive cholera comma-bacillus. Withdrawal of the state from the medical policing of epidemics that characterised the half-century after the arrival of cholera on the European continent ended with the rise of bacteriology and the discovery, by Koch in Berlin and Louis Pasteur in France, of the microorganisms that spread infectious disease. Under Koch’s influence, European governments, drawing on previous administrative practice but now acting under medical instruction, instituted massive preventive campaigns of quarantine, disinfection and the isolation of victims. Resistance to the new interventionism, like that offered in Hamburg before the cholera epidemic of 1892, was swept aside. The creation of professional police forces in the aftermath of the 1848 revolutions, the general process of centralisation that had taken place over the 19th century, the growth of rapid communications in the form of railway networks, and the general increase in the resources available to the European state, meant that such measures were infinitely more effective in the 1890s than they had been sixty years earlier.
MODERNITY, THE MICROBE AND THE MEDICALISATION OF LIFE
In 1880, the Liberal MP and scientist Lyon Playfair predicted that society would in time “become a well-behaved patient and public health a great field open to growing medical men”.16 The 20th century witnessed its ambiguous realisation.
The bacteriological revolution pioneered in the laboratories of Pasteur and Koch that isolated the anthrax, rabies, smallpox, cholera, tuberculosis and, in 1894, the plague bacilli announced a new era of scientific progress and the potential for the medical control of infectious disease. It endowed medical science with a new authority, access to government funding and bequests from charities like the Rockefeller Foundation or the Wellcome Trust. Prestigious research institutes like the Pasteur Institute in France, the Robert Koch Institute in Germany, The Imperial College of Science and Technology in London and Johns Hopkins University in Philadelphia developed, refined and applied scientific laboratory findings. By the early 20th century scientists had isolated the polio and mumps viruses, although the virus, which the Nobel prize winner, Peter Medawar, described as “a strip of nucleic acid surrounded by bad news” remained somewhat elusive.
Meanwhile, the pharmacological revolution that Alexander Fleming’s discovery of penicillin announced, and the subsequent mass manufacture of antibiotics by drug companies after 1945, seemed to presage the end of infection. By the 1950s, medicine’s triumph over infectious disease was increasingly taken for granted. The Conquest series of UK medical texts included titles like The Conquest of Tuberculosis, The Conquest of Disease and even The Conquest of the Unknown. In the century from Koch to mass-produced antibiotics one of the ancient dreams of medicine had come true. Reliable knowledge of what caused epidemics facilitated their prevention and cure. In the general euphoria some hard truths about the evolution of parasitic microorganisms, viruses and their human hosts were too easily forgotten. In retrospect, the period between Pasteur and Fleming may one day be nostalgically recalled as an anomalous exception in medicine’s Sisyphean labour to stave off microbial holokauszt.17
After 1945 WHO programmes of disease eradication reinforced the authority of science and the medicalisation of life. Modern democracies assumed the health and welfare of the people integral to the post-war social contract. Health was an incontrovertible good that appealed across the electorate. After 1945, the National Health Service provided universal health care for all UK citizens. Developing and developed states embraced various forms of health care insurance. Medical health became central to the new therapeutic bureaucracies that managed their populations in depth and detail.
By the 1980s, however, the medical establishment had evolved into an unwieldy leviathan comparable to the similarly sclerotic civil service. Medical power lies in the hands of Nobel prize winning researchers, presidents of prestigious medical schools and the boards of multi-billion dollar hospital conglomerates and pharmaceutical companies. In many states, health became the largest single employer, incompletely incorporated into the public domain. The politics of medicine became a governmental priority. As a result of what Sir William Osler in 1900 termed its “singular beneficence”, health care claimed a privileged autonomy. Yet its anxious protection of its status concealed its dependence as an institution on the market and the state for its funding.
This medical leviathan, over time, eroded the autonomy of the individual. With the birth of the clinic, scientific medicine first reduced the sick person to a patient, a pathological body beset with disease. This disappearing act of the autonomous self continued over the next two centuries, reducing the patient, in the process, to an element in equations dominated by economics, diagnostic technology, systems analysis, epidemiological modelling and, most recently, the elusive R factor.
An emerging medical totalitarianism intervened in all branches of life. A growing preoccupation with chronic disease meant physicians increasingly exercised a new ability to prolong life. The good death, the ars moriendi as a stage in the life process, yielded to a new medical technocracy. The health professional could render the infertile fertile, prevent pregnancy, abort life and revive the dead.
The medicalisation of life in the last hundred years is one of the most remarkable features of our post-historical world. Until the 20th century the role of clinical medicine in the improvement of health was minute. Whether populations grew or shrank had little to do with medicine, despite its best efforts. That changed utterly after 1945, and in not very well understood ways. But if medicine expanded almost beyond the bounds of imagination, the euphoria of the age of penicillin and the pill has turned, since the end of the Cold War, into dependence and anxious insecurity. The medicalisation of life has transformed society and rendered it iatrogenic. Despite being healthier and living longer, there is, as Roy Porter wrote in 1997, “a pervasive sense that our well-being is imperilled by threats from the air we breathe to the food in the shops”.18 In a media addicted to scaremongering, today’s headlines are more likely to be about a new cholera epidemic or an unknown virus emerging from a Chinese wet market.19 The age of infectious disease has given way to the era of chronic disorder. Longer life means more time to be ill or vegetate in a care home and medicine is more open to criticism. National Health has become a hollow achievement.
Medical self-confidence, moreover, has been increasingly shaken by the mysteries of virology. Influenza pandemics like the one that swept the world with unsurpassed virulence between 1918 and 1920 have proved difficult to anticipate or contain in an era of hyper globalisation. Since the 1980s infectious diseases from AIDS to Ebola, SARS and now the Coronavirus have shaken faith in scientific omniscience, yet they are what a Darwinian and Malthusian struggle for survival in a world of parasites looking for hosts would anticipate.
Medicine has conquered numerous ailments and provided relief from suffering for many but its mandate, as the current medical and government response to the Coronavirus demonstrates, has become confused. Is its primary duty and that of the medical surveillance state to keep people alive whatever the circumstances and cost? In Gulliver’s Travels (1725) Jonathan Swift satirised the folly of pursuing immortality depicting the misery of the demented Struldbrugs of Luggnagg who never die but age remorselessly. Modern medical science governments and the Big Tech companies that treat death as the last disease are addicted to the power of life. They might benefit from reading Swift. Pradoxically, the healthier a society becomes, the more it craves medical treatment. The patient/consumer regards it as both a right and a duty. The root of the problem is structural. It is endemic to a system in which an ever-expanding health establishment is driven to medicalise normal events like menopause or death, or a low-mortality pandemic, converting risk into disease. Boris Johnson captured the folly of our iatrogenic polity when he informed a locked-down people that the government’s decision to end the ruinous quarantine “will be driven not by mere hope or by economic necessity. We are going to be driven by the science, the data and public health.”20 The medical model of the state has reached a new contagionist apotheosis that 19th-century liberal sanitationists would deplore for its economic illiteracy, social damage and political danger. A correspondent of Adam Smith after the British defeat at the Battle of Saratoga wrote: “If we go on at this rate, the nation must be ruined.” Smith answered: “Be assured, my young friend, that there is a great deal of ruin in a nation.” Smith however would not be reassured by the recent conduct of either the British or European governments and their addiction to a dangerous valetudinarianism.21
1 Outlined in his Essais sur les médecines et les lésions organiques du cœur et des gros vaisseaux (1806), Laënnec succumbed to the disease shortly after.
2 Roy Porter, The Greatest Benefit of Mankind. A Medical History of Humanity from Antiquity to the Present. London, 1997, p. 306.
3 Ibid., p. 341.
4 Thomas Malthus, An Essay on the Principle of Population; or a view of its past and present effects on Human Happiness with an inquiry into our prospects respecting future removal or mitigation of the evils which it occasions. London (6th edition), 1826. https://oll.libertyfund.org/titles/malthus-an-essay-on-the-principle-of-population-vol-1-1826-6th-ed.
5 Charles Dickens, Bleak House. London, 1853.
6 Richard J. Evans, “Epidemics and Revolutions: cholera in nineteenth-century Europe”. In Ranger & Slack (eds.), Epidemics and Ideas, p. 151.
7 Ibid., pp. 151–153.
8 Ibid., p. 163. See also Peter Baldwin, Contagion and the State in Europe 1830–1930. Cambridge, 2004, Chapters 2 and 3; and Frank M. Snowden, Epidemics and Society: From the Black Death to the Present, Yale, 2013, especially Chapter 13.
9 John V. Pickstone, “Dearth, Dirt and Fever Epidemics; rewriting the history of British Public Health 1780–1850”. In Ranger and Slack (eds.), Epidemics and Ideas, p. 146. See also Erwin H. Ackerknecht, Medicine and Ethnology. Selected Essays. Baltimore, 1971.
10 See Evans, op. cit., pp. 162–164.
11 See Pickstone, op. cit., p. 148.
12 Porter, History of Medicine, p. 616.
13 Norman Howard Jones, The Scientific Background of the International Sanitary Conferences 1851–1938. WHO, 1975, p. 15. See also W. F. Bynum, “Policing Hearts of Darkness: Aspects of the International Sanitary Conferences”. History and Philosophy of the Life Sciences, 15, 3 (1993), pp. 421–434.
14 Norman Howard Jones, The Scientific Background of the International Sanitary Conferences 1851–1938. WHO, 1975, p. 17.
15 V. Huber, “The Unification of the Globe by Disease? The International Sanitary Conferences on Cholera 1851–1894”. The Historical Journal, 49:2 (2006), p. 457.
16 Porter, op.cit., p. 416.
17 Ibid., p. 461.
18 Ibid., p. 3.
19 As Porter puts it with a slight edit in his prescient introduction to The History of Medicine, p. 3.
21 Sir John Sinclair, The Correspondence of Sir John Sinclair. Vol. 1. London, 1831, p. 391.