Prof: This morning we'll
take up one of the themes--
that is to say,
we've described how the course
is about specific diseases,
but it's also about a number of
overarching themes,
and one of those is the
development of various public
health strategies.
So far, as you'll remember,
we've dealt with three public
health strategies.
 
One was the system of plague
measures: sanitary cordons,
lazarettos, quarantine,
and all the rest of it.
We've dealt with vaccination as
a public health strategy,
with regard to smallpox in
particular.
And we've talked about a third
policy, if we want to dignify it
in that way, and this was the
strategy of concealment.
This morning I want to talk
about a fourth approach to
public health,
and this was what's called
commonly the sanitary movement.
 
This was pioneered in Britain
in the 1830s and '40s,
and it was then exported to the
continent in North America,
assuming particular forms in
France and Italy,
with the actual rebuilding of
cities in accord with sanitary
principles.
 
Now, the sanitary movement was
the first to define itself as a
public health movement,
and it had two essential
meanings for its term.
 
The first was the prevention of
infectious epidemic diseases,
and the second was the removal
of filth.
So, it's based,
in a sense, on the relationship
of filth and disease.
 
Indeed, many people talk about
the filth theory of disease as
lying at the basis of the
sanitary movement.
Its focus, therefore,
was on the towns and cities
that had sprung up with
urbanization and the industrial
revolution.
 
Epidemic diseases
disproportionately claimed their
victims in the cities,
and correspondingly the legacy
of lasting effects was
especially pronounced in urban
areas,
and the sanitary movement is
one of those lasting legacies.
 
Now, there is a theory that we
may as well look at,
just for a second,
developed by the British
physician and demographer,
Thomas McKeown--and it's often
called his thesis--
where he was dealing with the
demographic fact of what he
called a mortality revolution;
a demographic transition in
which cities,
for the first time,
become places that are
dependent for their expansion
not only on inward migration to
the towns,
but on the fact that the
longevity and the birthrate come
to exceed the death rate;
which was something new,
a real demographic revolution.
And why was this achieved?
 
Many people have thought and
postulated that it was due to
medical science,
to conscious policy and those
sorts of explanations.
 
McKeown instead stresses two
factors.
He sees this as largely
unplanned and due to improved
nutrition, but also--and that's
the point this morning--to the
role of sanitation.
 
In other words,
the population explosion,
the demographic revolution,
is something that he postulates
was due to,
not to medical science,
but rather to the sanitary
movement,
and also to nutrition.
 
Well, what was the background
to the sanitary movement?
We've seen and mentioned that
there really was a tremendous
challenge to health in this
period of the industrial
revolution in European history.
 
There were tremendous changes
afoot in British society.
There was the rise of a modern
commercial agriculture,
and with it enclosure,
the driving of peasants off the
land.
 
We know about the major
demographic growth that was
underway by this period,
supported by the new
agriculture and the fading of
the threat of famine and the
fading of the threat of plague.
 
There was the rise of
manufacture,
and then the factory system,
especially the textile
industry,
and the associated and
unregulated horrors of things
such as long hours,
low wages, child labor.
 
You know, too,
that across Europe,
urban populations doubled in
the first half of the nineteenth
century,
and in so doing overwhelmed the
infrastructure of available
jobs,
the housing stock,
sanitary arrangements,
and all the rest,
so that we see the rise of
tenement slums,
sweatshops.
There was a mass movement of
population from countryside to
town, and with that went
psychological adjustments.
There was a breakdown of older
notions of social relations
based on paternalism,
of the customary notion of a
moral economy based on moral
obligation.
And we see instead the rise of
the principles of impersonal
relations,
of a free-market economy,
and laissez-faire,
epitomized in the new
discipline of political economy,
with such figures,
of course, as Adam Smith,
Ricardo, Jeremy Bentham,
Thomas Malthus.
 
The result, along with those
transformations,
was a rise of new social
tensions.
We've talked about the
nineteenth century as the
rebellious century.
 
Now, in Britain,
there were no social and
political revolutions,
nothing comparable to 1789 in
France,
or to what happened on the
continent in 1830,
and in 1848 and '49.
But contemporaries weren't
certain at all that this was
going to be a lasting fortune
for Britain,
and indeed Britain did have a
number of signs of severe social
tension as well.
 
There were large-scale riots.
 
One could mention the Chartist
Movement, and in the countryside
the movement known as Captain
Swing.
So, urban and industrial
centers, also in Britain,
were perceived as dangerous,
politically,
for fear of the so-called
dangerous classes who rioted,
perhaps committed crime,
threatened revolution,
and were dangerous medically,
as well;
that is, they were infected
with cholera and other diseases.
And it was cholera in
particular that was a real prod
to action, this new and most
feared disease of the nineteenth
century.
 
It's not by chance,
then, that the sanitary
movement begins in the 1830s and
'40s in Britain,
after, that is to say,
the first pandemic and the
second of Asiatic cholera.
 
And it lasts intermittently
down through the First World
War.
 
And this really was a vast
movement.
It was nothing less than the
retrofitting of the urban
centers of the nation,
with the specific goal of
removing filth,
because filth was held to be
the cause of disease.
 
So, we're talking about one of
the great public works projects
of modern history:
the establishment of sewer
systems,
a whole infrastructure of water
mains,
of waste removal,
street cleansing,
improved and less crowded
housing, the creation of parks
and public spaces.
We can see that Victorian
Britain truly was preoccupied
with that combination of
excrement and water.
All of this,
of course, presupposed as well
the emergence of a modern state.
 
It was state power that alone
provided the wealth and
organizational structures that
were needed to carry out this
enormous project.
 
And in turn we can see the
causal chain working in both
ways, because the sanitary
movement was a very important
factor in reinforcing state
power.
Its implementation meant that
the state now invaded areas of
life formerly regarded as
private, and appropriated for
itself enormous new powers.
 
And the reformers were
supported by Protestant and
especially evangelical Christian
churches.
Well, who were the leaders of
this movement?
I think we should turn first of
all to this man,
Sir Edwin Chadwick.
 
This is Edwin,
Sir Edwin, in his younger days.
This may be a slightly more
familiar picture of him,
I guess maybe at my age.
 
In any case,
Sir Edwin wrote a major work
collaboratively--
he produced it,
let us say--which was called
"The Report on the Sanitary
Condition of the Labouring
Population of Great Britain of
1842."
 
Now, Chadwick wasn't a
physician at all,
and this is part of the
background perhaps to the thesis
I was mentioning earlier.
 
He was instead a lawyer by
training from Manchester.
And he was already well known,
in particular for his reform of
welfare provisions in Britain;
that is, he was responsible in
large part,
for the passage,
from the old poor law,
which had provided relief as
the birthright of every citizen
in distress;
that is, the right to some form
of assistance or aid in time of
distress.
 
Chadwick's idea was to
economize, to minimize the cost
of payments, to discourage the
poor from applying for relief.
He wanted to make the
experience of receiving relief
more painful than the experience
of distress itself,
a principle that was dubbed
"the principle of least
eligibility."
 
The workhouse,
in other words,
was to be a place of
punishment, of pain and of
suffering.
 
So, work should be,
in the workhouse,
more unpleasant than any to be
found in the labor market.
And the diet should be
intentionally made to be
loathsome, more so than what
could be found by the poor
outside.
 
The poor law bureaucracy was
also invoked,
and was an essential foundation
of the information on which
Chadwick relied for the sanitary
report of the laboring
population of Great Britain.
 
This was the man who was the
same in both faces,
with the new poor law and with
the sanitary report.
The sanitary reform was also a
stark assertion of state power
as a means of social control.
 
The intention was to discipline
and civilize the working classes
in the interests of social
stability.
Following in the wake of the
report was the establishment of
a Public Health Act of 1848 in
Britain,
and a general Board of Health,
and such champions of sanitary
reform as John Simon,
Thomas Southwood Smith and Neil
Arnott.
 
Now, let's talk for a minute
about this man's ideology and
his intentions.
 
This was a class-based movement.
 
It was top-down and
centralizing.
In Chadwick's mind,
the poor were largely
responsible for their own
plight.
They weren't innocent,
and they certainly weren't
harmless.
 
His mission was to cleanse and
civilize the dangerous classes.
As I said, he wasn't a
physician, and his reforms were
not based on any new medical
discoveries,
on scientific experimentation
or observation to determine what
measures were most effective by
determining the causes of
disease.
 
His reform measures,
enormous as they were,
were based more on what was the
commonsense of the period and a
priori assumptions.
 
Public health,
in this way,
was separate from the
development of medical science.
His view--and this was widely
accepted--was that medicine was
about private persons,
not so much public policy.
And his idea was to use public
policy to cleanse the urban
environment, but not to deal
with other social and economic
determinants of disease.
 
We'll talk about that in a
moment.
We need to think about not only
about what Chadwick wanted to
do,
but we also need to think about
what he decided not to do,
what wasn't important to him.
And so we should see this as
progress, yes,
but progress that came at a
cost, and we want to know about
that as well.
 
Now, an influence on Chadwick's
thinking was "The Essay on
Population"
of Thomas Malthus,
who believed that there was a
law that in every society
population pressure sooner or
later pressed against the limits
of subsistence.
 
So, real improvement for the
poor was likely to be illusory,
short-term, and perhaps
counter-productive.
In the long run,
really significant improvement
couldn't occur,
according to Malthus.
It might even be
self-defeating,
leading to disease,
starvation and war,
those great positive checks on
population increase.
That idea of the limited nature
of possible improvement was in
Chadwick's mind;
the poor will always be with us.
There was also,
as I said, the filth theory of
disease.
 
We know it.
 
We've talked about miasma and
its long history in European
thought.
 
Well, filth now was associated
very closely with smell.
And if you are to read the
report at some point,
you would notice that smells
constitute an important part of
the report.
 
The report is filled with
descriptions of stench.
The authorities consulted by
Chadwick frequently used phrases
such as,
"I was assailed by a most
disagreeable smell,
and it was clear to me that the
air was full of most injurious
malaria."
By malaria, that's another word
that occurs throughout the
report.
 
And we should note that before
malaria came to mean a specific
disease,
it meant "bad air,"
from the Italian mal'
aria,
bad air.
 
And, so, this report,
in Britain in the 1840s,
is filled with descriptions of
what they called malaria.
Let me give you an example from
the town in the West Country of
Truro.
 
Reporting to Chadwick,
the reporting official said,
"Passing into St.
 
Mary's Parish,
the proportion of sickness and
deaths is as great as any part
of Truro.
But there's no mystery at all
in the causation.
Ill-constructed houses with
decomposing refuse,
clothes upon their doors and
windows,
open drains,
bring the oozings of pigsties
and filth to stagnate at the
foot of the walls.
Such are a few of the sources
of disease, which even the
breezes from the hills cannot
dissipate."
Everywhere the reports
discovered disease,
and they correlated the disease
with such findings as poisonous
vapor,
morbific effluvia,
filth, obnoxious effluvia,
poisonous exhalations,
miasma and malaria.
 
The moral of the texts of those
conditions also preoccupied
those who took part in the
report.
Vice, alcohol,
intemperance,
and then more poverty,
and still worse,
more filth.
 
Poverty was partly the result
of depravity and improvidence,
and those in turn reinforced
more poverty and more filth.
Well, there was a political aim
behind the sanitary reform,
and I think we might call this
a transformation that Chadwick
was aiming at in the demographic
composition of the British
population.
 
In Chadwick's mind,
trade unions,
which he abhorred,
demonstrations,
strikes, the Chartist Movement,
and all the rest,
were called by Chadwick
"wild and dangerous
assemblages."
 
But he noted that they were
mainly led by the young.
Older, experienced workmen,
with family responsibilities,
he found to be moderate and
temperate, and not to take part
in strikes and social unrest.
 
Therefore a high early death
rate,
and poor sanitary conditions,
were actually politically
destabilizing,
at least in his mind,
because they led to the early
death of workmen,
and hence to an
overrepresentation of the
dangerous young,
and an under-representation of
moderating older workmen.
 
If we want to understand and
explain this view,
perhaps we could invoke an
anachronism, to make an analogy.
And we could use the analogy of
a nuclear reactor,
and compare social unrest to a
meltdown of the reactor core,
with disastrous consequences.
 
Well, in terms of the reactor,
to prevent such events reactors
make use,
as you know,
of boron control rods that are
inserted to control the rate of
fission of uranium and
plutonium,
and to limit chain reactions.
 
In this way,
what Chadwick wanted to do,
by analogy, was to use older
people like control rods that
would have the calming effect of
preventing social meltdown and
social revolution.
 
But to do that you had to do
something about infectious
diseases, to achieve this
demographic transformation of
the population.
 
So, if infectious disease was
destabilizing for the state and
political order,
a population subject to
infectious disease moreover is
unlikely to be educated and to
be open to the moral influence
of the clergy.
And the absence of cleansing in
towns, Chadwick felt,
would lead also to
demoralization and further
depravity.
 
Now, in all of this thinking,
let's remember too at what was
lost.
 
A striking feature of
Chadwick's view was the
narrowness of its focus.
 
The cause of ill health in
Victorian Britain--
I think we should say not the
cause--
the causes were undoubtedly
multiple,
and one could think about low
wages,
unregulated factories,
inadequate diet,
poor clothing,
lack of education,
working conditions in
sweatshops,
mines and factories,
child labor,
overcrowded housing.
 
These I would call social and
economic determinants of
disease.
 
And there were voices,
particularly on the continent,
for an alternative public
health that would address
precisely such broad interests.
 
There was an older tradition of
what was called a "medical
police" on the continent,
and a current of thought of
what was called "social
medicine",
whose most prominent figure was
this man,
Rudolph Virchow,
a Prussian physician who lived
from 1821 to 1902,
and was one of the great
figures of nineteenth century
medicine;
a physician,
anthropologist,
biologist and radical
politician.
Now, his view was that disease
was not simply a biological
event, but a socially driven
phenomenon.
And his meaning of the term
"social medicine"
was that physicians should
treat not just individual
patients but entire societies,
and that they should pay great
attention to matters of the
economy,
to diet, wages,
housing, child labor,
working conditions.
 
Virchow was,
in a sense, the anti-Chadwick.
Chadwick's intention instead
was to focus on the narrow issue
of filth and water,
and his attention was confined
to the working classes and the
filth in which they lived.
At stake was the issue of how
broad should a public health
movement be?
 
And perhaps one could say that
one of the sad features of the
period was the triumph of the
narrowest gauge vision of public
health.
 
The solution,
in Chadwick's hands--and this
was a major event in public
health, there's no doubt about
it.
 
I'm trying to say--not that
this was unfortunate--it was
only unfortunately narrow.
 
Chadwick's solution involved
technological measures,
all good in themselves:
drains, sewers,
water pipes.
 
But they didn't include social,
economic and educational
reform.
 
And the reforms all came from
above,
and reinforced a centralizing
state,
rather than finding ways to
empower ordinary people to
participate in defending their
own health.
Let me give you an example of a
simple technological
improvement.
 
It might be hard to recognize
when you first look at it but--
and I'm talking about some very
humble movements that have
enormous political and medical
consequences.
What we're looking at is a
sewer main,
and these were established
under the soil of cities in this
period,
and one of the technological
inventions was to make the
sewers egg shaped,
so that you would maximize the
flow and they would be
self-cleaning and they would
drain most efficiently.
So, technological innovations
of that sort were part of it.
Now, the victory of Chadwick's
vision of public health wasn't
simply automatic,
and so it was worth to keep
alternatives in mind.
 
His side was the winning side
in a debate of the early
nineteenth century,
and a wider view,
like that of Virchow,
was present,
but lost the debate.
 
Let's be clear in summation.
 
I'd argue that Chadwick's
vision of public health was
highly successful,
that it was a crucial part of
the mortality revolution of
nineteenth century Europe,
but that at the same time
something was lost,
a broad vision of the causes of
disease,
and those causes weren't
addressed.
Although what Chadwick achieved
was a major and positive
advance,
it perhaps fell short of what
might have been,
and it demonstrates the
practical and positive impact of
miasmatic theory.
And public health,
a theory--and this is perhaps
something we ought to bear in
mind--
that a theory that is by now
rejected--
that is miasmatism,
the filth theory of disease--
did operate in such a way as to
promote major and positive
health results.
 
And one of the causes of this
movement was the epidemic
disease that we dealt with the
last couple of times,
and that is Asiatic cholera.
 
We might note there was a
sidelight that may be of
interest as well;
that this sanitary movement,
the literal sanitary movement,
was accompanied in some places
by what we might call a
figurative sanitary movement,
and that is moral sanitation.
 
And one of those was
particularly notable in France
where there was a great fear of
another disease,
that we'll be talking about
slightly later in the course,
and that is syphilis.
 
Remember, the early nineteenth
century, we're dealing with the
period in the wake of the
Napoleonic wars.
And with those wars,
as always happens--or
happened--there was a major
upsurge in socially transmitted
diseases, and in particular
syphilis.
And so this sanitary movement
was accompanied by the movement
for moral sanitation through the
registration and surveillance of
prostitutes.
 
And in France those responsible
for moral sanitation actually
made the link explicit;
that is to say that they
compared brothels with sewers,
and said that they,
the brothels,
should become the target of
sanitation.
 
So this was a form of moral
sanitation that was an offshoot
of the literal sanitary movement
that is our main theme.
The sanitary worldview led also
on the continent to further
offshoots,
and that--I want to talk now
about a continental form of the
sanitary movement,
the rebuilding of cities in
their entirety.
This was actually much more
comprehensive and systematic.
It means urban planning.
 
It's more comprehensive than
what happened in Britain,
which was the retrofitting of
cities with sewers and drains
and sanitary provisions.
 
It entailed the actual leveling
of whole cities,
or neighborhoods within them,
to start afresh,
in accordance with a
comprehensive plan.
There were a number of
prototypes.
In France, Paris,
Lyon and Marseilles.
In Belgium, Brussels.
 
In Naples--that is in Italy,
there was Naples,
as you know,
but also Florence,
La Spezia, and other places.
 
But let's begin in Paris,
because that established the
pattern.
 
Here again we see the influence
of epidemic cholera,
which ravaged Paris in the
1830s and again in 1849.
And this caused an enormous
psychological shock,
the idea that civilization was
no sure-fire protection against
sudden and agonizing disease.
 
There was an unbearable
contradiction that a city,
that is Paris,
that prided itself at being at
the heart of European
intellectual life,
at being the leading city in
the arts and culture,
a world center,
as you now know,
of scientific medicine,
could nevertheless be
devastated by a disease that was
associated with poverty,
with filth, and with the
colonial world.
Well, after the revolutions of
1848 to '49,
we have a reactionary and
authoritarian regime established
by Louis Napoleon Bonaparte,
or Napoleon III,
that soon became the Second
Empire,
that lasted from 1851 'til 1870.
 
There's Napoleon III.
 
He undertook a major movement
to rebuild Paris.
And I want to argue that this
had enormous sanitary
consequences,
intentionally so,
and that the experience of
epidemic cholera was very
important in the establishment
of that.
But I don't want to say that
the rebuilding of Paris was
solely designed as a health
measure, and solely to prevent
the return of cholera.
 
There were other gains as well.
 
Napoleon III wanted imperial
splendor.
He wanted a city that would be
worthy of the role of France in
the world, that would be a
showcase for his new political
regime.
 
He too was thinking about
social control.
So, there was a political aim;
that was, to destroy the
working class slums that had
been the sites of rebellion.
The idea was to use urban
renewal to remove workers from
the center of the city to
distant suburbs,
and in the center to construct
wide boulevards that could not
be defended by barricades,
and that the troops could use
to move quickly across the
cities,
and cannonballs could fire down
the boulevards to demolish
barricades.
 
In other words,
Paris was to be made
revolution-proof,
or at least that was the goal.
It was also a project of public
works;
that is, it was a means of
enormous patronage.
It would provide employment and
would defuse social tensions as
well.
 
So, Paris, under Napoleon III,
became a vast public works
project, enormous shovel-ready
projects.
The workers of Paris then would
be employed and therefore
largely pacified.
 
It was thought that this would
also have an economic role.
The new boulevards,
the wide spaces,
would facilitate the movement
of goods and assist free trade
and commerce.
 
And then there was the public
health objective:
to improve health,
to prevent the return of
infectious epidemics.
 
The task was entrusted to this
man, Georges Haussmann,
the Prefect of the Seine.
 
And often what was accomplished
is referred to as the
"Haussmannization"
of Paris,
with the so-called great works,
or grands travaux,
that were undertaken from 1852
until 1870.
Now, this project was
authoritarian.
The rights of individuals were
disregarded.
The population was not
consulted about being moved,
and it was an operation of
colossal complexity.
All of the affairs of one of
the greatest cities in France,
the great city in France,
were gathered into a single
pair of hands:
finance,
administration,
transport, sanitation,
engineering,
architecture,
evictions,
expropriation of land by
eminent domain,
slum clearance,
gas fixtures and lighting,
sewers.
All of this was an enormous
assertion, then,
of state power.
 
The means were broad
intersecting boulevards.
Let me show you the sorts of
plans--
were to have the great
boulevards of Paris,
that you can see today--such as
the Rue de Rivoli,
Boulevard de Strasbourg,
S�bastopol,
the Boulevard Saint-Michel.
 
The average size width of a
street in Paris was to be
doubled, and underneath the
streets there were to be sewers
and drains.
 
There was to be water supply,
and there were to be broad
parks and public spaces,
such as the Bois de Boulogne.
The aesthetics were the
aesthetics of the straight line.
We can see that there.
 
We can see it also here.
 
And you can see the
intersection of these broad
boulevards,
and you can see how these were
multi-purpose and would allow
not only--
part of the idea was the
miasmatic one,
that they would allow air and
light to sweep through the city
and remove the noxious smells,
and purify and cleanse the city.
And you can see as well that
they would be good for commerce
and for social control.
 
So, Paris, after Haussmann,
was clearly much healthier as a
city than before,
and cholera did not return
thereafter to the city center.
 
But there is an irony here,
that cholera did return,
less vehemently than before.
 
But in the 1890s it did return,
but not to the center of the
city.
 
In other words,
part of the sanitary problem of
Paris was not entirely solved,
but was exported to the
suburbs, and it was the suburbs
that experienced the return of
cholera in 1892.
 
We have to see this as an
enormous sanitary success,
but one that we ought to
qualify.
Let me look at--let's
look--this is a map--a picture
of the demolition,
to convince you of what a major
undertaking this was.
 
And there's a view of the new
open spaces, cleansed with light
and air, and germ free.
 
And also in Napoleon III's
mind, it would be also--make
revolution much more difficult.
 
Well there was--the political
success, as well as the
sanitary--was a success but one
that needs to be qualified.
There was an enormous
resentment among the working
people of Paris at Haussmann's
project,
and there was an enormous
history from that time down to
nearly our own of hostility of
the suburbs.
Paris becomes,
not by chance,
surrounded by a red belt of
concluding hostility to the
regime,
and this exploded in the spring
of 1871 in the Paris Commune
that brought down the regime and
led to the establishment of a
republic.
So, there are also political
qualifications.
Well, I'll move then to another
example very quickly,
and one that is in the reading,
and that is the Italian
version,
and in particular the
risanamento of Naples,
which was Italy's largest city.
As you know,
there was a massive epidemic in
the city--
this is the plan of
risanamento in Naples--
and as you know,
it led to the idea--
and here is something that is
actually unique;
that is to say that we've
talked about the retrofitting of
British cities and also American
ones.
 
We've talked about the
rebuilding of Paris.
Those were associated with a
variety of disease experiences,
and they had purposes other
than a single disease.
One can't see the retrofitting
of British cities as due solely
to epidemic cholera,
nor the rebuilding of Paris.
Here in Naples we have
something that's unusual and
probably unique,
which is the actual rebuilding
of a major European city for the
specific purpose of preventing
the return of cholera.
 
And the way that the plan was
developed reflected the specific
medical understanding of the
time of the cause of cholera.
And we see here too a form of
the filth theory of disease.
The rebuilding of Naples was
for this single purpose,
and the medical theory behind
the rebuilding project was
specifically the miasmatic
theory of this physician from
Bavaria,
Munich in particular,
who is Max von Pettenkofer,
who had an enormous influence
on public health.
 
And one aspect of his influence
was that his theory lay at the
basis of the rebuilding of
Naples.
He developed the most
sophisticated of miasmatic
theories in the nineteenth
century and was aimed--
the aim then behind the
rebuilding of Naples was to thin
out the population.
 
Overcrowding was a cause of
disease,
and poisonous vapors arising
from underneath the city
poisoned the air,
people breathed in the poison
and succumbed to cholera,
in Max Pettenkofer's view.
The purpose of
risanamento then was
first of all to raise the level
of the streets;
that is to say,
the danger and the miasma was,
if we like, fermenting beneath
the streets of the city.
So, you want to place a greater
distance between the population
living above and the poisonous
effluvia arising from below.
And, so, the aspiration was to
raise the level of the streets
to the second storey of the
houses.
And there would be,
if you like,
then a massive cushion,
including the mortar of the
streets themselves,
between the population of the
city and the danger lurking in
the groundwater beneath the
soil.
 
In addition,
the idea was that you would
have Naples--there's a picture
of the old city that's--in
various aspects--that's been
demolished;
and here what I wanted to show
was this, the great access at
the center;
and then there were various
cross streets.
 
The great boulevard at the
center was in the direction of
the prevailing wind,
and it was called a bellows of
fresh air that would allow the
wind to rush through the city,
drying up the effluvia and
blowing away the stenches and
allowing the sunlight to reach
ground level,
and then it would be crossed by
a series of wide boulevards as
well.
 
And then under the--if this
happened above ground,
there would also be work going
on beneath,
and you would have a whole
sewage mains being built under
the city.
 
So, risanamento,
this enormous project,
both above and below ground,
was related-- it was a cousin
of the sanitary movement in
Britain.
It was a first-cousin of the
rebuilding of Paris and Lyon.
But it was distinctive too,
because it's the only example
of a project conducted
exclusively for the purpose of
defeating a single disease,
and that was cholera.
Was it a success?
 
Well, Naples was rebuilt.
 
And there's no doubt that the
health of the city thereafter
was greater than it had been
before.
But unfortunately there too
there were qualifications.
The rebuilding was marred,
marred perhaps partly by the
flaws in its conception from the
outset,
but marred also by the fact of
corruption and the misuse of the
funds that were used to carry it
out.
And, so, we see thereafter that
although Naples was rebuilt in
the aftermath of 1884,
that there was a return of
cholera,
a major epidemic again, in 1911.
And there was even a small coda
to that, which is another
outbreak, even in 1973.
 
So, the irony and conclusion.
 
The sanitary movement in
Britain, retrofitting of cities,
the rebuilding of cities in
France,
the risanamento in
Naples, did achieve major
success.
 
But it's worth remembering that
they often weren't based on a
medical theory that was to
endure.
And indeed in the case of
Naples, it was a medical theory
that very soon after the
rebuilding was to be discarded.
No sooner had Naples been
rebuilt than the theories of
Pettenkofer were overturned,
with the coming of the germ
theory of disease.
 
So, when we're--one of the
questions we ask,
then, was the lasting impact of
epidemic diseases.
And I would argue that one of
the senses of lasting impact is
one that's embodied in bricks
and mortar, in urban planning.
And if you visit these cities,
then you can see the lasting
legacy of epidemic disease in
the urban landscape itself.
 
 
