As we determine what we must do to contain the virus in the coming months — be it through masks and social distancing or new tests, treatments or vaccines — we should also look back, to the origins of public health and why some in this country have never entirely bought into the public health approach.
In the early 19th century, cholera wreaked havoc on the world. Cholera is caused by a toxin-producing strain of the bacterium Vibrio cholerae. Patients suffer from the sudden onset of diarrhea and vomiting. Their skin is cold and clammy, turns a bluish gray and their eyes are sunken. As quickly as the illness comes on, in the absence of treatment, the victims of cholera too often die.
The Atlantic Ocean initially protected the United States. But by early June 1832, cholera had reached North American shores, first touching down in Quebec City and Montreal, then making its way down New York state’s canal system toward New York City.
Cholera was a disease of growing, crowded cities that had neither the public health infrastructure — clean water, sewage systems, hygiene and sanitation — necessary to prevent the spread of infectious diseases, nor the regulatory frameworks to balance private power and wealth with public good.
Some 30 years earlier, private banking interests had obstructed New York City’s plans for clean public drinking water, leaving the city as vulnerable and fertile ground for cholera to take hold. And as cholera began to spread, business interests prevented the action necessary to avoid an outbreak. The city’s health board was “more afraid of the merchants than of lying,” in the words of historian Charles Rosenberg.
Quarantines had effectively contained the spread of bubonic plague and smallpox, but they upended trade and commerce. Perhaps not surprisingly then, though Mayor Walter Browne prohibited any “vessel … having on board any person sick with … cholera” from approaching the city, quarantine hospital records for ships arriving between April and June 1832 disappeared, making it impossible to know whether quarantine regulations were being enforced. Cases might have slipped through in the name of commerce.
By late June 1832, New Yorkers were falling ill and dying of cholera, but this wasn’t immediately made public, even as physicians pleaded with officials to do so. The mayor and health board feared widespread panic and damage to the economy. Then, as now, journalists held public officials to account. The New York Courier and Inquirer condemned members of the health board for “their unwillingness to report facts.” This pressure made officials more forthcoming.
Almost half of the residents fled the city that summer. The poor, unable to leave and living in squalid neighborhoods like the infamous Five Points, bore the brunt of the disease. More than 3,500 died of cholera, equivalent to almost 120,000 relative to the city’s population today.
Cholera again struck the United States about a decade later, this time killing many not only on the Eastern Seaboard but also along the Mississippi River down to New Orleans and out West, following the California Gold Rush. An estimated 150,000 succumbed to the second (1829-1851) and third (1852-1859) cholera pandemics in the United States — about 1 percent of the nation’s population.
It was during the world’s third cholera pandemic, however, that John Snow solved the mystery of cholera’s transmission. The British physician hypothesized that cholera was transmitted by contaminated water. When cholera broke out in London in 1854, Snow went door to door, mapping the water source for each household: the Southwark and Vauxhall Waterworks, which drew water from sewage-polluted sections of the Thames, or Seething Wells. Snow found that homes receiving the sewage-polluted water had a cholera death rate 14 times higher than other homes.
Snow’s research would help catalyze a new approach to disease control — the public health approach. The science of public health is epidemiology: gathering data, identifying and defining problems, characterizing and measuring risk factors and protective factors, developing and testing preventive measures and scaling up the measures that work. The philosophy of public health is social justice.
Elected officials, informed by Snow’s work, passed laws requiring water companies to move their intakes upriver along the Thames. Officials greeted subsequent cholera pandemics with more public health regulations: water filtration and chlorination and the establishment of health boards.
A confluence of interests helped further public health initiatives. Political revolution spread, first in France in 1789 and 1830, and then across Europe in 1848. A wave of strikes roiled Victorian-era England between 1837 and 1901. The ruling elite feared that if allowed to fester, poverty and disease among the lower classes would lead to civil unrest there, too. Social reformers also understood that a strong economy depended on healthy workers and social stability. “Simple prudence and self-interest,” writes historian Frank Snowden, “and not just humanitarian sentiment indicated reform.” In the United States, even robber barons like Andrew Carnegie recognized the need for “the reconciliation of the rich and the poor — a reign of harmony.”
To this day, the public health approach has been most likely to prevail when this sort of self-interest — be it economic, political or cultural — and humanitarian sentiment align.
The public health approach enjoyed its heyday in the early 20th century during such a period of alignment. There were New Deal programs and policies to support the poor and unemployed. Life expectancy rose by more than 30 years, almost all of which was attributable to public health advances, most importantly better hygiene, sanitation and housing, as well as immunizations.
In the decades to come, the public health approach would bring about the eradication of smallpox, decrease smoking rates, reduce motor vehicle deaths through safer car and roadway design, and produce many other triumphs.
But the second half of the 20th century also saw the rise of modern medicine. While both modern medicine and public health leveraged science to improve health, there was a crucial divergence. Modern medicine did tremendous good for those who could access it but was blind to those who could not — because of inability to pay, distance, a lack of time off for an appointment, systemic racism and more. Public health, however, sought out the marginalized, the oppressed and the hardest to reach. Snow went to the homes of the afflicted, not just the well-to-do who could afford the services of a physician. Public health recognized the value of all human lives, while in medicine, doctors focused on the patients in front of them. Modern medicine helped decouple the fates of the individual and the common.
During the same period, Americans witnessed the expansion of health insurance tied to certain kinds of employment. Racism played no small part in determining who had earned a right to health care and was considered deserving, and who was not. Health became an individual commodity and responsibility. Funding for public health has correspondingly declined relative to economic growth and total health-sector spending. Meanwhile, Europe, Canada and other developed nations established national health systems — a combination of public health and modern medicine — for the common good.
The biggest myth of the coronavirus pandemic is that it’s the great equalizer. The privileged have always had the option to flee to safer ground, literally or metaphorically, today more than ever. Our president says, “It affects virtually nobody.” Perhaps the more than 200,000 Americans who’ve died of the virus aren’t somebodies who count. The real question is: How much economic and social instability will it take for our nation’s elites to buy into a common good? Though science marches forward, public health advances only with a steadfast commitment to its philosophy.