Johnson, Steven, The Ghost Map: The Story of London's Most Terrifying Epidemic -- and How it Changed Science, Cities, and the Modern World, Riverhead Books, New York, 2006. 299pp.
[cross-posted on chicagoboyz]
The Ghost Map is a retelling of the events and consequences of a famous outbreak of cholera in Golden Square Soho, London in the late summer of 1854. As a result of dogged investigation by a polymath doctor (Dr. John Snow) and a gregarious Anglican assistant curate (Dr. Henry Whitehead), the ultimate cause of cholera was pinpointed, and practical steps were taken to contain the disease. Because the cholera bacteria was too small to see in the microscopes of the day, the efforts to control the disease were not only constrained by the tools of science but also by the competing theories of disease etiology (causation).
The major competitor at the time was the "miasmic" or "bad air" theory ... bad smells were the basis of disease. Johnson opens his book with a detailed and hair-raising chapter on how the Victorian city of London managed the feeding and waste management for two million closely packed humans. Suffice it to say, people got their hands "dirty" ... and conducted daily animal slaughter and recycling on a scale, and at a level of detail, that would put the modern industrialized world to shame. The humble and poor of the London would have quickly recognized the lives of garbage-pickers in Mexico City or Mumbai, however. Pity for a moment, those designated to collect each day's supply of dog excrement on the London streets, recycled for use in the tanning industry. Nothing was wasted ... in a way that would make any Hollywood Indian proud.
Bad smells, foul liquids, and indescribable solids were part and parcel of the streets, courtyards and alleys of 19th century London. Human waste was haphazardly dispersed, and largely subject only to the laws of gravity which carried it down to the Thames, creating a massive open sewer. Cess pools and cess pits were slowly being replaced by regular service by night-soil men but the recent innovations in indoor toilets (water closets) had suddenly boosted the demand for water in the city. And water, whether piped in or pumped out of local wells, was increasingly susceptible to both contamination and distant transport. The conditions were ripe for waterborne disease to reach new hosts in new ways.
The cholera bacteria normally feeds on plankton, and the latter requires light for survival. Under ordinary conditions, cholera should little affect human populations because it is not concentrated enough to trigger disease on ingestion. In crowded city conditions, however, where concentrations of cholera in the runny stools of the sick can find easy transport to fresh water sources, and in turn new hosts, the cholera bacteria can rapidly evolve into terrifyingly lethal strains. The result is colonization of the intestinal track, rapid shedding of the mucosal lining, a constant evacuation. Such a vicious strain formed in the bowels of a single sturdy Soho infant. As the dehydration and slow decline of the baby took hold, the mother emptied the messy diapers into a basement cess pool, which happened to be but a few feet from the casings around the well water of Broad Street, London. Cross-contamination occurred. As the baby suffered out of sight in the tenement building, the locals outside were pumping the much prized Broad Street water for their families in the surrounding streets. The water also made its way out of London to those who particularly prized its taste and clarity. Some folk began dying within hours of drinking the water. Others took days to die. A few survived. Many others fled the small section of Soho, shuttering stores and homes as the spectre of cholera, and its unknown source spread fear and heartbreak through Golden Square. The pump continued to supply a fresh, but dwindling, supply of cholera bacteria to the community.
As Johnson notes, imagine if you took a weekend trip and returned home to find 10% of your neighbours dead and the death carts making their way down the streets, carrying them to their graves. Such was the Broad Street cholera epidemic. Certainly not "London's most terrifying epidemic" as the book's subtitle would claim. London was used to waves of epidemic disease, including the plague, throughout its two thousand years of existence. But the hundreds who died on Broad Street in the mid-19th century were to have an out-sized impact on our world and on urban history of the planet.
Part of the myth surrounding the events of the epidemic is the removal of the handle of the Broad Street pump by the Board of Governors of the local parish. Over the course of the next few days, the incidence of cholera in the community dwindled and finally halted. Apocryphal tradition claims that the waterborne theory of cholera transmission was proven that day. The reality is far more complex, and it is that complexity that makes The Ghost Map a fascinating and worthwhile read.
As mentioned, Johnson begins his book with the "status quo ante" picture of London waste management. Building up a day by day description of the progress of the disease through Golden Square (house by house, family by family), he interleaves the biographies of the principal protagonists of the Broad Street story. Surprisingly, the Broad Street cholera epidemic is more a pivot point of the larger subject of cholera control rather than genesis. Dr. John Snow had written on the disease before the epidemic, and it was some years later before his efforts (along with those of curate Whitehead) were to have an impact on the medical community.
Ironically, it was the appearance of the London Great Stink of June 1858 which was to have the biggest impact ... the Thames had become so foul that Westminster and the Houses of Parliament were uninhabitable. Clearly, miasmic theory of disease dictated that Londoners should experience a wave of disease. Yet all they were doing was gagging on the smell. The Stink triggered a massive investment in waterworks and sewage treatment which was to consume London for years, and reroute London's waste away from the Thames (or at least far downstream to where ocean tides could move the sewage out to sea).
With the miasm theory on the ropes, a second cholera epidemic in June 1866 in a different part of London encouraged the public health officials of the time to examine the water supply, and indeed to engage the services of Dr. Whitehead (Dr. Snow having died earlier of a stroke). Sure enough, using the methods made famous in our era by institutions like the CDC, the investigators were able to track back the spread of cholera to the East London Water Company's supply fouled at its source by nearby sewage, and piped promptly down to London homes and businesses. From that day forward, London paid a great deal of attention to the purity and construction of its water supply ... and was unaffected by subsequent cholera epidemics which swept through the Continent in the late 19th century.
Other cities around the world took note. A particularly savage cholera epidemic in Chicago in the 1880s triggered an equally dramatic public works project to separate drinking supplies and waste handling. As cities around the world followed London's model, the incidence of cholera dropped away from the experience of industrialized nations. Today, cholera is a Third World disease, and often a companion of war ... as an outbreak in Basra, Iraq in 2003 highlighted.
The Ghost Map is very strong in its careful description of the Broad Street epidemic, scraping away the public health myths and over-generalizations that have accumulated in the last 150 years, revealing in its place a story that is just as compelling, just as amazing. Snow's innovative use of street maps and diagramming to track the spread and results of the disease were to gain high praise from no less than Edward Tufte, 20th century guru of visual communication. And Curate Whitehead's deep compassion and intimate knowledge of the families in Soho was to be critical in allowing doctor and cleric to track down the origin and dispersal of cholera, family by family, in the months after the outbreak. Publishing their careful investigations, they met with indifference. As time passed, however, their approach and its results gained more and more prestige until their work at the turn of the 20th century was acknowledged as ground-breaking and exalted as one of the first steps in the modern advance against communicable disease. Their information was a key link in the efforts to change urban planning and construction into our own time.
Having told the story of Broad Street so well, admittedly with a bit of obligatory tut-tutting about class consciousness in 19th century London, Johnson turns more briefly to tackle the larger issue of what large, and relatively healthy, city life has wrought in the 20th and 21st centuries.
Here he falls back on more familiar authors of urban life such as Jane Jacobs, and he makes the case that the dramatic urbanization of world population in the last century is, in fact, the most "eco-friendly" way that we could occupy the planet. The concentration of humans allow economies of scale and distance that reduce energy consumption and optimize the very waste-handling and city infrastructure pioneered by the London engineers of the 1860s and 1870s.
He also notes how the success of Snow and Whitehead was very much about the sharing of information across the lines of class and profession. Turning to his own experience with the "311" service in New York City, he describes how the interaction of diverse urban communities with city government leads to a pooling of critical information and flexibility in response to crisis. The has the shape, indirectly and without acknowledgement, of a strong Wisdom of Crowds or Army of Davids argument.
As for our own time, Johnson makes an very interesting point about the challenges of communicable disease like avian flu or SARS. The evolution of scientific knowledge about the genetic level of life is progressing so rapidly that it can even out-compete the pace of natural selection in the bacterial and viral words. Those tiny and occasionally deadly entities must respond to human hosts in "reproductive time" while modern medicine is, a la Ray Kurzweil, now beginning to compete at "computational and chemical time." For Johnson, the window of our global vulnerability to epidemic disease will probably last for another decade or two, and then fall away. Science (and associated surveillance methods) will simply be able to move faster than the bugs.
The secondary challenge of artificially manufactured disease organisms, or bio-warfare, offers greater danger than the natural world but there too, Johnson feels fairly confident that science will increasing provide the tools for counteracting novel disease organisms. Maybe.
Finally, and in a way that seems rather more idiosyncratic to his own interests and background, Johnson makes a case for the ongoing danger of nuclear and radiological weapons. Here, he believes, science and technology do not work in our favour. There is no protection from a nuclear event, though medicine may ameliorate its impact. True enough. And true enough in 1950. In this arena, I believe our protections are political rather than scientific ... cause enough for worry, I suppose, if one believes that global politics isn't subject to rapid change.
Finally, it wouldn't be a recent book by an American science writer if there wasn't an obligatory swipe at Intelligent Design and the backwardness of Christian folk in accepting Darwinian principles. The great irony, of course, is that Johnson's book is written around the critical role that the exceptional compassion of a 19th century Anglican curate played in changing global health. Much like the latest round of breast-beating that greeted the anniversary of the role of the British in ending the slave trade, there's a comfortable blindness to the impact of Anglosphere Protestantism on the improvement of the lot in life of millions of the poor, most now who don't worship Christ. One would like to think that the fundamental values of Christianity will reconcile themselves eventually with the powerful good that can come from scientific understanding. And for those hunting for historical factoids in support of Christianity's positive role on human history, Dr. Whitehead in Soho in 1854 is a pretty good find. "By their fruits shall ye know them."
Here again, I think of the story of humble people in London, one hundred and fifty years before the Broad Street cholera epidemic, attempting to make sense of Newton's Principia (with the initial support of Anglican clerics!) and building a dynamic industrial and scientific community in the markets, coffee houses, and workingman's institutes of the city (reviewed in the book Practical Matter on chicagoboyz). Maybe it was just chance that led two Britons of modest origins, such as Snow and Whitehead, to have such a big impact on human history. Chance that somehow keeps showing up in the UK history, however, and latterly (with the Green Revolution of Norman Borlaug or the Rotary Club's role in the global eradication of polio) in places like America. As Johnson so eloquently writes, in most histories the great men take pride of place. In the story of Broad Street, and its impact subsequent human history, the great are bystanders. And it is the poor, named and known only in tragedy, who provide the grist for the tale told by investigators.
Professor Alan Macfarlane has written a fascinating book on the Origins of English Individualism but we've yet to have a scholar write a book for the general public on the impact of English Individualism over the last four centuries ... there's just too much of it, I suspect. The Ghost Map is a great example of the topic, approached inadvertently.
Steven Johnson is an excellent writer so his book is a very enjoyable read just on style points alone. While his confidence in handling the material sometimes strays into smugness and political correctness, he provides a great service in revisiting the specifics of the Broad Street cholera epidemic. Progress toward the suppression of cholera was halting and delayed, even after its waterbourne origins were carefully described. But the many tangents and implications of those few fearful summer days in Victorian London create a context for the story that's deeply compelling.
If you have a teenager interested in the health or biological sciences, this is an ideal choice for birthday or holiday gift. Your search is over.
If you have a precocious middle schooler, you can open up a wealth of discussion on the topics of society, health, and "olde times" with this book. The "Ewwww" factor alone, in the introductory section on Victorian London's recycling, should keep boys fully engaged until the story grips them.
For an undergraduate in the sciences, here's the beach reading that will educate them, fascinate, and distract them from their schoolwork. And for the general reader of nonfiction, if the subject matter seems at all interesting, you'll really enjoy this book.
Table of Contents
Monday, August 28 The Night-Soil Men 
Saturday, September 2 Eyes Sunk, Lips Dark Blue 
Sunday, September 3 The Investigator 
Monday, September 4 That is to Say, Jo has Not Yet Died 
Tuesday, September 5 All Smell is Disease 
Wednesday, September 6 Building the Case 
Friday, September 8 The Pump Handle 
Conclusion The Ghost Map 
Epilogue Broad Street Revisited