Knowledge in the Time of Cholera (24 page)

In arguing for allopathic control, sanitary-minded physicians aligned the calls for reform with the professional goals of the society, and thereby gained NYAM's endorsement.

These early reforms received a boost from newspaper exposés that blamed the poor sanitary condition of the city on political corruption. The
New York Times
(June 25, 1856, 3), in an editorial provocatively entitled “Killing Off Our Children—By Authority,” drew the link between patronage and needless death: “Thousands of lives are lost, and thousands that live are demoralized and broken in constitution—all because our mock sanitary officers have not the intelligence or the enterprise to fill up these sunken lots, and drain these poisoned valleys.” The not-so-subtle moral of this editorial was clear: the greed of politicians was responsible for the fever nests that killed children. Exposés like this focused public attention on the harms caused by lax sanitation and placed culpability for filth squarely on the shoulders of unresponsive city officials.

NYAM, however, was not able to translate this support into tangible reforms. Its plans were derailed by the city's machine politics, as the Democratic political machine of Tammany Hall persuaded the state assembly to reject the proposed legislation. The legislative failure gave those within the allopathic profession initially skeptical of reforms fodder for backing out of future reform efforts. They dismissed any further forays into public health reform as a waste of time and resources, given their political unlikelihood and marginal payoff. Consequently, after this brief flirtation with sanitary reform, NYAM, and regulars in general, remained content to sit on the sidelines as others took up the fight against entrenched political interests (Duffy 1968). Physicians were free to support the cause individually, but without the support from the medical society.

When the academy bowed out, the reform mantle was assumed by a diverse group of sanitarians. Whereas the regulars proposed reforms focused
on
medical control, the subsequent push for reform offered a more ecumenical vision of sanitary science. Elite, sanitary-minded physicians, like John Griscom, Elisha Harris, Joseph Smith, and Stephen Smith, collaborated with community leaders, like wealthy industrialist/philanthropist Peter Cooper. This eclectic group of elites was united by a commitment to responsible citizenry, not by any notion of professional expertise, for while physicians were central to the burgeoning sanitary movement, the bulk of the movement consisted of lay community members. As such, calls for sanitary reform took on a less explicitly medical character. First through the New York Sanitary Association and later the Citizens' Association of New York, sanitarians worked to portray the existing boards as woefully and irredeemably corrupt. They produced reports and pamphlets that connected disease to filth and filth to political corruption. Their justification for special recognition rested on the purported apolitical disinterestedness of their sanitary science. “Politicians make poor sanitarians,” because it was against their political interests to produce accurate sanitary knowledge requisite for effective intervention (Halley 1887, 241). From 1859 to 1866 reformers continuously introduced sanitary bills to the legislature, only to be defeated by the Democratic Party machine and “paltry officials who hang like leeches to the municipal body,” as the
New York Times
described opponents of the bill (Duffy 1968, 546). Defeating such entrenched interests was proving to be a heavy lift.

In 1863, the Citizens' Association established the Council of Hygiene and Public Health, charged with conducting a thorough sanitary survey of the entire city. The new survey was carried out in order to rebut a city inspector's report, which denied the existence of any sanitary problems. The comprehensive
Report of the Council of Hygiene and Public Health of the Citizens' Association of New York upon the Sanitary Condition of the City
was an impressive feat of investigation. The council divided the city into thirty-one specified districts, assigned an inspector to each district, and supplied them with a standardized form to record the sanitary conditions of their district. Inspectors were instructed to gather information on a wide variety of conditions, from “the nature of the ground” to the “location and character of water closets” in tenement houses (Smith 1911, 54–55). Stephen Smith (1911, 54–55), author of the final report, outlined the exhaustive list of relevant factors that investigators were asked to note:

Commencing at a given corner of the district, he [the investigator] was first to go around the square and note: 1. Nature of the ground. 2. Drain
age
and sewerage. 3. Number of houses in the square. 4. Vacant lots and their sanitary condition. 5. Courts and alleys. 6. Rear buildings. 7. Number of tenement houses. 11. [
sic
] Drinking shops, brothels, gambling saloons, etc. 12. Stores and markets. 13. Factories, schools, crowded buildings.14. Slaughter-houses (describe particularly). 15. Bone and offal nuisances.16. Stables, etc. 17. Church and school edifices.

Returning to the point of starting, he was to commence a detailed inspection of each building, noting:
a
. Condition and material of buildings.
b
. Number of stories and their height.
c
. number of families intended to be accommodated, and space allotted to each.
d
. Water supply and house drainage.
e
. Location and character of water closets.
f
. Disposal of garbage and house slops.
g
Ventilation, external and internal.
h
. Cellars and basements, and their population.
i
. Conditions of halls and passages.
j
. Frontage on street, court, alley—N.E.S. or W.18. Prevailing character of the population. 19. Prevailing sickness and mortality. 20. Sources of preventable disease and mortality. 21. Condition of streets and pavements. 22. Miscellaneous information.

The identification of so many different conditions demonstrates the breadth of sanitary knowledge. When aggregated into a single report, the findings were both surprising and disturbing, as the report revealed the presence of cholera nests and unearthed an invisible smallpox epidemic to boot. The sheer scale and detail of the
Report
impressed the media and the public, who joined in denouncing the sanitary situation of the city. By making disease in the city legible, sanitarians had produced a comprehensive condemnation of politicized sanitation (or lack thereof).

In addition to the
Report
's revelations about the failure of city officials to perform their trusted duties, additional investigations found outright fraud. In conjunction with the survey, the Citizens' Association issued a pamphlet chronicling the abuses of the City Inspector's Department and showed that despite a generous allocation of funds for sanitation, little of the money actually went to cleaning up the city: “Under the present rule of ignorant and corrupt politicians, this city expends directly and indirectly nearly half a million of dollars for health purposes, not
one dollar
of which is intelligently applied to improve its sanitary state. Small-pox, scarlet fever, cholera infantum, and allied diseases, rage among the poor like consuming epidemics without one effort put forth by our
one hundred and eighty-three
health officials” (
American Medical Times
1862, 99). Politicians were not just inept;
they
were corrupt. They had abused their power and betrayed the public's trust.

With the reports attracting widespread attention, reformers reintroduced a bill in 1865, hoping to capitalize on the renewed outrage. This time reformers received a much-needed boost from an unlikely ally—cholera. The arrival of cholera in port aboard the
Atalanta
in November brought a new sense of urgency to the proposed reforms. Although cholera remained contained to the port until spring, the looming specter of another epidemic lent credence to the reformers' calls. The disease was poised to attack the filthy city again. Faced with a looming epidemic, the press ratcheted up their critiques of the City Inspector's Department and their editorial support for the reforms. While
Harper's
mocked the board's apathy in a cartoon, the
Nation
(“Street Commissioners to the Cholera” November 9, 1865, 583) did so in verse:

Cholera, cholera, cholera, come!

Come to the city we dock for thy home! Come to Manhattan!

New York never gave

Prince, hero, charlatan, exile, or knave,

Cholera, such a reception as we,

Queen of men's terror! Have plotted for thee!

By not attending to the egregious filth, the city was rolling out a welcome mat for cholera, so went the criticisms.

Pressured by sanitarians, the media, and the looming threat of cholera, the legislature passed “An Act to Create a Metropolitan Sanitary District and Board of Health Therein.” It became law on February 26, 1866. The sanitarians' dream of an independent board of health was finally realized. The decade-long reform effort came to an end just as cholera arrived.

The composition of the first permanent board of health and its wide-reaching activities indicated both a particular understanding of cholera—cholera rooted in place as filth—and a broad view of relevant knowledge. Sanitation was framed as thoroughly social, not narrowly medical. While physicians were recognized as an integral part of the Metropolitan Board of Health of New York City, the legislation expressly ensured that they would remain in the minority, as reformers did not want the board to be dominated by doctors (Duffy 1968, 2). The board consisted of four police commissioners, the health officer, and four other commissioners appointed by the
governor,
three of whom had to be physicians. Valued as having pertinent insight, physicians had a total of four seats on the board, but lay community members maintained the majority with five, and leadership positions went to nonmedical members. Thus, the board was decidedly
not
the medical organization under the control of allopathic physicians envisioned by NYAM in 1857. Rather, it was constructed as a coalition of lay community members and relevant professionals committed to sanitary science as a cooperative endeavor patterned on “mutually supporting roles” (Rosenkrantz 1974, 58). This reflected the intellectual ecumenism of sanitary science and the cooperative, but not dominant, place of medical knowledge within it. The broad understanding of the relationship between disease and the environment precluded defining sanitary science in terms of medical knowledge only.

Cartoon showing political board appointees asleep on the job from
Harper's Weekly
, August 5, 1865, p. 496. Courtesy of the National Library of Medicine.

The actions of the board reflected the numerous forms of knowledge it brought to bear on cholera. When Governor Fenton issued a “Proclamation of Peril” on April 24, giving the board wide authority to carry out the reforms necessary to combat cholera, it immediately set to work (Duffy 1974). Two thousand police officers fanned out across the city, reporting every instance of sanitary neglect over the fifty telegraph lines that the board had es
tablished
throughout the city (Chambers 1938, 274). Upon notice, the board removed the offending nuisances, as it took control of the street-cleaning contracts and garbage removal. In dealing with cases of cholera, doctors were instructed to report all cases to the board, which would confirm each case and quickly remove those with cholera to quarantine hospitals. Cholera nests were destroyed, their inhabitants relocated, while salvageable buildings were disinfected. Furthermore, the board closed the most egregious of the city's polluters (e.g., fat- and bone-boiling establishments), sent engineers to investigate new buildings for adequate ventilation, and organized a corps of physicians to staff cholera hospitals. As they went well beyond medical interventions, these diverse actions required the input and coordination of a wide array of experts.

The board's proactive approach seemed to pay off. Cholera threatened the city throughout the summer of 1866 but never really gained a foothold. Whether legitimate or not, the board received credit for the epidemic's mildness (Duffy 1968, 18). In its review of the epidemic on its one-year anniversary, the
New York Times
(March 31, 1867, 3) applauded the board:

The community was watching with considerable anxiety for the advent of cholera, and speculations were freely indulged as to the effect which its presence would exert upon the health and business of the City. A newly-formed Board of Health had entered upon its duties; people were hoping that it might in some way be instrumental in averting or diminishing the ravages of what had been in previous years a terrible scourge. Although it may be said that no inference can be drawn from the fact that mortality from cholera last year in New-York was less than during the previous visitation, we are unwilling to admit the validity of the assertion. In other cities on the continent where the disease obtained a foothold the loss of life was fearful, and certainly the conditions which favored its spread existed in full force in New-York. Hence we believe that the methods adopted by the Board of Health were instrumental in saving many lives and even in limiting the epidemic.