Empire and the Industrial Revolution
The United Kingdom was hit by cholera outbreaks on just four occasions over four decades: 1831–1832, 1848–1849, 1853–1854 and in 1866. Yet the speed and violence with which cholera killed its victims made it the most feared infectious disease of the nineteenth century. Cholera is a bacterial disease that is transmitted in water or food that has been contaminated with infected faeces. Vibrio cholera enters the body through the mouth. When the bacteria reaches the gut, it is attacked by the immune system; but as the pathogens die, they release a very powerful toxin that is dramatically expelled from the body, resulting in projectile vomiting and explosive diarrhoea. Victims can lose a quarter of the body’s fluid within a few hours. Severe dehydration makes victims look shrivelled and ruptured capillaries turn their skin blue. Before modern medicine, about half of those who developed symptoms died within a few days.[i]
Although cholera first reached the UK in the nineteenth century, it is, in fact, a very old infectious disease. There are references to what is thought to be cholera in Sanskrit texts dating back to the fifth century BCE.[ii] However, it does not appear to have spread beyond its endemic haunts in the Ganges Delta until the arrival of the British. The Warwick-based historian, David Arnold, points out that there is a “literal correspondence between cholera and armed conflict in early colonial India”.[iii] The East India Company had been present in Bengal since the mid-1700s, but it was only at the end of the century that it began to extend its power to the rest of the subcontinent. The first outbreak outside of northern India occurred when the British invaded the Maratha Empire in 1817. The local population believed that the outbreak was caused by gods angry that British troops killed and ate cows. But of course, it was the movement of troops across the subcontinent, combined with the crowded, insanitary, and unhygienic conditions in which they lived, that helped to transmit cholera.
Cholera was a serious problem for the British military in India: it was responsible for the deaths of over 8,500 British soldiers between 1818 and 1854, and one third of all troop fatalities between 1859 and 1867.However, the numbers were small when compared to civilian deaths, with cholera killing an estimated 33–38 million people in British India between 1817 and 1947. Cholera had an especially strong impact on the poor. It hit hardest during the devastating famines that periodically struck British India. For example, cholera killed over two million people in the Madras Presidency during the Guntur famine (1833). There was a similar coincidence of cholera and famine again in Madras in 1866 and 1877, in Bombay in 1877 and 1900, and during the devastating Bengal famine (1943–1944). These famines were, as the Nobel Prize-winning Indian economist, Amartya Sen, points out, a direct consequence of apathy and inaction on the part of the colonial administration.
The remarkable growth of Britain’s towns and cities in the first half of the nineteenth century was unplanned. Consequently, many urban areas lacked basic infrastructure, such as sewerage and safe drinking water. Human waste was thrown onto the unpaved streets, stored in cellars, and piled up in overflowing cesspits. From there it flowed into the streams and rivers that were the main source of water. In The Condition of the Working Class in England (1845), Friedrich Engels described the situation in parts of Manchester as “filth, ruin, and uninhabitableness”, and “Hell Upon Earth”.
Cholera thrived in these conditions. As the Cambridge-based historian, Richard Evans, points out: "it arrived in the mushrooming towns and cities of a society in the throes of rapid urbanization, it took advantage of overcrowded housing conditions, poor hygiene and insanitary water-supplies with a vigour that suggested that these conditions might almost have been designed for it”.[iv]
Anyone who could afford to lived outside the slums, so cholera disproportionately affected the urban working classes. This is apparent in statistics from London during the outbreak of 1848–49 and 1854, which show that the mortality rate from cholera was 25 times higher in the working-class districts of Rotherhithe than the upmarket area of Hampstead.[v]
When cholera arrived in the UK in 1831, doctors had no idea what it was or how to treat it. They devised all manner of treatments, including injecting turpentine and mutton stew into the intestines via the anus. The authorities responded with public health measures that had been developed to stop the spread of the plague after the Black Death: quarantines and cordons sanitaire that limited movement, and the isolation of sick people in hospital. If these interventions seem familiar, it is because they closely resemble the lockdown and isolation policies that governments used to slow transmission of COVID-19 before the development of vaccines.
Cholera brought latent social tensions to the surface. Outbreaks invariably occurred in poor urban areas. Doctors, soldiers, and officials turned up to limit the movement of people and to take the sick away. The local population responded angrily. Popular anger was directed at doctors. This was because distrust of the medical profession was already at fever pitch in the United Kingdom. In 1828, William Burke was convicted and hanged for murdering sixteen people and selling their bodies to the University of Edinburgh’s medical school for dissection. A similarly infamous case had happened two years earlier when three barrels waiting to be shipped from Liverpool docks to Edinburgh were found to contain eleven partially salted dead bodies. Investigations led to a house where another nineteen bodies were discovered. It soon became apparent that the corpses had been dug up from a nearby graveyard. Thus, when doctors were attacked as they tried to take suspected cholera victims to hospitals for isolation, the crowds had genuine—albeit unfounded—concerns that their friends, family, and neighbours were going to be killed and their bodies used for medical research. Liverpool was worst affected by the unrest, with eight riots in the summer of 1832. London had three similar incidents around the same time.[vi]
The Sanitary Movement and the Politics of Cholera
In the early nineteenth century the landed aristocracy still dominated politics. The Industrial Revolution created enormous pressure for electoral reform amongst the middle and working classes. The Great Reform Act of 1832 allowed about one in seven adult males—those with significant property—to vote in national elections, and the 1835 Municipal Corporation Act established representative local government voted for by ratepayers. The working class remained disenfranchised, while the new electorate was dominated by the middle class. As the Cambridge-based historian, Simon Szreter, points out, the latter group was dominated by small businessmen whose main concern was to keep their taxes low.[vii] Consequently, after the voting reforms of the 1830s, the only electable governments were those committed to laissez-faire ideology, which advocated minimal taxation and limited state intervention.
This new political context led to an almost immediate transformation in the welfare state. The old system of poor relief was seen as too generous. Critics argued that welfare handouts encouraged dependency and indolence. The New Poor Law, passed in 1834, was designed to differentiate between the so-called deserving poor—i.e., the sick and elderly—and what the architects of the new system saw as scroungers. This was achieved by making welfare support so difficult for able-bodied people to get that they would only ask for help when they found themselves in the most desperate circumstances. To receive poor relief in the reformed system, families had to enter the dreaded workhouse. Life inside was designed to be worse than the worst possible existence available in the outside world: parents were separated from each other and their children; work was hard and boring; and food was so scarce that, as Charles Dickens pointed out in Oliver Twist (1837–39), the workhouse simply gave the poor a choice between starving quickly at home or slowly inside.
Edwin Chadwick was one of the authors of the New Poor Law. He was so shocked by the conditions in which the urban poor lived that he became the leading figure in the sanitary movement that emerged in the 1830s and 1840s. The sanitary movement argued that to improve the health of the urban poor, it was necessary to clean up towns and cities by constructing sewerage and water infrastructure. This was influenced by the “filth theory of disease”, which blamed the foul smell of sewage and other waste for illness and death. At a time when urban slums were both the smelliest and most disease-ridden, it is not hard to understand why this seemed plausible. Chadwick was not concerned about the wellbeing of the poor, per se. Rather, he realised that the terrible health of the working population undermined the productivity of factories and created a drag on the economy. There were, however, many others—including Charles Dickens—whose support for the sanitary movement was motivated by sympathy and solidarity.
In the early 1840s, Chadwick persuaded London’s authorities to divert human waste into the drains that had been built to carry rainwater to the Thames. This plan made perfect sense to those who believed in the filth theory of disease, as it removed sewage away from inhabited areas. Yet the measure had devastating consequences: several hundred tonnes of raw sewage flowed into the river each day, transforming it into what Benjamin Disraeli described as “a Stygian pool reeking with ineffable and unbearable horror”.[viii] The sanitary movement did not understand that diseases like cholera were waterborne, so they were not concerned with the public water supply. This was still provided by a patchwork of largely unregulated private companies, many of which drew water from the polluted Thames. The cholera outbreaks that hit the capital throughout 1848–49 and 1853–54 were without doubt made worse by Chadwick’s changes to the sewerage system. Tens of thousands of Londoners died as a result.[ix]
The new industrial towns and cities of northern England were less willing to clean up their act. In response to Chadwick’s urging, the government passed the UK’s first Public Health Act in 1848. It was no coincidence that this happened at the same time as the country was being struck by a devastating cholera outbreak. As a contemporaneous article in The Times pointed out, cholera was “the best of all sanitary reformers”.[x] The British historian, Asa Briggs, highlights how public health reformers in Australia—which was not affected by epidemics during the nineteenth century—expressed the hope that their country would experience an outbreak in order to jolt the public and politicians out of their complacency.[xi] The Act allowed local authorities to levy taxes to pay for improvements in water and sewerage infrastructure. Ratepayers were so appalled that central government was trying to force municipal authorities to increase local rates that Chadwick was forced to resign as one of three commissioners of the General Board of Health in 1854.
Two decades after the passage of the 1848 Public Health Act, not one town or city had built the kind of integrated sewerage networks that the sanitary movement advocated.vii When one compares the inertia surrounding urban sanitation with the astonishing feats performed during the “railway manias” of the 1830s and 1840s, it is clear the problem was not lack of money. The middle classes invested enormous amounts of money into private railway companies. Local politicians fell over themselves to help these companies, as being connected to the railway was seen as crucial to the prosperity and prestige of a town. City centres were knocked down and rebuilt to accommodate tracks, stations, and yards. This transformed Britain. By mid-century, passengers could travel across a network that covered every major settlement in the country at speeds that would have been unthinkable just a few years before.
The main obstacle stopping municipal authorities from dealing with the rising tide of sewage and corpses in working class neighbourhoods was political. Local and national governments in the mid-nineteenth century were beholden to middle-class voters who invariably supported politicians who promised to keep taxes low. This made it impossible for municipal authorities to invest the vast sums of money required to build the massive infrastructure necessary to provide sanitation and clean water for the masses.vii
John Snow and the "Great Stink"
During the cholera outbreak of 1848–49, John Snow, a London-based doctor, famously compared the impact of cholera on households supplied by two private water companies. One of these companies extracted water from the Thames upstream of the city, while the other took it from the centre of the capital. Snow demonstrated that mortality rates from cholera were many times higher among those who got their water from the latter company. He reasoned that cholera must be a water-borne disease and that germs in the water were making people ill. In 1854, Snow demonstrated that his argument was correct. He traced a cholera outbreak that killed 500 people to a water pump in Broad Street (now Broadwick St), Soho. When he persuaded the local authorities to remove the pump’s handle, making it unusable, the outbreak stopped.xi
Snow is now regarded as one of the great heroes of British public health and the father of modern epidemiology, but his research had little impact at the time. A committee appointed by parliament to investigate the 1854 outbreak dismissed Snow’s research, stating that after “careful enquiry we see no reason to adopt this belief”.[xii] Instead, the committee backed the filth theory of disease. When Snow died in 1858, his thirty-three-word obituary in The Lancet did not even mention his research on cholera. It would take several more decades for the ideas that he pioneered to become mainstream.
It was the “Great Stink of London” in the summer of 1858 that prompted the government to clean up the Thames. The hot weather turned the river into a foul-smelling sludge, making life almost unbearable for anyone who went near it. This was not just a problem for the capital’s poor. It also affected many of the city’s wealthy inhabitants who lived and worked close to the Thames. This included politicians in the newly completed Houses of Parliament at Westminster. Holding handkerchiefs over their noses, MPs passed legislation that compelled London's Metropolitan Board of Works to build an extensive sewerage system to transport human waste far to the east of the city. When the UK was hit by another cholera epidemic in 1866, London was largely spared. The main outbreak in the capital occurred in the East End, one of the few parts of the city that was not yet connected to the new sewers. More than five thousand Eastenders died.x
It was not until the last quarter of the nineteenth century that Britain’s provincial towns and cities constructed sanitation and water systems. These developments were driven by political reforms. In 1867 legislation that followed the Second Reform Act quadrupled the number of men who could vote in urban local elections. More than 60% of working-class men were now enfranchised.vii Most of these new voters did not pay local rates and their support was critical to anyone who wanted to get elected. This transformed the nature of municipal politics. Local governments were no longer in thrall to the middle classes that had dominated electoral politics since the reforms of the 1830s, and who were primarily concerned with keeping taxes as low as possible. New voters were far more receptive to local politicians’ plans to build vast and expensive water and sewage infrastructure, precisely because they would not have to pay for them directly through local taxes.
As Simon Szreter points out, these political reforms had a transformative impact on public health. All the major towns and cities in the country had created municipally owned monopolies over utilities such as water, gas, electricity, and public transport. The revenues from these corporations were used to fund improvements in sanitation, water supplies, and other public health programmes.vii The UK was never again afflicted by cholera.
Epilogue
It was not until after cholera had disappeared from the UK that germ theory became widely accepted and medical science began to understand the exact causes of infectious diseases, as well as ways to prevent and treat maladies. In 1876, the German physician and microbiologist, Robert Koch, identified the first bacteria: Bacillus anthracis, which causes anthrax. In 1884, he isolated the bacteria that causes cholera. By this stage, cholera was very rare in western Europe, so he had to first travel to Egypt—where he missed an outbreak—and then on to India to get hold of a sample.
In 1885, Louis Pasteur, the French microbiologist and chemist, developed a vaccine for anthrax. He used heat to weaken or attenuate the bacteria, so that although the pathogens are still recognised by the immune system, and therefore train our bodies to respond, they cannot cause illness. This made it possible for microbiologists to develop vaccines against a variety of diseases caused by bacteria. The first effective cholera vaccine was created in 1892, although it took several years of testing in Calcutta for it to become accepted. While cholera vaccines are still used today, their development was far too late to explain the decline of the disease in Britain and the rest of western Europe. Antibiotics can be used to lessen the effects of cholera, but Alexander Fleming only chanced upon penicillin in 1928, and antibiotics were not widely available until the late 1940s.
It is now easy to prevent and treat cholera—people do not contract it where they have access to clean water, sanitation, and vaccines. If one has cholera, it can be effectively treated with oral rehydration therapy and antibiotics. Consequently, cholera has been absent from western Europe and North America since the late nineteenth century. Despite this, the World Health Organization points out that there are still several million cholera cases and tens of thousands of deaths from the disease every year. This is shocking, but not surprising, as more than two billion people drink water from sources that are contaminated with faeces, and 2.4 billion do not have basic sanitation facilities according to the Global Task Force on Cholera Control. Devastating cholera outbreaks still occur periodically and tend to strike particularly hard when normal life has been disrupted. For example, the biggest recent epidemics took place after Haiti was hit by an earthquake in 2010 and during the recent Yemeni Civil War in 2017.[xiii]
Cholera was eliminated in the UK because of political commitment to invest in public health infrastructure. Medical science has advanced enormously in the last century and a half, but to eliminate cholera in the rest of the world it is necessary to make sure that there is political commitment on the part of international and domestic actors to ensure that everyone everywhere has access to clean drinking water and basic healthcare.
[i] Frank M. Snowden, Epidemics and Society: From the Black Death to the Present (New Haven, Connecticut: Yale University Press, 2019).
[ii] Jason B. Harris, Regina C. LaRocque, Firdausi Qadri, Edward T. Ryan, and Stephen B. Calderwood, “Cholera,” The Lancet 379, no. 9835 (2012): 2466–2476.
[iii] David Arnold, “Cholera and Colonialism in British India,” Past & Present 113 (1986): 118–151.
[iv] Richard Evans, “Epidemics and Revolutions: Cholera in Nineteenth-Century Europe,” Past & Present 120 (1988): 123–146.
[v] Paul Bingham, Neville Q. Verlander, and M. J. Cheal, "John Snow, William Farr and the 1849 Outbreak of Cholera that Affected London: a Reworking of the Data Highlights the Importance of the Water Supply," Public Health 118, no. 6 (2004): 387–394.
[vi] Sean Burrell and Geoffrey Gill, “The Liverpool Cholera Epidemic of 1832 and Anatomical Dissection—Medical Mistrust and Civil Unrest,” Journal of the History of Medicine and Allied Sciences 60. no. 4 (2005): 478–498.
[vii] Simon Szreter and Michael Woolcock, “Health by Association? Social Capital, Social Theory, and the Political Economy of Public Health,” International Journal of Epidemiology 33, no. 4 (2004): 650–667; Simon Szreter, “Economic Growth, Disruption, Deprivation, Disease, and Death: on the Importance of the Politics of Public Health for Development,” Population and Development Review 23, no. 4 (1997): 693–728; Simon Szreter, “The Importance of Social Intervention in Britain's Mortality Decline c.1850–1914: a Re-interpretation of the Role of Public Health,” Social History of Medicine 1, no. 1 (1988): 1–38.
[viii] United Kingdom, Hansard Parliamentary Debates, vol. 151, cc1508–40 (1858), available at https://api.parliament.uk/historic-hansard/commons/1858/jul/15/first-reading.
[ix] Steven Johnson, The Ghost Map: The Story of London's Most Terrifying Epidemic—And How It Changed Science, Cities, and the Modern World (London: Penguin, 2006).
[x] Sean Burrell and Geoffrey Gill, "The Liverpool Cholera Epidemic of 1832 and Anatomical Dissection—Medical Mistrust and Civil Unrest," Journal of the History of Medicine and Allied Sciences 60, no. 4 (2005): 478–498.
[xi] Asa Briggs, “Cholera and Society in the Nineteenth Century,” Past & Present 19 (1961): 76–96.
[xii] Stephen Halliday, "Death and miasma in Victorian London: an obstinate belief," British Medical Journal 323, no. 7327 (2001): 1469–1471.
[xiii] Jonathan Kennedy, Pathogenesis: How Germs Made History (London: Penguin, 2023).