Of Urban Health and Plagues

If two people are close enough to exchange an idea face to face, they're also close enough to share a virus
" You should care about urban death in Africa primarily because they're people, too."
" You should care about urban death in Africa primarily because they're people, too."Special arrangement

“At their heart, cities are the absence of physical space between people. Cities are density, proximity, closeness.” That proximity has plenty of upsides, like the ability to spread knowledge or to facilitate trade. But it also has downsides like too much crime and too much traffic congestion.

Perhaps the most important downside of urban density is the spread of disease. And for thousands of years cities have been trying to limit the awful costs of urban contagion. If you live in a city in the west, you probably view contagious disease as an annoyance, not a terrible life threatening scourge. If two people are close enough to exchange an idea face to face, they're also close enough to share a virus. Contagious diseases including cholera, AIDS and Covid-19 have slaughtered urban populations throughout the globe.

We now have tools, antibiotics, vaccines, aqueducts that have so far worked pretty well at preventing modern plagues. The one big exception was AIDS, which caused enormous damage to urban America during the 1980s and 1990s, and it still kills abundantly in Sub-Saharan Africa. If you live in a wealthy country, you are now far more likely to die from cancer than cholera, but that wasn't true in the past. In 1900, a boy born in New York City was still expected to live six years less than a boy born in the country side. That was about the same life expectancy gap that existed in the time of Shakespeare's London.

I’ll try to explore the contagious diseases that have often threatened cities. Why should you care why every sip of urban water doesn't carry the flavor of death? As Covid-19 reminds us, disease could strike again. And we need to be ready to fight back with the knowledge of how we fought disease in the past. You should also care about urban health because many of the developing world's cities remain remarkably unhealthy, and we're going to explore how to reduce illness in those places. You should care about urban death in Africa primarily because they're people, too. But perhaps also because plagues that begin in Africa might not stay in Africa. If we continue to treat waterborne illness with antibiotics rather than with better water systems, we may end up creating an antibiotic resistant superbug that could threaten all of mankind.

Finally, the story of urban health also matters because it helps us to understand how cities can work together to solve their own problems. The story of the fight against cholera remains relevant for thinking about the coalitions that could fight high housing costs today or excessive transportation congestion. Perhaps the most important advantage of urban proximity is that it enables us to work together to make our world better.

We celebrate many of the positive sides of urban life, but of course there are also demons that come with density. And certainly one of the worst of those demons is that when people live close to one other, diseases can hop from person to person-- being carried by animals or just in the water stream. And for thousands of years cities have been battling epidemics which have broken out occasionally. What are the first of these urban epidemics that we see in the historical record?

We talk about the plague of Athens as being an early plague in a city. Athens was a city-state and although I've never seen pictures of what Athens was like, I'm sure it was crowded. People massed together in public places to hear Pericles, among others. The sanitation in Athens was probably better than it was in most European cities that we are more familiar with. But still people were crowded together. Interestingly, we actually don't know what the "Plague of Athens" was. It certainly was not the bubonic plague or the Black Death. And since we don't know exactly what it was, we can't be sure about how it was transmitted.  But more than likely, the close proximity of people, the lack of what we call social distancing was a factor. So when people flock into the cities, it's inevitably going to cause a greater urban density and increase the chance of a spread of infection. And cities like Athens are also entry points; they're great ports that welcome in boats. Then those boats may themselves be carrying the plague. And then we have the big one, Justinian's plague in the sixth century 

You know, we're not going to talk about these other diseases, but for example, typhus during the more modern wars, in trench warfare-- huge toll. Malaria in World War II in the Pacific amphitheater took far more casualties than the war itself and was a major factor in who was prevailing. So there are a number of possibilities for why the plague seemed to have been disappeared for five centuries or so. I guess it's also a possibility that we had less of this because we had smaller cities, right? Europe greatly deurbanized after the fall of Rome. And you had a lot more social space.

What did urban governments--and typically, we think of many of the cities of this period, like Venice, for example, as having in some sense, the most effective governance of anything for its time. How did they respond to these plagues? The cities, in general, were really cesspools. Animals were living in the city. Slaughterhouses were in the city. The sewage was running in the gutter. People were throwing their, you know, feces and urine out the window. That's why, by the way, men walk on the outside in the streets. So they'll take the brunt of this onslaught. So the cities were really pretty foul. But Venice, the Doge, having a very well-organized government, did a lot of things which tell me that they understood it wasn't just miasmas and bad air. And so here are some of the things they did.

First, well, maybe it was the food, right? So they inspected wine, fresh meat, and the water. If you don't know, just inspect. Ships were boarded and searched for--I hate to say this in this time but-- foreigners. They didn't know to look for rats, but they looked for foreigners, those foreigners, and corpses. They improved the sewage. They had a sense that it wasn't good to have feces floating in the streets. So they improved the sewage. They had burial regulations, so the corpses were thrown into barges. For various diseases, these would be the right response, right? They happened not to be the right response, but-these are good responses.

These are good public health responses, that they controlled crowds. You couldn't have a religious procession without a license, even though people wanted to go out and manifest their faith in God to do something about the plague. Public drinking houses were shut down for two reasons. Folks thought that immorality was an invitation to God to punish you with the plague. But also, they're meeting places, they restricted beggars and prostitutes and told the military to stop carousing in the town. This is the first time people actually recorded the causes of death. This is a glimpse of modern epidemiology. If you start getting data, you can begin to look for patterns. And I thought that was very interesting. This reminds me of one of my favorite images from Venice, which is in the Doge's Palace, they have this wonderful room where they have these glorifying portraits of their notaries. And a society that believes its notaries are heroes is a society that believes in data.

They had a cordon sanitary. You had to have a health pass. It's like when you're in a classroom in the good old days, you'd have to have a green lavatory pass to go to the bathroom. You had to give a pass to get into Venice or to leave. They had an incident command structure. This is a very modern idea now for any pandemic. You establish a command and control center, just as you would in the military, that makes all decisions and makes sure everybody knows what they are. So, for example, if somebody had the plague, they painted the house with vinegar and fumigated it with sulfur. That sounds like they have an idea there's contagion there. The command center point is a point that's routinely made nowadays by Kennedy School experts on how you deal with disasters. So they, for example, will emphasize that the fire service, when they deal with fire, is just great at putting together this command and control. And this was a major failure in Katrina, was the failure to establish a clear command and control structure. 

It's very important and critical element in dealing with all sorts of disasters and they set up pest houses or lazarettos. They seized dwellings from people to set them up, and there was a formal board of health, which I haven't seen any earlier board of health. That's pretty incredible. So the degree of sophistication, we tend to paint people in the ancient days as ignorant. And they believe in miasmas. And they wear masks with big beaks with herbs in it so that they don't smell the miasmas. But they were actually cleverer than that.

Shabir Ahmad is a UPSC aspirant from Raiyar Doodhpathri.

DISCLAIMER: The views and opinions expressed in this article are the personal opinions of the author.

The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.

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