Yellow Fever and Public Health in the New South

John H. Ellis

• Publisher: The University Press of Kentucky
• Year: 2021
• Print ISBN: 9780813117812
• eBook ISBN: 9780813188423
• Topic: Medicine
• Subtopic: North American History

The public health movement in the South began in the wake of a yellow fever epidemic that devastated the lower Mississippi Valley in 1878—a disaster that caused 20,000 deaths and financial losses of nearly $200 million. The full scale of the epidemic and the tentative, troubled southern response to it are for the first time fully examined by John Ellis in this new book.

At the national level, southern congressional leaders fought to establish a strong federal health agency, but they were defeated by the young American Public Health Association, which defended states' rights. Local responses and results were mixed. In New Orleans, business and professional men, reacting to the denunciation of the city as the nation's pesthole, organized in 1879 to improve drainage, garbage disposal, and water supplies through voluntary subscription. Their achievements were of necessity modest.

In Memphis—the city hardest hit by the epidemic—a new municipal government in 1879 helped form the first regional health organization and during the 1880s led the nation in sanitary improvements. In Atlanta, though it largely escaped the epidemic, the Constitution and some citizens called for health reform. Ironically their voices were drowned out by ritual invocation of local health mythology and by unabashed exploitation of the stigma of pestilence attached to New Orleans and Memphis. By 1890 Atlanta rivaled Charleston and Richmond for primacy in black mortality rates.

That the public health movement met with only limited success Ellis attributes to the prevailing atmosphere of opportunistic greed, overwhelming debt, economic instability, and inordinate political corruption. But the effort to combat a terrifying disease not fully understood did eventually produce changes and the vastly improved health systems of today.

1

Beginnings of the Public Health Movement

The public health movement in the South originated in the aftermath of the lower Mississippi Valley yellow fever epidemic in 1878, one of the worst disasters in American history. This study will assess the movement’s early development during the period 1878–88 by focusing on the responses of New Orleans, Memphis, and Atlanta to the crisis of the epidemic and to the ensuing denunciation of southern cities in the national press as dens of filth, pestilence, and death. The movement was distinctive in ways peculiar to the region and to the cities. Each city represents a particular era in southern history—the Anglo-French struggle for empire, the day of the land speculator and river flatboat, and the advent of the railroad—and the response of each was unique. Led by businessmen and physicians, the public health movement sought to reduce the economic and social costs of the South’s long-standing reputation for sickliness and high mortality through sanitary reform, thereby ushering in a new era of health, prosperity, and progress. For guidance in their endeavors, the southerners looked to the earlier experiences of sanitarians in the North and in England, a crucial development in itself.

The sanitary campaign of the nineteenth century, the forerunner of the modern public health movement, followed the rise of an urban industrial economy. “The transformation of society by the industrial revolution,” writes John Duffy, “compounded virtually every urban social problem.”¹ In England, where the movement began, London, Liverpool, and Bristol grew rapidly between 1800 and 1830. But the rise of the inland factory cities—Birmingham, Manchester, Sheffield, and Leeds—was even more spectacular. “By the early 1830’s,” notes a British labor historian, “seven Manchester cotton firms each employed more than 1,000 workers, a further thirty more than 500 and forty-six more between 200 and 499.”² According to George Rosen, the Poor Law Amendment Act of 1834 served its immediately intended purpose of reducing the poor rates, yet it also directed an ever-increasing flow of population from rural areas to the factory towns and port cities.³ Then in the 1840s, with the English cities already overwhelmed by growth, thousands of starving Irish fled their famine-stricken homeland to compete with native migrants for employment and for housing in the cities’ crowded cellars and tenements.⁴

The initial response of large numbers of the well-to-do and middling classes to the social transformation of their cities was to retreat to the suburban periphery or to nearby rural settings, thus abandoning the increasingly congested districts to become working-class slums. One observer, describing Manchester in 1832, noted the residence of a few wealthy families in midcity, “but the opulent merchants chiefly reside in the country, and even the superior servants of their establishments inhabit the suburbal townships. Manchester, properly so called, is chiefly inhabited by shopkeepers and the labouring classes.”⁵ In a report to the House of Lords in the early 1840s, a committee of medical men said of Birmingham that “the more opulent inhabitants reside in the surrounding country; comparatively few live in the town.”⁶ More families in easy circumstances lived within Sheffield and Leeds, yet even there the neighborhoods of the well-to-do were distinctly segregated from the quarters of the working poor. But in Manchester, “at the very moment when the engines are stopped, and the counting-houses closed, everything which was the thought—the authority—the impulsive force—the moral order of this immense industrial combination, flies from town, and disappears in an instant.”⁷

In the working-class districts, whole families—men, women, and children—working for pittances in the workshops, foundries, and cotton and woollen mills and living at the margin of existence, crowded into single rooms and slept as many as five to a bed. A newspaper correspondent noted in 1849 that thirty thousand of Birmingham’s poorest lived in about two thousand congested, disease-breeding courts.⁸ Sanitary provisions were correspondingly meager. Numerous families might share a single privy or, lacking that, a “necessary” tub. Waste from overflowing privies and cesspools saturated the soil and seeped into cisterns and wells, contaminating the only sources of water. Tenement courtyards, streets, and alleyways served as depositories of household slops, accumulations of animal dung, and the offal of markets, butcher shops, and saloons. Under such squalid conditions, the teeming slums of Birmingham and Manchester, like the waterfront districts of Liverpool and Bristol, became hotbeds of infectious disease. Health conditions in the workplace were bad also, especially for women and children. Consequently, during the 1830s and 1840s the death rates in cities shot upward, and that in Birmingham almost doubled.⁹

In general, city residents of the comfortable classes took a complacent view of disease in the slums, regarding it as a just requital for the alleged immorality and viciousness of the working poor. Any risk to themselves seemed to be minimized by physical and social distances. This outlook was severely shaken, however, by epidemics of Asiatic cholera in 1831–32, which paralyzed the cities and disrupted manufacturing and trade. The inhabitants of the crowded dock districts and industrial neighborhoods bore the brunt of suffering and misery, but cholera also claimed victims among those of social standing and moral habits. The importance of the cholera epidemics for the beginning of the sanitary movement can hardly be exaggerated. More than any other events, they eventually brought thoughtful members of the upper and middle classes to the conviction that sickness and festering conditions in the slums threatened their own lives as well as those of their families and friends.¹⁰

Believing that administrative precision was necessarily based upon exact statistical evidence, the English disciples of Jeremy Bentham, the prophet of utilitarianism, instituted registration of vital statistics in 1831.¹¹ Then, by applying “political arithmetic” to morbidity and mortality rates, they concluded that disease itself was a major cause of pauperism, which was in turn related to the evils of vice and crime. Since sickness and premature death increased the number of a community’s widows, orphans, and other dependent persons, it seemed clear that one cost of a high death rate was a high tax rate. Seeking further to refine their analyses and to determine precisely the costs of ill health, the statisticians assigned numerical values to human life and activity. Such factors as days of productive labor lost to sickness, costs of medical and nursing attention, and the expenses of burials were figured into the complex equations. The result of these calculations seemed to indicate that excessive mortality rates were a form of preventable loss that acted as a drag on industry and commerce and retarded a community’s prosperity. Thus, one of the most powerful ideas of the sanitary movement was the belief that “health is wealth.”¹²

There is good reason to question the standard interpretation of the movement, which holds that physicians and the medical profession generally played a secondary role.¹³ It is true that throughout most of the nineteenth century the medical profession engaged in bitter internal disputes over three partially erroneous theories of disease causation. Contagionists adhered to the position that infections and epidemics were caused by specific disease entities, or contagia. Anticontagionists attributed epidemics of infectious disease to miasma, an infected state of the atmosphere that induced disease through human respiration. Adherents of this position believed that foul, noxious “emanations” from decaying organic matter combined with certain atmospheric conditions to produce the deadly miasma. Contingent-contagionists took the eclectic view that the operations of either specific or nonspecific agents of infectious disease were contingent upon their relation to atmospheric, environmental, and social conditions.¹⁴

Therefore, according to the standard view, physicians were able to contribute little tangible knowledge to health problems, and medicine’s role in the public health movement remained secondary. The pioneering studies of health conditions in the cities, forerunners of the sanitary survey, however, were the work of physicians. C. Turner Thackrah of Leeds, in The Effects of Arts, Trades and Professions and of Civic States and Habits of Living on Health and Longevity (1831), and James Philips Kay, in The Moral and Physical Condition of the Working Classes of Manchester (1832), exposed the stark wretchedness of working and living conditions associated with high mortality rates. Southwood Smith, physician and Benthamite, was the moving spirit behind the organization of the Health of Towns Association. Young William Farr, who would have an enormous influence on medicine in Victorian society, expressed his belief in the mid-1830s that the medical profession was witnessing the dawn of a new age. “There is, in short,” he wrote, “a general movement in the profession. Medical men live less for themselves, and more for mankind.”¹⁵ The movement in various communities, according to G. Kitson Clark, “suggests the importance of the influence of the local medical men.”¹⁶

The outstanding figure in the English sanitary movement, Edwin Chadwick, was a zealous Benthamite crusader for administrative reform in government and in social policy.¹⁷ While serving on the Poor Law Commission in the 1830s, he instigated and largely directed a study of health conditions among the working classes of England and Wales. The result was the commission’s massive Report on an Inquiry into the Sanitary Condition of the Labouring Population of Great Britain (1842). This document, a landmark in the history of the public health movement, set forth an interpretation of data drawn from the anticontagionist theory of disease causation to which Chadwick personally subscribed. It showed an essential relation between disease, mortality, and bad sanitary conditions: poor drainage and pollution of the soil by human waste, inadequate and contaminated water supplies, and accumulations of filth and debris in courtyards, alleyways, and streets. In one portion of the report Chadwick emphasized the preventive value of sanitary reform, insisting that “drainage, street and house cleansing by means of supplies of water and improved sewerage, and especially the introduction of cheaper and more efficient modes of removing all noxious refuse from the towns, are operations for which aid must be sought from the science of the Civil Engineer, not from the physician, who has done his work when he has pointed out the disease that results from the neglect of proper administrative measures, and has alleviated the sufferings of the victims.”¹⁸ Carried out under the administrative authority of boards of health, these basic measures would result in savings, greater capital formation and economic growth, and the prosperity of cities and nation. The gospel of public health elaborated in Chadwick’s principles inspired sanitarians throughout the nineteenth century.¹⁹

Meanwhile, social deterioration in the cities marked by poverty, overcrowding, crime, disease, and rising mortality aroused further the apprehensions of the upper classes. The revelations of a parliamentary Select Committee on the Health of Towns and the subsequent report of a royal commission headed by Sir Robert Peel led directly to the formation of several voluntary associations that addressed themselves to social problems. Among these, one of the most important was the Health of Towns Association organized in 1844.²⁰ Its leadership included titled nobility and men of wealth, but the rank and file was drawn from members of middle-class business and professional occupations: merchants, bankers, lawyers, physicians, and clergymen. These sanitarians, as they came to be called, waged a vigorous campaign to educate and enlist public opinion in obtaining health reform legislation. Their initial endeavors, however, encountered the opposition of vested interests and met with discouraging results.

Then, when a horde of sick and starving Irish famine refugees descended on Liverpool in 1846, the emergency brought enactment of the realm’s first comprehensive health law, the Liverpool Sanitary Act. The sponsoring Health of Towns Association subsequently intensified its efforts, appealing to the English working class to demand further action from Parliament. This campaign, together with news of devastating cholera epidemics on the Continent, secured passage of the monumental Public Health Act of 1848. The law created the National Board of Health, which was empowered to establish local boards with authority over sanitary matters. A major victory for the sanitarians, the Public Health Act of 1848 served as a benchmark for the development of English public health administration during the next quarter century. Humanitarian sentiment was of much less importance in the movement than the applied principles of political economy and social utility advocated by Jeremy Bentham and the Philosophical Radicals. From the perspective of an emerging urban industrial bourgeoisie, epidemic diseases and excessive mortality were preventable causes of economic loss and social disorder.²¹

The sanitary movement in the United States began in response to urban conditions similar to those in England. In 1800 serious health problems related to poor sanitation and infectious diseases, including yellow fever, were nothing new to the young nation’s former colonial cities.²² “From the standpoint of American public health,” writes John Duffy, “the period from 1793 to 1806 deserves to be known as the yellow fever era.”²³ During those years the disease ravaged Philadelphia, New York, Baltimore, and even New Haven, resulting in the establishment of early health organizations and bringing about modest sanitary reforms. Over the next three decades, however, the impact of developments in transportation on commerce and industry brought stressful growth to New York, Boston, Philadelphia, and Baltimore. By 1830 older, uncongested, and intimate patterns of residence and relationships in the cities were being supplanted by crowding, segregation, and anonymity. Thus, the earlier health reforms inspired by yellow fever were undermined by emerging industrialism and a burgeoning philosophy of individualism.²⁴

In New York hogs roamed the garbage-strewn streets, privies were common visual and olfactory landmarks, and residents jokingly referred to the city’s water source as a sure purgative. But the worst sanitary conditions in the cities existed in districts where blacks, Irish immigrants, and native white laborers crowded into shabby tenements and damp cellars.²⁵ Citizens in comfortable situations viewed these districts as dens of sin and iniquity where a just God occasionally punished the miserable inhabitants by visitations of disease and death. Yet in New York, as in Liverpool and Manchester, this outlook was challenged by an epidemic of Asiatic cholera in 1832 and again in 1849.²⁶ When upstanding, moral members of the community fell victims, infectious disease acquired a new significance, a more important, personal meaning.

“Sanitary change in the antebellum United States,” argues James Cassedy, “was stimulated by many forces. However, as a self-conscious reform movement in the 1840s and 1850s it got its primary impetus from the dynamic, numerically based, and politically effective sanitary movement which had begun in Great Britain about a decade earlier.”²⁷ As in England, pioneering studies of ...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• List of Tables and Illustrations
• Preface
• 1 Beginnings of the Public Health Movement
• 2 The Necropolitan South
• 3 The Epidemic of 1878
• 4 The Quest for National Health Legislation
• 5 The New Orleans Sanitary Association
• 6 Tales of Romance from Memphis
• 7 The Sanitary Question in Atlanta
• 8 Public Health in the New South
• Notes
• Index