Comparing Pandemics (Part Two)

Autor: Samuel J. Williams

Learning from Cholera: On Erwin Ackerknecht

Frédéric Keck identifies a significant difference between a logic of pandemic preparedness in East Asia and a logic of prevention prevalent in Europe. Yet comparing recent responses to COVID-19, the differences between European countries are also striking.

Why, given shared medical knowledge, might countries in Europe choose different strategies for mitigating epidemic disease?

Although not well known today in anthropology, historians studying this question have sometimes found it helpful to address the work of an erstwhile anthropologist, Erwin Ackerknecht (1906-1988).

A graduate in medicine from the University of Leipzig (with a thesis on Rudolf Virchow) and a committed Trotskyist, Ackerknecht trained as an ethnologist at the Musée de l'Homme under Marcel Mauss, Lucien Lévy-Bruhl, and Paul Rivet. Fleeing the German occupation to the United States, he worked for a time as Assistant Curator of Anthropology at the American Museum of Natural History, where Franz Boas had found his first job in New York more than a generation earlier. Unlike Boas, however, Ackerknecht wasn’t able to secure a permanent position in any anthropology department. Instead, he developed his comparative approach to medicine as a human science—combining Sozialmedizin, French ethnologie, and Boasian anthropology—as an historian of medicine, initially at the University of Wisconsin and later in Zurich.

Ackerknecht published widely, but the paper historians tend to cite is a lecture he presented in 1947 to the American Association of the History of Medicine. Having devoted much of the previous two decades to medicine in small-scale societies—exploring how people find medical beliefs and practices compelling not so much because they work but because they fit with other non-medical beliefs and practices—Ackerknecht turned to a puzzle in the intellectual history of nineteenth-century Europe: comparing how different countries responded to cholera.

If SARS was the first pandemic of the twenty-first century, cholera proved a defining pandemic of the nineteenth century. First emerging out of the Ganges Delta in 1817, cholera spread by land and sea along the trade routes of a transforming world economy, killing millions in six great outbreaks that punctuated the century and spanned every inhabited continent.

By century’s end, the outbreaks were less lethal, thanks in no small part to ground-breaking work by Louis Pasteur and Robert Koch in the 1870s and 1880s. Koch’s isolation of the cholera baccilus in 1884 was a landmark in the scientific triumph of the germ theory of disease.

Nineteenth-century debates on the aetiology of epidemic diseases like cholera swung back-and-forth between the poles of ‘contagionism’ and ‘anti-contagionism’. Pasteur and Koch stressed physical contact but other scientists focused on the causal role of unhealthy living conditions, insisting that these diseases could proliferate without direct contact through ‘miasma’ or bad air.

The scientific chronology is not straightforward. On the one hand, well-before the discoveries of Pasteur and Koch, contagionism had already begun to consolidate internationally as the received medical wisdom on cholera. Indeed, the intellectual heyday of anti-contagionism was much earlier, in the first half of the century. On the other hand, the established scientific position varied considerably between countries, especially during early cholera outbreaks, but even in the decade immediately following Koch’s breakthrough.

Ackerknecht’s Thesis is that this variation in scientific beliefs about cholera—from the disease’s aetiology (contagionism vs anti-contagionism) to the most effective methods of prophylaxis (quarantinism vs sanitationism)—followed the shifting faultlines nineteenth-century European politics.

Compulsory sequestration, creation of cordons sanitaires and the battery of other quarantinist tactics traditionally marshalled against the threat of contagion were readily embraced for cholera in authoritarian polities like Prussia and Austria. Popular with military and bureaucratic elites, these forms of state intervention were typically resisted by commercial interests. In more liberal states like Britain and the Netherlands, these new classes were amassing political power. It was here that new forms of sanitationist response developed and anti-contagionism was consolidated as the establishment view. Emphasising voluntarism over compulsion and civil society over state, sanitationists responded to cholera by encouraging hygienic reform in those locales where cholera cases clustered, focusing on how people related to the environment at a local level (waste disposal, water supply, housing patterns).

Ackerknecht’s argument is often glossed as a Manichean opposition between liberal sanitationism and autocratic quarantinism, positions that fluctuate in line with the great political arc of revolution and reaction across the century. The characterization is not unfair, but there’s an intellectual subtlety to how Ackerknecht makes this argument. Until Koch’s discoveries in the 1880s, the science was equivocal – European countries had a shared medical knowledge, but by the same token, shared medical uncertainties. Ackerknecht’s claim is that states differed in their epidemic response, not because politicians chose to weigh the science differently against competing interests, but because, faced with these real uncertainties, countries made sense of the science differently, filling in the gaps and figuring out what mattered in terms of larger, shifting political ideals of how the world should work.

Surveying the subsequent half century of historical research on responses to pandemics in Europe, Peter Baldwin (1999) reflects that “the Ackerknechtian position… is a powerful and elegant argument that continues in enviable historiographical health.”

One of the foremost experts on the cholera outbreaks Ackerknecht studied, Baldwin suggests that what scholars find so compelling in Ackerknecht’s Thesis is an abiding tension in how Europeans have struggled to make sense of the threat of pandemics: “on the one hand, a view of [epidemic] disease as an imbalance between humans and the environment whose prevention requires a reequilibration… [and on the other, an understanding] of [epidemic] illness as the outcome of a specific external attack on the autonomous integrity of the body which … [can] be rendered innocuous, from the community’s point of view, by ensuring the victim does not infect others.”

Perhaps in Frédéric Keck’s terms these are just two modalities of a logic of prevention, but analysis of this tension may prove helpful in comparing why European states respond so variously to epidemics. The ultimate lesson Baldwin draws from studying a century of public health responses to contagious disease is “to each nation its own preventative strategy.”

Indeed, Baldwin’s final chapter, ‘The Politics of Prevention’, is an intriguing companion piece to Keck’s book. Flipping Ackerknecht’s Thesis on its head, Baldwin ventures that correlations between prophylaxis and politics in European history are not because national traditions of epidemic response have been shaped by different political cultures, but because European states have been critically shaped by what they’ve learnt from different histories of contagious disease.

References

Ackerknecht, Erwin H. 1948. Anticontagionism between 1821 and 1867. Bulletin of the History of Medicine 22(5): 562-593.

Baldwin, Peter. 1999. Contagion and the state in Europe, 1830-1930 (Cambridge, UK: Cambridge University Press).