Contagion and the State in Europe, 1830-1930 (review)

Peter Baldwin. Contagion and the State in Europe, 1830-1930. Cambridge: Cambridge University Press, 1999. xiii + 581 pp. $69.95.

If epidemic diseases are universal biological phenomena, the work of stateless germs, why then do the responses of states to them vary with what Peter Baldwin calls a "polymorphous perversity" of entangled rationales and practices (p. 525)? In reflecting on the variety of responses to cholera, plague, and yellow fever by mid-nineteenth-century medical scientists, Erwin Ackerknecht suggested in 1948 that this was a situation in which the facts available did not allow a rational choice between competing contagionist and anticontagionist etiologies. ¹ There was consequently recourse to ideology: contagion and quarantine persisted in authoritarian states, while more liberal states (e.g., England) rejected commerce-stifling quarantines and viewed the same diseases as having environmental causes and remedies. The so-called Ackerknecht thesis flourished, but it also changed over the years. A growing appreciation of medical thought as cultural, social, and political made it seem plausible that the links Ackerknecht identified might prevail whatever the epistemic status of the rival theories; indeed, that those theories were necessarily and not incidentally wedded to the rival polities. Surely authoritarian governments would express their authority by seeking to control human action, while liberal governments would put disease out of business with reforms. Thus, to those for whom etiology was inherently ideological, the Ackerknecht thesis, which had originally carried little axiomatic baggage, became a prescient exemplar. Even if it were not quite right, it was eminently plausible, an elegant correlation of ideas, actions, and political structures that worked well in the lecture room. But it gained that status without thorough empirical test.

This expanded and transformed Ackerknecht thesis is the departure point of Peter Baldwin's magisterial study. Baldwin examines three diseases--cholera, smallpox, and syphilis--in four places: Britain, France, the German states (and later the united Germany), and Sweden, over the course of a century. While this is not primarily an archival book, and while it is concerned more with policy than with action, in terms both of secondary and of published primary he examination is carried out with unprecedented thoroughness.

Space precludes a close review of Baldwin's nearly five hundred pages of findings; his conclusion, however, is that the expanded Ackerknecht thesis is inadequate empirically and incoherent conceptually. Viewed from a distance, it seems to fit in some cases, but not in others, and where it apparently fits, a closer view discloses complications. A state's response to a disease changes with time; the tendencies one sees in one disease are not replicated in others. In the case of smallpox the liberal, sanitarian English seek to impose mandatory vaccination; on grounds of personal liberties, the centralized French state refuses to mandate vaccination--at least until the end of the century, when it has become more liberal. Many more groups than the autocrats and liberal merchants who loom large in Ackerknecht's account are involved, and their interests and concerns are vastly more manifold: class relations, population distribution and flux, and religious movements are important factors in various places. Even merchants, notes Baldwin, reacted in more complicated ways than we have been led to expect: quarantines were not necessarily problematic for them, though inequitably applied quarantines were; and if environmental reforms interfered too much with warehousing or distribution, quarantine might be the preferred option. Cost was a factor in selecting prophylactic policies: quarantines, or vaccination, or targeted inspection were usually vastly cheaper than more comprehensive reforms.

More important than the disclosure of anomalies, however, is Baldwin's conceptual brush-clearing. The grand categories that have governed debate are here exposed in their true ambiguity: "The issue was thus not one of interventionism vs. laissez-faire, action vs. inaction, authoritarianism vs. liberalism, but of different forms of intervention, some more drastic and apparent, others more subtle, but nonetheless effective for that" (p. 535). One...