Introduction

On August 24, 1892, senators of the Prussian city of Hamburg summoned the renowned discoverer of the cholera bacillus, Robert Koch, to help them control an explosive cholera outbreak. More than 17,000 cases appeared in just a couple of weeks, leading to more than 8,000 deaths by the time Koch arrived. As international sanctions against the port's shipping operations unfurled, the epidemic threatened to undermine the city's economic vitality. High costs and slashed company profits motivated laissez-faire business leaders to risk scrutiny by Koch, his assistants, and their unforgiving microscopes. In just a few days Koch demonstrated that water purification by the sand filtration system installed in Altona, just across the Elbe, kept that city cholera-free. Altona, moreover, drew fouled water from the river after it flowed past Hamburg with its discharged waste, which should have made Altona more at risk to any waterborne epidemic. Canvassing the stricken Hamburg, Koch confided in a letter to his future wife, "I felt as if I was walking across a battlefield." To his companions and trailing members of the international press, he declared, "Gentlemen, I forget that I am in Europe" (Evans 1987: 312–13).¹

Koch's work in Hamburg reinforced an argument that the failure to control preventable disease was a failure of governance.² Public health authorities who subscribed to this view throughout Europe and North America seized on Koch's findings. For example, the Boston sanitary engineer Allen Hazen (1895) summarized the evidence that an official Prussian commission had produced in the wake of the Hamburg epidemic. Hazen also assembled data in the 1890 U.S. census related to the mortality rates from typhoid fever. Selecting cities with more than 50,000 inhabitants in the registration states, Hazen (ibid.: 210–12) showed that 46 of 54 cities in the United States had typhoid mortality rates higher than any large city in transalpine Europe. By the turn of the century less dramatic, but nonetheless embarrassing, high mortality from waterborne diseases led U.S. cities to confront the necessity of publicly funded sewage treatment and refuse removal (Cain and Rotella 2001). Data about deaths and their causes became available points of comparison, spurring (among other things) national pride, municipal action, and focus on the reliability of reported causes of deaths.

Koch's intervention coincides temporally with the decline of adult mortality in privileged Western nation-states: the middle phase of a multicentury demographic transition (Smith 1993). We now know that this reduction of mortality necessarily preceded a later fertility transition. Mortality decline always occurs earlier, though at varying schedules for different nations and regions across the twentieth century (Reher 1999, 2004). And the essence of this great mortality transition is captured in the aftermath of Hamburg's 1892 health crisis: after politicized attention to Hamburg's pestilential embarrassment, both infant mortality and overall mortality in Hamburg plummeted. Infant mortality rates dropped from about 250 per 1,000 live births in 1890 to about 180 in 1895. Overall, general death rates per 1,000 declined from nearly 26 in 1890 to 18 in 1895 to just under 17 in 1900 (Haines and Kintner 2000).

Between the Franco-Prussian War of the early 1870s and the onset of the Great War, shame attached to physicians, public health authorities, and even national governments when they failed to attend what were known to be treatable causes of mortality among their citizens. But knowledge about disease identification, disease causes, and available remedies often diffused within professional, social, and cultural enclaves. As a result, improvements to public health and noticeable decline in mortality in any age group fall along historically varying schedules, both local and national, of the first phase of the modern demographic transition. Moreover, case studies of cause-specific mortality over the later nineteenth century have not proved conclusively that falling mortality rates were due principally to improvements in sanitary infrastructure, because alternative explanations cannot be ruled out (Beemer et al. 2005). Even at the time the evidence for competing public health strategies, such as hospital isolation, could be difficult to evaluate (Eyler 1987). Thus the mortality transition...