In April, British Prime Minister Boris Johnson became one of the first high-profile world leaders to contract the novel coronavirus. He was hospitalized for about a week, including several nervous days in an intensive care unit where, according to Johnson, “things could have gone either way.” The prime minister recovered and used the occasion of his eventual release from the hospital to praise the National Health Service—the United Kingdom’s government-run health-care system. “The NHS has saved my life, no question,” Johnson said. Although successive Conservative governments have sought to privatize parts of the NHS, the system has remained deeply popular and a source of national pride. Johnson piously insisted that the United Kingdom would fend off the COVID-19 pandemic “because our NHS is the beating heart of the country. It is the best of this country. It is unconquerable. It is powered by love.”
U.S. President Donald Trump struck a rather different note when he became sick with COVID-19. Unlike Johnson, his stint in the hospital did not fill him with great reverence for social institutions or public health infrastructure but rather an admiration for himself. “I think I would have done it fine without drugs,” he told Fox News after receiving a cocktail of sophisticated medications and steroids. “You don’t really need drugs.” The president reportedly told advisers that he wanted to emerge from the hospital wearing a Superman shirt to show Americans that he had, through the force of his own indomitable strength, conquered the disease.
Johnson’s and Trump’s opposite responses to recovering from COVID-19 are indicative of two different personalities, but they also reflect an ingrained difference between the United Kingdom and the United States. Johnson affirmed the notion that combating disease is the task of a whole society, while Trump viewed his fight with the coronavirus as an individual struggle. That difference manifests most powerfully today in the countries’ disparate modes of health care. British citizens enjoy universal health care mostly free at the point of service, whereas the United States predominantly has a byzantine system of private insurance pegged to employment. Johnson and Trump may both be right-wing populist leaders, but they rule countries with contrary understandings of the role of the state and the individual in health care.
The divide between the British and the U.S. approaches to public health was apparent as long ago as the nineteenth century, when another pandemic, cholera, ravaged urban populations around the world. British thinkers, journalists, and medical professionals connected the disease to troubling social conditions and came to the conclusion that curbing the pandemic required a broader societal response. Their American contemporaries, on the other hand, saw the disease in large part as a moral failing and the responsibility of individuals.
These different responses in the 1830s did not entirely determine either country’s system of health care or approach to public health, but they did trace the trajectories the two countries would take in delineating the responsibilities of the government and the individual regarding health care. Britons and Americans still live with the choices their countries made during that time.
CHOLERA AND THE SATANIC MILLS
In 1831, cholera moved quickly from Central Asia through Europe and then to the United States. Newspapers on both sides of the Atlantic followed its deadly course in grisly detail. The pandemic was truly horrific: people who were seemingly healthy in the daytime would be dead by nightfall. In the United Kingdom, cholera swept away thousands in just hours. Desiccated bodies—the disease causes severe dehydration—lay strewn in the streets.
The British public linked the appearance of cholera to other crises overtaking the country. Beginning in the 1780s, hundreds of thousands of people left the countryside for booming industrial textile towns, such as Leeds and Manchester, where they lived in slums and worked for near-starvation wages. While they suffered, their labor produced great wealth for some in the expanding British economy—the merchants, factory owners, importers, and bankers.
The development of factories displaced and shattered rural communities and funneled people into truly unsanitary environments. The “dark satanic mills” that William Blakedescribed in the preface to his 1810 poem, “Milton,” loomed large in the British imagination in the years before the cholera pandemic. Throughout the nineteenth century, Conservative and Whig politicians, political philosophers such as Jeremy Bentham and John Stuart Mill, and writers such as Charles Dickens debated the merits of and the destruction wrought by Britain’s sprawling new landscape of power looms, cotton gins, and steam- and water-powered factories, all built on the backs of laborers who lived and died in horrendous conditions.
The health of the worker became a poignant symbol of the excesses of capitalism. As Frederich Engels, himself an heir to a Manchester textile factory, wrote in his classic 1845 book, The Condition of the Working Class in England, it was “self-evident that a social class which live under the conditions that we have described and is so poorly supplied with the most indispensable necessities of existence can enjoy neither good health nor a normal expectation of life.” The ravages of cholera in London, Manchester, and other industrial centers alerted the public to the depths of a social crisis in which the industrial economy and its malign distribution of wealth enabled the spread of disease.
Despite Engels’s outrage, the suffering of the poor did not result in the overthrow of capitalism—but it did lead to a discussion about the responsibilities of the state in shaping the environment in which people lived and the services they received. In the wake of the cholera epidemic in the 1830s, social reformers such as Edwin Chadwick took note of the disintegrating health and well-being of large swaths of Manchester’s working class and began pressing for new housing laws and major investments in sewer systems, street cleaning, and water supplies.
In 1842, Chadwick published a 536-page report called The Sanitary Condition of the Labouring Population of Great Britain, which would inspire enormous infrastructural investments in British cities in the coming decades. Chadwick refused the narrow definition of sanitation—sewers, water supply, and garbage collection—in favor of a broad survey of the underlying conditions affecting housing, nutrition, and labor. His report suggested that the factors contributing to the diseases that killed the urban poor included such things as the construction of homes, the conditions in factories, and air quality. “These many subjects,” he wrote, “cannot be . . . overlooked in any report on the sources of disease among the laboring classes.”
In linking disease, the environment, and social policy, Chadwick set the stage for rethinking the role of government and public health in people’s lives. By the middle of the nineteenth century, doctors such as John Snow would realize that changing the environment—for instance, by taking the handles off water pumps and disabling them in streets served by polluted stretches of the Thames River—was the most effective way to address disease. Chadwick’s efforts helped convince many Britons that matters of health were embedded in social conditions, leading in the twentieth century not only to the NHSbut also to public health services that were integrated into a broader social welfare system.
MEETING CALAMITY WITH SERENITY
The cholera epidemic did not prompt a comparable meditation on the responsibilities of the state on the other side of the Atlantic. U.S. newspapers reported the progress of cholera across Europe, detailing the rising number of deaths in London, Paris, and other European cities, but Americans remained largely untroubled by the prospect of the disease’s arrival. “Whether pestilence assails us in its most appalling form or whether under the favor of the Almighty, we escape altogether, or if peradventure in should please Divine Providence to bring calamity home to our doors, we and our fellows citizens will meet it with serenity,” the New York City Board of Health, a temporary body established for but a few months in the summer of 1832, gently reassured the population.
The epidemic soon spread. Religious leaders, state and local politicians, and even President Andrew Jackson called on the nation to observe “a day of fasting, humiliation, and prayer” and to go to church to ask God’s forgiveness as the means of ending the epidemic. As the weather grew colder, contemporaries believed their prayers were “answered” as the epidemic receded. Boards of health around the country told “their fellow citizens, that they consider the Health . . . so far re-established as to render the further continuance of their daily reports unnecessary.” Officials who were worried about the persistence of the disease generally took solace in the belief that it really affected only “the dissolute and intemperate” or that in smaller communities, such as Oyster Bay in Long Island, victims of cholera were “all Blacks.” Personal frailty and racism helped explain away the threat of the disease and assuage the fears of white citizens.
But by the middle decades of the nineteenth century, the toll of cholera and other epidemics in the United States had become undeniable. Cholera, typhoid, and yellow fever swept through cities along the East Coast and along the trade routes up and down Mississippi River towns from New Orleans to Minneapolis. As many as 48 people died for every 1,000 residents in New York City during these epidemics and thousands more, both infants and adults, Black and white, died in the rural South and Midwest. Scholars such as John Griscom in New York and Lemuel Shattuck in Boston surveyed their cities and found some of the same conditions that Chadwick identified across the ocean. Griscom wrote The Sanitary Condition of the Laboring Population of New York in 1844, two years after Chadwick produced the similarly titled report in the United Kingdom. Griscom celebrated Chadwick’s approach but gave it a special and telling American slant. He emphasized to his American readers that improving the social conditions of the poor would uplift their moral standing; the purpose of fighting disease, he argued, was in large part to make a more virtuous society. Would not education, for example, instruct the poor to avoid filthy habits and therefore disease? “Teach them how to live, so as to avoid diseases and be more comfortable,” he wrote. Although he recognized that social circumstances influenced health outcomes, Griscom still saw the poor and their habits as the root of the problem. Unlike in the United Kingdom, where disease was being cast as a social problem whose reach might extend across classes, in the United States, disease was still perceived as trouble for those deemed the “unworthy poor.” Those of high moral character and the wealthy were generally not thought to be at risk.
THE WORTH OF THE INDIVIDUAL
The United States adopted stratified systems of care informed, in part, by the notion that poor health signaled personal moral failing: private health insurance served the wealthy and the fully employed; Social Security and Medicare helped the aged and others who might have suffered through no fault of their own; and welfare and Medicaid tended to the so-called unworthy. Americans tied the provision of health care to the moral and social worth of the individual. Dwight Moody, perhaps the most popular and influential revivalist preacher in the United States in the 1870s, spoke to enormous, largely middle-class audiences in Boston, Chicago, and New York City and explained to them that there was so much “great misery and suffering” in their cities because “the sufferers have become lost from the Shepherd’s care”—not because millions were being squeezed into crowded tenements or because of the wider consequences of the inequalities of an emerging urban, industrialized society. In the following century, American charity workers, social policy experts, hospital administrators and trustees, and others in the middle-class professions and the political elites would distinguish between those people who had become dependent and sick because of circumstances beyond their control—the so-called worthy or deserving poor (or the “truly needy” in President Ronald Reagan’s words)—and those who brought suffering upon themselves through their own moral failings—the unworthy or undeserving. As a result, many American institutions, including hospitals and social services, tend to perceive suffering in highly individualized terms. In the United Kingdom, by contrast, from fierce debates among reformers, radicals, Conservatives, Whigs, and workers arose a new social welfare state that treats health and economic inequality as fundamentally linked and tasks the government with a major redistributive role.
The social and health crises of the nineteenth century thus created disparate futures for the United Kingdom and the United States. Today, as Trump and his acolytes dismiss the recommendations of public health officials as infringements on their personal liberties, they echo an earlier time, when Britons and Americans grappled with epidemics and came to very different conclusions. The United Kingdom’s success in reckoning with COVID-19 now depends on the marshaling of the resources and authority of the state to protect individuals—the collective enterprise that Johnson recognized after he left the hospital. In the United States, on the other hand, over 70 million Americans voted for a president who tried to convince them—in the face of all evidence—that his own virtuous conquest of the disease was proof that they had little to worry about.
This article was originally published on ForeignAffairs.com.
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