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Published On November 10, 2020

POLICY

Rage in the Streets

Are there echoes of the “cholera riots” in the age of COVID-19?

Russia faced an outbreak of cholera in 1831. At its peak, when it was killing some 600 people per day, rumors began to spread that the disease had been unleashed on purpose, to cull the poor who were dependent on public coffers. Doctors were prime suspects, and crowds of angry people, cut off from their livelihoods by quarantines and travel checkpoints, began to riot. Demonstrators in St. Petersburg gathered in Sennaya Square and accused the city’s doctors of poisoning wells. They sacked the main cholera hospital, murdering several of the physicians inside.

Any violence against health care workers during a pandemic is an extraordinary tragedy. Such attacks are not, however, only an artifact of the distant past. The International Committee of the Red Cross has recently reported more than 600 notable acts of violence against health care workers during the COVID-19 pandemic, including a case in Pakistan where the family blamed a doctor for one patient’s death, called the disease a hoax and assaulted the hospital. In Mexico, many doctors and nurses ride bicycles to work to avoid potential attacks on public transportation.

The “cholera riots” of 1831-1832 were the high-water mark of collective violence against physicians, and the levels it reached have mercifully not been repeated. But the event may have lessons to teach about mistrust towards medicine in a health crisis, not the least of which is the atmosphere—a mix of rumor, political mishandling, vulnerable populations and a desperate fear—in which those attacks could incubate.

After the Russian episode in 1831, cholera spread rapidly through Europe and brought civil unrest where it touched down, with riots breaking out in Hungary and France. When the disease arrived in the United Kingdom, it was again the medical establishment that became the primary target of public outrage, a state of affairs, curiously, that was related to the country being among the most advanced centers for medical study in the world.

Many of the first cases were concentrated in London, but Liverpool soon became a center of the outbreak. The bustling city had recently emerged as a hub of the world’s cotton trade, and its population had grown dramatically in a short time. But many of the new inhabitants were poor and lived in crowded conditions, often in basements with no sewage or waste removal. These conditions were ideal for cholera, which is characterized by diarrhea that is highly infectious.

Physicians followed the coming of the disease with great interest, yet they were locked out of the initial public health response. Liverpool had established a Central Board of Health that contained no doctors at all. When the board finally created a forum for the medical community, one of those in attendance, a Dr. James Collins, said that it was an insult during a medical emergency for physicians to have “to take the law from, and give passive obedience to the decree of a few fat-bellied magistrates.” When the first cases did arrive, the board denied their existence for as long as it could—afraid that the pandemic would shut down the local economy and prevent cotton ships from arriving or leaving.

In London, meanwhile, some newspaper pundits claimed that the government had fabricated the pandemic to distract attention from the need for parliamentary reform. The term “cholera humbug” caught on widely, and The New York Times published an anonymous letter accusing doctors of being paid 20 guineas per day to whip up “cholera phobia.” Others who did believe in the disease said that physicians were spreading it on purpose to collect a £10-a-week cholera fee from local governments.

Additional suspicion fell on physicians because of a notorious Scottish court case in 1828. In preceding decades, the modern science of anatomy had been pioneered at the University of Edinburgh by Alexander Monro, Robert Knox and others. But as students traveled from all over Europe to learn about the human body, there was a need for fresh corpses to study that far outstripped supply. Graverobbing had become common, and William Burke and William Hare, it came to light, had murdered more than a dozen people in order to sell the bodies to Edinburgh physicians. Their trial exposed an unsavory industry that the public viewed with fear and outrage.

This nineteenth-century march of science did yield direct benefits for the treatment of cholera. Some physicians began to advocate rehydration with saline solution, which remains a cornerstone treatment for the disease today. But the more widespread and preferred remedies were those peddled by traditional medical personages, who recommended bleeding and brandy—treatments that only exacerbated dehydration—and, bizarrely, tobacco enemas.

The city soon established cholera hospitals to quarantine and care for the victims. But for the public, they existed under a cloud of suspicion. As one patient was being taken to the Toxteth Park Cholera Hospital in May 1832, a crowd of more than a thousand gathered, shouting “there go the murderers” and “bring out the Burkers”—a reference to Burke and his grim trade. The mob threw bricks at the windows and assaulted hospital staff.

That turned out to be only the opening sally in a wave of riots that lasted two weeks. On June 2, doctors were accused of “giving patients stuff that killed them and made them turn blue”—a reference to cyanosis, the blue tint of the skin when blood becomes too thick to be properly oxygenated, a result of dehydration. One mob stormed a dispensary, where, as the Liverpool Chronicle reported, “even in the room where the woman, now in a dying state, was lying, and the medical gentleman who was attending her was obliged to seek safety in flight.”

The riots ended with the fading of the cholera outbreak, which burned itself out by the end of 1832. In a little more than a year, the country had seen not only 20,000 lives lost to the disease but more than 70 protests.

In 2018, the World Health Organization updated its resource for managing modern pandemics. The new materials pointed to the dangers of a concurrent “infodemic”—a glut of rumors and information that commonly spreads during a health crisis. Some of these rumors can take aim at health officials themselves.

A study published in early October 2020 by an international team of public health researchers looked at the misinformation that spread across 87 countries during the early COVID-19 pandemic. Some 8% of those stories gave a nefarious origin to the pandemic, many saying that COVID-19 was created by the medical community in an effort to boost vaccine sales. One example in the United States was the “Plandemic” video, which cast Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, and the Bill and Melinda Gates Foundation as villains who spread disease in order to profit from it.

The outcome of such misinformation is predictably tragic. The CEO of the National Association of County and City Health Officials told The New York Times that its members have “a big red target on their backs” and are “villainized for their guidance.” Already, more than two dozen health officials have resigned. Fauci has received death threats, which he has said “seem inconceivable” given that he is “trying to promote public health principles to save people’s lives.”

To take the long view, two good things did come out of the 1831 cholera pandemic. The riots spurred a national conversation in the United Kingdom about a more comprehensive approach to health care, which eventually resulted in the 1848 Public Health Act, the first of its kind. The law’s proponents pointed to the cost of pandemic diseases in money, lives and social good will. Clean drinking water and public medical officers were two of its innovations, and the law proved a foothold for the British health care system in place today.

The second positive outcome was the experience of a young apprentice physician named John Snow, who tended cholera victims in a small coal-mining village. His insights into the disease led him, during a later outbreak in 1849, to pinpoint the disease to a single well in Soho, London, part of the work that made him a founder of epidemiology. Both outcomes point to how a health crisis and its hard lessons can be of value to future generations—who, one hopes, don’t need to learn their terrible lessons a second time.