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A tale of three cities: the places transformed by pandemics across history

Marseille in 1720, Hamburg in 1892 and the Swedish city of Östersund in 1918 were all indelibly shaped by diseases. 

At first sight, it might appear an odd undertaking to search for emblematic places in a pandemic. The defining feature of one, after all, is that its effects are felt everywhere. Yet pandemics do have places; places that they hit the hardest, places in which they leave the deepest marks and – encouragingly – places in which they are eventually mastered. Our journey begins in Marseille, which in 1720 suffered Europe’s last major outbreak in what was the worst and longest-ever pandemic to befall humanity: the second plague. 

On the one hand, it is unsurprising that the bubonic plague should have struck in a port city whose trade was primarily with the Levant, the epicentre of the slow-motion pandemic that started with the Black Death in 1347. Yet precisely due to this, the Marseille of the early 18th century had built up a sophisticated system of regional intelligence-gathering and local geographical barriers, which had kept the city plague-free for the best part of two centuries. 

Consuls across the Mediterranean helped Marseille’s sanitation board compile lists of rumoured outbreaks against which inspectors would check the logs of captains wishing to enter the port while assessing the crew and their cargo for signs of contamination. Vessels suspected of contact with the plague were quarantined at a safe distance on the tiny Île Jarre, just off the secluded coves of the calanques, while other vessels were allowed to enter the Bay of Marseille proper, yet only as far as Frioul, an archipelago of rocky outcrops facing the harbour. Here, they were then held in quarantine for a minimum of 18 days – and longer if the inspectors suspected other diseases. Only after clearing these three barriers, two geographical and one temporal, were ships allowed passage into the port.

Visitors to the Îles du Frioul today can easily get a feel of bygone times: only ten minutes by ferry from the Old Port, the archipelago is close, yet strangely – unsettlingly – exposed. The wind, often Provence’s famously infuriating mistral, is almost incessant, preventing all but the hardiest of vegetation from gaining a foothold and, in the scientific understanding of the time, dissipating the miasmas to which much disease was attributed. As most tourists disembark on the first island for the Chateau d’If of The Count of Monte Cristo fame, those who stay on to Pomègues, the old quarantine island, can feel as if they are on an unexpectedly sunlit version of Charon’s ferry. The bleakness of bare white limestone baking in the heat is enhanced by the ruined Second World War gun batteries and the concrete tourist promenade built when the armed forces left in the 1970s.

Standing atop these rocky spines, with the city as tantalisingly close as it is insurmountably far, it’s easy to see how Marseille kept the plague quite literally “at bay” for so long – and hard to imagine how it made it across. The answer is to be found in a classic conflict of commercial interests and civic duty among those who governed the city, the échevins, drawn from its trading aristocracy. In June 1720, the Grand-Saint-Antoine arrived off Jarre carrying a valuable cargo of silk destined for a summer fair and ash required for the production of Marseille’s famous soap. Despite several suspected plague deaths on board and inspectors ordering strict quarantine, the vessel was allowed to progress to Frioul, from where its cargo was spirited into the port. Days later, dockers started falling ill and the ship was quickly dispatched to be burned. 

Having already prioritised commercial concerns over established precautions, the échevins then proved reluctant to declare that the plague had entered the city for fear of the quarantine that would ensue. Yet they were left with little choice, as within weeks infectious bodies were being thrown out of windows by panicked citizens. In a previously unimaginable act of desperation, galley slaves were offered freedom in exchange for burying the dead. The plague raged for two years and left close to 50,000 dead – out of a population of about 80,000.

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Proud port cities run by oligarchic merchant classes seem to show a particular susceptibility to avoidable epidemics. Hamburg, today Marseille’s German twinning partner and also its country’s principal trading port, suffered the last serious outbreak of cholera in western Europe – and the only one there during the fifth pandemic – in summer 1892, decades after it had been eradicated elsewhere. As the historian Richard Evans has recently detailed, the city’s government of part-time senators/full-time merchants proved singularly incapable of preventing and then of managing the outbreak, practising a laissez-faire approach imported from a Victorian Britain to which they had close cultural and commercial ties. Rather than tackling the poverty and squalor that created the conditions for the disease, they kept municipal expenditure (and thus taxes) low, continuing to argue against the vastly improved scientific knowledge of their day that miasmas were responsible for spreading cholera, not unsanitary conditions.

To the trained eye, three places in the city tell the story of their failure. Kaltehofe, today a popular stop along a cycle path, is an islet in the Elbe River which, following the epidemic, was given over to filtering its water. Especially in hazy evening light, its squat pumping stations resemble gatehouses, small fairy-tale castles even, in a multitude of enchanted miniature lakes. Intended to demonstrate civic pride in the neo-gothic red-brick architecture of their day, they in fact testify to reprehensible penny-pinching 50 years earlier. In the aftermath of the Hamburg fire of 1842, the British engineer William Lindley, commissioned to redesign the city’s antiquated sewer system, recommended filtering the notoriously filthy river water. The Senate built the sewers, but rejected the filtration plant as an unnecessarily expensive luxury – only to find itself rushing the job in 1892 after the cholera epidemic had killed about 8,000 people in the space of ten weeks, wreaking havoc with the city’s economy and reputation after increasingly farcical attempts to cover it up. 

At the height of the outbreak in late August, with over a thousand cases daily, the Prussian government intervened, sending the head of the state’s Institute for Infectious Diseases, Robert Koch – who had himself discovered the cholera bacteria in water in 1884 – to take charge. Koch, who placed the city under quarantine, organised treatment for those infected at a makeshift facility next to the city hospital in the then somewhat rural suburb of Eppendorf. Erected on higher ground in the 1880s in accordance with the miasmatic doctrine that “bad air” around the harbour was responsible for the annual outbreaks of salmonella and various other maladies, the hospital is today a leading university clinic; the last of its original 1880s redbrick buildings are currently making way for steel-framed multistoreys. Those looking for the wooden Cholerabaracken used to isolate stricken patients in 1892 will now find a well-appointed park with an outdoor kindergarten overlooked by an exclusive retirement home – the comfortable, roomy urban fabric of major German cities today.

During his quasi-regency, Koch, after whom both a nearby street and Germany’s public health body are named, was shocked by the unsanitary Gängeviertel or “alley quarters” down in the old city, where Hamburg’s underclasses thronged in dilapidated wooden-frame houses, cheek-by-jowl with passing sailors and emigrants waiting for their steamers to the US. One of his salutary recommendations was to offer less cramped – and less central – accommodation for the growing numbers of passengers from cholera-stricken regions in Poland and Russia; the result are the low-slung brick chalets on the river island of Veddel where, from 1901 onwards, transient eastern Europeans could await their passage in somewhat more salubrious surroundings.

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The role of poor urban accommodation and sanitation in the spread of disease would become particularly visible in 1918 in the far smaller, geographically remote city of Östersund, 700 miles to the north in the expansive highlands of the Swedish interior. Sweden, which was neutral during the First World War, displayed the distinction between the effects of the conflict and those of the pandemic far more clearly than combatant countries – such as Spain, whose national adjective was co-opted for the H1N1 influenza virus for much the same reasons. Specifically, it was in Östersund, a military town and staging post for the construction of the inland railway to the far north, that the population was most vulnerable, the state most conspicuous by its absence, and the death rate highest, earning it the title “spanska sjukans huvustad” – “the capital of the Spanish flu”. 

During the years of heightened military alert, and in preparation for the railway work, Östersund’s population had swollen rapidly from 9,000 to 13,000 inhabitants, yet construction had not kept pace. Navvies, loggers and labourers fleeing rural poverty – frequently malnourished – crammed into unsanitary tenements in an overnight boom-town that didn’t even have a hospital. Meanwhile, the city’s regiments, in a state of denial, continued to hold planned exercises even as stricken young privates were clogging their under-dimensioned infirmaries. As deaths soared to 20 a day, Carl Lignell, a maverick bank director who, recognising that the severity of the situation had been underestimated in far-away Stockholm, took matters into his own hands, misappropriating funds at his disposal and requisitioning a school as an emergency ward (read my full account here). 

Retrospectively, the pandemic can be seen as a milestone on Sweden’s journey towards its mid-20th century apogee as a social welfare state. Östersund had already experienced violent demonstrations for workers’ rights in 1917. After the pandemic it was unrest that spread through the industrial centres of the Swedish north, culminating in the Ådalshändelserner of 1931, when the army was called in to quash demonstrations. The ensuing deaths shook the nation and precipitated Sweden’s shift to a consensus-orientated model of labour relations, yet the state had already begun expanding its infrastructure in an effort to improve living standards. By the time the railway north was finished in 1937, Östersund was one of many increasingly well-to-do small Swedish cities – with a purpose-built hospital for cases of flu, scarlet fever and polio. 

Today, this Epidimisjukhus houses the regional health authority. It is to the hulking 1970s clinic next door that the unenviable task of fighting today’s pandemic now falls. With one of the lowest ratios of intensive-care beds to inhabitants among developed countries, and a government that has been slow to enact measures to slow the spread of the virus, there are fears that Sweden may yet find itself on the list of places indelibly associated with this pandemic (as of 20 April, the country of 10 million people had recorded 14,385 cases and 1,540 deaths). Reassuringly, however, the military recently called off a scheduled exercise named Aurora. In any case, it is unlikely to be Östersund which makes the headlines, as the rate of infection and lack of capacity in Stockholm are the cause of most concern; the hurried field hospital in the capital’s expo centre is where the coronavirus pandemic will visibly crystallise. 

Even after it is returned to use as Stockholmsmässan, “Alvsjö sjukhus”, as it temporarily known, and its “NHS Nightingale” equivalents will remain – both as a historical testament to official inventiveness in times of crisis and as prime exhibits that four decades of shrinking state provision have left Western democracies unconscionably vulnerable. 

The public inquiries and recriminations set to dominate political life in countries whose health services have proved under-resourced will most likely be absent in Germany, which seems destined to figure among the places where the pandemic was brought under control most quickly. Yet this victory will have occurred more by luck than by judgement: while there were indeed decisive measures taken early to monitor and reduce the spread of the virus, swathes of the country’s much-vaunted spare intensive care capacity were, until the outbreak, slated for closure; in a healthcare system run on economic incentives, many clinics are – perversely enough – currently sending staff home on short hours as lucrative planned procedures are postponed. The places most associated with this pandemic in Germany may end up being the intensive care wards in small-town hospitals that were never full-to-overflowing during the crisis – and which were granted pardons as the axe was about to fall.

And what of Marseille’s Frioul archipelago? As yet, the islands have yet to record a single case – and shuttle boats to the mainland are now reserved for its roughly 150 residents only. Those looking to hole up there for a few weeks are being turned back at the jetty.

Brian Melican is a journalist and the author of Germany: Beyond the Enchanted Forest: A Literary Anthology