Russia in the Time of Cholera: Disease under Romanovs and Soviets 9781350987869, 9781786733658

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John P. Davis is Assistant Professor of History at Hopkinsville Community College, Kentucky. He has previously taught at Ohio State University and the University of Kentucky, where he received his PhD.

‘John Davis’s research on cholera in Russia is a groundbreaking synthesis of political and social history with environmental history and the history of science. By considering Russian responses to the disease in the context of nineteenth-century scientific debates, Davis challenges the received wisdom both about the nature of the scientific “bacteriological revolution” and about the “backwardness” of Russian science. Davis casts Russia’s environment as a powerful actor in the story of the diffusion of cholera and explores the particular difficulty of containing cholera in Russia because of its geographical and geo-epidemiological characteristics. Davis also explores the profound continuities in the battle with cholera across the revolutionary divide, showing how Soviet medicine built on Tsarist policies to conquer the disease.’ Karen Petrone, Professor of History, University of Kentucky ‘John Davis’s pioneering volume makes a distinct contribution to scholarship. It treats intelligently an important and long-lasting episode in Imperial Russian and Soviet history. It adds to medical and environmental history as essential components of cultural history by arguing that the study of the cholera in Russia paralleled the modernisation of the country. The book demonstrates that the history of epidemiology can tell us much about the intersection of sociopolitical unrest and economic dislocation.’ Lucien Frary, Professor of History, Rider University ‘Russia in the Time of Cholera makes important contributions to both Russian history and the history of medicine. Arguing that Russian physicians were creative and pragmatic in fighting cholera epidemics, John Davis shows that they had reasons to eschew the contagionist measures favoured by their German counterparts in the late nineteenth century. Given the public health challenges they faced in the vast and underdeveloped Russian Empire, physicians there relied instead on environmental and social approaches to disease. Davis also demonstrates striking continuities with the Soviet period, when Russian specialists continued to develop social medicine and proved largely successful in eradicating cholera. Well researched and carefully argued, Davis’s book provides a rich, multi-dimensional analysis of health and society in Imperial and Soviet Russia.’ David L. Hoffmann, Distinguished Professor of History, Ohio State University

Library of Modern Russia Advisory board – Michael David-Fox, Professor at Georgetown University – Mark Edele, Professor of History at the University of Melbourne – Sheila Fitzpatrick, Bernadotte E. Schmitt Distinguished Service Professor Emerita at the University of Chicago – Lucien Frary, Associate Professor at Rider University – James Harris, Senior Lecturer at the University of Leeds – Robert Hornsby, Lecturer at the University of Leeds – Ekaterina Pravilova, Professor of History at Princeton University – Donald J. Raleigh, Jay Richard Judson Distinguished Professor at the University of North Carolina at Chapel Hill – Geoffrey Swain, Emeritus Professor of Central and East European Studies at the University of Glasgow – Vera Tolz-Zilitinkevic, Sir William Mather Professor of Russian Studies at the University of Manchester – Vladislav Zubok, Professor of International History at the London School of Economics Building on I.B.Tauris’ established record publishing Russian studies titles for both academic and general readers, the Library of Modern Russia will showcase the work of emerging and established writers who are setting new agendas in the field. At a time when potentially dangerous misconceptions and misunderstandings about Russia abound, titles in the series will shed fresh light and nuance on Russian history. Volumes will take the idea of ‘Russia’ in its broadest, cultural sense and cover the entirety of the multiethnic lands that made up imperial Russia and the Soviet Union. Ranging in chronological scope from the Romanovs to the present day, the books will foster a community of scholars and readers devoted to a sharper understanding of the Russian experience, past and present.

New and forthcoming Building Stalinism: The Moscow Canal and the Creation of Soviet Space, Cynthia A. Ruder Criminal Subculture in the Gulag: Prisoner Society in the Stalinist Labour Camps, Mark Vincent Dissident Histories in the Soviet Union: From De-Stalinization to Perestroika, Barbara Martin Fascism in Manchuria: The Soviet– China Encounter in the 1930s, Susanne Hohler Ideology and the Arts in the Soviet Union: The Establishment of Censorship and Control, Steven Richmond Myth Making in the Soviet Union and Modern Russia: Remembering World War II in Brezhnev’s Hero City, Vicky Davis Nomads and Soviet Rule: Central Asia under Lenin and Stalin, Alun Thomas Power and Conflict in Russia’s Borderlands: The Post-Soviet Geopolitics of Dispute Resolution, Helena Ryto¨vuori-Apunen Power and Politics in Modern Chechnya: Ramzan Kadyrov and the New Digital Authoritarianism, Karena Avedissian Russia in the Time of Cholera: Disease under Romanovs and Soviets, John P. Davis Russian Pilgrimage to the Holy Land: Piety and Travel from the Middle Ages to the Revolution, Nikolaos Chrissidis Science City, Siberia: Akademgorodok and the Late Soviet Politics of Expertise, Ksenia Tartachenko Soviet Americana: The Cultural History of Russian and Ukrainian Americanists, Sergei I. Zhuk Stalin’s Economic Advisors: The Varga Institute and the Making of Soviet Foreign Policy, Kyung Deok Roh The Communist Party in the Russian Civil War: A Political History, Gayle Lonergan The Idea of Russia: The Life and Work of Dmitry Likhachev, Vladislav Zubok The Politics of Football in Soviet Russia: Sport and Society after Stalin, Manfred Zeller The Russian State and the People: Power, Corruption and the Individual in Putin’s Russia, Geir Hønneland et al. (eds) ¨ nol The Tsar’s Armenians: A Minority in Late Imperial Russia, Onur O

RUSSIA IN THE TIME OF CHOLERA Disease under Romanovs and Soviets

JOHN P. DAVIS

BLOOMSBURY ACADEMIC Bloomsbury Publishing Plc 50 Bedford Square, London, WC1B 3DP, UK 1385 Broadway, New York, NY 10018, USA BLOOMSBURY, BLOOMSBURY ACADEMIC and the Diana logo are trademarks of Bloomsbury Publishing Plc First published 2018 by I.B. Tauris & Co. Ltd. Paperback edition first published 2020 by Bloomsbury Academic Copyright © John P. Davis, 2018 John P. Davis has asserted his right under the Copyright, Designs and Patents Act, 1988, to be identified as Author of this work. For legal purposes the Acknowledgements on p. xv constitute an extension of this copyright page. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage or retrieval system, without prior permission in writing from the publishers. Bloomsbury Publishing Plc does not have any control over, or responsibility for, any third-party websites referred to or in this book. All internet addresses given in this book were correct at the time of going to press. The author and publisher regret any inconvenience caused if addresses have changed or sites have ceased to exist, but can accept no responsibility for any such changes. A catalogue record for this book is available from the British Library. A catalog record for this book is available from the Library of Congress. ISBN: HB: 978-1-7883-1168-7 PB: 978-1-3501-3011-1 ePDF: 978-1-7867-3365-8 ePub: 978-1-7867-2365-9 Series: Library of Modern Russia 7 Typeset by OKS Prepress Services, Chennai, India To find out more about our authors and books visit www.bloomsbury.com and sign up for our newsletters.

To Elena

CONTENTS

List of Illustrations Acknowledgements

xiii xv

Introduction Major Contributions Russia’s Vulnerability to Cholera The Russian Intellectual Framework Tsarist and Soviet Anti-Cholera Strategies Cholera’s Departure from Russia Historiography Sources Organisation

1 4 5 6 7 8 8 13 13

1.

Cholera and its Environs: The Case of Russia Transportation and Disease in Russia Russian Science and Cholera Immunology and its Reception in Russia Conclusion

15 21 24 29 32

2.

Tsarist Russia and the First Five Pandemics, 1817– 94 The First ‘Time of Troubles’ The Tambora Volcano and First Pandemic, 1815–23 The Second Pandemic and ‘Hungry’ Forties: 1829– 49 The Crimean War and Third Pandemic: 1852–9

34 34 35 39 45

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The Fourth Pandemic, 1865– 73: The Great Reforms, Famine and Preventive Medicine The Krakatoa Volcano and the 1892 Cholera Epidemic The 1892 Epidemic: Its Course and Characteristics Erismann and Russian Bacteriology The Pasteurisation of Russia, 1883– 1928 Conclusion

47 51 55 58 62 66

3.

The Sixth Pandemic Enters Russia, 1902–7 ‘The Troubles’ Begin, 1902–7 The Siberian Epidemic of 1902 The Tsarist Cholera Rules, 1903 The Persian Expedition of 1904 The Cholera Epidemic in Saratov, 1904 The SEC Railroad Sub-Commission, 1904 The Saratov SEC, 1904 Gamaleia’s Investigation of the 1904 Epidemic The 1905 Revolution and Pirogov Cholera Conference Zemstvo Physicians versus Koch Conclusion

68 68 71 74 77 78 79 80 84 88 94 97

4.

Cholera Returns to Russia, 1907– 13 Cholera Reappears in Russia: Samara, 1907 The 1907 Cholera Epidemic and Investigation in Samara The MVD Returns to the Volga, 1908– 9 The Tsarist Railroad and Cholera The Threat of Cholera on the Russian Railroad and the Muslim Hajj, 1907– 9 Gamaleia and the Great 1908 Epidemic in St Petersburg The 1910 Epidemic Conclusion

5.

The Troubles Continue: World War I, 1914– 17 The Outbreak of World War I and Russian Public Health, 1914 The Pirogov Society and the Threat of Cholera, 1914 Organisation of the Russian Military-Medical Apparatus, 1914– 15

99 100 102 110 111 112 115 118 121 123 124 127 130

CONTENTS

The Tsarist Retreat and Moscow Cholera Epidemic of 1915 The Progressive Bloc The Beginning of the End, 1916 Conclusion 6.

The Revolutions, Civil War and War Communism, 1917–21 Russia’s Second Bloody Sunday: The February Revolution, 1917 Lenin Returns to Russia, 1917 The Provisional Government and Public Health, 1917 The Bolsheviks, War Communism and the Unification of Soviet Public Health, 1917– 18 The 1918 Epidemic in Russia Cholera Comes to Petrograd, 1918 An Impending Crisis Applause from the West Moscow versus Petrograd Bolshevik Vaccination General Shortages and Other Problems Conclusion

7.

The New Economic Policy (NEP), 1921 –8 The Troubles in Saratov Province, 1921 Social Hygiene and General Hygiene Lenin Confronts Cholera, 1921 Weaknesses in the NEP, 1921– 2 Conclusion

8.

The End of ‘Classical’ Cholera Epidemics in the Soviet Union Cholera Wanes in Southern Russia, 1921 Sanitation in the Ports of Southern Russia Disinfection on the Soviet Railroad Soviet Microbiology, Epidemiology and Famine during the NEP, 1922– 7 The Role of Soviet Vaccination in Cholera’s Withdrawal The Sixth Pandemic Departs Europe: 1923–7 Conclusion

xi

140 141 150 151 153 153 155 156 161 165 167 169 173 189 191 193 194 197 198 199 204 216 219 221 222 225 226 234 236 240 249

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Conclusion

251

Glossary of Terms and Organisations Notes Bibliography Index

257 261 298 310

LIST OF ILLUSTRATIONS

Figures Figure 1.1 Movement of trade through Russia c. 1900.

22

Figure 1.2 The Mariinskaia water system (general route).

23

Figure 5.1 The railroad and cities west of Saratov c. 1915.

146

Figure 6.1 Cholera in St Petersburg/Petrograd, 1892, 1908 and 1918.

180

Figure 6.2 Railroad network between Petrograd and Rybinsk/Iaroslavl’.

187

Figure 8.1 Distribution of cholera between India and the Soviet Union, 1923.

241

Figure 8.2 Distribution of cholera between India and the USSR, 1924.

244

Figure 8.3 Distribution of cholera between India and the Soviet Union, 1925.

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Tables Table I.1 The sixth cholera pandemic in Russia: 1899– 1927 Table 5.1 Deaths from cholera in Moscow in 1915

3 139

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Table 6.1 Cholera cases and suspicion of cholera by district in St Petersburg/Petrograd, 1892, 1908 and 1918

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Table 6.2 Daily numbers of cholera cases and deaths in Petrograd for July, August and September, 1918

177

Table 7.1 Percentage of properties with active waterworks and sewage systems and the percentage of cholera patients per 1,000 residents in the Saratov city districts, 1921

218

Table 8.1 Cholera in the Soviet Union in 1921, 1922 and 1923

223

Table 8.2 Provision of treated water in Petrograd, 1912– 22

228

Table 8.3 Tests of water quality at the Aleksandrovskii Mechanical Factory, 1922

231

Table 8.4 Cases of typhoid, cholera and dysentery among the population of the Aleksandrovskii Mechanical Factory on the Nikolaevskii Railroad, 1910– 21

232

Table 8.5 Cholera in the USSR in 1923 up until 24 September

242

Table 8.6 Deaths from cholera reported in British India, 1896–1925

248

ACKNOWLEDGEMENTS

In the course of writing this book, I have received wise counsel from many scholars and the assistance of great institutions. This support included the Junior Faculty Fellowship at the Ohio State University’s Center for Historical Research (CHR), the University of Kentucky (UK) Albisetti Fellowship for Research in Europe, two UK/Northern Kentucky Alumni Fellowships, a grant from the UK Department of Modern & Classical Languages, Literature & Cultures, and two US Department of State grants for the Summer Research Laboratory at the Russian, East European and Eurasian Center (REEEC) at the University of Illinois, Urbana-Champaign. At the University of Kentucky, Karen Petrone, Daniel Rowland, Ellen Furlough, Eric Christianson, James Albisetti, Cynthia Ruder, Jeanmarie Rouhier-Willoughby, David Olster, Erin Koch, Edward Lee and the former Dean of Arts and Sciences, Steven Hoch, rendered vital counsel. Richard Gilbreath constructed the excellent illustrations. Medical librarian Frank Davis went beyond the call of duty, tracking down obscure articles and documents. In Russia, I was fortunate to befriend Professor Dmitry Mikhel’ of Saratov State University, the University’s chief librarian, Lida Viktorovna, and the wonderful librarians at the Museum of Hygiene in St Petersburg. At the Ohio State University, John Brooke, Nicholas Breyfogle, Chris Otter, David Hoffmann, John Burnham and my colleague and fellow visiting scholar, Natasha Sarkar, provided insight and context to my scholarship. The OSU CHR provided me with funds and time to peruse the holdings at Ohio State and travel to the National Library of Medicine, where I received outstanding assistance from Crystal Smith

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and other staff. In spring 2017, OSU ABDs Jim Harris and Paul Niebrzydowski invited me to join them in a timely panel on war and disease at the American Society of Environmental History in Chicago. I have been equally fortunate to receive great moral encouragement and support from my colleagues at Hopkinsville Community College, including Thomas ‘Taylor’ Carlisle II, Ken Casey, Julia Laffoon-Jackson, Bernd Sauermann, Amanda Sauermann, Donald Hoover, Justin BraxtonBrown, Mel Evans, Kevin Felton, Daniel Wilkinson, Alissa Young and the inimitable Brett Eugene Ralph. My students inspire me daily, especially the members of HCC’s Outstanding Club for 2016– 17, the Hopkinsville Community College History Club. At I.B.Tauris, my editor, Thomas Stottor, took great interest in this book and provided outstanding guidance and support throughout the writing and publishing process. Many thanks to the wonderful management and staff at I.B.Tauris, not only for making this book possible, but for publishing scholarship that builds bridges between academia and the public. Any errors in grammatical, analytical or any other context are mine alone. Most of all, I would like to thank my beautiful wife, Elena Davis, to whom this book is dedicated, for her love, support, leadership and guidance. My multi-talented and beautiful step-daughter, Polina Eshenkova, brings great joy to my life. The memories of my father, Jack Frederick Davis, USN WWII, and brother, William Joseph Davis, inspire me. Seven years ago today we lost the second of the two matriarchs of our families, my beloved and wise mother, Fannie F. Davis, and one month prior, my mother-in-law, Aleksandra Vasilievna Kolesova. Their memory guides us.

INTRODUCTION

Diseases change and have a history of their own, which depends upon a possible modification of bacteria and viruses and of the human landscape in which they live.1 Fernand Braudel Few countries have dealt with cholera epidemics over a longer duration or with greater intensity than Russia. Seven global diffusions of cholera, initiating from a chain of climatic factors, crossed Russia’s southern extremities and spread over human travel networks. This was primarily due to the country’s pursuit of ‘great power’ status in Europe, military expeditions, market networks and trade-related pursuits. Volcanos, El Nin˜o cycles and other natural forces often contributed to a vital interplay between humans and nature. This prompted the former to orally ingest the cholera microbe, or vibrio, the agent that caused the disease, upon which it entered human gut tracts as it was carried and deposited through the fecal route into other environments and transmitted to individuals through similar channels. In the nineteenth century, imperialism, warfare, religious pilgrimage, revolution and violent social upheaval, migrant labour and other forces spread the disease yet further through endemic and semi-endemic regions and into temperate zones. Food deficits related to drought, torrential downpours and flooding kept humans weak, and famine was a constant component linking these processes. Appearing along the coasts of the Black and Caspian seas and the Steppe region of southern Russia, the disease spread to other districts within the country and adjoining areas of the temperate zone.

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Between 1823 and1922 Russia suffered 5.5 million cases of cholera, approximately 2.2 million deaths, and 50 ‘cholera years’ in which the country suffered more than a few cases of the disease. Cholera first appeared in Russia in 1823 during the first pandemic, then during the second in 1829– 49, the third in 1852–9, the fourth in 1865–73 and the fifth in 1892– 4. In 1901–26 during the sixth pandemic Russia was free of cholera only in 1903 and 1906, with infrequent cases in 1912–14. The pathogen resided in Russia almost constantly until 1921 (see Table I.1), convincing many physicians that the disease lived in the country ‘in a semi-endemic state’.2 Comparing the efforts of Russian physicians to thwart cholera epidemics in the Romanov Empire and Soviet Union, this book examines the years 1815–1928, focusing in particular on the sixth pandemic, which occurred in 1899–1926. The factors that contributed to cholera epidemics, particularly famine, helped precipitate the downfall of the Romanov or ‘tsarist’ Empire. True to the ruthless scientific empiricism and military and ideological zeal that would put the first human in outer space, the Soviets were able to control cholera by 1925, earning respectability in the West and bragging rights over the Old Regime. However, it was arguably tsarist industrial development, imperialism, trade, warfare, its physicians and even administrators and statesmen who created the theoretical, scientific and institutional framework and material and civil society that permitted the Soviets their achievement. Scholars of Russian public health typically view the manner in which tsarist physicians dealt with cholera, their outlook on science, the theories from which they drew, the outcomes they achieved, and a string of government (in)actions and strategies as the culprit for Russia’s lingering susceptibility to cholera, a disease that signified ‘backwardness’.3 The traditional narrative is that once Robert Koch discovered the cholera vibrio in 1883, developed countries prevented cholera through ‘contagionist’ measures such as quarantine, the isolation of cholera ‘carriers’, or those who might transmit the disease to others, and sanitation. Re-considering geography, recent scientific studies, imperial, diplomatic and economic considerations, this book will demonstrate the flaws in this narrative, particularly regarding the role attributed to tsarist physicians’ environmental and social approaches to disease. My argument contains two interrelated aspects. First, that late cholera epidemics and physicians’ broad environmental orientation in tsarist

Table I.1

The sixth cholera pandemic in Russia: 1899– 1927

Year

Number of Provinces

Cases

Deaths

1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 Total

– – – 4 – 13 8 – 50 69 50 72 29 2 7 15 53 17 10 37 33 53 – – – – – – –

– – – 2167 – 9226 598 – 12,703 30,705 22,858 230,232 3416 9 324 1800 34,582 559 134 41,289 3998 22,106 204,2281 86, 1782 1413 9 11 1 0 707,274

– – – 1393 – 6950 296 – 6424 15,542 10,677 109,560 1646 3 129 761 859 – – 12,927* – – – – – – – – – 167,167

Source: L. Tarasse´vitch, Epidemiological Intelligence: Epidemics in Russia Since 1914, Report to the Health Committee of the League of Nations, Part 1: No. 2 (Geneva, 1922), p. 39. *Incomplete data. No data for deaths in 1919– 26. 1 A. I. Dobreitser, ‘Kholera v 1922 godu’, Gigiena i sanitariia putei soobshcheniia 3 –4 (June/July, 1923), p. 85; Epidemiological Intelligence, Part II, No. 5, 7. There were at least 176,885 civilian cases and 5,837 in the military. The numbers included all allied republics. 2 Epidemiological Intelligence: Statistics of Notifiable Diseases, 1924 (Geneva: League of Nations, 1924), p. 24; Epidemiological Intelligence No. 8 (Geneva: League of Nations, 1923), p. 14. There were 21,312 cases in Ukraine and 121 in Poland. 3 Numbers for 1924 through 1926 are taken from Fourth Epidemiological Report for the Year 1926 (Geneva: League of Nations, 1927). The number for 1923 included 14 cases in Ukraine.

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Russia and the Soviet Union were related to the country’s path to European modernity. Both were influenced by an accumulation of predisposing events that were relative to Russia’s location and pursuit of great power status. Second, I would argue that the complicated aetiology of cholera epidemics and responses to them in Russia caused physicians to gradually develop an evolution of medical methodology and social cohesion. They eventually came to view the ‘struggle’ with cholera in terms of alleviating the economic, environmental and social conditions under which it flourished. This was a preventive approach conceived in the Great Reforms of the 1860s, originating with European concepts of chemistry, applied within the framework of Darwin’s theory. The Soviets improved technology, sanitation, and water supplies where they could, but their plan emphasised broad measures as under the Tsar. Hardened by years of ideological struggles, revolution and warfare the Soviets administered their plan with zeal and military precision, the missing elements in tsarist public health.

Major Contributions Reconsidering this ‘struggle with cholera’ (as Russian physicians called it) within its zeitgeist allows for consideration of the forces that motivated Russia’s modernisation, scientific development, tsarist legislation, the country’s push for great power, economic and commercial context and pressure to modernise. In this respect, the present analysis of Russian efforts to stop cholera supports the scholarship arguing that Russian modernisation and pursuit of empire was a matter of survival. Russia’s relationship with Europe, the quest to acquire the lands of the dying Ottoman Empire (the ‘Eastern Question’), and Russia’s place in the European economy, made the prospect of shutting down commerce unthinkable. Russian Europeanisation compelled the nation’s leaders to vigorously pursue the very technologies that brought cholera to Europe. Imperial Russia was the world’s fourth or fifth largest industrial power and Europe’s top food producer. This was obviously a consequence of its size, but its industry amounted to only 20 per cent of Britain’s and 40 per cent of Germany’s. With rapidly growing military-industrial threats in Japan and Germany, soldiers, statesmen and manufacturers charged with Russia’s defense could hardly have, as one prominent Russian historian points out, screamed ‘unfair’.4

INTRODUCTION

5

This book aims therefore to deepen the understanding of Russia’s experiences with cholera, particularly regarding the epidemics after 1900, when the disease had mostly disappeared from Western Europe. Rather than a stunted medical development, Russian physicians’ attempts to stop cholera within a difficult social, environmental and political terrain, led them to eschew a system based strictly on quarantine. Russia’s more flexible strategy was influenced by many factors, which roughly fall into four categories: (1) The multi-faceted nature and scale of cholera-related threats that Russia faced. (2) Russian intellectuals’ broad understanding of cholera epidemics, itself a consequence of their educational and professional development and experiences in Russia. (3) The viability of the flexible strategy devised to balance the threats of cholera with pressures for the country to modernise. (4) The manner in which Russia responded, particularly the practical limitations and degrees of coordination, cooperation, energy, effectiveness and social cohesion encountered.

Russia’s Vulnerability to Cholera Russia’s location, size, internal environments and place in the European diplomatic order made the country more vulnerable to cholera epidemics than other European countries. The vibrio struck from Asia, appearing without warning and lasting over 100 years in 1823– 1926. Russia’s location and cholera’s relatively uniform diffusion away from (and dissipation back into) India made the country both the first and last in Europe to deal with the disease. Russia’s connection with Western Europe and the measures it applied offered the rest of the continent a degree of protection and warning that it did not enjoy. The country’s size and dispersed populations were key factors in the difficulties encountered in coordinating a response to outbreaks.5 This account provides additional layers to this concept. Russian imperial pursuits, including trade and warfare, brought its military into endemic and semi-endemic regions of cholera in the ‘Orient’, or India, Afghanistan, Central Asia, Turkey and the biblical lands, much of which lies adjacent to Russia’s borders.6 As a food producer and

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exporter, the harsh weather caused by El Nin˜o and volcanic activity struck Russia disproportionately, periodically destroying harvests and creating widespread famine, both weakening people’s ability to ward off cholera while clandestinely mobilising its diffusion. After 1883, industrialisation, railroad construction and increasing commerce and human mobility over natural environments that served as reservoirs of cholera bacteria made the problem even more acute. Also, as consideration of the later epidemics reveals, the dominant bacterial agent in the cholera epidemics after 1900 was likely not Koch’s cholera vibrio, but a milder and more durable version that killed fewer human hosts but proved more capable of surviving in Russian environments. With fewer physicians and resources and more vulnerable populations and environments than their European peers, the evidence detailed throughout this account reveals that Russia suffered disproportionately, especially after 1900.

The Russian Intellectual Framework The threats of cholera facing Russia motivated physicians to nurture a broad environmental understanding of the disease which was not backward, but rather creative and pragmatic. This understanding was based on observations in both natural and artificial environments, and social conditions within their own country, combined with the latest European theories of bacteriology and hygiene. In 1860 – 80 Russian physicians reasoned that chronic famine and socio-economic conditions rendered the treatment of disease in Russia practically useless. Instead they espoused a rural-based system of free treatment and preventive health that was unique in Europe.7 Loosely based on local political councils known as zemstvos, the preventive concepts this system endorsed coalesced with the European theories of hygiene and bacteriology of Max von Pettenkofer and Louis Pasteur, both chemists. Comparing these theories with the studies of modern epidemiologists, this book reveals how close both of these scientists came to anticipating what is known about cholera today.8 Developing a methodological alliance and loyalty to these schools based upon germ-environment interaction in soils, Russian physicians followed in their footsteps, resisting the methodology of the rival school of Germany’s Robert Koch. Koch, who discovered the cholera vibrio in 1883, focused on

INTRODUCTION

7

using quarantine, isolation of potential carriers of the disease, disinfection and other ‘contagionist’ measures. While he had supporters in Russia, the most prominent Russian physicians rejected his approach due to the complicated nature of the environment in Russia.

Tsarist and Soviet Anti-Cholera Strategies Imperial Russia’s problem with cholera was unique due to its geography, industrialisation and general modernisation. The country’s various systems of medical defence complied with international law, and were devised and carried out in full consideration of mainstream European medical thought, of which Russia’s physicians were a vital component. Rather than simply avoiding the implementation of quarantine, Russia built a flexible emergency response system that both permitted the free flow of commerce and avoided the violence associated with cholera riots. Using philosophies drawn from European schools of medical thought, Russian physicians gradually (and painfully) improved this system over many years. Building on broad anticholera measures, these evolved in the 1920s under the new ‘Union of Soviet Socialist Republics’ into a system built around human immunity, the evolution and diminution of the strength of the cholera microbe, on Darwin’s theory. This approach featured flexible (rather than strict) quarantine measures, more reliance on the surveillance of suspected cholera carriers, emergency food provision and sanitation in key areas, select improvements of water sources and sewage systems and, finally, a policy of vaccination intensely applied in areas under imminent threat. Given Russia’s myriad cholera threats, this approach was pragmatic, recognising the limitations of strict quarantine in a country facing not only unlimited cholera threats, but also the possibility that the disease had become endemic in Russia. The cholera response system that began in Imperial Russia and evolved under the Soviets relied upon better communication and speed of response, anticipating modern relief efforts. This book details the painfully slow process of the development of this strategy, from its origins in the aftermath of the 1892 cholera epidemic and tsarist Cholera Rules of 1903. Despite the Soviets forming their own response plan, it was clearly modelled after the tsarist decree, as were many related aspects of Soviet public health.

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Cholera’s Departure from Russia The waning of cholera epidemics in Russia after 1925 did not occur due to superior sanitation efforts under the Soviets, but due to a better understanding of the links between the disease and the broader social and environmental factors that caused it. Famine was the common ingredient. Warfare and revolution, inadequate wages and the state control of food supplies caused increasing famine during the war years. Increased food consumption in the 1920s boosted the ability of individuals to resist cholera, as did vaccination, eliminating the breeding grounds that had permitted the vibrio to flourish. While sanitation and clean water supplies played a role in this process, these improvements were less pivotal than previously thought. This conquest was more a victory of command, control and coordinated response. The Soviet Union did not construct effective water filtration nor sanitation systems in key areas before the 1970s.9 Nor did they ever inhibit shipping or industrial output, as some scholarship extrapolates or infers. Through an understanding of Darwin’s theory Russian physicians theorised that the elimination of cholera’s breeding grounds assisted the weakening and evolution of the microbe, as it was unable to find vulnerable natural environments; most importantly, starving human hosts. They used high-tech processes such as vaccination but also less technical measures such as limited private markets, emergency water provision and increases in the food supply. Soviet scientists came to view human gut tracts as part of the natural environment, permitting increasingly benign versions of the microbe to appear. Vaccination provided only short-term protection, but the Soviets maximised its value, applying it in regions and areas that were likely to be struck, facilitated by improved intelligence networks. Elimination of famine and other improvements in social conditions, along with a cessation of the natural forces that routinely mobilised the vibrio, caused epidemics to subside.

Historiography Europeans have long viewed Russian society as fundamentally different than Western Europe.10 Russian historians have viewed revolutionary Russia through long-term tension between opposing forces, ‘dual

INTRODUCTION

9

polarisation’ in 1902–17 both between government power (vlast’) and society (obshchestvennost’), and between the privileged classes and the masses. Industrialisation exposed the Russian dependency on foreign markets, placing an excessive burden upon the peasantry. The bureaucracy attempted to preserve an obsolete government, as society struggled to modernise it.11 However, educated elites dominated the tsarist body politic, both shaping government/bureaucratic structures and protesting government actions or policies.12 These forces appear in this book and are significant in that Russia physicians wrestled with disease amid these conflicts, shaping the view of many so-called ‘community’ or ‘public’ physicians who worked for local land councils known as zemstvos. Beneficiaries of European-like or European education, their mission brought them to observe the country’s problems through the lens of infectious disease. Russian historians draw upon a European and international framework to understand native institutions, government and culture. Imperialism and native populism shaped Russian modernity. Great power pressures left Russia to choose between colonisation by a European power or an increase in inequality and poverty. Statesmen viewed expansion and seizure of territory as self-defence, even when this accumulation of hostile lands put them in precarious localities in the acquired territories.13 Imperialism also involved subtle agendas, such as the peaceful incorporation of the Muslim pilgrimage to Mecca.14 Russian social upheaval during 1900–17 reflected a general trend rejecting constitutional experiments. Marxist violence in 1905 –24 stemmed from ‘intersecting’ European and native forces throughout the revolutions, World War I and the Civil War in 1918– 21, thereby militarising civil society. Ideological violence predated the Russian Civil War, appearing in other countries, as did government centralisation, surveillance and state-controlled food supplies.15 The legitimacy of the medical policies that Russian physicians formulated are pertinent to this history. The historical literature indicates that that the schools of European great powers were defined by an ‘institutional setting’ and a recognised ‘master’, but also a ‘cognitive network of similarly minded workers’.16 The Russian physicians encountered in this book formed connections and loyalties to these schools. Concepts flowed through such networks between Western Europe and Russia, where hygienists and bacteriologists continued,

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often bitterly, to contest the struggle for ideas. Far from reflecting detachment from Western Europe, the Russian situation necessitated the alteration and adaptation of these concepts to the natural and social environments within its borders. Russian scientists rested their conclusions on observable data, operating in a manner that was mostly indistinguishable from their Western peers. While Russian and Soviet scientists often bear the taint of backwardness, historians are increasingly viewing their legacy in a new light. Breakthroughs in epigenetics, hereditary changes between generations rooted in the phenotype rather than genotype, have inspired a partial rehabilitation of the work performed by T. D. Lysenko, the leading Soviet geneticist under Stalin. Lysenko’s questionable theories not only spurred agricultural production in unanticipated ways but have been found to have a basis in fact.17 Recent advances in epidemiology permit a similar rehabilitation of Russian physicians who advanced broad environmental expositions of cholera aetiology. Historians of Russian medicine and public health have produced positive literature, while accepting that late cholera epidemics in Russia reflected a flawed medical system. Positing that tsarist physicians’ continued emphasis on environmental theories of causation, misleadingly referred to as ‘anti-contagionist’ or ‘miasma’, these historians link the later cholera epidemics to a failure in organising quarantine regulations and poor sanitation under the tsars. Primarily concentrating on the years prior to the New Economic Policy, or NEP, scholars extrapolate that the more technologically-adept Soviets quickly rectified these sanitary and theoretical deficiencies. Assigning credit to the Soviets, Roderick McGrew blames uncleanliness and cultural backwardness in Asia and Eastern Europe for keeping Russia and other regions vulnerable to cholera after 1890. Accepting Koch’s experiments as the ‘final evidence’ of bacterial causation of the disease, he argues that physicians emphasised the environment to relieve them of the need to formulate quarantine regulations, resisting bacteriological explanations of the disease.18 Heaping praise on tsarist physicians, Nancy Frieden nonetheless observes that in Russia, ‘a continuing rise in cholera mortality [. . .] indicated a serious failure to keep pace with medical progress in the West’.19 Russian historians recognise a ‘rapprochement’ after 1900, something of a political accord between ‘bacteriologists’ and ‘populist’ physicians in

INTRODUCTION

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the zemstvos, who overemphasised social and environmental conditions fearing that bacteriology would obstruct their programme for social reform.20 Arguing that populist political leanings predisposed Russian physicians toward anti-contagionist reasoning, Russian scholars argue that they created what John Hutchinson pejoratively coined ‘activist bacteriology’. Hutchinson praised the top ranking tsarist physician, G. E. Rein, who, with D. K. Zabolotnyi and N. F. Gamaleia, pushed for a centralised administration based upon science, but he glossed over their environmentalism.21 Lisa Walker observes that Russian physicians’ populism caused them to understand the people as ‘an elemental soil’, providing long-term impetus to environmentalist interpretations of disease.22 On a more material level, Walker argues that Russian doctors used a broad range of measures in dealing with cholera after 1900, agreeing with Hutchinson that cholera’s aetiology ‘enabled’ them to employ expansive methodology.23 Elizabeth Hachten argues that bacteriology did not revolutionise Russian public health, and identifies the emergence of a new approach emphasising ‘the surroundings’ of the vibrio in lieu of its victims.24 D. V. Mikhel’ observes that D. K. Zabolotnyi defied the eminent physiologist I. P. Pavlov at the Institute of Experimental Medicine, taking his investigations out of the laboratory and into the field by the early twentieth century, Mikhel’ comments on the environmentalist theories of N. F. Gamaleia and other Russian bacteriologists, observing that the entire country essentially became one large laboratory.25 These conceptualisations, along with the overall framework of Russian medicine that Nancy Frieden, John Hutchinson, Samuel Ramer, Susan Solomon, Nikolai Krementsov and other Russian historians provide, make an excellent backdrop for elaborating on the positive forces that inspired the broad social and environmental aspects of Russian public health.26 Charlotte Henze recently rejected this avenue, however, arguing that Russian physicians’ emphasis on the environment permitted them to wield power in a government concerned with commerce, but did not stop cholera. According to Henze, even after the 1892 epidemic the Russian government did not understand that only extensive quarantine preparations would have protected Russia.27 This blunder, Henze asserts, led the tsarist Ministry of the Interior (MVD) to devise a plan in 1903, the so-called ‘Cholera Rules’, which was ‘unrealistic’ and enabled the vibrio to thrive until 1925.28 Henze’s articulate presentation of this

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argument contains considerable merit, for increased contagionist intervention certainly contributed to the waning of cholera in the Soviet Union, and commerce played a role in the actions that Russia undertook. However, Russia’s specific social, environmental, political and diplomatic contexts, even its geographical location, made pursuing such an approach untenable. As Peter Baldwin has argued, a country’s location relative to India, its ‘geoepidemiology’, helped determine how it battled cholera. Russia’s broad open frontiers were vulnerable and the country’s size, large administrative districts, shortages of soldiers and other factors exposed it to cholera from India. Russian physicians developed a system akin to what Baldwin calls ‘neo-quarantine’, using a system of strategic checkpoints.29 Nowhere within this book will the reader encounter the assertion that tsarist anti-cholera efforts were perfectly conceived, nor that Russian industrial development equalled that of Great Britain or Germany. This book concentrates on positive forces, the so-called ‘material turn’.30 Yet, there was indeed a connection between environment and culture. The environment influenced how Russians reacted under stress. Statesmen suffered administrative paralysis, concealed epidemics and refrained from bold initiatives, which may be a reflection of their ancestors’ experiences in foreboding environments and vast geography. As Edward Keenan argued, in the medieval period the Eastern Slavs eked out a precarious existence in unfertile northern forests. Poor soil, low agricultural yields and fear of famine created a conservative mind-set, a reluctance to overreact and precipitate social breakdown.31 Russian soldiers, statesmen and physicians considered their country’s terrain and size when planning defences, rarely stopping human or microbial invaders at the border, but used a passive strategy, relying on their country’s size, buying time, mobilising resources and strategically bringing them to bear against intruders. Indeed, even before the Crimean War, Russia’s military was becoming adept at evacuation.32 Tsarist physicians exercised pragmatism and avoided negligible returns. They understood that in Russia, Koch’s discovery of the cholera vibrio would permit a comprehensive explanation of the aetiology of the disease only by comprehending its role in the environment and the social sphere. One of the darkest epochs in Russian history, a period which spanned World War I, two revolutions, a civil war, war with Poland and one of the worst famines in history, brutally drove this point home.

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Sources This book is primarily based on sources located in archives and libraries in Saratov, St Petersburg and Moscow. Due to its location on the lower Volga River, Saratov was one of the most vulnerable cities to cholera in Russia. The city had a vibrant civil society and, for a provincial city, an excellent zemstvo and medical organisation, proving itself a significant location in nearly all the historical epochs under study. Similarly, St Petersburg, known as Petrograd during World War I and Leningrad after 1924, was the Imperial capital and was located at the extreme north end of the Volga/Mariinskaia River and canal system, one of the most important trade routes between Asia, Russia and the West. Despite its obvious political and commercial importance, Moscow, the ‘Muscovite’ and Soviet capital, sat on high ground, detached from waterways connected to the Volga/Mariinskaia System. Other cities of perhaps equal importance to Saratov are Kazan’, Iaroslavl’, Rybinsk, Astrakhan’ and others, mentioned throughout this book. The varying cholera threat that Saratov, St Petersburg/Petrograd and Moscow faced, and their significance to the history at large, provide excellent profiles for comparison.

Organisation Chapter 1 details the epidemiology of cholera in Russia, and how tsarist physicians used European theories of bacteriology and hygiene to develop a broad approach to combat it. Chapter 2 provides background on the five cholera pandemics between 1817 and 1892, describing their correlation to the El Nin˜o Southern Oscillation (ENSO), volcanos, imperialism, drought, famine and revolution. The chapter ends with an overview of the 1892 epidemic, which mobilised intellectual, social, practical and material forces. Chapter 3 details cholera’s entry into Russia during 1902, explaining the implications of climate, railroad construction, war, famine and social problems. This chapter provides an overview of the Cholera Rules devised by the Ministry of Interior (MVD), their implementation in 1904, and the Pirogov Cholera Conference in 1905. Chapter 4 deals with the return of cholera in 1907–10. Also explored are the theories debated by physicians relating to the epidemic’s origin and the role of both the railroad and Muslim

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pilgrimages in this regard. An excellent harvest, stable social conditions and decline of cholera in 1913 indicated that tsarist physicians were primed to control it. Detailed in Chapter 5, World War I brought cholera’s return when it penetrated the country’s borders from the European and Crimean fronts. The Union of Zemstvos and Towns, known collectively after 1917 as Zemgor, organised evacuation during a massive retreat and furthering development of a checkpoint system. During this period, famine also precipitated the fall of the monarchy. Chapter 6 addresses how these food crises and lack of initiative continued during the Provisional Government, which quickly fell to the Bolsheviks. War Communism and grain requisitioning nearly toppled this new government. Despite intense measures, famine and cholera flourished in 1918– 21 due to conditions created by climate and war. A series of social crises caused Lenin to acquiesce to policy changes advocated by reformers. Chapter 7 discusses these changes, which constituted a return to the tenets of zemstvo medicine which was compatible with the New Economic Policy (NEP, 1921– 8). Emphasising prevention, the Soviets sought to raise the material and cultural level of the people in part to combat cholera. Chapter 8 addresses the decline of cholera epidemics in Russia in 1922–7, illustrating how the final cases followed the famine, retreating through the same routes through which they had often emerged. This uniform retreat reflected cholera’s persistence in certain environments, illustrating the Soviets’ success in weakening the microbe and inducing immunity in potential human hosts. Chapter 8 explains cholera’s correlation with its diffusion from India in 1921– 5 and the Soviets’ successful effort to drive it out of the country.

CHAPTER 1 CHOLERA AND ITS ENVIRONS: THE CASE OF RUSSIA

The aetiology of the cholera vibrio, or how it works in nature, is effected by a number of factors. Located squarely along the lines of communication between cholera’s source in India and Western Europe, southern Russia included vulnerable ecologies and susceptible topography that was often saturated with victims of famine, on caravans, steamboats and trains, pilgrimages to Mecca or military expeditions. Southern Russia’s borders were the most vulnerable to cholera in Europe. Russian physicians’ broad scientific orientation was based on this ecological and topological diversity and drew from a range of disciplines, including chemistry, biology, physiology, botany and even psychology. These factors provided their basis for understanding cholera’s aetiology in Russia. The cholera microbe is dynamic, capable of adaptation and evolution and has appeared in over 140 variations.1 Throughout four modern pandemics the microbe remained a mystery. Then, in 1883, Germany’s Robert Koch discovered Vibrio cholerae 01, which is resistant to antibiotics, resilient in high alkaline levels, but subject to neutralisation by stomach acid upon oral ingestion. In some cases, the microbe enters the intestine, secretes an enterotoxin that clings to intestinal plasma cells, emits a sub-enterotoxin and flushes massive quantities of water and electrolytes from the intestines, triggering intense vomiting, dehydration and a high risk of death.2 Koch’s vibrio is considered the causal agent of the fifth world cholera pandemic.

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While Koch’s vibrio continued to appear, another form of cholera soon emerged. In 1905 the German, E. Gottschlich discovered V. cholera 01 El Tor at the quarantine station of the same name, on the Sinai Peninsula of Egypt. This bacterium was less lethal but more survivable than Koch’s vibrio and has been linked to the sixth modern pandemic, which this book addresses.3 Other studies indicate that non-01 cholera, which inhabits aquatic environments and is considered non-agglutinative (incapable of causing the disease), also played a role in the sixth pandemic. This form of cholera survives undetected, undernourished and dormant in many coastal waters worldwide and can cause severe stomach sicknesses.4 The seventh pandemic was caused by 01 El tor, but an even more survivable biotype appeared by 1993, provoking fears of an eighth pandemic. With different versions of the vibrio appearing simultaneously, varying aquatic environments and changes in the immunity of human hosts play a role in cholera’s genetic changes, influencing which variation of the microbe dominates an outbreak.5 Cholera is thus a diverse disease which materialises differently in various environments, depending on changes related to its genetic component. Russian physicians in 1883–1928 were well aware of Koch’s and Gottschlich’s experiments, sometimes even making observations that were undoubtedly related to discoveries that modern epidemiologists have recently disclosed. Wrestling with the ramifications of Koch’s discovery amid burgeoning transportation networks, warfare, climatic catastrophes and human upheavals, the Russian physicians appearing in this book understood, and often emphasised, that diversity of microbes and conditions prevailed in their country and played a role in contagious outbreaks. Fear of these epidemics influenced medical scholarship and policy. The pages of the Russian Physician, the main journal of Russian ‘community’ physicians who were generally employed by the zemstvos, expanded considerably in the years when an outbreak was expected, which included 1905, 1907–8 and 1911–12. The internationally respected Soviet bacteriologist and immunologist, Lev Tarasevich, believed that the alarm prevalent prior to a cholera epidemic was desirable, due to the preparations that it precipitated. In a report to the League of Nations in 1922, he noted that the study and prevention of cholera generated more attention, energy and extraordinary measures than other diseases, particularly after 1900. Special monetary expenditures for cholera motivated more accurate

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reporting and over 90 per cent statistical accuracy, drawing advances to organise anti-epidemic campaigns.6 The vibrio selected and adapted to environments that were most conducive to its longevity and it emerges in this book as a dynamic entity, seeking to ensure its survival in natural and built environments. Constructed and natural environments lie within what the Australian geologist, Edward Suess, called the ‘biosphere’. In the nineteenth century, two geochemists, the Russian V. I. Vernadsky and Frenchman Pierre Tielhard de Chardin, promoted this entity, which included everything from ‘Himalayan glaciers [. . .] to bubbling seafloor vents teeming with bacteria’.7 Both extremes were essential to cholera epidemics, which most often originated from ocean bottoms in the estuary of the Bay of Bengal at the base of this same mountain range. The scientific world is discovering material relationships between cholera epidemics and volcanic activity in the Pacific Ocean’s ‘ring of fire’, particularly in Indonesia’s Sunda Arc. Most of the world’s seismic and volcanic activity occurs in the ring of fire, a circle along the borders of the Pacific Ocean. Of the 3,000 volcanoes that are active worldwide at any given moment, approximately 100 are in the Sunda Arc.8 In 1936, Sir Gilbert Walker recognised an ‘oceanic El Nin˜o’, sometimes referred to in this book as the El Nin˜o Southern Oscillation (ENSO). These events involve rising atmospheric pressure in the eastern-Pacific Ocean, which generally reduces density in the ocean’s western regions. Changes in ocean temperatures in the Pacific produce increased atmospheric pressure that causes far reaching ‘teleconnections’, affecting climatic processes across the ocean. In the 1960s meteorologists discovered that these processes altered precipitation in the Asian monsoon, including intense downpours and long dry spells in Indonesia, India, the Philippines and Australia. Altered precipitation caused drought, flooding and crop failure.9 While the precise chronological and material relationship between ENSO events and Russian famine and cholera has not yet been discovered, they were important in that they created conditions among human populations in India, Asia and elsewhere, causing widespread flooding, dehydration and famine and cholera, often reaching into the southern Russian breadbaskets. The climate in the Southeast Steppe of Russia is susceptible to high atmospheric pressures from Asia, which results in early autumn frosts and heavy spring winds, which create soil erosion and crop failure.10 The continued reappearance

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of famine was most important. Symptoms appearing in patients such as nausea, bloody vomiting, diarrhoea, sharp intestinal disorders, gastroenteritis, were signs that the ‘Blue Death’, cholera, was imminent. As climate change weakened the human organism, it simultaneously ensured that the cholera vibrio arrived in a timely manner. Warm rains caused temperature changes and variations in the salt content of estuaries and coastal waters in the Bay of Bengal, where an influx of large volumes of non-salt water created mixed or ‘brackish’ water, mobilising stored nutrients in the bottom sediments.11 Some of the most dynamic environments on earth, estuaries create more organic matter than similar-size forests, grasslands and farmlands and support a unique variety of animal and plant life.12 Fluctuations in water temperatures and tides fed the vibrio in estuaries with inorganic sources of nitrogen, carbohydrates and minerals that were specific to its requirements.13 The changes occurred in low oxygen ‘dead zones’, in which mobilisation of nitrogen and phosphorus prompted eutrophication, a process in which phytoplankton causes large algae blooms or zooplankton to appear near the surface.14 In 1908 the Russian bacteriologist, N. N. Klodnitskii, identified a similar place on the Volga River at the mouth of the Caspian Sea, in Astrakhan’, which he also called a dead zone. Klodnitskii was in charge of the Ministry of the Interior’s (MVD) bacteriological laboratory in Astrakhan’.15 Subject to tidal disturbances, estuaries are often still, with low oxygen or an absence of it near the ocean floor. The microbe emerged through navigation of marine and human channels of ingestion and waste, starting in shrimp-like copepods, which survive both anaerobically (without oxygen) and aerobically (with oxygen), then through the gut tracts of larger shellfish such as oysters, clams, crabs and humans.16 In 2007, the epidemiologist Alfredo Morabia observed that cholera’s activities in these waters rendered Koch’s discoveries insufficient to stop cholera in some locations.17 Southern Russia was clearly one of those places. Due to Pasteur’s influence, some Russian physcians were considering anaerobic and aerobic developments along coastal regions by the first decade of the twentieth century. In India’s Bay of Bengal these processes initiated the larger cholera epidemics of the nineteenth and early twentieth centuries. The southern end of the Bay was formed by alluvium flowing south with water from the Himalayan Mountains into the Ganges river basin, creating a plain of old and new deposits. The western plateau rested less than 100 feet

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above sea level and was vulnerable to cholera bacteria flowing from rivers above the plains.18 In 1908 one of Russia’s foremost hygienists, G. V. Khlopin, cited ‘high streams and river channels’ as ‘the most harmful features affecting the health of the people’ in the city of Astrakhan’, which was located on the Caspian Sea at the mouth of the Volga River.19 By 1900, the year after India’s Great Famine, 100 million residents in the Ganges valley were exposed to approximately one-fourth of India’s drainage. Millions of sick, starving and dying humans flocked to the area on religious pilgrimages. Human sewage spread the microbe, creating oxygen deficits and destroying marine life.20 The abundance of underfed human hosts and natural processes to ensure its reproduction permitted the vibrio to cause the deaths of approximately 10.7 million Indians, during the sixth pandemic in 1896– 1925.21 The almost universal appearance of food crises before cholera’s mobilisation caused further complications that made response to epidemics difficult. The World Health Organization (WHO) recognises famine as a predisposing factor to cholera and other epidemic diseases due to physical weakness and decreased human immunity to the vibrio, increases in foraging, social upheaval and factors related to demographic movements between cholera reservoirs. Disruption of service infrastructures, respiratory ailments and increased diarrhoeal diseases related to famine all help the microbe defeat sanitary defenses. Flooding creates the same health hazard whether it is caused by climate change or other means.22 Causing crop failure and famine, flooding spreads the bacterium through an overflow of brackish and polluted waters into interior water sources. Drought destroys crops and causes heightened bacterial concentrations in water sources, resulting in reckless human consumption due to dehydration. Famine due to climate events is likely to result in an epidemic due to the simultaneous mobilisation of nutrients and microbes in the estuaries discussed above, but the connection between the two was not always immediately evident. Socio-economic issues and agricultural deficits accumulated over several years, creating long-term stress that later caused collapse in food supplies due to another catalyst. Such accumulations occurred in the years prior to the 1891 famine and between 1918 and 1921 during the Civil War.23 The rural physician Andrei Shingarev, the Minister of Agriculture in the Provisional Government in 1917, commented that only about one out of ten Russian peasant farmers in the

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nineteenth century produced sufficient grain to subsist between harvests. Rural residents survived winters by consuming ‘famine bread’, a mixture of goosefoot, nettles and other weeds ground with rye husks, dried potato peelings, bark or any remotely edible substance.24 Famine reduced human immunity to disease. Moreover, recent studies in epigenetics have concluded that traits associated with recurring famine can change metabolic rates and render successive generations prone to certain diseases.25 Whether Russia’s repeated exposures to hunger caused an acquired vulnerability to cholera is speculative, but famine certainly lowered immunity and predisposed Russians to cholera each time it appeared. Famine eternally preceded cholera in Russia and any effort against it was a de facto anti-cholera measure. Starvation forged a path for cholera in 1822, 1834, 1840, 1848, 1853, most of the 1860s, 1871–2, for plague in 1877 and again for cholera in 1890–1, 1896–1902, 1905–8, 1911–12 and 1921.26 The famines in 1822, 1871, 1877, 1890–1, 1896–1901, 1905–8 and 1911 have been linked to ENSO events.27 Historians of disease have been hesitant to consider famine’s role in epidemics. Russian emergency relief softened famine’s influence, but battling cholera was next to impossible in a country that experienced regular food shortages. In this atmosphere quarantine would have had little effect. Human mobility due to famine, commerce, imperial pursuits, religious pilgrimages or other causes assisted the development of epidemics. From the Bengal estuary, humans carried cholera through the famine-ravished regions of northern India, Afghanistan, Central Asia or Persia, around the Caspian and Black seas into southern Russia, or west through the tropics and into adjacent temperate zones. The first commercial routes north into the temperate zones went up the Volga River, or west through the Don River basin to Western Europe. Southern Russia’s broad borders and environmental similarities with Bengal provided hospitable jumping off spots for the vibrio. The most vulnerable places in Russia to cholera, the Astrakhan’ Province and the Don Cossacks’ Province, were ‘two of the flattest and most low-lying’.28 Located on the southern edge of the Steppe, a grassy-lowland that was once the floor of a vast ocean joining the Black and Caspian seas, cities in southern Russia were susceptible to runoff from immense river basins, including the Volga, which was the largest river in Europe, the Don, Dneiper and Dneister. Within the fragmented Volga delta and its

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intricate estuaries on the Caspian Sea, cholera struck Astrakhan’ 18 times between 1830 and 1892 and, as the St Petersburg Professor G. V. Khlopin observed, ‘wreaked havoc’ in 1830, 1847, 1872 and 1892.29 In amenable natural environments amid dense demographic movements from the Orient, the vibrio thrived.

Transportation and Disease in Russia Improved shipping routes within Russia expanded the means of spreading cholera. In 1710, Peter I ‘the Great’ commissioned John Perry of Scotland to plan a canal connecting the Volga River and St Petersburg. Opening in the late eighteenth century, a series of canals known as the ‘Mariinskaia System’ connected the Caspian and Baltic Seas through the Volga and other rivers. Shipments moved up the Volga to Rybinsk, delivering cereals, ‘iron, copper, colouring matters, naphtha’ and ‘salt, wood, bristles, wool, tallow, hides, furs and fish’.30 The system continued north through a series of rivers and lakes, the Mariinskaia canal, then more waterways to Lake Ladoga, the Neva River and St Petersburg (see Figures 1.1 and 1.2). Engineers improved the 1100 kilometre system throughout the nineteenth century.31 By 1890, 600 steamboats, 2,000 barges, 1,100 vessels on the Caspian Sea and countless riverboats operated on these waterways. During a good harvest, this fleet transported 1 to 1.5 million tons of cereal to Rybinsk between early May and 20 June, coinciding with cholera’s arrival.32 Thirty to 35 ships departed Rybinsk for St Petersburg daily, amounting roughly to 3,000 vessels during the harvest season. The system handled 642,857 tons of produce annually, but could not transport enough grain for sale to St Petersburg before September when products arrived from the United States. The Rybinsk-Bologoe railroad also hauled 401,785 tons to the capital.33 Industrialisation thus connected vulnerable riverine estuaries on the Black and Caspian Seas with their counterparts in the north, the Baltic Sea and Gulf of Finland, especially at St Petersburg. The railroad brought the vibrio to St Petersburg by 1865, moving up the tracks from the Don and Caucasus governments to the capital.34 Linking the Volga Region and the centre provinces, workers built 7,086 kilometres of track in the 1860s and 14,537 kilometres in the 1870s, a total of 21,623 kilometres.35 The tracks connected the Odessa and Black Sea ports to the Don River provinces.36

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Figure 1.1 Movement of trade through Russia c. 1900. Source: Carte des voies navigable de la Russia // Apercu des chemines de fer des voies navigable de la Russia (St Petersburg, 1900).

Simultaneously, rural migrants seeking work in industry occupied the extremities of river cities.37 As migrant labourers and immigrants arrived in the agricultural districts of the Volga, Don and Steppe regions, engineers built sanitary systems that protected residents within cities, but practical limitations in fresh water provision and canalisation of drainage left migrants along riverbanks, inlets and peripheries vulnerable. In the low-lying city of Astrakhan’, workers built a waterworks in the 1880s that used filtration and chemical cleaning, but it was inundated with runoff. Sewage from barges and ships rested on ice

Figure 1.2 The Mariinskaia water system (general route). Source: Professor Richard Gilbreath, Department of Cartography, University of Kentucky.

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in winter, melted in spring and fell into this system, one which served 80 per cent of the population. Further north, the Tsaritsyn waterworks employed advanced filtration, but could not service residents on the riverbank. Unable to build sewers, in part due to low elevation, workers deposited wastes in the river, which residents in unserviced areas used as their main water source.38 Saratov designed projects to improve sanitation, but could not complete them.39 On the Baltic/Neva estuary in St Petersburg, engineers encountered similar problems.40 Hygiene in these cities saved thousands of lives, but cholera diffusion due to industrialisation outpaced the engineers’ capacity to improve sanitary infrastructures. The influx of migrant workers strained municipal services and complicated Russia’s cholera problem, forcing physicians to use their scientific knowledge to devise new means of response.

Russian Science and Cholera Chemistry’s advanced development as a science exercised a great deal of influence in the founding of public health throughout Europe in the early and mid-nineteenth century, an inspiration for broad academic inquiry that Russian bacteriologists and hygienists retained during the period under study. Russian bacteriologists were interested in questions linking the living and inorganic worlds, and concentrated on disciplines ranging from chemistry to botany, physiology and even psychology. Being the first science to develop in Russia, chemistry was particularly important. Many Russian biologists took chemistry courses, viewing the discipline as providing a fuller explanation of life, particularly as it related to the inorganic world, a means of pursuing knowledge and practical utility, and as the foundation of physiology and the underpinning of psychology.41 The discipline proved essential in building the ground work of bacteriology. Historians routinely cite ‘Koch and Pasteur’ as methodologically undifferentiated ‘bacteriologists’. Yet, Pasteur was a chemist who refuted Justus Liebig’s argument that ‘putrefaction’ of compounds in soil was a process that was diametrically opposed to life. Acknowledging the environment as a factor in epidemic disease, Pasteur recognised that certain germs could survive in soil and other environments without oxygen, inventing the terms anaerobic and aerobic.42 Stressing specific yeasts’ role in fermentation, which he described as ‘respiration in absence of air’, he proved that particular living germs caused specific diseases.43

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Russian physicians emphasised Pasteurian bacteriology, retaining an environmental orientation grounded in chemistry and the gamut of sciences and social sciences. I. I. Mechnikov, a zoologist turned immunologist who shared the Nobel Prize with Germany’s Paul Ehrlich in 1908, noted that Pasteur recognised ‘the true role of microbes in nature and as destroyers of all kinds of organic matter’.44 The Russian bacteriologist A. M. Shapiro described Pasteurian bacteriology as emphasising the ‘rotting, decaying and smoldering’ of microorganisms in compounds such as ammonia, nitrogen, nitric and carbolic acid in soil, being the creative force behind the ‘special bacteria’ that caused disease.45 Because of Russian physicians’ interest in the soil and affinity for Pettenkofer’s theory, some historians refer to them as ‘miasmatists’.46 This characterisation is not necessarily inaccurate, but is used pejoratively, implying that Pettenkofer’s empiricism was antiquated and ignoring the chemical element that it shared with Pasteur’s methodology.47 Few of the top Russian physicians after 1900 believed that airborne vapors or gasses emanating from soil caused cholera, as ‘miasma’ is commonly construed. Indeed, Pettenkofer perhaps came closest of all of the nineteenth-century thinkers to anticipating the aetiology of cholera. Erring at times, he understood the multifactorial nature of cholera’s origin, rejecting mono-causal theories resting upon germs as oversimplified.48 Tsarist physicians understood that microbes could survive within Russian environments for long periods of time, and that bacterial interaction with various compounds in and about the waters of shorelines affected the development of epidemics. A chemist and physician, Pettenkofer stressed fermentation of decomposing matter as an influence on the receptiveness of a given area to epidemic diseases. He accepted that a contagious element might be present in the spread of cholera, but did not at first consider it important, nor believe that the disease could spread through water systems. Pettenkofer, a successful scientist with many inventions, essentially founded the field of hygiene.49 Pettenkofer relied almost entirely upon empirical observation rather than laboratory investigation and, to the frustration of the contagionists, his school long remained viable.50 Like most theorists of the time, Pettenkofer was influenced by the miasma theory. Before Koch’s discovery he thought that the cholera germ became an airborne gas after rotting in soil. Like Pasteur, he

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viewed soil as a major enabling or prohibiting factor in the development of disease. Soils in high rocky or dry areas, he believed, were unable to produce a cholera miasma, but ‘low porous soils could’. Concluding that cholera occurred during conditions of low groundwater in the dry summer months, he erred in thinking that a miasma originated in coastal areas between the groundwater and its former surface.51 He thus failed to account for increased consumption of polluted water and fruits during summer and periods of drought, when the concentration of the vibrio in the water of wells and on shallow riverbanks intensified.52 Considering that we now know that cholera emerges from shallow coastal regions during periods of low water and drought, his conclusion was logical. Emphasising individual predisposition to disease, geography, climate and socio-economic status, Pettenkofer, like Pasteur, embraced the idea that each disease had its own specific aetiology.53 Both scientists believed in processes in the soil that were similar to fermentation, developing allied foundational principles.54 The leading Russian bacteriological school in Odessa worked within this paradigm throughout the period under study. By 1892 even the most extreme Russian environmentalists understood germs and searched for conditions in nature which might cause an epidemic. Also called ‘localists’, they emphasised environment as the key to understanding epidemics. The ‘contagionist’ methodology emerged as a school of thought in the 1840s under Koch’s mentor, Jacob Henle, centring on the idea that a ‘contagion animation’ or ‘living virus’ caused epidemics. However, the idea that human intercourse promoted the transmission of disease was not invented by the bacteriologists of the nineteenth century. The word ‘contagion’ comes from the Latin contagio, meaning ‘contact’, therefore, contagious theory involves the transfer of disease between individuals through direct or indirect contact. One of its major staples of defense, the practice of ‘quarantine’ originated during the epidemics of plague in the seventeenth century in Venice when Italian authorities detained ships for forty days or, in Italian, a quarante.55 By 1840 the German Jacob Henle published Pathologische Untersuchungen, arguing that microorganisms that could not be detected by contemporary microscopes entered the body through contact between sick and healthy persons.56 The field of chemistry was more developed than biology during this period and Henle’s idea was

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overshadowed by the theories of Justus Liebig, causing him to stop studying disease.57 In the 1850s the Italian bacteriologist, Filippo Pacini, discovered cholera bacteria, but was also ignored. Pacini gained posthumous recognition in 1965 when an international bacteriological commission named the microbe ‘Vibrio cholerae Pacini 1854’.58 Nonetheless, the term ‘Koch’s vibrio’ is a consequence of the highprofile context in which the Prussian scientist discovered cholera and other microbes in the 1880s.59 Isolating the cholera vibrio in 1883, Henle’s prote´ge´, Robert Koch, espoused a contagionist anti-cholera programme based upon quarantine, isolation of patients, disinfection, and water purification with little emphasis on environment.60 He was very influential, even in Russia, but many tsarist physicians were reluctant to discard the environment. Accepting Koch’s vibrio, they contested his conclusion that quarantine, isolation and clean water sources could keep it at bay.61 Working in a country with broad borders and diverse natural environments and populations, Russian physicians rejected this methodology as unviable, due to Russia’s social context and geographic location. The further south and east a country was located in Europe, or the closer it was to India and tropical and semi-tropical seaports, the more likely it was to suffer epidemics. Physicians learned this gradually through experience. Russian physicians adopted a contagionist approach in the 1830s while Anglo-Indian and Indian physicians generally opted towards miasma theories, which the Russians accepted by 1848.62 Their English counterparts relied upon reports from their colleagues in India and embraced localism. A professor at the University of Munich, Pettenkofer developed a ‘compromise’ position between localism and contagionism based on reports of Indian physicians and English hygienists.63 Physicians in England finally opted for John Snow’s theory that water supplies caused the disease, adopting contagionism by 1867.64 Koch’s contagionist approach prevailed over Pettenkofer’s miasma theory in a contentious public dispute during the Hamburg epidemic in 1892.65 Meanwhile, in Southern and Eastern Europe medical officials still favoured the localist approach. Public health officials in the Italian city of Naples adopted Pettenkofer’s localist theory in 1910.66 The successors of Pettenkofer, including Eduard Buchner, who succeeded him at the University of Munich, emphasised ‘how an infection was ignited’,

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arousing ‘an environmentalist counterattack’ in Eastern Europe, emphasising that germs could lie latent and start and epidemic under proper local conditions. Adolf Gottstein, a medical officer in Berlin, emphasised bodily resistance due to better housing conditions and diet.67 Russian physicians’ emphasis on the environment is welldocumented.68 Nations with southern coasts and those located furthest east were vulnerable to cholera due to climate, topography, greater numbers of cholera carriers and other factors. Pettenkofer’s work exerted influence in Russia, where Friedrich Erismann applied many of his principles. A native of Switzerland, Erismann married the Russian physician N. P. Suslova while studying in St Petersburg in 1869. Focusing on statistical investigations, he travelled to Western Europe to study under Pettenkofer and in 1875 moved back to Russia, where he spent most of his career. The Russian government authorised Erismann to study disease’s link between factories and rural areas during a plague scare in 1878.69 Becoming Professor of Hygiene at Moscow University in 1882, he encouraged students to concentrate on prevention, the cornerstone of zemstvo medicine.70 Zemstvo medicine stressed causation between science and the laws of nature, sociological phenomena and public and private human actions that aided in discovery of these laws.71 Like epidemiology, zemstvo medicine involved amassing data related to local populations, including sanitation, customs, mores and social practices, made connections between these activities and the spread of disease, and provided curative and preventive care.72 In Russia, this was precisely the type of approach that was needed to combat cholera. Russian physicians’ emphasis on chemistry, environment and nature provided a basis for appreciation of Charles Darwin’s evolutionary principles. The chemist A. N. Beketov became Russia’s first botanist and, along with his peers, cited a struggle (bor’ba) while investigating the role of soils in processes such as deforestation of the Steppe. Beketov considered reproductive capacity ‘the most powerful tool of (a species’) struggle against harmful environmental conditions’.73 This idea resonated among Russian scientists battling disease. The immunologist, Mechnikov, for example, argued that white blood cells ‘struggled’ against pathogenic invaders in humans in a battle between unicellular entities and parasites. In 1886, along with N. F. Gamaleia and I. Iu. Bardakh, he founded Russia’s first and most influential bacteriological

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station in Odessa, where L. A. Tarasevich, P. N. Diatropov, D. K. Zabolotnyi and other bacteriologists began their careers.74 These individuals became important in the struggle with cholera. Indeed, in his capacity as the leading Soviet immunologist, Tarasevich helped originate and was a leading proponent of the Darwinist rationale that ultimately facilitated cholera’s withdrawal beyond Russia’s southern borders.

Immunology and its Reception in Russia Immunology did not become as important to battling cholera as hygiene until World War I, but the rivalries between the Pasteur Institute and the German schools in the nineteenth century proved incredibly important to battling cholera in Russia. In 1879, Pasteur performed a successful experiment by immunising chickens against cholera.75 This discovery led him to perform experiments for other diseases, including anthrax. His work on anthrax served as basis for vaccines for rabies, cholera and swine. He experimented with live cultures of weakened virulence, which were capable of a small degree of multiplication within a patient, and tried to use dead cultures to obtain the same results. His work in developing chemical vaccines provided the path that his future work would have followed, but he soon fell ill.76 Pasteur undoubtedly influenced Mechnikov’s studies in immunity. By the late 1870s the latter was working on his theory of phagocytosis, a process that resists microbes and invasive organisms within cells. Meanwhile, German scientists were working on the ‘humoral’ theory, which posited that the body’s resistance to disease was based in hormonal fluids. Mechnikov refrained from bringing his research into the open until August 1883, presenting ‘The Curative Forces of the Organism’ in Odessa at the Seventh Congress of the All Russian Naturalists and Physicians.77 Mechnikov’s theory faced resistance even from scientists who were friendly with him, including the imminent pathologist/ statesman Rudolph Ludwig Karl Virchow (1821– 1902), who had been a member of the Frankfurt Parliament during the 1848 revolution, the German pathologist Moritz Wilhelm Hugo Ribbert (1855– 1920), and even Pasteur.78 The attacks from less friendly German pathologists were vicious. Mechnikov was not associated with the German schools and these more

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established scientists were indignant that a Russian zoologist had dared to question their work. One of Robert Koch’s pupils referred to Mechnikov’s theory as an ‘Oriental fairy tale’.79 The pathologist Baumgarten declared that ‘Mechnikov’s observations are not only insufficiently grounded but even contradict logic and truth’.80 The Germans mistrusted Mechnikov’s belief in ‘the existence of a struggle between bacteria and leucocytes’, white blood cells that are the equivalent of phagocytes in humans. They argued that when microbes invaded blood and tissue, phagocytes were absent, having ‘deserted the battlefield’.81 Mechnikov countered that the phagocytes were neither inactive nor passive, but the victims of an unequal struggle, succumbing to overwhelming numbers of microbes, illustrating phagocytic vitality and warding off their arguments.82 Mechnikov’s use of Darwin’s theory to make his argument could not have proven more influential to the Russian ‘struggle’ with cholera. Mechnikov criticised Darwin’s theory in the 1860s and 1870s. Later, he used it to formulate an explanation to his critics, crediting it as the force behind his discovery. He became fascinated with evolution, discovering that phagocytes in a starfish responded to foreign matter entering the body. When the bacteriological station in Odessa was suspected of causing an anthrax outbreak in 1887, Mechnikov left Russia and moved to Paris. Pasteur had showed interest in the phagocytic theory after Koch imperiously dismissed it.83 However, the German pathologists made some good points. Mechnikov’s concentration on lower organisms singled him out as an upstart. He did not realise that Western pathologists of the eighteenth and early nineteenth century had dismissed the argument that inflammation was a reactive defense of the body against foreign stimuli as ‘teleological’.84 Even Virchow and Pasteur cautioned Mechnikov about the pitfalls in his line of reasoning. Physicians affiliated with the Pasteur Institute and German physicians supporting humoral theory sparred for 25 years. In 1887 Pasteur used his influence to permit the multilingual Mechnikov to showcase his work, publishing ‘Sur la lutte des cellules de l’organisme contre de l’invasion des microbes’, in the Annales de l’Institut Pasteur. Despite reservations, Pasteur referred positively to Mechnikov’s ‘very original’ and ‘fertile’ theory.85 While ambivalent, by praising Mechnikov and affording him an opportunity to publish, the French genius undoubtedly sensed an opportunity to add a viable theory of

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immunity to his institute and gain an edge on his German rivals.86 He may have also sympathised with an argument that, in some respects, mirrored his refutation of Liebig’s theory which emphasised vital as opposed to inert or passive processes. The gamble brought a generation of Russian microbiologists into a theoretical and practical alliance with the Pasteur Institute. German scientists remained unimpressed with Mechnikov’s work and responded with great vigor. In 1891 the German physiologist and army surgeon Emil Adolph Behring (1854–1917), who worked under Koch at Berlin’s Institute of Hygiene and claimed the Nobel Prize in 1901, took exception with Mechnikov’s formulation.87 Behring claimed that the theory rested upon ‘secret forces of the live cell’, going so far as to write to Mechnikov in 1892 and state that cellular theory was ‘an excursion into the realm of metaphysical speculation’.88 Mechnikov had struck a nerve within the German scientific community. A series of experiments once again put Mechnikov on the defensive. The San Francisco native and Cambridge professor George H. F. Nuttal, together with members of his laboratory, proved that blood lacking red and white corpuscles and fibrin (clotting matter) was capable of destroying bacteria. Carl Flu¨gge produced information that leucocytes ingested only those bacteria that bactericidal substances had already killed. Emil Behring linked natural and acquired immunity to characteristics of blood plasma and lymph. Impressivly, Richard Pfeiffer and the Russian-born V. Isaev, who would later work on the 1892 cholera epidemic in Hamburg with Koch, produced evidence that when virulent cholera bacteria was introduced into the peritoneal cavity of vaccinated, presumably immune, guinea pigs, the pathogens died in the absence of intervention by phagocytes.89 The discovery of the so-called ‘Isaev–Pfeiffer Phenomenon’, in conjunction with the other newlydisclosed information, proved sufficient to overtake the phagocytic theory of immunity as the dominant mode of thought. In 1890 at the International Hygiene Congress in Berlin, Koch announced that ‘humoral theory, which was based upon all of the theories arising in opposition to Mechnikov, had eclipsed cellular theory in importance’.90 The debate between cellularists and humoralists is yet another example of how the cognitive structures of research schools caused conflict in the nineteenth century, particularly between students of Pasteur and Koch. Fortunately, these issues were mostly decided by 1908

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and students of immunology in Russia such as Daniil K. Zabolotnyi and Lev. A. Tarasevich (both of whom started their careers in Odessa) could pursue vaccination without concern for the mandates of a particular school. The humoralists had not entirely rejected the idea that white cells sometimes inhibited the effects of microbes on the human organism. Arguing that inflammation was not a protective process, the humoralists rejected Mechnikov’s insistence that phagocytes were ‘the essential and primary element in typical inflammation’ that protected against a ‘harmful agent’.91 Contemporary medicine essentially combined the cellular and humoral theories. The work of these immunologists quickly gave rise to a practical effort to apply cholera vaccination. In 1885, the Catalan Jaime Ferran prepared an anti-cholera vaccine and, without any real verification in the laboratory, treated victims of a cholera epidemic in Spain. Russian bacteriologists were aware of this undertaking. According to the Mechnikov prote´ge´, A. M. Bezredka (1870–1940), Ferran achieved good results, but the disease spread to neighbouring nations. Put in charge of an expedition to deal with the epidemic he ran into ‘a wave of unfortunate conditions’ that prompted the French ministry to declare his experiment unsuccessful. His use of vaccines prompted some immunologists to return to using bacteria taken from patients.92 In other words, they returned to ‘inoculation’ as opposed to vaccination, a step backward. One of Russia’s brightest bacteriologists, N. F. Gamaleia was also working on a cholera vaccine. On 20 August 1888, Pasteur announced to the Paris Academy that Gamaleia had achieved success.93 In fact, none of these early efforts proved sufficient to justify carrying out of mass vaccination. Russia would deal with the fifth pandemic and most of the sixth without the benefit of an effective anti-cholera serum, but some doctors had high hopes that Koch’s experiments would help them defeat the disease in the upcoming epidemic. Unfortunately, cholera control in Russia proved far more difficult than they anticipated.

Conclusion The basis for tsarist Russia’s anti-cholera strategy rested upon an environment influenced by its large size and geographical position at the northeastern extremity of Eurasia, its internal geographical features,

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trading system, industrial development and a broad scientific orientation based in chemistry and other sciences. The country’s leaders sought to compete with the Western European countries and become a great power in their own right. Late industrialisation, tsarist Russia’s relatively close proximity to regions where cholera was endemic, the traffic related to it and the country’s immense size all conspired to make it impractical to develop a defensive strategy based on quarantine and contagionist measures. Russian physicians used their training in the sciences and social sciences to develop an anti-cholera programme that recognised environmental influences within their country. While Koch and his Berlin school would exercise influence in Russia in the late nineteenth century, Russian bacteriologists and hygienists ultimately coalesced around the environmentally-grounded theories of chemists like Louis Pasteur and Max von Pettenkofer, using them as the groundwork for a broad-based anti-cholera strategy.

CHAPTER 2 TSARIST RUSSIA AND THE FIRST FIVE PANDEMICS, 1817—94

The First ‘Time of Troubles’ In the early seventeenth century a series of hardships and chaos in Russia, known as the Time of Troubles, unfolded within the framework of an outbreak of colder temperatures known as the Little Ice Age (1300 – 1850). The first Time of Troubles continued after Tsar Boris Godunov was killed in a palace coup in 1605, and finally came to an end with the coronation of young Michael Romanov, the first tsar in the Romanov Dynasty (1613 – 1917). In the late 1700s, another cluster of events related to climate began to amass. Poor terms related to trade with Britain, a dry spell in 1788 and bitter cold in winter 1788 – 9, along with the soaring grain prices, contributed to the French Revolution. Again, the timing of these events was perhaps even more significant than the climate.1 A series of wars, political alliances, diplomatic structures and the cholera epidemics of the nineteenth century would follow. This chapter provides a sketch of the events and changes that occurred during this period. Climate change, imperial pursuits, warfare and, most important to cholera, famine, connected these events and the epidemics that accompanied them. Due to several clusters of climatological, geological and human events, cholera’s spread from India and Russia’s location, its size and status as an industrialising European power, and most importantly, an innate susceptibility to famine and drought, made Russia’s encounters with cholera more frequent than its neighbours to

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the west, despite its leaders responding to the crises in a manner that was similar to the other powers.

The Tambora Volcano and First Pandemic, 1815 – 23 Cholera had long flourished in India, Ceylon and Burma, appearing in the 1770s, but disappearing without entering Europe.2 The harsh climate of the Little Ice Age undoubtedly contributed to the famine and bread riots that were behind the storming of the Bastille in France in 1789. Napoleon’s Grand Arme´e spread typhus, diarrhoea, gastric fever and dysentery to Russia in 1812 and across Europe until 1815, but not cholera.3 In 1809 a massive volcano, the so-called ‘1809 Unknown’, occurred at an unidentified location in Indonesia. The coldest decade in recorded history followed; ten years of storms, droughts, summer frosts, alterations in food stores, flora, fauna and seismic activity.4 In 1812 there were two major volcanic eruptions, including Soufriere on Saint Vincent Island in the Caribbean and at Mayon in the Philippines.5 Then, on 15 April 1815 the strongest volcanic eruption in recorded history, more powerful than all 5,559 volcanic eruptions that occured since the last ice age, happened in the Sunda Arc of Indonesia at Tambora, setting off explosions that were heard hundreds of kilometres away. The Tambora eruption, the Vienna Congress on 8 June and Napoleon’s defeat at Waterloo on 18 June formed a flashpoint, unleashing imperial pursuits and natural forces that sparked the cholera epidemics of the nineteenth century.6 The terror of the French Revolution was fresh in the minds of European monarchs, who formed the Concert of Europe with Russia as their enforcing arm. The Russian government took steps to strengthen its imperial might. Statesmen from France, Great Britain and Russia resolved to decide the Eastern Question in their favour, seeking to acquire the lands of the dying Ottoman Empire or Sick Man of Europe. As a vast land empire, Russian imperial rule has been characterised as a contemporary of the Ottoman and Austro-Hungarian empires. However, Russia’s colonial engagements, military conquests and defeats, should be included in the context of Western European ventures. Russian military expansionists particularly studied the French ventures in Algeria and, in turn, the Russia campaigns drew the eye of French expansionists.7 To pursue the concept of Empire, Russia also

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sought to incorporate the tens of thousands of Muslims travelling annually to the hajj under its banner.8 Climate change and empire laid the groundwork for the cholera epidemics that followed. Like its colleagues in the Concert of Europe, Russia’s appetite for territory was prodigious. Warring with the Ottomans and pursuing lands along their southern boundaries, the Russians desired acquisition of the Turkish ‘straits’, or the isthmus between Anatolia and Eastern Europe and Greece, a warm-water port with access to the Mediterranean Sea. Russia’s contest with Great Britain was also contentious, described as a ‘Great Game’ to occupy Central Asia, Persia, Turkey, Afghanistan and perhaps even India. In hindsight, Russia’s threat to British India was probably miniscule, but climatological events and demographic movements related to imperialism and the hajj brought the peoples of Britain and Russia into contact with cholera. After the Tambora eruption, uncommonly hot temperatures and tropical winds in the Bay of Bengal interrupted the monsoon season, while Arctic winds struck New England and Western Europe. The monsoon arrived in Bengal three weeks early, in May. An unusual hailstorm followed between June and August before the worst dry spell in India in modern times. The backlash of the drought, a torrent of downpours and floods wrecked crops throughout Bengal, left people dead and dying of cholera in and about the waters of the Ganges. The cold and darkness in Western Europe in 1816 became known as the ‘the year without summer’. The devastation of crops from Bengal to Manchester brought widespread suffering until 1850.9 The discovery of potato and other food sources in Western Europe caused famine and cholera to wane in the second half of the century, but such was not the case in Russia.10 Although agriculture suffered severely after Tambora resilient farmers in Russia and the United States achieved a bumper harvest by 1818.11 This windfall saved many lives, but such abundance did not always provide reprieve for the labouring classes and indigenous peoples. The European powers usurped resources from imperial territories, breaking free of the economic slump and boosting commercial and industrial upswing while generating the poverty that still plagues their former colonies. Famine was due to climate, scarcity and imperial policy.12 Due to bountiful agricultural districts in southern regions, Russia’s dependency on the harvest and status as a major food producer made it vulnerable to the harsh cycle of the El Nin˜o Southern Oscillation

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(ENSO), which contributed to the countless famines. Cholera usually followed. Tambora caused the diffusion of a new strain of cholera.13 The new virulence of the microbe may also have been associated with a particularly vicious outbreak that appeared in Bengal the year before.14 Some medical officials attributed the cases in India in 1815 to consumption of polluted fish, but other physicians rejected this diagnosis. The epidemic remained local for almost two years until imperial warfare initiated its westward distribution. Fighting the Maratha War and encamped on the banks of a river valley on the southern outskirts of Gwalior, Lord Hasting’s ‘Grand Army’ soldiers were among the first European victims, experiencing an epidemic that was so intense that the general moved his army across the River Sinde. Between 15– 22 November 1817 Hastings’ troops groaned from misery while the vibrio killed 10,000 men, women and children. Suspecting that camping along a swamp caused the outbreak, he moved his army to higher ground in Erich above the River Betwah.15 His action saved thousands of lives. In 1817–23, the powerful vibrio spread into the Middle East and northern Africa, northern India, Ceylon, Nepal, Singapore, Indonesia and other Asian cities. By 1821, the microbe occupied most of the tropical zone, travelling east to Japan, Malacca, Singapore, Burma, China and, the following year, the Philippines.16 In 1823, Russia came under threat. The Russians were aware that warfare made their southern borders vulnerable to disease. Battles with the Persians and Ottomans had brought epidemics to the Lower Volga region since 1720 and contributed to cholera diffusion after Tambora. Russia, along with Prussia and Austria, defended the diplomatic social order in Europe after 1815, justifying military action to uphold the balance of power.17 In accordance with an 1810 statute, the tsarist army created quarantine stations and cordons across their border with the Caucasus and established six trading posts.18 The longevity and functional capacity of these quarantine stations is unknown, but despite their presence cholera appeared in this region repeatedly over the next 100 years. This military construction and the Russian policy of toleration toward religious minorities that had begun under Catherine the Great in the late eighteenth century, brought the Russians into contact with

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Muslims pilgrims travelling to and from Mecca. Tsar Alexander I reluctantly banned the hajj in the Caucasus in 1822, but corrupt Russian officials provided pilgrims with false papers, permitting them safe passage. Ambivalent about infringing on religious rites, Russian commander, A. P. Ermolov assured Islamic leaders in 1824 that he would soon lift the ban and open roads.19 By that time, cholera had arrived in the region. Appearing in Muscat on the east Arabian shore in 1821, the microbe entered Persia, paused during the winter and made its way to the Tigris River in spring 1822. From here it threatened Kurdistan, moved west in 1823 and entered the western extremity of Syria at the end of the Central Asian Silk Road at Aleppo. Continuing south along the Palestine coasts, the vibrio simultaneously moved north to Tiflis along a canal and river to Baku in the Trans-Caucasian frontier, then to a fort on the Caspian Sea and finally to Astrakhan’, where it killed several people in September.20 The route of the vibrio in the days before massive railroad construction was clearly caused by contagious transmission, but as we shall see the vulnerability of this region, its coastlines, canals and rivers, brought cholera to Russia over the next 100 years. Famine was the major factor in the epidemic’s progress. The Karbardian, Inguish and Ossetian peoples in what is now Georgia, all required salt for livestock and food preservation, and the Russian army used sanitary precautions as a pretext for traders to make local populations dependent upon the commodity, creating hardship.21 Famine prevailed by 1820. On 14 April 1822, Tsar Alexander I’s ministers passed comprehensive famine relief legislation. A central government bureau authorised a monetary allotment to local authorities in at-risk districts. If they exhausted these funds, they could apply for emergency relief. This legislation was, sadly, too far ahead if its time. Local bureaucrats retained a great deal of control and were responsible for amassing statistics, upon which food supply commissions based decisions. Rural administrations were weak and district and provincial officials did not always understand local needs. Bureaucrats established cash reserves when granaries would have been preferable, resolutions required passage through several agencies and relief administrations remained dependent on the government, constantly requesting aid.22 The tsarist government was willing to attempt to help people threatened by famine and cholera in its empire, but never at the expense of pursuing

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imperial greatness. The government’s famine relief failed to stop either famine or the epidemic. The number of cases among local populations in Azerbaijan, Armenia and Georgia were unavailable for this study, but between 4 October and 10 November 1823 there were at least 392 cases and 205 deaths in Astrakhan’ Province.23 The degree to which the Russian military used quarantine is unclear. Convening a cholera council at St Petersburg, the government apparently made recommendations but did little else.24 The extent to which either famine relief or quarantine or both exercised a quelling effect on the epidemic is difficult to estimate, but it might at best have delayed the vibrio until autumn, after the trading season. The tsarist government in St Petersburg saw little reason to address rumours about a mysterious disease on a far-away border.25 Slow communications during this period made responding effectively to a disease that struck with lightning speed highly improbable.

The Second Pandemic and ‘Hungry’ Forties: 1829 –49 In January 1826 Governor Ermolov reduced enforcement of the ban on the hajj to a regulatory role, passing new rules for Muslim passports that enabled Russian officials to determine their number. Tsarist agents in the Caucasus monitored applicants and restricted documents to ‘wellintentioned Muslims’. This policy mirrored colonial governments in other parts of the world. Ermolov’s measures were intended to show Russian tolerance for Muslims and bolster security, as uprisings were flaring up.26 The Shi’ia Clergy in Persia authorised the Shah to declare a jihad, or ‘holy war’, on Russia over a territorial dispute. In July, the Persian Crown Prince Abbas Mirza moved on Tiflis, but Ermolov initiated a counter-offensive, capturing Tabriz and Ardabil, threatening Tehran and forcing the Shah to treat with the Tsar. Emboldened, the Russians went on the offensive, fighting the Ottomans until February 1828 and signing a treaty at Turcoman, advancing to the Euphrates and Araks rivers in Eastern Anatolia in autumn. Capturing Erzurum, the Russians moved against Trabzon, occupied a Black Sea port and the Turkish caravan route to Tabriz. The Ottoman Sultan sued for peace at Adrianople in September 1829. The Russians annexed the 464 kilometre stretch from Anapa to Poti on the northern and eastern coasts of the Black Sea and expressed interest in supporting Greek

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independence. Cholera contributed to the Russian decision not to intervene.27 Just prior to the Treaty of Adrianople, Persian caravans carried the vibrio across the Russian border to the southern Urals at Orenburg.28 On 26 August 1829 a soldier of the Third Battalion on the Orenburg line experienced what would become familiar symptoms: diarrhoea, profuse vomiting, stomach pain, thirst, bluing of the lips, coldness, cramping in the limbs, weak pulse, waning strength and terror. Five cases materialised over the following week and on 11 September medical officials announced an epidemic.29 As the vibrio struck Orenburg, the local medical board considered both contagionist and human predisposition as part of the equation. In 1829 they formed a cordon around the city and did not permit anyone to enter. Due to moderate mortality, 32 per cent in Orenburg between August 1829 and February 1830, there were no social disturbances. Tsarist officials worried about restricting trade from Asia and profits at the annual fair at Nizhnii Novgorod, but while business-oriented citizens and government entities generally detested contagionist methods, the medical councils emphasised ‘social stability and the danger of rebellion’ in political circles.30 Religious considerations and potential unrest, in other words, order in the Empire exercised the dominant influence in how the Russians responded. The enforcement of contagionist measures caused common people in Russia to fear that the government was trying to eliminate them. In 1830 rioting broke out in Sevastopol, due to strict quarantine measures. The provisional military governor, Lieutenant General Stolypin, declared an investigation. Restricting movement along the seashores in Korabel’naia, he prolonged the quarantine for further investigation. Seamen, dockworkers and poor residents in the district tore down the manned stations designed to restrict their movements, attacked soldiers, destroyed churches and even murdered Stolypin and other officials. Anarchy reigned between 22– 24 May before police restored order. This type of violence was repeated at quarantine stations throughout the nineteenth century. In a vast multi-religious empire, strict contagionist and quarantine measures sparked violence.31 Such violence often motivated the tsarist government to keep cholera’s presence quiet to quell hysteria and avoid economic disruptions. In a large, decentralised empire, the mindset prevailed

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that rapid response would prove useless. This secrecy and hesitancy to respond which extended throughout the tsarist period was a manifestation of ‘preserving the empire’. In Russian Poland, revolutions created violence, famine and demographic movements related to cholera diffusion. The microbe appeared in Poland in 1830 before the Russians arrived to quash the rebellion, although the Russian expedition is often blamed for the outbreak.32 Social complications such as revolutions frequently appeared concurrently with cholera epidemics and both were often related to living conditions, usually famine. The second pandemic spread across Russia and Europe, peaking in 1830–8, costing over 250,000 lives out of at least 500,000 cases in Russia, a mortality of nearly 50 per cent.33 During Russia’s first experience with cholera, fear of the unknown and social inequities created mistrust between peasants, the government and the gentry.34 In the 1830s, many residents of Europe, not only Russia, considered cholera’s victimisation of the lower classes to be a godly reckoning for failing to live well; in short, their drinking, debauchery and forbidden behaviours.35 Russian historians have criticised the tsars for not acting promptly, arguing that they held the means to deal with the disease but were slow compared with countries such as England, which passed the Reform Law in 1832. One common accusation concerns Russian use of harsh methods to enforce quarantines, which purportedly caused more social turmoil than in ‘enlightened’ governments in Western Europe.36 These claims must be considered within the context of empire. In 1892 Americans and Germans turned their anxiety over cholera outward, targeting Russian Jews. Hamburg officials blamed the cholera on Russian Jews travelling from St Petersburg, surreptitiously placing them on ships bound for America before confirming the epidemic there. The American press described these immigrants as ‘human riff-raff’ and the ‘scum of invalided Europe’. Mobs roamed the docks of New York City, refusing to permit Russian Jews, even those who had passed inspections, to come ashore.37 Eight years later, American and British execution of quarantines in the Philippines led to starvation of native islanders due to a lack of food during a quarantine.38 In the St Pauli suburb of Hamburg on 9 October 1893, a mob ‘brutally kicked and stamped to death’ a policeman and sanitary officer during a cholera riot. An article in the New York Times observed that this incident was just the latest in a spate

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of cholera-related violence. Soldiers with fixed bayonets finally quelled the disturbance.39 Predominantly carried out in the peripheries of the empire, Russian administration of quarantines were perhaps no crueller than those of Western European countries or the United States. Great Britain’s Reform Law did not stop cholera from returning to the British Isles, as scattered epidemics continued for years, including two deaths on the Humber Estuary of Grimsby, Lincolnshire as late as 6 October 1893.40 The United States and Great Britain had limited ports of entry and cholera victims arrived exclusively on board steamships, making them easier to pinpoint. Differences in social temperament between Russians and Westerners were less dramatic than scholars of Europe have suggested. The size of Russia, its vast expanses and social disparities in the Empire, religious pluralism, poverty and educational deficiencies, promoted fear and violence. These complications made responding to cholera epidemics in Russia more difficult. Moreover, Russian quarantine measures benefitted Western Europeans, who mimicked the Russian approach in the 1830s. Austria and Prussia followed Russia’s lead in using strict quarantines and later, more moderated forms.41 These measures alleviated cholera’s intensity in the West. Saxony, for example, benefitted from Russian, Prussian and Austrian quarantines. Saxony used no quarantines and required foreign visitors to undergo quarantine only if they had crossed infected regions, particularly in eastern-Europe in Galicia, Poland and Russia, within the last 20 days.42 As cholera ascended the temperate zone into Europe, Russia’s status as the first nation to confront cholera made it the leader. Later, as cholera descended into endemic regions in Asia, Russia’s status as the last European nation to experience the disease caused Western scholars to consider it backward. Just two years after Britain passed the Reform Law, Tsar Nicholas I sought to revise the 1822 famine legislation while retaining its basic principles. The new law required local commissions to maintain reserve grain supplies and cash, but reduced local autonomy. They were permitted to distribute small-scale resources and required to petition the central government in times of crisis, but local efforts after passage of the law proved less effective than hoped. The programme strained the treasury and many locations received insufficient provisions. Tsar Nicholas I even experimented with the novel idea of making famine a

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matter for the routine handling of public works, but was unable to resolve the problem.43 Yet, tsarist efforts to feed a vast, rustic empire and subsequent epidemics must be considered in context. The casualties from famine and cholera were large in comparison with Western countries, but small in contrast with those occurring within the British protectorate of India, which suffered far more casualties because it faced a greater threat. Both tsarist and British famine relief undoubtedly saved thousands of lives. The chance that Russia might somehow have avoided cholera in the 1830s was slim. The country possessed the most complex web of riverine environments in the world. Steamboats were becoming faster and Nicholas I was contemplating building Russia’s massive railroad system. Introduced into Russia, the bacterium found refuge in underfed populations that had never been exposed to the disease. The incidence of cholera, its morbidity and percentage of deaths (mortality) were highest where socio-economic levels and living conditions were the worst.44 Penetrating a huge landmass with burgeoning, broadly-dispersed urban centres, a widening transportation network and a dependency on agricultural regions that routinely suffered drought and famine, the ‘Asiatic guest’, as the Russians called the vibrio, took up seasonal residence. Even while the 1830s outbreaks were winding down the forces that spread cholera once again began amassing. In 1835–41 a series of volcanos with an overall index of 4,200, only 200 points less than in 1811–18, brought extended cold weather.45 These events coincided with Russian expansion. By 1834 the army had consolidated its southern expansion through acquisition of Fort Aleksandrovsk, opposite Astrakhan’ on the Caspian Sea facing the Aral Sea. By 1838 they had built forts across a 720 kilometre line, threatening the Central Asian khanates.46 The climatic events prompted the Great Famine in Ireland while its counterpart in Russia paved the way for epidemics in 1841 and 1848. In 1840 and 1848, Russian physicians recommended consumption of famine bread, but this eclectic mix of seeds, grasses and parched plant skins caused protein deficiencies, diarrhoea, vomiting and gastrointestinal disorders, spiking the already high death toll.47 Local authorities used quarantine at ports while the state established legislation on the practice for the borders and heartland in 1841. However, the regulations applied to plague rather than cholera. The law mandated stringent

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measures such as isolation of infected houses, abandonment of schools, stockpiling of equipment and medicine, disinfection means, food and water, while mandating fines and the death penalty for violating the quarantine.48 This approach gained a modicum of success, particularly in that the 1841 policy included food and water provision and securing of medical supplies, but would have been less than effective in the epidemics that lay ahead.49 Fortunately, the Russians abandoned this approach for a hands-off strategy during the 1847–8 epidemics. The Imam Shamil was plotting against the Russians, supplied and supported by Muslim clerics and Sunni hajj pilgrims of the Ottoman Empire. Russian diplomatic officials were hamstrung by their strategy to register and support participants of the hajj.50 A rigid quarantine with steep fines and the death penalty would have proven disastrous in 1847– 8 during the widespread famine, cholera epidemics and revolutions. The Russians were not alone in taking an anti-contagionist stance in 1847–8. Southwood Smith, Edwin Chadwick and other physicians of the British General Board of Health rejected quarantine throughout the epidemic, later defending their position. In Germany, Rudolf Virchow, C. F. Reich and Justus Liebig supported anti-contagionsim as did the editors of the Medizinische Zentral Zeitung.51 In 1849 A. A. Tardieu, a great French hygienist, stated ‘It is very evident that measures taken in view of the contagion are entirely without avail, and that consequently the contagion itself is very improbable’.52 While we now know that cholera is contagious, the observations of eminent authorities who witnessed the epidemic that quarantine was ineffective during these famine years should not be easily dismissed. Russia’s approach was nearly identical to those in the West. Widespread famine caused the microbe to spread in epic proportions. In 1846 starving Bedouins raided food and water reserves in the desert, overpowering and killing would-be rescuers. These robberies caused further shortages. The price of animal fodder and camel transport rose drastically. Hundreds of pilgrims, horses and camels perished in the desert.53 On 16 October 1846, the bacterium appeared along the coast of the Caspian Sea and then the Caucasus. Reaching Baku, the outbreak remained light until the spring of 1847. Striking Astrakhan’ on 4 July, the vibrio spread from the Caucasus to the Black Sea province of Ekaterinoslav by mid-month, then through European Russia, causing

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190,846 cases and 77,719 deaths. Wintering in cities from Poltava to Orenburg, including Moscow, Chernigov, Orel and Kazan’, the vibrio advanced north and south on the Volga from Kazan’, soon appearing in St Petersburg. Russia experienced 1,742,439 cases and 690,150 deaths in 1848, the highest number of cholera casualties in Russian history. The area between the Black Sea and the Lower Volga and Astrakhan’ in the Don Cossack region suffered the most deaths, especially Ukraine. Cholera preceded the revolutionary upheaval and although disorder undoubtedly spread the disease, its original diffusion was more likely due to climatic change and famine. In 1847– 51 there were 1 million deaths and 2.5 million cases in Russia.54 Eager to keep commercial routes open, in 1851 the French organised a sanitary conference in Paris and along with the British, questioned the contagious nature of cholera and use of quarantine. The Mediterranean countries wanted to conduct quarantines. Citing the threat of plague, Russian delegates opposed limits on land cordons and opposed the French and British.55 In the days before John Snow’s work in London and Koch’s discoveries and in the aftermath of 1848, the British and French position was understandable, however, all these points were soon moot. Geopolitics over the Straits brought Russia into conflict with the Ottomans, Great Britain and France.

The Crimean War and Third Pandemic: 1852 –9 The Russians kept up the military pressure along their southern frontier. In 1853, General Perovskii captured the fort of Ak Mesjed 540 kilometres from the Aral Sea, renamed it for himself and founded the city of Alma Ata, now Almaty, which is currently the capital of Kazakhstan.56 In 1853 –6 Russia became ensnared in the Crimean War, which became one of the most significant conflicts in its history. Tsarist encroachment into the Crimea and the quest to control both the Straits and Mediterranean Sea brought about war against an unlikely triumvirate. The Ottoman-Anglo-French military alliance denied Russia its prize. Once again, warfare brought famine and cholera. The English physician John Snow investigated a cholera epidemic in London in 1854, discovering the vibrio’s connection with polluted water sources. Snow constructed a map of the locations of the victims and published On the

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Mode of Communication of Cholera.57 The London epidemic was almost certainly connected with famine at the battle front. British, French, Sardinian and Turkish forces camped in Bulgaria and Turkey in the summer of 1854. Crippled by fatigue, exposure and malnutrition due to a broken supply-line from Balaclava, British soldiers suffered diarrhoea, dysentery and cholera through the winter of 1854– 5 and again the following summer.58 Returning veterans likely brought the cholera to London. The war cost the Allies and non-combatant Austrian Army of Occupation approximately 155,000 deaths, of which 95,000 were due to disease and 18,000 to two waves of cholera.59 The London epidemic was fuelled by famine, before its dissemination into Soho through the Broad Street pump. The Russian military suffered approximately 100,083 cholera-related deaths in 1853 and 131,327 in 1855.60 The disparity between the number of cholera fatalities in the Russian and allied camps likely resulted not from only conditions within the Russian army, such as inadequate food and impure water sources, but the passage of Russian supply lines through endemic and semi-endemic regions of cholera. Still, the Russians clearly understood the military loss and the prevailing conditions in which it occurred, as a complete failure. The Russian military defeat in the Crimean War became one of the most important moments in Russian history, resulting in widespread calls for reform. Encamped across the bay from the British at Sevastopol, the young and brash physician, N. I. Pirogov, embarked upon a career that brought changes both to the Russian medical system and society, becoming the most venerable medical practitioner in Russian history. Operating under impossible conditions during a nine-day bombardment at the front and dealing with thousands of wounded, he and his assistants built upon pe-existing systems of evacuation, hospital organisation and sanitary transport, developing a system of rapid sorting, orderly evacuation from the front and attention to nutritional deficiencies at checkpoints.61 The military evacuation and checkpoint system became important to cholera prevention in Russia, but Pirogov’s main breakthrough was his idea that economic and social conditions in Russia entailed that prevention of epidemics would be more effective than treating them. Preventive medicine became the cornerstone of the Russian medical philosophy, a movement led by ‘community’ physicians who worked for the zemstvos that were formed during the Great Reforms of the 1860s.

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Despite their losses, Russia’s experience in its first world conflict since battling Napoleon provoked the formation of organisational infrastructures and medical methodologies that would help shape Russia’s modernisation; a microcosm of what would occur in World War I. Pirogov’s legacy as a symbol of Russian medical success endures to this day. Community physicians named the largest and most important society for public physicians, the ‘Pirogov Society’, in his honour, an organisation that was a wellspring for improvement throughout the period under study.

The Fourth Pandemic, 1865– 73: The Great Reforms, Famine and Preventive Medicine During the Great Reforms, Russian authorities wrestled with medical issues, broad ideas of government, public health and law. Tsar Alexander II emancipated the serfs in 1861 and made efforts to modernise the electorate. He did not permit elected officials in the centre of government, but instead authorised representative bodies at the local and district level. These zemstvos were land assemblies elected according to property holdings by landowners, city residents and peasants, as were similar city councils with stricter property requirements. Teachers constituted approximately 50 per cent of these councils, which also included physicians, lawyers, feldshers (medical assistants), statisticians and bookkeepers. While the state was the primary source of revenue for this ‘third estate’, it regularly blocked any reforms.62 The inconsistency of this relationship unsurprisingly caused frustration. There was widespread dissatisfaction with the reforms, especially famine relief. The new peripheries required more officials and resources than the government could spare. Passed subsequent to yet another food crisis, the Famine Relief Statute of 1866 mixed both the 1822 and 1834 laws. Abolishing the food commissions and placing provision in the hands of the zemstvos, the law increased the authority of the Ministry of Internal Affairs, or MVD, Committee of Ministers. Granaries were responsible for stocking nine bushels of grain per male inhabitant. Authorities collected this portion annually and kept it under guard. The district zemstvo was responsible for reconsidering the supply every six months. Local officials investigated ethics breaches, maintained

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elaborate security measures and limited the distribution of community reserves.63 These efforts faced near insurmountable odds. The famine in Russia was irrepressible, becoming so widespread by the 1860s that, by decade’s end, one of the founders of zemstvo medicine, I. I. Molleson, expressed astonishment that ‘people do not die one and all’, pointing out that medicine could not eradicate hunger and that ‘the peasant needs to be fed rather than treated’.64 Scholars attribute the outbreak of cholera in 1863 to Muslim pilgrims travelling from the hajj.65 Famine undoubtedly weakened Russia in preparation for its fourth experience with cholera, as did various climatological and economic developments. Cholera outbreaks in Mecca helped spread the massive pandemic by 1865, causing the MVD again to consider limiting passports for Muslim pilgrims. As the disease spread to Western Europe and the United States, approximately 200,000 people died worldwide.66 Cholera carriers on board steamboats brought the vibrio to the Black Sea port of Odessa on 27 July 1865. The outbreaks in European Russia were sporadic and weaker than in the previous pandemics.67 However, a new stretch of railroad brought cholera through the Don and Caucasus governments, where a significant outbreak developed along the railroad to St Petersburg.68 In 1866 Russian legislators expanded the law relating to quarantine to cover yellow fever, smallpox and cholera.69 With famine rampant, quarantine did not stop cholera. Russian physicians would have to design a system to suit their specific place, time and circumstances. By 1869, British physicians in India understood this problem, stating that cholera was multi-causal, that the ‘special physical geography of Hindustan’, weather and precipitation, particularly the Asian monsoon prevented contagious explanations from predicting or explaining the development of epidemics.70 They could not have been more correct. Moderate El Nin˜o events struck India and China in 1867– 70 and the former in 1873–4. A stronger El Nin˜o event struck India, China, Brazil, South Africa, Egypt and Java in 1876– 8, bringing drought to the Lower-Volga region in 1876 and 1877.71 In 1871 cholera outbreaks appeared in massive numbers in Jeddah, which was located near Mecca in the large region of Syria known as the Hejaz.72 In 1871–2 the microbe struck Russia, the Red Sea and the Sudan. Severe suffering motivated the British colonial government to pass the Indian

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Quarantine Act, which permitted the practice in ports. The Sanitary Commissioner, J. M. Cunningham, who formerly opposed measures supporting the notion that cholera or plague were contagious, changed his mind in 1867. Recalling the role that British interference with local religious customs had played in sparking the Indian Mutiny and Rebellion of 1857 (or as the Indians called it, the ‘Great Revolt’) Cunningham espoused limited use of cordons by municipalities to guard against infections while opposing widespread implementation.73 The British’s moderate approach in India was an understandable shift, a practical response to climatological data and unrest in its Empire. That same year, Great Britain passed the quarantine act, applying it in a stable home front. Scholars have understood Britain’s adoption of quarantine in 1866 as a triumph of contagionism over anticontagionism, without recognising that the Commonwealth had one approach in its colonies and another in the home isles.74 Understanding this difference is key to understanding the approach that the Russians would come to favour. The British imperial strategy in India mirrored Russia’s more flexible approach due to the ineffective nature of quarantine the closer one came to endemic homes of disease. The proclivity of the measure to produce violence of imperial subjects also favoured a looser strategy. In an interconnected land empire like tsarist Russia, however, imperial actions amounted to an extension of the country’s borders and implementation of a dual strategy like the British used was logistically impossible. Thus, the Russians were forced to use the more flexible version for their entire country. Place and circumstances altered anticholera efforts even at the same time. India and Russia faced a far graver threat than the British Iles. Due to interference with trade and other problems caused by quarantines in the part of the Straits known as the Bosporus, tsarist physicians called for an international sanitary conference in 1874.75 Modernisation, including increasing trade networks and growing capital, were also rendering quarantine less viable. By 1869, 8,000 kilometres of railroad lines connected cities in India.76 In the 1860s and 1870s the Russians added 21,623 kilometres to their railroad infrastructure, linking the Black Sea, Odessa and the central provinces by 1871.77 Many Russian physicians understood the futility of a strategy centred on quarantine. The nation’s endless, sweeping frontiers were penetrable, making it impossible to secure the Persian border due to

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large, dense human populations. Due to their unique environment, they felt that the disease was endemic in their country.78 The Crimean defeat did not quell Russia’s imperial thirst. Bringing Bukhara into the Empire in 1868, Russia claimed the area of the deposed Mongolian khans to the lower reaches of the Hindu Kush Mountains. The Russians eyed Afghanistan and some Afghan refugees defected to the Russian army in Bukhara. The army enveloped huge swaths of land, including Kabul, the Khyber Pass and Indus River Valley, the Merv oasis in modern Turkmenistan, Herat, Kandahar, the Bolan Pass and the Kokand Khanate. By 1876, the frontier armies had formed an arc from the Dorah to the Karakoram Pass at the headwaters of the Indus River.79 Emboldened and seeking revenge for the Crimean War, in April 1877 the Russian army attacked the Ottomans, gaining victory along the southern front. Shir Ali of Afghanistan signed a treaty with Governor Kaufmann in August and the British occupied Kabul and Kandahar.80 Preceded by strong El Nin˜o activity in 1876– 7, drought appeared in the lower-Volga region in 1876– 8, also affecting India, China, Brazil, South Africa, Egypt and Java.81 Plague appeared on the Volga River at Vetlianka, Astrakhan’ Province, in 1878.82 However, the epidemic was nothing compared with the storm that mobilising climatic forces would soon bring. As the 1870s came to a close Russia was modernising along European lines. Tsarist physicians called for a conference with European countries and used mainstream methodologies, copying their anti-cholera efforts, and being copied in return. The country retained formidable military prowess, had freed the serfs and was making great progress in its legal system. Meanwhile, the geopolitical situation was changing. The Meiji Restoration in 1868 started the Japanese on the path to building an industrialised military. The Prussian leader Otto von Bismarck led Prussia to military victory over France and unified Germany in 1871, vowing to solve the nation’s problems through ‘Blood and Iron’. Russia found itself lagging behind in this new, aggressive atmosphere. Events on the home front further weakened Russia’s position. In 1881, the Russian terrorist group ‘The People’s Will’ assassinated the reformer, Tsar Alexander II. His son, Alexander III, replaced him, striving to reinforce traditional Russian government and institutions. By 1881, G. V. Plekhanov was contesting the Marxist logic that Russian backwardness would not produce the bourgeois revolution

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that, as Marx had viewed it, would serve as precursor for socialist revolution. Arguing that scientific socialism would entail delays, Plekhanov encouraged Russians to welcome capitalist liberalism. Plekhanov’s ideas found receptive ears among Russians who liked the idea of being part of an international movement as opposed to the stifling rhetoric of slavophiles about the distinctive nature of Russian society. Some socialist agitators espoused an expedited timetable.83 Political, social and natural events occurring after Alexander II’s assassination accelerated the revolutionary course. As usual, cholera accompanied the discord.

The Krakatoa Volcano and the 1892 Cholera Epidemic There is the antiseptic system, there is Koch, and there is Pasteur, but the essential reality is not altered a bit; ill-health and mortality are still the same.84 Andrei Efimich in Ward No. 6, Anton Chekhov, 1892 The challenges that Russia faced in the last years of the nineteenth century began in 1883. As Robert Koch conducted his famous experiments, a familiar series of climatic and human events began unfolding in the Sunda arc of Indonesia.85 A massive eruption at Krakatoa, approximately half of the strength of Tambora (with an index of 1,000), brought the strongest recorded gales since 1815.86 ENSO events caused disastrous floods and over a million drowning deaths in China between July 1886 and June 1887 and later in 1889–90. Korea experienced drought, famine and social protests. Clustered El Nin˜o events followed in 1888–9 and 1891–2. The erratic climate caused shortfalls and price shocks, drastically affecting markets across continents.87 In 1888–90, the harvest in Russia declined. Low winter temperatures and summer drought in 1891 brought famine to the Black Earth districts of southern Russia, the Lower-Volga Region and the wheat fields of Orenburg.88 The government’s knowledge of the food shortfalls up to January 1891 is unknown, but problems in these breadbaskets after the 1890 harvest should have been obvious.89 In 1890, the Russian middle class was not strong enough to challenge the government and nobility, but the centre of obshchestvennost’,

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an ‘educated society’ that possessed the consciousness to address social ills, had formed.90 The zemstvos responded to the famine, but their efforts were undermined by lack of experience and friction with local authorities. New zemstvo bosses in 1889 fostered communication between villages and towns, but lacked experience and understanding of the nuances of local government. The physician Kapustin militated for sustained famine relief in Kazan’ directed by medical authorities, with the jurisdiction to battle cholera, typhus and typhoid. Physicians in Simbirsk distributed 102,082 meals to the population, with 1,031 in one district alone.91 Perhaps most effectivly, physicians constructed food and medical supply stations along the Black Sea in Kherson Province to feed the thousands of migrant workers who flocked annually to work the fields. The type of cooperation required to marshal this relief was generally limited to the central provinces, where three quarters of the country resided.92 Moreover, threatening to shut down presses for mentioning ‘famine’, the government severely blundered by postponing a ban on exporting cereals until August, prompting merchants to expedite shipments of grain that might have saved peasants’ lives. Russian scholars generally agree that the 1891– 2 famine and cholera epidemic mobilised intellectual and popular forces that undermined the autocracy. Alexander III, followed by his son Nicholas II, stubbornly attempted to preserve autocratic government.93 Cooperation with the zemstvos and acceptance of a constitution might have saved the monarchy and would have certainly reduced disease. Pirogov physicians understood that famine relief was essential for stopping not only cholera, but diphtheria, typhoid, typhus, dysentery and malaria. As Erismann pointed out at the Fourth Pirogov Conference, 30 to 40 per cent of the deaths in Russia resulted from epidemic disease and treatment did not reduce mortality.94 The persuasive Erismann and his colleagues fostered constructive relationships with altruistic industrialists and the ruling class in Moscow Province that their peers in less developed cities could not reproduce.95 Building trust and cooperation in outlying areas with landed gentry and religious minorities amid language and cultural barriers was more difficult. The tsarist government proved unable to close the wedge between these competing entities, suffering much of the blame. Rather than supporting the government’s emphasis on commercial trade and capital, Pirogov physicians, who were almost exclusively government employees,

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quite bravely risked their careers and reputations to support their fellow Russians in need. The physician I. Ia. Stol’kind later charged the government with wrecking the economy in the 1880s, increasing taxes on basic necessities, kerosene, matches, sugar and other provisions and putting billions of rubles in its coffers. Stol’kind asserted that these actions caused the failed harvest, the 1891 famine and a 20 per cent increase in mortality over the previous ten years. He claimed that the Russian budget grew 9.1 per cent while its counterparts in England and France rose by 2.4 and 2.8 respectively. Complaining that the zemstvos in the Caucasus were dominated by a gentry that intentionally provoked unrest between religious groups and nationalities, a form of divide and conquer, Stol’kind made these charges at the Pirogov ‘cholera conference’ amid the excitement of the 1905 Revolution.96 While in many ways correct, he could not have considered issues related to climate that have since come to light. The Krakatoa eruption placed enduring stress on the Russian economy in 1883–91. The socio-economic conditions and rural poverty that creates famine keeps societies on the brink of disaster for years before some event vaults it over the edge. Undoubtedly in some ways responsible for creating the famine, in other ways the government response prevented an even larger crisis. The Russian intervention actually compares favourably to the relief administered in the British Raj in 1899–1900. The British assisted less of the Indian population, 18 per cent, compared to Russia’s 30 per cent in 1891.97 In 1896–7 several hundred thousand Indians perished from disease and famine. In 1897, there were 15,000 deaths due to cholera every week in India and even more in 1899.98 Stol’kind’s statistics were perhaps also skewed by inclusion of spending in the peripheries of Russia’s land empire while considering only the main British Isles. Admittedly, comparisons of the British and Russian empires have limitations. India’s location caused it to suffer more ill effects than Russia after Krakatoa and its immense population renders a comparison based upon percentages rather than absolute numbers imbalanced. Most important, the British and Russians, bearing responsibility for these crises, reacted with the likeminded benevolence that European imperialists sometimes exhibited in their colonies. The Russian government’s policy of incorporating Muslim pilgrimages into the empire increased travel on the southern frontier,

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facilitating cholera’s entry into the country. By the 1880s, tens of thousands of Muslims discontinued caravan travel through Ottoman, Persian and Indian territories. Making the trek through southern Russia through Black Sea ports, Muslims returned from Arabia through Russia and its borderlands in Khiva, Bukhara, Persia, Afghanistan and China. Creating a network of external consulates for pilgrims of the hajj, Russia incorporated diverse peoples from beyond its borders into the Empire.99 Preoccupied with industrialisation and military pursuits, a combination of erratic climate, poor crop yields and government neglect in feeding citizens made famine and cholera almost inevitable. New railroads and military expeditions caused heightened speed and density of travellers. General Annekov’s workers built the Trans-Caspian Railroad for the coronation of Tsar Alexander III in 1888. Intended for military use, the government used the line more for commerce and passenger transport, shortening the trip between Samarkand and the Caspian Sea from many days to approximately 60 hours.100 The Russian army in Persia had annexed much of the Russo-Persian frontier into the Empire, including the oasis at Merv and the Pendjdeh on the Murgab, threatening Herat.101 Only 200 kilometres from the city, Russian workers linked the Trans-Caspian Railroad with Merv and Kushka, and with the Caucasus, the Trans-Volga region, the Urals, western Siberia and the central Russian provinces. In 1892 this new construction permitted a newly-invigorated vibrio to cross the border and strike the Russian interior with unprecedented ferocity.102 Russia experienced over 600,000 cases and nearly 295,000 deaths, while Western Europe suffered comparatively low casualties.103 The new railroad linkages of diverse sections of the southern frontier and increases in Muslim pilgrims fortified a burgeoning empire, but also brought cholera. The most vulnerable places in European Russia were Astrakhan’ Province and the Don Cossacks Province. Located on the ‘estuary of the Volga’, Astrakhan’ drained ‘by countless mouths into the Caspian Sea’ and was nearly defenseless. Sections of the province and the city resided below the level of the river and were flooded by its runoff. ‘Whether Professor von Pettenkofer’s theory be accepted or not’, concluded the British attache´ to Russia, Frank Clemow, here resided ‘conditions known to be favourable to the diffusion of cholera’.104 In fact Pettenkofer had been correct. The immense drainage at the base of the largest river in Europe into the lowly-elevated city with its multiple estuaries and

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limited canalisation created perhaps the most epidemiologically dangerous conditions in Europe. Indeed, the places in Russia with the highest cholera rates were typically located on the outskirts of municipalities along the shores of waterways. Like the Tambora volcano in 1815, the Krakatoa eruption undoubtedly strengthened the 1892 vibrio, which moved rapidly over the new transportation network.

The 1892 Epidemic: Its Course and Characteristics Pursuit of European modernity had its price. The St Petersburg professor G. I. Arkhangel’skii noted that the epidemic not only moved much faster than its 1830 and 1847 counterparts, spreading quickly up the Volga and westward into Ukraine, but was unusually lethal, fully encompassing south-western Russia by mid-June. The vibrio killed up to 114 victims a day per 45,000 inhabitants in Baku, claiming approximately 2.5 per cent of the population. Entering Astrakhan’ in the second half of June, over 200 of every 74,000 inhabitants fell ill, causing approximately 3,500 deaths in a city of 1 million people. Continuing north up the Volga, cholera spread through Tsaritsyn, Saratov and Samara, reaching Moscow and St Petersburg with unprecedented speed.105 Arkhangel’skii detected a mathematical decrease in intensity the further north the vibrio spread, but there were exceptions. Iaroslavl’, for example, sat farther north and began experiencing cases three days later than Kostroma, but suffered 104 cases for every 100,000 inhabitants as opposed to only 31 for the latter. This disparity was due to Iaroslavl’ Province’s status as a distribution centre for trade and textiles. Local conditions also caused deviations in St Petersburg and the Polish governments of Lublin and Siedlic. Sometimes, the vibrio leapfrogged several places, attacking a distant province in great strength, but leaving its origin and destination, cholera-free. By 1 August, for example, the vibrio skipped Kiev and Volynia, establishing itself in Ekaterinoslav, Kharkov and Poltava on one side and Lublin on the other. It entered Moscow and St Petersburg on 20 July, leaving the two governments between, Tver’ and Novgorod, cholera-free for 16 and 26 days respectively.106 Observation of the pattern of trade illustrated in Figure 1.1 partly explains this disparity, as the numbers of seasonal travellers moving up the Volga and along the Mariinskaia System to

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distribution points of commerce, and disparities in environmental vulnerability explain why cholera reached both capitals before some of the places between them. Increased railroad construction also influenced the epidemic’s course. Despite immense railroad construction, however, the route up the Volga River remained the fastest. The vibrio traversed the Volga with great speed first and, second, through Ukraine to the west. The speed that it ascended the Volga was astonishing. Cholera leaped from Astrakhan’ Province on 13 June to Saratov Province the next day, to Samara Province on 23 June, to Simbirsk the next day and Kazan’ by 25 June. The vibrio had travelled just less than 1,200 miles in 12 days. From Kazan’, it continued north up the Volga entering Nizhnii Novgorod on 7 July, Kostroma on 18 July, Iaroslavl’ on 21 July and Tver’ on 5 August. (Figures 1.1 and 1.2) By late July, cholera had penetrated the central governments, entered St Petersburg and extended to 10 Polish governments then north to Vologda and Olonets in August. The only unscathed provinces in European Russia were Archangel’sk, Kovnia, Finland, Estonia and two Polish governments.107 Contagionist measures along the Volga River proved a complete failure and the bacterium’s speed, strength and unpredictable behaviour render explanations that more elaborate preparations could have stopped its penetration into the country’s interior doubtful at best. The epidemic progressed more slowly along its south-western route. Reaching the Territory of the Don Cossacks’ capital, Rostov-on-Don, on 28 June, the vibrio did not appear in the adjacent province of Kharkov until ten days passed, and did not enter the neighbouring city of Poltava for four more days. Continuing at this slower pace, the disease spread south, entering Ekaterinoslav Province on 23 July and continuing west to Taurida Province in the Crimea on 3 August. The epidemic moved to Kherson by 8 August and to Kiev by 16 August, failing to reach the border governments of Bessarabia and Podolia until 26 and 30 August respectively.108 Since the steamboats could only travel halfway across the Don from Rostov toward Voronezh, smaller craft were necessary to complete the voyage. The third longest river in Europe, the Dneiper, was nearly impassable for large ships below Kherson, where there were several waterfalls.109 Natural features slowed the speed of cholera’s progress upriver, but did not explain why it moved slower over the railroad in the

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south-west. The railroad should have accelerated movement more quickly to the west, but trains did not always travel along vulnerable shorelines or dump potentially lethal microbes into rivers. While not exerting the same effect as the steamboat, railroad travel confused the understanding of (and response to) the epidemic. Tsarist officials in the Ministries of Internal Affairs, Trade and Transport considered blocking land routes to force Muslims pilgrims to use the railroad and steamboat routes over the Black Sea, but wisely decided against this policy due to unfamiliarity with the broad terrain along the borders and fear of backlash.110 In places, the Russians, influenced by the notion that Koch’s experiments provided a panacea to cholera, attempted to use cordons, enforce quarantines and forcibly isolate patients in cholera barracks. These actions caused cholera riots and disorder in southern Russian and Central Asian cities. For example, tsarist officials used forcible compulsion on Central Asians in Tashkent to comply with their programme of ‘sanitary engineering’, which caused mass resistance. Such unparalleled tsarist intrusion in Central Asian affairs caused local inhabitants to question their relationship with the Empire.111 Use of cordons led to murders and assaults on medical personnel in the Lower Volga region and cholera riots in Astrakhan’, the Donbass coal-mining town of Iuzovka and several other places.112 Enforcement of contagionist measures in 1892 also caused further cholera riots and did not stop disease. Henze argues that the government should have devised an extensive system of quarantine, asserting that the government broke with its tradition of state control. She suggests that a relaxed quarantine policy invited coercion due to inadequate government instruction regarding quarantine administration, leaving local officials free to disregard medical opinion. Citing haphazard clarification of instructions for quarantine measures along Russia’s ocean edges and broad, separated land borders, Henze asserts that tsarist planners should have formed observation points along rivers, stockpiled medical supplies, built barracks and deployed personnel, just as they had in 1841.113 This argument underestimates social, industrial and commercial complications, the railroad construction, borderland acquisitions and burgeoning cities that had emerged in the fifty years since 1841, not to mention the intensity of the famine and virulence of the 1892 vibrio.

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After attempting to implement cordons, a group of zemstvo and municipal officials, professors, and bureaucrats chosen by provincial governors met in October of 1892 and recommended abandonment of quarantines, arbitrary inspection of travellers, and disinfection of baggage. This programme mirrored the plan endorsed by F. F. Erismann, who was perhaps the most ardent supporter of zemstvo medicine.114 Meanwhile, the director of the Kronstadt Plague Fort near St Petersburg, V. I. Isaev, was in Hamburg studying the epidemic with Koch. One historian has argued that Isaev’s absence left unnamed Odessa ‘hygienists’ in charge, arguing that this development created the erroneous impression that Erismann had been correct after cholera subsided in 1893, resulting in a flawed environmental agenda.115 However, the Odessa laboratory, the brainchild of I. I. Mechnikov, N. F. Gamaleia and I. Iu. Bardakh, was a bacteriological laboratory that produced P. N. Diatropov, L. A. Tarasevich and other important scientists. The environmental orientation of Odessa bacteriologists, who were working within the Pasteurian paradigm, was harmonious with the views of the hygienist, Erismann.

Erismann and Russian Bacteriology The differences and similarities between bacteriologists and hygienists requires explanation. Russian historians recognise a professional struggle with two hostile camps in which the bacteriologists, who were on the cutting edge of medicine, were able to overtake their antiquated peers through diplomacy, quelling their apprehensions and acknowledging that they made a few good points. In fact, the scientific paradigm in which Russian bacteriologists worked had a great deal in common with the doctrine of the hygienists. The ‘rapprochement’ that historians have recognised was much less an exercise in diplomacy than an understanding of two parties who shared vast similarities in their philosophies. The most common event used to designate the origin of this ‘feud’ is a heated discussion that took place between Erismann and Mechnikov at the 1887 Pirogov Conference. Citing Robert Koch’s discoveries, Mechnikov argued that bacteriologists should immediately occupy all chairs of hygiene at Russian universities. Mechnikov’s blunt suggestion inferred that all hygienists should lose their positions, but Erismann’s

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eloquent defense of hygiene has been interpreted as articulate sophistry resting on the argument that bacteriologists had not comprehensively articulated cholera aetiology.116 However, Erismann’s erudite explanation rested on experience and data. As professor of hygiene at Moscow State University, the Swiss-born hygienist, along with Odessa bacteriologists, was paramount in shaping the Russian position on cholera, an outlook that was entirely compatible with legitimate European science. A thorough review of his position is warranted. Erismann argued that the ‘bacteriological fever’ that ensued after Koch’s experiments motivated undue focus on the vibrio without understanding its aetiology, promoting ignorance of epidemiological developments in its absence and failure to clarify the conditions that caused epidemics to develop. Contagionists used localism as a starting point, causing some bacteriologists to become extreme localists who posited that cholera could appear spontaneously after residing in the environment for long periods of time. Erismann rejected this view.117 Progressive Russian physicians did not believe in spontaneous generation. They were contingent contagionists, who believed that germs must be brought to Europe from Bengal, but understood that environment played a role in cholera aetiology. Erismann knew that Anglo-Indian physicians had concluded that cholera aetiology worked differently in India than in England. The vibrio’s ability or inability to propagate in various environments caused deviations in its patterns, particularly in regions closer to Bengal. The English physician D. D. Cunningham had served 33 years in India. His studies and experiences with cholera caused him to conclude that cholera diffusion did not perfectly correspond to routes of transportation away from Lower Bengal. He observed correctly that the disease originated in the environment in Bengal due to atmospheric conditions. Erismann cited Cunningham’s experience in his lectures, arguing that the routes of travel played a lesser role in India. He also noted that places outside of the epidemic zones often developed sporadic cases that were not genetically related to the cholera in Lower Bengal. Europeans referred to these outbreaks as ‘cholera nostrus’. Cunningham had considered six locations that were located directly on the routes of military railroad transport and six that were far away from the railroad. In the distant locations, 16 out of 10,000 people died from cholera, as opposed to only 6.2 in locations close to the lines.118 Cunningham and Erismann agreed

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that the railroad in India did not strongly influence cholera diffusion.119 The implications of this study indicated that the environment was an important factor in cholera diffusion, particularly in India. Erismann had an advanced understanding of cholera’s aetiology. He knew that it behaved differently in various venues due to environmental influences and that various strains could cause weaker, less-deadly outbreaks. Recent studies have corroborated these observations. The construction of a vast railroad network alongside one of the longest and most complex web of inland waterways in the world complicated understanding and combating cholera in India and Russia. Industrialists in India built the Southern Maratha Railway in the 1880s to assist famine relief by carrying grain to stricken regions. Such development helped alleviate famine, but the railroad was built with promises of profit to a corporation in Manchester.120 The strengthening of transport between India, Russia and the West increased cholera diffusion. Erismann, Arkhangel’skii and other tsarist physicians studied how railroad travel affected cholera transmission in their country, but industrialisation and food distribution often altered patterns. Disagreements regarding how to approach the disease in the aftermath of Koch’s bacteriological discoveries often created more confusion than clarity. Russian physicians, quite correctly, refused to throw out everything they had learned. While the European scientific community was intoxicated with bacteriology, Erismann cautioned that physicians should rely upon the new science gradually and integrate it with what they already knew. He acknowledged that Koch’s experiments had contributed to the knowledge and understanding of cholera. Investigators had come to recognise that the vibrio played a role in causing the disease, but its precise function remained ambiguous. Koch’s experiments provided clarification regarding the biological characteristics of cholera, the development of ‘the cholera poison’ within the body and the ‘epidemiology of the disease’. These disclosures permitted scientists to discover information regarding the behaviour of the vibrio in population centres, about human immunity to the disease and bacteriologists’ capacity to distinguish cholera from other diseases. Erismann praised Koch for spurring mass interest in bacteriology, making important observations and prompting an ‘extremely rich literature’.121 In this case, Erismann comes off as the diplomat, trying to appease unreasonable

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bacteriologists, rather than the opposite. His persuasiveness in the face of overwhelming enthusiasm for the opposite position speaks volumes to the veracity of his words. Some bacteriologists began supporting an autochthonist interpretation, arguing that the vibrio could rise in epidemic form in congenial environments when certain climatic and other conditions prevailed. Although we now know they were correct, it is important to realise that bacteriologists supported the most extreme environmental scenario imaginable. Both Pettenkofer and Erismann rejected this possibility, which differed from miasma in that the physicians supporting it did not believe in a vapour or spontaneous generation, but that pathogenic microorganisms survived in soil or other environmental components and regenerated in epidemic form after interaction with accelerants.122 Few Russian physicians in 1900 were miasmiatists, but most felt that environment-microbe interactions produced cholera epidemics. While not understanding the role of estuaries, like Pettenkofer, they focused on water-soaked soil near or on the shorelines of rivers, lakes, seas, oceans and in water pools. While not precisely accurate, they were closing in on what would take investigators nearly a century to discover. Citing Arkhangel’skii, Erismann argued that Asiatic cholera did not self-generate from the environment in Europe, but was carried onto the continent from East India. Investigators had confirmed the biological link between the properties of Indian and European cholera. The tsarist government, he argued, had incorrectly interpreted the 1829 epidemic in Astrakhan’ as ‘self-rising’, stemming from ‘an unusual change in the weather’.123 He cited an epidemic in France in which the cause was later linked to India. Several scholars argued that the conditions in Lower Bengal that had led to cholera’s birth could be duplicated elsewhere.124 Their intuition was almost certainly correct. The French Medical Inspector, M. Fauvel, had concluded that a cholera epidemic in 1884 in Toulon had materialised through local conditions, but Erismann argued that Fauvel was mistaken and that the Toulon epidemic was ‘real Asiatic cholera’.125 Given Toulon’s location on the coast of France, Fauvel could have been correct and the same for the tsarist government’s position on the 1829 epidemic in Astrakhan’. Erismann was interpreting the epidemics using the best science of the period, and arguing that cholera investigations should not be anchored to laboratory experiments, but conducted through the study of cholera’s aetiology.126 Frank Clemow, a

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British contagionist who spent years studying cholera, observed that that Erismann expressed ‘the clearest exposition’ of the environmentalist interpretation of cholera epidemics, acknowledging ‘strong evidence’ that elevation and moisture in soil influenced an epidemic.127 Both physicians acknowledged ‘exceptions’ that defied contagionist reasoning. Erismann admitted that some outbreaks could not be explained by identifying the ‘splits or cracks’ as Pettenkofer had called them, through which the vibrio slipped. Pettenkofer believed that Asiatic cholera could be brought surreptitiously into a location without starting an epidemic, remain there for an extended period in absence of the conditions to spark an epidemic when the proper circumstances materialised. Erismann observed that advantageous environmental conditions and perfect timing could produce ‘small local outbreaks’, observing that Koch’s vibrio had become the only agent accounting for ‘actual cases’. However, he pointed out that neither contagionists nor localists were able to explain increasing cases in Europe, questioning instead how these ‘cholera-like’ cases should be classified, and recognising the probability that certain forms of cholera were not durable and easily destroyed.128 The outbreaks that Erismann described may have been associated with 01 El tor or similar pathogens. Epidemiologists would not sort out these issues for decades, but Erismann’s description was very advanced. Historical assumptions that Koch’s experiments should have enabled Eastern Europeans to stop cholera have not accounted for the complexity of the issues. Russian physicians understanding of cholera aetiology within their Motherland was equal to their peers in Western Europe.

The Pasteurisation of Russia, 1883– 1928 The French sociologist Bruno Latour has commented on the heroic legacy that Louis Pasteur built in France, and a similar phenomenon occurred in Russia.129 By the beginning of the new century, Russian bacteriologists were building a cognitive foundation for fighting cholera that was based more upon the principles of Pasteur than Koch. In an article regarding the Saratov waterworks in 1900, the bacteriologist A. M. Shapiro provided an account of the evolution of water quality that reflected this comprehension. He identified the period lasting up to 1850 as being one when scientists relied upon physical appearance, the taste and smell of water, the period between 1850 and 1880 was

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characterised by scientists using chemical testing and appraisal and finally, the years after 1880 were when physicians began relying on bacteriological screening.130 Given Koch’s prestige, it would be easy to conclude that Shapiro would, if not should, hold views that were harmonious with Koch. Instead, he observed that Pasteur had refuted Liebig’s theory of putrefaction by proving that ‘fermentation occurs, individually, under the influence of microorganisms, that rotting, decaying and smoldering during the process of ammonia, nitrogen, and nitrogen acidity and also of carbolic acid occurs only under the influence of the capacity of living microorganisms [. . .] typhoid, cholera and other (diseases) enter into our organism by special bacteria’. Since it was possible for water that had passed chemical tests to cause cholera and typhoid fever, bacteriology eclipsed chemistry as the dominant discipline.131 Shapiro’s history of water quality provides an understanding of the manner in which Russian bacteriologists reconciled the investigations of Pasteur and Koch. Both scientists had proven that specific microbes caused particular infectious diseases but Pasteur’s analysis contained an environmental component that demonstrated that conditions in nature beyond the presence of the microbe precipitated or hindered epidemic development, recognising that processes such as fermentation were potential catalysts for outbreaks. Tsarist physicians were, in essence, searching for Pettenkofer’s unknown substrate ‘y’ in the formula x þ y ¼ z, where ‘x’ was the biological agent or cholera bacterium, ‘y’ the possible catalysts such as nitrogen, carbon and other elements, and ‘z’ the epidemic disease. S. N. Vinogradskii, who directed the Institute of Experimental Medicine from 1902 to 1905, was interested in the role that ‘nitrification’ in soil played in the development of disease. Vinogradskii later moved to Paris and began working at the Pasteur Institute.132 Tsarist physicians’ environmental conceptualisation of cholera was based upon creative use of European bacteriologic and hygienic principles that helped view the aetiology of a microbe through a multifactorial lens, rejecting mono-causal explanations. The pathologist Mechnikov also criticised Koch’s work. He observed that the findings of immunology were consistent with epidemiologists who maintained that cholera was one of several ‘viruses’ that had to be carried into a location where it did not naturally exist.133 However, he took issue with pathologists who, after Koch’s discovery of specific bacterial agents, concluded that they must locate the pathogen within a

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patient because it did not exist in healthy individuals or those with other diseases. He cited the observations of the Prussian Friedrich August Johannes Loeffler (1852– 1915) who, having located the diphtheria bacillus in the throat of a healthy child, rejected it as the cause of the disease. Mechnikov knew that pathologists had verified that the diphtheria microbe caused the disease. In a similar vein, he knew that Koch’s vibrio was the causative agent in Asiatic cholera, but had been discovered in the digestive canal of healthy persons.134 He concluded that healthy carriers of cholera could pass the disease to others. Like their European peers, Russian medical personnel knew that apparently healthy individuals could carry the vibrio and cause an epidemic. Like Erismann and Mechnikov, N. F. Gamaleia discovered weaknesses in Koch’s discoveries, observing that they had not met the requirements necessary to satisfy his procedural standards, the well-known Koch’s Postulates. Gamaleia cited problems with the morphological and biological quality of Koch’s specimens and procedural errors.135 To satisfy Koch’s Postulates, Gamaleia noted, one must find the specific bacteria for a disease in every case and if it was absent there should be no disease. The scientist must isolate the bacteria in clean form and, when injected into laboratory animals, this culture must reproduce the disease. Gamaleia pointed out that Koch had been unable to reproduce cholera in laboratory animals and that his experimental specimen did not possess sufficient distinguishing colour or form to constitute a clean isolate of the culture.136 He called for ‘a revision of the entire system in order to be consistent with the latest knowledge of the disease’.137 To be fair, Koch was aware of these problems, but Gamaleia’s observations testified to his scientific capacity. Unfortunately, Gamaleia’s critique had repercussions. He was passed over for director of the Military-Medical Academy in St Petersburg, a consequence of criticising Koch and defending Pasteur and Mechnikov against, as the historian John Hutchinson observed, ‘savage and often unjustified attacks’ from Koch’s followers. In 1892, the St Petersburg medical establishment fully backed Koch and chose one of his Russian associates, S. P. Botkin, whose achievements were not equal to Gamaleia’s, as the director of the Military-Medical Academy. The Academy then began emphasising research over pedagogy. In 1898, V. I. Isaev, who had worked with Koch and Richard Pfeiffer during the 1892 cholera outbreak in Hamburg and was co-discoverer of the

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‘Isaev–Pfeiffer Phenomenon’ in cholera immunology, was appointed director of the new Kronstadt Plague Fort, which produced serums for vaccination.138 The struggle between adherents of these research schools remained an important factor in shaping Russian public health. Koch’s backers increasingly found themselves in the minority after 1892, as physicians who were more theoretically aligned with Erismann, Pettenkofer, Pasteur, Mechnikov and other Paris and Odessa bacteriologists came to prominence in the Capital. Influenced by Pasteur and Mechnikov, the Odessa bacteriologists believed strongly in immunology and vaccination. One of the most influential, Mechnikov, worked on cholera immunology and by 1901 completed his work on ‘phagocytes’’, the equivalent of white blood cells in lower animals. Working in Paris, but determined to stop cholera in Russia, Mechnikov described ‘Asiatic cholera’ as capable of toxic action over distance or through close contact between living components. The vibrio, he noted, secreted a poison in the intestine, penetrating mucus membrane and forming a ‘purely toxic’ disease. In infantile cholera, or other cases in which the aetiology was unclear, however, the secreted poison might constitute the entire sickness, remaining in the intestines and causing a deadly intoxication without penetrating the blood or tissues. Experimenting on geese, he observed that a pathogen could pass through the body before the poison began to work, a phenomenon similar to one that typhoid researchers had observed in horses. Cholera, Mechnikov noted, differed from diseases such as anthrax, which upon penetrating the skin almost always caused death. Even in large quantities cholera often caused only minor disorders. However, once the disease entered the digestive canal, deadly ramifications followed.139 Mechnikov made steady progress. Observing that frogs possessed a degree of natural immunity to cholera, he injected cholera bacteria into the dorsal lymphatic sac (and other areas), where phagocytes forcefully opposed, consumed and absorbed them. However, when he introduced a very weak dosage of the cholera toxin as opposed to the microbe into the frog, the animal quickly died. Mechnikov concluded that the natural immunity of the frog resulted from phagocytosis, a process in which cells engulf other, pathogenic cells after identifying it, through an elaborate detection process. Mechnikov theorised that phagocytosis in frogs prevented the production of the cholera poison.140 Other researchers theorised that phagocytes only ingested dead organisms, but

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Mechnikov countered that cholera microbes universally maintained their potency prior to ingestion, concluding that immunity resulted from phagocytosis.141 Receiving the Nobel Prize in 1908 and other awards for his work, Mechnikov convinced a generation of physicians that it would be possible to devise a system of mass vaccination as part of a comprehensive system of anti-cholera measures. As his Nobel Prize demonstrated, he was fully the equal of his European peers and, along with the discoveries of Paul Ehrlich, with whom he shared the Nobel, his work motivated a generation of Russian immunologists, later proving important in the Soviets’ decsisive actions against cholera.

Conclusion The Russian cholera epidemics of the nineteenth century were a consequence of clustering natural forces. El Nin˜o events and the disruption of the monsoon caused drought and flooding which destroyed crops and caused famine in human populations. Simultaneously, altered ocean tides and global temperatures mobilised chemical components on the floors of estuaries that initiated cholera’s travels through nature’s ecological chains, including human beings. From oxygen-minimum zones by means of copepods, then larger crustaceans and humans, cholera made its way into the intestines of under-nourished and under-hydrated humans. The vibrio was transported across the globe by the imperial armies of the nineteenth century, commercial transportation, itinerant laborers, religious pilgrims and other examples of human migration. The first among European nations to experience the disease and the last to deal with its withdrawl, Russia suffered disproportionately. Due to the work of John Snow, Pettenkofer and English hygienists, cholera was receding from Western Europe even before Koch’s experiments, which hastened the process after 1883. Koch’s discoveries upset the balance of power of European scientific paradigms. Contagionist anti-cholera intervention worked more expediently in Western lands that did not experience quite the immense saturation of cholera carriers as Russia. In Russia, this methodology worked less effectively, certainly more slowly, and countries that continued to experience epidemics took on the stigma of backwardness. Russian physicians, who were considered leaders among European physicians after 1830, the most experienced of their European peers, suddenly fell within the latter category. Within

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their ranks, a well-schooled cadre of physicians led by F. F. Erismann considered alternate theories that involved environment, famine and other social problems. Learning from successive cholera pandemics in the nineteenth century, Russia’s physicians developed broad knowledge of the disease. Russia’s defeat in the Crimean War had promoted reforms that included a medical system geared toward prevention of disease. As Pasteur had developed bacteriology, Russian physicians embraced a form of the new science that included chemical actions in nature and social conditions in humans. Robert Koch’s experiments in 1893– 4 entailed that the European scientific paradigm that would eventually undermine cholera in the Soviet Union suddenly seemed outdated. With the theoretical foundation in place after the 1892 epidemic, building the legal and administrative apparatus to go along with it would take years.

CHAPTER 3 THE SIXTH PANDEMIC ENTERS RUSSIA, 1902—7

‘The Troubles’ Begin, 1902 –7 Tsarist physicians’ emphasis on social conditions and wariness of cholera riots were compatible with their broad scientific orientation, their limited capability to mobilise within the broad expanses of their country and its need to modernise along European lines. In 1902, Francis Galton’s ideas regarding eugenics appeared in Russia in the textbook Psychical Races, sparking scattered interest in the Tsar’s minority subjects.1 This interest furthered, but complicated, the broad idea that social conditions in Russia were the primary cause of cholera epidemics. Confronting a complicated social science in a period of intense turmoil created many hypotheses, but few solid conclusions.2 In 1903 the government passed its Cholera Rules for dealing with outbreaks where they appeared within the country’s borders. This effectively meant that they retained control, whilst placing the financial burden on local zemstvos. This policy outraged zemstvo physicians, who were continually foiled in their attempts to gain professional autonomy.3 While putting these physicians, hygienists and bacteriologists together in cholera commissions caused tension, the new organisations nurtured working relationships and an ongoing dialogue between stakeholders over the best ways to handle epidemics. As the following pages detail, Russian physicians on the Sanitary Executive Commissions (SECs) and Railroad subcommissions began addressing nuts and bolts issues over cholera, while N. F. Gamaleia continued to study cholera aetiology in

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Russian environments and began his flirtation with social hygiene and Eugenics. Public health, indeed the entire country, suffered from a lack of focus in 1903– 6 due to the Russo-Japanese War and 1905 Revolution, but the discord discreetly nurtured small advances in the infrastructure that would later help control cholera. Military losses and the destruction of the entire Russian fleet, among other factors, created an ineffectual and frightened government that orchestrated one blunder after another.4 Both the government and nobility destructively resisted the efforts of Pirogov physicians to limit famine, obstructing what undoubtedly could have been a successful initiative to stop cholera and hunger, effectively derailing it until 1921. While Saratov experienced an epidemic, the vigorous activities of local activists and physicians kept the epidemic small and added to the foundation for cholera control. Unfortunately, a new accumulation of predisposing events, industrialisation, warfare, religious pilgrimage, irregular climate and famine, kept cholera live and well in the Empire. Like the pandemics that preceded it, the sixth diffusion of cholera across the globe followed an accumulation of events that led to both famine and the presence of cholera in India. El Nin˜o events occurred in 1896–7, 1899– 1900 and 1902.5 In 1897, India suffered 20,000 cases and 15,000 deaths of cholera per week. In 1899, the casualties grew to even more horrific proportions.6 Overall, ENSO events led to 6.1 –19 million deaths in India in 1896– 1902.7 At first, monumental faminerelief efforts by the Pirogov Society kept hunger at bay in Russia. Unfortunately, bureaucratic resistance undermined these efforts by 1902.8 As usual, cholera followed the famine and the two co-existed for much of the next two decades due to climate shifts, agricultural decline, warfare and commercialised industry. Industrialisation created cities along rivers that were excellent respites for the cholera vibrio. By 1897 Russia had 11 such cities with over 100,000 residents each, including Odessa on the Black Sea, Baku on the Caspian Sea, Saratov and Kazan’ on the Volga, Ekaterinoslav on the Dnieper River, Rostov-on-Don and Tashkent in Central Asia. The latter is an ancient city on an oasis on the Silk Road that was formed on the Chirchik River at the western base of the Tian Shan Mountains. There were 1.2 million residents in St Petersburg and 1 million in Moscow.9 Industrialisation prompted large numbers of poor to leave the

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countryside and mass on the outskirts of Saratov and other industrial centres.10 Forced to leave the countryside to earn a living, hungry, poor and unprotected by sanitary facilities, these reluctant urban dwellers served as ideal hosts for the vibrio. Frenzied railroad construction provided expedited travel for the vibrio and its human carriers between these cities. In 1896– 1901, while El Nin˜o was mobilising the natural forces that strengthened the vibrio, workers built 19,312 kilometres of railroad lines and 11,811 in 1899– 1901, which were the largest aggregates in Russian history.11 Drought, flooding and famine had also weakened the population for the vibrio’s arrival. Battling the famine, the Pirogov Society fell upon hard times. Supporting student unrest, Erismann was deported, never to return. The zemstvo medical legend, I. I. Molleson, left the Saratov zemstvo under pressure after a dispute with local leaders. D. N. Zhbankov, the illegitimate son of a nobleman and serf, stepped up to address the issue. In 1899, the 600 members of the Society travelled to Kazan’ for the Seventh Pirogov Congress, witnessing devastation in the famine districts along the way. Zhbankov questioned the effects of medicine when citizens lacked food, clothing and homes. In Kazan’ the Pirogov Commission for Famine Relief employed 4 clinics and 14 canteens, feeding 150 people over a 45-day period and volunteering a dozen medical personnel, including 2 physicians who treated 5,000 patients. The Commission in Kherson distributed more than 500,000 meals to 11,000 people and saved 50 villages from starving.12 Such work, in key cities, undoubtedly helped delay cholera’s arrival in Russia. On the other hand, the attempts of the government and local authorities to inhibit the activities of zemstvo physicians’ famine relief helped cholera return to Russia. In Elizavetgrad, the Odessa section of the commission was prohibited from feeding patients by local zemstvo bosses, but surreptitiously distributed food in hospitals. On 10 October 1900, authorities in Kherson accused Pirogov physicians of exceeding their authority. A famine relief law was passed on 12 June 1900, limiting Pirogov and other voluntary participation in famine relief. Across Southern Russia physicians found themselves blocked from overseeing food distribution. Authorities registering undocumented workers in Samara Province were also ordered to cease and desist. This action proved particularly ruinous as Samara often experienced famine and cholera over the next 20 years. By 1903, the Pirogov Society faced

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resistance along a broad front. Arguments that physicians, who were often the only educated people in rural districts, should have broad latitude in prescribing treatment fell on deaf ears. Two petitions in 1902 questioned the competence of Pirogov physcians to engage in famine relief. Professor A. A. Bobrov of Moscow University met with the Minister of Justice and requested Pirogov participation in famine relief on the grounds of scientific research, but was still awaiting an answer when the Ninth Congress met in 1904. The official denial came on 8 March 1905.13 Community physicians supported the 1905 Revolution as they found their attempts to battle famine and introduce other social changes undermined. The chronological correlation of the vibrio’s reentry into Russia as state power brokers obstructed famine relief is impossible to ignore. Famine continued regularly over the next 20 years, with cholera in constant tow.

The Siberian Epidemic of 1902 Pirogov famine relief efforts kept cholera at bay along the traditional points of entry on the southern border until 1904, but in 1902 the vibrio entered Siberia along the new railroad tracks. Seeking to prevent carriers from bringing the disease across borders, the government enacted the ‘instructions for maritime physicians’ observational stations and establishment of naval quarantines for the Black Sea’. Established by an Imperial commission on 5 January 1902, the law mandated that steamships passing through high-risk locations undergo stringent disinfection.14 Without famine relief, these actions accomplished little. On 28 July, the New York Times reported that 15 cholera-related deaths had occurred in Astrakhan’ Province the previous Friday and that the government was concealing the epidemic from the public.15 This report was undoubtedly accurate. Reticent to declare an epidemic, the government regularly concealed them from the public. Decisive action was never a strong suit in tsarist Russia. Unprepared for an epidemic in 1902 and concerned about cholera riots, this denial encouraged inaction when physicians should have been marshalling forces. Physicians hesitated to criticise the medical arrangement out of fear of reprimand, but those who spoke out were concerned about the railroad. The Pirogov Society’s Department for Medicine of the Railroad and Waterways of Communication had held a conference on 7 July 1900.

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As reflected in the society’s journal, The Physician, P. Ia. Meziatsev complained of a need to place specially trained sanitary physicians in prominent roles in the medical organisation on the railroad. A lack of specialists, he noted, left this task in the hands of overworked physicians in local districts. Performing patient management, home consultation, business trips, chancellery work, neither local district nor senior physicians had time to perform sanitary activities.16 Meziatsev complained that medical inaction stemmed from fear for their professional lives. He and his colleagues suggested familiarising railroad physicians with special sanitary requirements, removing specialists from subordinate administrative positions, appointing them to the Ministry of the Ways of Communication or other posts where they could direct activities, forming a sanitary bureau in the Ministry to analyse demographic movements, documenting deaths and leadership.17 As would become the norm after 1900, the Pirogov Society took the initiative to challenge the status quo, bringing to light complaints that required addressing. Published in 1902 by an anonymous author, another letter in the Pirogov Society’s newly-named, Russian Physician, corroborated Meziatzev’s note, charging physicians in Siberia of nonfeasance. Mentioning that 438 cases of cholera and 369 deaths had occurred before 14 June, the anonymous author expressed alarm at the lack of preparation. Physicians learned of the threat only when the epidemic reached Harbin in Russian Manchuria. Simultaneously, the vibrio reached the Chinese railroad in Khailar and then the area surrounding Lake Baikal. On 4 July, an inmate in the Chita jail fell ill and his neighbours and acquaintances followed. On 22 June, a passenger on the steamship Aleksandr on the Amur River fell ill, constituting the epidemic’s furthest diffusion to the west. The author expressed scepticism about reports in a Siberian newspaper, but noted that ‘cholera-like’ cases were threatening Irkutsk.18 The appearance of weaker cases in an environment that lacked an extensive transportation network or other viable breeding grounds may have reflected the microbe’s attempt at survival. The anonymous author, who undoubtedly feared retaliation, was using the vibrio’s entry into Siberia as a means of using ‘Asiatic’ elements in Siberia as scapegoats for Russian failure. His mention of a lack of ‘European culture’ reflected the pseudo-scientific racism that permeated

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all European science. Indirectly criticising the tsarist administration, he placed blame on ‘uncivilised’ local inhabitants, portraying Siberia as a cultural backwater and cause for failure.19 Charging that Siberian physicians shirked defensive planning, preparation of defences and decisive action, the writer observed that sanitary organisation in Siberian governments looked good ‘on paper’, lamenting that hospital and prison physicians were tasked with training personnel, inspecting produce and organising hospitals and industries. This state of affairs had improved since 1897, but was still inadequate.20 The author masked his criticism by directing it at Siberians, but he was clearly addressing issues that prevailed in the tsarist system. The letter writer particularly addressed the lack of communication, stating that ‘the first news of cholera initiated something of a game of hide and seek’. Fearful that cholera was imminent, one district physician reported his apprehension only to be met with silence. Sending a second telegraph on 13 July to report that cholera had appeared, the notice fell on deaf ears for three days, prompting the senior physician of the railroad to send a series of telegraphs along the lines ordering all physicians to report the measures that they were employing at depots. No one answered, provoking a second message ordering senior district officials to inspect the depots, finally being met with replies that no measures had been taken. As railroad officials finally began preparing defences, the author complained that overworked city physicians received no help from the Sanitary Executive Commissions until after the disease appeared.21 In fact, the actions that both authors described reflected deficiencies in tsarist public health. Local SECs seldom responded to epidemics with alacrity, often requiring further prompting; a fatal defect in cholera prevention. The SECs were a Russian construct, likely crewed by Russian physicians, but hardly disposed yet to addressing serious problems like cholera. Few community physicians were kindly disposed to the SECs, which the MVD had formed after the 1892 cholera epidemic. Created by additions to existing legislation on plague, the SECs suffered from strife between the government, provincial medical organs and zemstvo physicians. In 1899 the Minister of Finance, S. I. Witte, argued that the zemstvos were incompatible with tsarist authority, proposing the Cholera Rules as an avenue to absorb the zemstvos into the bureaucracy. The rules and SECs were devised for provinces that lacked zemstvo

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councils. Counter to the Minister of Justice’s counsel, the MVD did not consider the intricacies of implementing the rules in provinces with zemstvos nor provide procedures for instances when both plague and cholera appeared. The overlapping jurisdictions of the SECs and zemstvos caused friction in central provinces or where both existed.22 The lack of effective zemstvos in peripheral areas hurt Russia’s efforts against cholera throughout this era.

The Tsarist Cholera Rules, 1903 A more unified command would have helped fight cholera in 1902, however, a lack of physicians and resources, broad borders, isolated populations and the vast, remote nature of Siberia made preventing epidemics difficult. This difficulty increased in 1903 when the International Sanitary Conference in Paris forbade land quarantines. The tsarist government complied, removing soldiers from the Persian border and forming land-observation points to inhibit the vibrio through bacterial analysis, quick detection and immediate intervention. Scholars have criticised this approach as an unrealistic policy, designed solely to permit trade to flourish.23 However, the law followed a trend in international public health that relied upon risk assessment and control, better intelligence, an emphasis on quarantine and screening at points of embarkation rather than ports of entry.24 Russia’s medical policies, strategy, training, even its Social Darwinism, reflected fin de sie`cle European practices and attitudes. The St Petersburg physician V. P. Krasnukh later charged that the Minister of the Interior, V. K. Pleve, a staunch conservative, created the law as a means for limiting self-government and to ‘weaken and cripple the nation in the presence of the regime’.25 Yet, despite weakness, the Cholera Rules provided uniform directives that, as the following pages will indicate, brought together members of the medical community from disparate public and private sectors. While hastily constructed in the aftermath of the Siberian epidemic and undoubtedly created to strengthen the government, Pleve’s rules provided a basis for an organised response to inhibit the spread of the vibrio, within a framework of what was known about its aetiology. Adopted on 11 August 1903 and revised on 19 August for the railroad and waterways, the MVD’s ‘Imperial proclamation of 11 August, 1903

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of rules for carrying out measures to halt cholera and plague during their appearance in the interior of the Empire’ became known as ‘the rules of 11 August’ or, more simply, the Cholera Rules.26 As the title indicated, the legislation included provisions for contagionist style measures such as isolating patients, but was not geared toward preventing the disease from penetrating Russia’s borders. Eight days later, Russian officials added rules for ‘the prevention of the spread of cholera and plague along the railroad and interior waterways’.27 Despite criticism by community physicians, and later scholars, the rules reflected a response to some of the criticism of community physicians in 1902, a flexible strategy of resisting an epidemic along traditional and new paths of transmission. Although in some respects overly-complicated and vague, the rules included procedures for channels of notification and response, a foundation upon which the Soviets would later build. The strategy considered Russia’s geoepidemiology, which made preventing cholera’s entry into the country improbable, and vulnerability to cholera riots. Less government intrusion minimised both cholera riots and disorder, and considered the dangers posed to physicians as Erismann and his colleagues had requested. The rules cleared the way for Russia to pursue trade and industrialise, to reconcile public health and construct a modern state, a goal nurtured by all European countries. At the same time, the rules placed accountability on local authorities. Section 2 gave governors, mayors, chiefs of oblasts and other regional administrators the most responsibility, including immediately sending a telegraph to the MVD and the War Ministry when necessary in cases of plague or cholera, and reporting the details of measures such as isolation of patients, disinfection of suspicious articles and quarters and individual persons who had contact with patients.28 Sections 3 through 7 reorganised the SECs, making them an arm of the imperial government with broad powers in the jurisdictions in which they were to be established. Section 3 placed the Governor and the chief of oblasts in charge of activating the SECs, which were to ‘direct the carrying out of measures against (human) carriers of cholera and plague and the struggle with epidemics during their presence’. The fourth paragraph, Section 4, created railroad SEC sub-commissions, while Section 5 placed the Main Railroad SEC in charge of measures undertaken along the lines, but granting the power to terminate the

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proceedings of the SECs to administrators of the railroad and its branches. Section 6 appointed the military authority over preventive measures in the outer regions of the Empire. However, Section 7 indicated that the rivers and large interior water routes fell under the authority of the tsarist Minister of Communications, who could issue instructions to local councils.29 As mentioned above, governors were placed in charge of the SECs in provinces, districts and cities with over 20,000 inhabitants. Small towns were permitted to form SECs as needed with the permission of the governor.30 While the rules permitted contagionist measures such as isolation of patients, the railroad SECs oversaw implementation of these actions or, as was too often the case, inaction. The power of the railroad SECs and their physicians created a problem, and progressive zemstvo reformers often argued that the railroad should carry out more proactive intervention. Section 1 of the rules mandated that the chief administrator or authorised council in places threatened by cholera must activate the Primary Railroad SEC and order the activation of all Railroad SEC subcommissions. According to Section 2, the Main Railroad SEC was to consist of all serving railroad administrators, the senior member of the railroad police with oversight through these administrators by the governor, the provincial council or oblast’ administration.31 The new law signalled the government’s intention to administer the struggle with cholera in Russia, particularly along the railroads and water routes and at the provincial level, in the districts and larger cities. However, the administrators of local governments bore responsibility for notifying the tsarist government that an epidemic was imminent or present and reporting the measures that were being taken. Not all of community physicians’ apprehensions were ill-founded. The rules had weaknesses. The statute gave the local and railroad SECs almost complete authority over investigations in their jurisdictions. The legislation placed tremendous discretion in the hands of provincial governors who owed their position and were accountable to the Tsar. They could choose members of the SEC and decide whether a small town could form one. As written, the tsarist government controlled all anticholera operations throughout the Empire. The power of governors to appoint members of the SECs could leave qualified physicians sitting on the sidelines. The subordinate positions of the zemstvos and requirement that they pay for the SECs, however, was unjust and foolish. The

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provision led community physicians in the Pirogov Society to support the 1905 Revolution. However, their support for the Revolution was not universal. And while the Cholera Rules provided formation of an organised response, a means of channelling sparse resources into places where they could do the most good, coordination between municipal, district and provincial organs, especially railroad commissions, civilian and military authorities, was terrible. This problem was especially acute in central provinces with effective zemstvo medical arrangements. Pleve’s efforts to merge Russian monarchial tradition with improvisations in international law shaped modernity in Russia, but interference on the part of the government with a vibrant social force such as the Pirogov Society was particularly unwise.

The Persian Expedition of 1904 Russian efforts to increase epidemiological intelligence and foster European culture in the Orient facilitated both trade and anti-epidemic agendas. In 1904, the Russian government gave the Imperial Institute of Experimental Medicine permission to send a group of medical officials and physicians, including the bacteriologists S. I. Zlatogorov and V. A. Taranukhin, to assist the Persian government in battling its 1904 cholera epidemic. This important duo built up their knowledge of Persian culture, made contacts, provided free services and garnered good will.32 However, this mission was almost certainly motivated by more than sheer altruism. The tsarist government had not authorised the fullscale use of vaccination. Zlatogorov and Taranukhin’s work in Persia afforded them firsthand practical experience in a semi-endemic region of cholera, in what would become an important sphere of Russian cholera control. Zlatogorov administered thousands of vaccinations to Persian subjects and, along with similar work by P. V. Khavkin in Japan, helped construct its practical framework. At the Pirogov Cholera Conference the following year, the influential Moscow bacteriologist V. K. Vysokovich used these expeditions to argue in favour of carrying out preventive vaccinations. Vysokovich and other immunologists used vaccination in various locations during the 1907– 10 epidemics and L. A. Tarasevich and other Russian physicians pursued the practice with great enthusiasm after World War I broke out.33 Immunologists found vaccination for cholera a tricky business. However, while not as

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successful as with typhoid, smallpox and some other diseases, the Soviets would use it with great success. Unfortunately, in 1904 the process was not sufficiently developed to control cholera in Russia.

The Cholera Epidemic in Saratov, 1904 As Pirogov famine relief faced increasing obstruction, cholera reappeared in southern Russia in 1904. The outbreak of war with Japan added an additional threat to European Russia. The 1904 epidemic in Saratov and the Trans-Caspian Region induced panic that the horrors of 1892 were imminent and that physicians would be in the centre of the fray. The new Cholera Rules were in effect and the revised SECs activated. Local activists such as A. M. Shapiro in Saratov had made efforts to study and improve water filtration and sewage systems, but the city on the Lower Volga, approximately 800 kilometres north of Astrakhan’, was vulnerable to the Asiatic guest. As in 1892, cholera appeared along the shoreline of the Volga River, and spread throughout the city.34 The Saratov physician and historian, N. I. Kovalevskii, portrayed the actions of the local populace as heroic. The City Council had already begun preparations, activating the SEC on 5 July. The city was divided into 108 medical-sub-districts, but the SEC formed larger districts in August, placing the second and fifth under the supervision of P. N. Sokolov, who had founded the local sanitary trustees in 1901.35 Sokolov’s trustees were well versed in statistical investigation and sanitary inspection and educated the population about hygiene.36 They organised activities, such as providing treated water to citizens on perimeters, checking water quality along the river banks, constructing water boilers, opening tearooms and placing barrels of boiled water in squares and bazaars. The trustees recommended the provision of clean water to factories, tractor workshops, steamboats and wharves, constructed sentry boxes with clean water and closed wells in hazardous ravines. Prohibiting river traffic from travelling within 700 feet upstream and 350 feet downstream of water intake stations, they expelled 14 watercraft and all riverboats from the shoreline.37 This action prevented the still water that formed around docked watercraft that promoted accumulation of microbes. On 18 September the city invited six physicians and six medical students, feldshers and sanitary

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workers who worked around-the-clock, isolating and disinfecting suspected patients. As Kovalevskii reported, local authorities transferred all medical and sanitary personnel without exception to work against the epidemic.38 Saratov personnel obviously knew of the vulnerability of river shores, ravines and other environments. Their actions and the late arrival of the epidemic likely kept it relatively mild. This type of response, although inadequate in 1904, anticipated later responses by the Soviets. P. N. Sokolov was one of the early firebrands of this approach, representing the crucial second district in the SEC and overseeing some of the most dangerous places in the city.39 The Volga River flowed into ravines in Saratov and other river cities. Places of respite for cholera and typhoid, the most infamous was the Glebuchevskii Ravine, which at the time ran from the river directly through much of the city. Located further south, the Beloglinskii Ravine was somewhat smaller, but also posed a hazard, both environmental and social. The writer and physician, Anton Chekhov, wrote about the unhealthy nature of these gullies in Russia.40 The inhabitants were poor and politically disenfranchised, with no access to city water. They had lived like this for decades. In Sokolov however, they had an advocate who was willing to fight for them, a leader who understood their plight and the dangers of these environments. Indeed, as we shall see, most physicians in Saratov were well aware of environmental impacts of various locations, none more so than the members of the new SEC Railroad Sub-Commission.

The SEC Railroad Sub-Commission, 1904 The 1903 Cholera Rules mandated that the Society of the Riazan –Urals Railroad form a SEC sub-commission for Saratov Station when an outbreak began. The commission’s first report detailed the activities of meetings on 9– 10 September, revealing an environmental approach that cited problems at 67 points along the line. Entries noted that the restroom at the 420 kilometre point had neither gutters for urine nor drainage tubes or cesspools for refuse. Urine flowed under the courtyard fence to a receiving tray. Garbage lined the area around the fence and the outhouse required disinfection. The commission ordered attention to be paid to these problems. In cases of violations, the commissioners advised corrective action. Inspectors cited an absence of cesspools, poor

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construction, open wells, no restrooms and a lack of boiled water and disinfection chemicals, ordering replenishment of boiled water, construction of the restroom, availability of cleaning materials and construction of a drain in a hot bath where leakage was causing dampness in a subfloor. One report noted dilapidated cowsheds on land that sloped in the direction of a pond, a deep icehouse that extended beneath groundwater and musty air. The commission ordered the problems to be corrected.41 Clearly protecting its own operation, the Railroad SEC failed to advocate surveillance of cholera carriers and isolation of patients along the lines, but the problems that they cited were important. Such cleansing of local areas adjacent to means of transportation would continue into the Soviet era. More significantly, the legal infrastructure that the rules composed provided an administrative body for zemstvo physicians to address much needed improvements in local cooperation over the following years.

The Saratov SEC, 1904 The record of the earliest meetings of the Saratov SEC provides insight into dynamics between members, their medical training, loyalties and divisions. The members were competent physicians, gubernatorial appointees who were professionals striving to rid Russia of cholera. Early on, they seemed to be searching for a panacea that would permit them instantly to wipe out cholera rather than to formulate collective resistance to the disease. They insisted on extensive documentation and were hesitant to act when confronted with ambiguity. This tendency perhaps reflected their conservative nature, but also a commitment to science and reluctance to waste time and resources by doing more harm than good. The ravines were one of the primary topics of conversation at the meetings. On 13 October P. N. Sokolov expressed concern over eight uncovered wells, which were located near the Beloglinskii ravine. Sokolov noted that the residents in this district did not have access to drinking water from the city waterworks, creating a dangerous situation. He suggested that workers immediately close the wells, that the city provide these citizens with filtered water as soon as possible and that the council issue an order to those responsible for early detection of cholera to pay attention to these areas.42

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P. N. Sokolov’s push for action appears to have been out of the ordinary, irritating some of the members. A. P. Minkh was a scholar who had defended his dissertation in St Petersburg under the physiologist, I. P. Pavlov.43 Attacking Sokolov’s report as ‘unscientific’ and lacking ‘statistical data’, he noted that those responsible for inspecting this area had known about the conditions in the ravine for a long time. In fact, Minkh said that he had personally inspected the wells and added that the reports of poor water quality were not new, but agreed that the wells should be closed. L. S. Lebedev observed that other places in the city such as the Glebuchevskii ravine and the trading posts and area around the women’s home had equivalently poor conditions, adding that most Saratov residents used this type of water for soaking cucumbers. Nonetheless, he also agreed that the wells should be closed.44 Minkh and Lebedev knew about the wells and had essentially taken no action. Their main point perhaps was that these conditions were so widespread that closing the wells would do little good. Other members began weighing in on the issue. A. V. Briuzgin was the physician for the local Real Catholic Seminary School and a local Gymnasium.45 He noted that ten years of investigations had revealed up to 400 such wells. The director of the Medical-Sanitary department, N. O. Nikol’skii, agreed that the conditions of the wells were well known.46 Noting the difficulty of the deciding, he proposed evicting the residents of the ravines. Fortunately, the city architect A. M. Salko commented tactfully that the situation would be better handled by eliminating the problem as opposed to the residents. Another member, A. M. Maslennikov, agreed, quashing further consideration of the idea. Since 1871, Salko had advocated improved living conditions through enhanced water quality and appointing leaders in apartments who would remind residents to use proper sanitary precautions.47 Nikol’skii’s proposal was radical, but Western political leaders and aspirants have all too often made similar ludicrous suggestions. Salko’s idea of improving social conditions and cohesion bore the stamp of the zemstvo tradition. Moreover, Sokolov’s willingness to challenge his peers to take action seemed to mark a break with past activities. The SECs provided an opportunity for local traditions such as those of Salko and Sokolov to amalgamate. The discussion of the wells continued. Citing Odessa, where Mechnikov, Gamaleia and other scientists had conducted their work,

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Maslennikov observed that all measures should conform to ‘wellestablished principles and orderly methods’. The medical inspector, T. K. Schmidt, argued that nobody doubted the presence of undisclosed infected wells in other parts of the city, but that should not impede the closing of the Beloglinskii wells due to cholera rates in the vicinity.48 I. S. Veger, the city health officer, suggested that the commissioners familiarise themselves with the wells before taking action, gathering statistics and data. He questioned the reasoning behind paying so much attention to the Beloglinskii ravine while ignoring the larger Glebuchevskii gully.49 He agreed that it was necessary to give the population treated water, but also knowledge to protect themselves, inferring that the investigators who had inspected the wells lacked know how and cautioned the commissioners not to take an unfounded report to the Duma.50 Veger’s reluctance reflected not only the Russian tendency to amass extensive knowledge, but questioned the credentials of the trustees. The following year he joined the Saratov Doctors’ Strike and lost his job when he refused further cooperation with the SEC.51 Veger’s subtle charges appeared to upset the mercurial Sokolov, who complained that the commissioners were pointing their arguments at him and, presumably, his trustees. Observing that ‘the unsuitability of the water in the wells of the Beloglinskii Ravine is obvious’, he asserted that scientific investigation would not change the situation and that, while thorough investigatory practices were desirable, under the current circumstances ‘moving slowly is criminal’ because the wells presented an ‘outrageous danger to the city’. Residents used the wells for soaking watermelons and other daily chores, placing them in grave danger, and Sokolov concluded that it was his duty to report this to the commission.52 Veger replied that the commission was investigating, lecturing Sokolov that sanitary questions required systematic study while conceding that if people needed clean water and the wells were dangerous he would not oppose closing them.53 Sokolov’s hectoring moved the commission to order the closing of eight wells, the provision of clean water, the identification of new water sources and the installation of water boxes.54 The conversation regarding the Beloglinskii wells provided an insight into one of the first meetings of the SECs. Like many tsarist bodies, the Saratov SEC was reticent to act. The highly educated Minkh and Veger seemed to consider Sokolov rash, perhaps even incompetent.

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Veger’s reluctance to accept Sokolov’s data reflected perhaps a strict adherence to scientific method, but also a degree of chauvinism. Certainly, Veger was not trying to ingratiate himself with the government, since he defied it the following year. Yet, only five physicians, including Minkh, refused to work with the SECs in 1905. The conflicts within the SEC reflected social and professional tensions between parties, the first stage in forming a useful dialogue. The debate provoked much thought regarding the degree of evidence required to take action and the point at which it proved beneficial to move forward without complete certainty. Some members may have held ulterior motives, but most were responding in line with their prior training. The commissioners ultimately supported Sokolov’s proposal, which resulted in an order to assist the people in the ravine, an action that seemed out of the ordinary. Almost from the start, the SECs proved to be institutions of progress, but it would take years to make the necessary improvements. The SECs’ conversations addressed the difficulties of applying practical application to theory. In a related matter, T. K. Schmidt spoke about a project regarding the cleaning of drainage pipes from the Aleksandrovskii Hospital, which were suspected of polluting the ravines. N.O. Nikolskii and A. P. Minkh observed that the cleanliness of the hospital wells was poor and reported that the city architect was calculating an estimate for their reconstruction.55 The Journal of the Leadership of the Saratov SEC for 29 September 1904 featured the chemical analysis results of the water in the pipes and at other locations, such as the wells of the city slaughterhouse. A local pharmacist conducted the analysis, detecting Ammonia, Dinitrogen trioxide and Dinitrogen pentoxide.56 One would have thought that the SEC might search for the cholera vibrio, the agent that caused the disease. Yet, their training in the Pasteurian paradigm caused them to concentrate on conditions that could precipitate an epidemic. Pasteur and Pettenkofer considered microbial/chemical interactions critical, that some agent of a disease come into contact with fecal matter or certain soils to produce fermentation.57 Pettenkofer had dropped his miasma requirement, recognising Koch’s vibrio, but emphasising its interaction with elements similar to those that the pharmacist identified. Under this logic, the conditions that activated the vibrio were just as important as the agent itself. Due to their training in the research schools, Russian physicians still studied chemical actions as a supplement to bacteriology.

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Gamaleia’s Investigation of the 1904 Epidemic Maslennikov’s mention of Odessa may have prompted the arrival of the bacteriologist N. F. Gamaleia, who conducted a probe of the region’s outbreaks and also those in Saratov. A founder of the nation’s first bacteriological laboratory, Gamaleia was the youngest of 11 siblings and was educated at elite private institutions. He became a graduate of Novorossiiskii University and the Military Medical Academy, studied at Strasburg University and spoke fluent French, German, English and Italian. He was raised in a wealthy family and supported himself through his inheritance, permitting him a degree of independence most scientists in Russia lacked. He admired the work of the Englishman, Havelock Ellis, who was one of the founders of social hygiene. Gamaleia’s interest in social hygiene would lead to his becoming the father of Russian Eugenics. Due to his admiration of Ellis, it follows that Gamaleia emphasised the importance of environmental, social and cultural issues and infectious disease, though he later claimed only to be interested in pure sanitation and hygiene.58 He began his report: ‘The fear that prevails just prior to cholera epidemics has done more for the cleanliness of the populations and cities of Western Europe than all of the mandates of science or the requirements of daily life. The influence of cholera on culture fully establishes the need to teach the history of its continued appearances in Europe’.59 By all measures a bacteriologist, at least one prominent historian has described Gamaleia as standing ‘at the forefront of modern medicine’. His scientific credentials, track record and credibility were unassailable.60 Gamaleia’s mention of Western Europe indicated that he was aware of Russia’s tenuous status, in no small part due to cholera epidemics. Gamaleia had completed his dissertation on cholera during the epidemic in 1892, and investigated the 1904 cholera epidemic in Saratov. He observed that the disease moved along the coasts of the Persian Gulf from southern to northern Persia, causing a large number of deaths. In June, a virulent epidemic struck Tehran then moved to Meshed, Merv and southern Azerbaijan, crossing the Russian border in October at Erivan, Elisabetpol’skii and then Baku Province.61 Gamaleia observed that this was almost precisely the same route by which the 1892 epidemic had arrived. On 15 August cholera struck Baku, then moved east to Saratov, south to Astrakhan’ and to various districts in

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Saratov Province.62 Once again, cholera had appeared by route of the Caspian and Black sea shores, lasting from 4 September to 8 November, resulting in 51 cases and 31 deaths in the city of Saratov, a 60.8 per cent mortality rate.63 The places of low elevation along the Volga River suffered most, particularly Uleshi and Uvek, where there were railroad stations. The disease then moved along the boundaries of the city to Degtiarnoi Square and Brekh, which were relatively close to the river.64 Gamaleia’s investigation of the epidemics in Baku and Saratov reflected the importance that he assigned to environmental and social forces as causative factors. The cases in the Trans – Caspian provinces occurred individually, then in dozens, until finally thousands of individuals succumbed. Gamaleia argued that poor routes of travel slowed cholera diffusion, and that while winter helped to halt it, he predicted that cholera could ‘embrace all of Russia’ in the spring. Gamaleia’s declaration that fear of cholera brought progress and his forecast of imminent epidemics probably played a role in creating the intense fear of cholera that prevailed in 1905. Gamaleia noted the late start of the 1904 epidemic as its distinguishing feature. In 1892, he pointed out, cholera struck Astrakhan’ on 7 June, Saratov on 8 June and Samara on 13 June, but the disease did not appear in these cities in 1904 until September. This delay provided time for officials to take action along the borders and in Persia, but, significantly, ‘these measures all the same did not prevent cholera from appearing’. While the vibrio entered Baku on 15 August and Saratov on 4 September, he mentioned that investigators were unable to trace an exact route of transmission.65 Gamaleia’s observations regarding the ineffective measures on the border, poor travel routes and untraceable diffusion of the disease indicate that he sought a more comprehensive explanation. Gamaleia contested Koch’s theory, which asserted that people transmitted cholera along precise routes through fecal matter or direct contact with infected produce. Koch’s school, he observed, emphasised that contact epidemics were characterised by slowly rising numbers of patients, manifesting in small groups in close contact with other victims, family members, friends, acquaintances and visitors. Waterborne epidemics, on the other hand, featured an ‘explosive beginning’, with numerous cases following bacterial pollution of the main water source. In such cases, the number of patients rose quickly, then descended.

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Gamaleia accepted the two explanations as theoretically sound, but somewhat lacking.66 The 1904 epidemic in Saratov was one of the exceptions. The people who had travelled into the city were most prominently located in the lowest districts near the river between Degtiarnoi Square, which was located not far from the Volga River, the Soldiers’ Quarters, the steel factory and Uleshi. The few cases that passed to other parts of the city were connected to the shoreline. Five patients, who lived in the centre of town, worked every day on the river bank. The ‘localisation’ of cholera around the shorelines was not happenstance. There, as in 1892, the epidemic originated and reached its highest intensity. Gamaleia concluded that the shore had a special predisposition to cholera because the residents did not receive filtered water from the city waterworks, taking it instead with buckets from the Volga River. He argued that the disease was not transmitted over the routes of communication. The first patient was a railroad worker at Uleshi who fell ill, then a few cases occurred along the wharves, but the first victim’s status as a railroad worker was irrelevant. Gamaleia disputed a theory that cholera carriers had brought the disease over the railroad through freight because none had been unloaded at the station.67 Therefore, Gamaleia argued, the cholera appearing along the riverbank was not due to carriers, but conditions along the shoreline that precipitated its appearance. He placed the greatest importance on interactions in the ecosystem, stating that while it might appear that cholera had been brought into Saratov by infected goods and passed from person to person, all baggage was transferred in Astrakhan’, usually twice. The first transfer occurred near Astrakhan’ because sea vessels could not travel on the Volga. The second transfer occurred in the city of final destination. Therefore, the cases brought from Baku would have first appeared in Astrakhan’, where no cases had yet developed, then Saratov. The first victim did not have contact with any freight or baggage because there was no unloading at Uleshi. Moreover, no freight was carried over the railroad between Baku and Saratov. None of the railroad workers who were patients had contact with high risk cargo. Gamaleia concluded that the supposition of infected baggage causing the epidemic was ‘completely unfounded’.68 Gamaleia argued that the disease originated from the waters of the shoreline, emphasising that people in the Glebuchevskii and

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Beloglinskii Ravines did not receive water from the waterworks, but procured it in buckets from the Volga. The river was polluted by garbage and the city stockyards, which emptied wastes and filth into it. The passage of vessels along the river in this area was obstructed by sandy islands, narrowing the distance between their sandy banks and the shoreline, where the branches and creeks were narrow. He postulated that the still waters around these islands were places where the cholera vibrio presided. He also observed that watercraft may have discharged cholera infected fecal matter into the river.69 In their critical analysis of Koch’s work, Gamaleia and his Odessa colleagues were undoubtedly motivated by the professional doctrines under which they were trained. Gamaleia’s training under Pasteurian bacteriology taught him to look for factors beyond simple transmission and presence of a microbe. Also, the SECs investigation of the wells and zemstvo hospital demonstrates how the Russian environment encouraged such investigation. The Russian approach to cholera control was forming around the investigation of zemstvo, and SEC physicians and Odessa bacteriologists. Citing the epidemic in Baku as a second example of why contagionist reasoning alone could not account for the 1904 epidemic, Gamaleia focused on local Muslim women. Admitting that time did not permit the neccessary complete investigation of the water that might have provided decisive results, he asserted that, after the first case in Baku on 15 August, the number of cases rose extraordinarily slow. Peaking in mid-September at 20 cases daily, all occurring immediately after the arrival of Tatars, he observed that no proof linked the epidemic to cholera carriers. Gamaleia stated that samples of sea water taken from the areas surrounding the city’s water sources in places of drainage also did not reveal the presence of the cholera bacteria. However, bacteriological investigations of the water in public baths produced positive results, particularly in the areas of women’s facilities. Gamaleia observed that Muslims often used hot baths for bathing and noted that this was especially true of the women who gathered at these baths and often congregated there from morning until night. The baths were not very large and stayed full of dirty water for extended periods. A few baths were identified as places where cholera often appeared, particularly in the rural parts of the city, which were located under forts. Cholera patients frequented these baths and bacteriological investigations discovered the

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cholera vibrio in ‘very large quantities’ in eight out of 20. The vibrio could have passed through infected linens of patients as cause or consequence of an epidemic.70 As observed in the report from Siberia in 1902, interest in race was alive and well in Russia, fuelled by anthropology and the Russo-Japanese War. This tendency revealed itself regularly at the 1905 Pirogov Conference the following year. However, as one historian of Russian science argues, the loose and unorganised nature of interests in Eugenics in Russia meant that it never blossomed into a fully fledged movement.71 In fact, even before the conference, other investigators of the Baku epidemic identified Muslim women as the most prominent victims. Two community physicians, I. M. Leplinskii and I. S. Eliashvili, reporting their findings in the Russian Physician, voiced their opinion that the ‘breeding grounds’ of the epidemic originated in the baths. The authors observed that the baths, located in dark basements, were seldom cleaned, meaning that cholera remained exclusive to Muslims and that women were the primary victims. Leplinskii and Eliashvili observed that five to ten Muslims would inhabit the baths at the same time, and that 50 or more would use one. Sometimes, the women used the dirty water of the baths to clean linen. They used the occasion as a social gathering, drinking tea and eating kebob and plov. Leplinskii continued this analysis at the cholera conference.72 As the rhetoric of the 1905 Revolution kicked into gear, community physicians criticised the government for failing to lift the cultural level of its subjects. Their observations were often tainted by racial overtones, but interests in race reflected contemporary European norms and seems to have actually encouraged their inclusion of social conditions into the equation of cholera aetiology.

The 1905 Revolution and Pirogov Cholera Conference In 1905 life in Russia was changing radically and most Russians found themselves residing under a government that did not fulfill their basic needs. The strife was exceptionally strong in Saratov, but mirrored the political and professional upheaval in other cities. Most historians agree that the origins of the February 1917 Revolution share a direct line, at least as far back as 1905. Rather than the specific manifestation of a utopian vison the revolution was more of consequence of widespread

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discontent with the government.73 The country moved away from the traditional rural existence that emphasised kinship, the Orthodox Church, estates, and service to the state, toward one dominated by the nuclear family, flexible social classes and a modern, urbanised commercial culture. In the city, large stores replaced kiosks and the church’s role was increasingly diminished. These changes reflected the European trend toward a separation between work and family in which the home was no longer the site of economic production, but used more for privacy, rest and respite.74 As these changes took place, Russian citizens considered new European schools of thought regarding how their country should be governed. The most important trend of the era involved Marxism. Russian society basically reflected the general European trend in other ways. The two leaders of factions within the Social Democratic Workers’ Party split over how the two leaders viewed the party. Iu. O. Martov wanted to build a massive, working class party while V. I. Lenin desired a tighter, more disciplined group of elite professional revolutionaries. Losing the vote, but claiming a majority, his enemies in the Jewish Bund walked out over a collateral issue and Lenin was able to claim the title ‘Bolsheviks’, or ‘men of the majority’ over the ‘Mensheviks’ or ‘men of the minority’. A lawyer by trade, Lenin considered Russian law bogus, and sought to speed up the Marxist timetable which advocated that bourgeois development, a revolution of sorts, must precede its socialist counterpart. The charismatic Lev Trotsky, who became a close confidant, motivated Lenin to consider peasants’ grievances related to the land as a potentially revolutionary issue. In this respect, Bolshevism was a mix of Marxism, which was international in character, and native Russian populism.75 Almost all European nations during this period considered these political forces, and they played an important role in the development of most of them. Ironically, it was not a Marxist, but a man of traditional values who provided the spark to the 1905 revolution. Following the work of Sergei Zubatov, who tried to start a police dominated trade union in 1903, Father G. A. Gapon organised the Assembly of Russian Factory and Mill Workers. After the Japanese victory over Russia and a strike at the Putilov Factory in St Petersburg, Gapon and his followers gathered signatures on a petition and marched to see the Tsar. Their naı¨vete´ reflected a myth among the peasantry of the good Tsar, who would correct

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wrongs if he became aware of them. On 9 January 1905, the group marched into the centre of St Petersburg and were fired on by skittish troops, killing approximately 200 Russians.76 ‘Bloody Sunday’ forever altered the Russian social fabric, alienating workers who considered themselves loyal patriots. Virtually all spheres of society were effected. Just over two months later between 21–23 March, 1905, Russian community physicians convened the Pirogov cholera conference in Moscow, a pivotal event in the history of Russian medicine. Community physicians were concerned that the SECs restricted their autonomy and were incensed that the zemstvos were required to pay for them. While not all physicians were revolutionaries, the rhetoric at the conference was often affected by the revolution. The papers of the Pirogov physicians at the conference reflected fear of government reprisal, and a dislike of contagionist anti-cholera strategies and measures due to their endangerment of medical personnel. In fact, the Cholera Rules minimised such danger. However, Pirogov physicians’ assertion that the government would neither acknowledge nor address the insufficient standards of living that caused cholera epidemics was a point that would later prove correct. This interest coincided with interest in race and Social Darwinism, Beginning with a discussion of cultural problems in Asia, N. V. Kirilov, who published several articles about Chinese medicine, presented a paper on the superstitious and ‘naı¨ve’ nature of Chinese practices. Originally published in 1904, the article touched upon some of the measures that Chinese physicians used to combat cholera epidemics and added information that censors had rejected in the earlier version. Kirilov, who had studied Chinese national medicine for 20 years, stated that the system operated as if administered by ‘quacks’. He observed that Russian physicians working in Chinese-dominated regions must familiarise themselves not only with the customs of inhabitants, but ‘the naı¨ve ideas of primitive medicine’.77 Kirilov often seemed more interested in a purge of Asian culture than bringing these inhabitants into the European fold. He started by, rather bluntly, criticising the Russo-Japanese War. Addressing the problems that refugees presented during military conflicts, N. V. Kirilov observed that war had brought cholera to Northern China and Manchuria in the late 1800s, a state of affairs that still prevailed. He observed that ‘war interrupts the normal concerns of

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world populations’, compelling them to live in isolation in the Manchurian mountains, where both military and civilian populations in theatres of war were subject to military discipline, making them ‘nervous and tense’ and causing many to fall ill. Kirilov stressed that this state of affairs was abnormal, lamenting that nutritional deficiencies prevailed in Manchuria. People survived without vegetables or bread or completely without food. War and famine, he observed, facilitated the onset of cholera.78 According to Kirilov, social and cultural conditions linked to the Russo-Japanese War were responsible for the cholera epidemic. Indeed, famine was the theme that resoundingly linked the arguments that physicians were making. E. Ia. Stol’kind of Moscow began by discussing the Caucasus, which had suffered approximately 162,000 cases of cholera and 84,000 deaths during the 1892 epidemic, over one fourth of all Russian casualties.79 He attributed the high rate of cholera to a lack of education, inadequate medical staffing and poor sanitary and social conditions.80 Stol’kind linked the inaction of the government to improve sanitary conditions to ‘the culture and welfare of the population’. Citing documents from 1891, he noted problems that included polluted drinking water, sewers, drains, dumps and garbage facilities and sewage-soaked soil. Sanitary insufficiencies existed in rural areas, small towns and villages and larger cities, particularly in peripheral areas such as the Caucasus. Poor hygiene prevailed among Armenians, especially Tatar exiles. There were large heaps of manure and other unsanitary conditions in inhabited areas. The streets were narrow and crooked; the people lived in crowded homes and drank polluted water from streams and rivers.81 The government spent approximately seven and a half kopecks per year for each person in the Caucasus, while the average in the rest of the Empire was 22. Medical strength was lacking as usually only one physician attended to each district or military district. Tatars and inhabitants in rural areas distrusted physicians and sought the services of ‘quacks’.82 Like Kirilov, E. Ia. Stol’kind complained that the Russian population was not fed properly. The country lacked the economic infrastructure to feed its population. Factories and artisan establishments suffered from crowded conditions, inadequate maintenance, poor ventilation of gases and steam and insufficient drainage.83 Stol’kind’s recognition of poor sanitary conditions and famine as predisposing conditions for cholera epidemics was undoubtedly accurate. He complained of the lack of

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educational opportunities in the Caucasus. There was only one school in Dagestan Oblast’, which encompassed 1,277 square kilometres and had 315,000 inhabitants. Only 3 per cent of the budget in the Trans – Caucasus Region was allotted for education while 62 per cent was set aside for police and prisons.84 These statistics indicate that the residents likely had reason to distrust tsarist officials, who were busy empire building and had little time to spare on social niceties unless it directly benefitted them. However, in a land empire like Russia, casualties from cholera were counted as Russian, as opposed to say the ‘Indian’ cholera victims in the British Empire. Such assessment resulted in uneven perceptions between Russian and English imperial rule, but Stol’kind had a more relevent point to make. Asserting a need for zemstvo self-government in the Caucasus, Stol’kind expressed regret that these councils were dominated by nobility who practised the concept of Kulturtra¨ger, using the zemstvos to control local populations through a divide and conquer strategy to keep nationalities fighting one another. Weak and exploited, the people knew the causes of disease, but due to mistrust of the government practised native or holistic medicine. Armenians, Georgians, or Tatars who fought for their freedom were ‘silenced’ through imprisonment, shootings, banishment and ‘pogroms’.85 Stolkind linked this repression to the reduced living conditions that caused cholera, adding: ‘It is understood here in the Caucasus, now as in 1892’, that ‘once again we are awaiting terrifying cholera epidemics’.86 Stol’kind’s description of the treatment of Caucasian peoples mirrored that of colonised peoples in what became the Third World. Russian physicians often embraced a version of Rudyard Kipling’s ‘Civilising Mission’ to uplift the ‘lesser races’. Tsarist treatment of underprivileged subject peoples in the extremities of Empire reflected a general pattern of European imperialism. Stol’kind’s mention of pogroms was undoubtedly a reference to the Tsar’s Jewish subjects, whom he described as enduring ‘even worse’ living conditions in regards to ‘cultural-sanitary and economic conditions’. Citing a report from 1887 by the Imperial Proclaimed Commission on the Jewish question, he noted that the director reported that nine-tenths of the Jews ‘live from day to day in the very worst hygiene and living conditions’.87 The commission described the Jews as a ‘despairing proletariat’, unequalled in any region of Russia.88 A professor named Subbotin had written that of the residents in the Pale

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of Settlement (a western region of Imperial Russia with a substantial Jewish population) in 1898, 139,000 were farmers, 112,000 were ‘black workers’ (labourers who worked with their hands), approximately 64,000 worked in factories and 450,000 were artisans. By 1903, the Jewish working class was converting into ‘proletarians’, marked by an inability to flee or fight and far worse off than other European proletariats. Workers in small artisan shops were paid 3.5 to 4 rubles weekly and sometimes as low as 2.5 to 3 or even 1.5 to 2. Raises were rare and sometimes wages dropped.89 The residents lived in damp cellars without adequate nutrition for themselves or their children. In Vilnius, thousands of Jews resided in two-floor cellars. In Odessa, over 2,000 lived in cellars without windows.90 Stol’kind cited unfortunate conditions but, at times, seemed more interested in identifying support for the revolution than quelling cholera. Gradually, he worked his way back to the point. In 1892 and 1894 he stated that ‘cholera found well prepared soil among the Jews’, elaborating that the high mortality rate was increasing and that he would not be surprised if ‘beggary, chronic hunger, pogroms, wars etc’. produced higher numbers of Jewish victims than in 1892.91 Russian community physicians dreaded a return of 1892 and were apprehensive that the next epidemic might be worse. Stol’kind’s ‘well-prepared soil’ was a reference to material and cultural conditions, the consequences of poverty, famine and war that resulted in cholera epidemics. One might interpret this usage as ‘populist’, but also as an actual condition among the peoples in the Empire that permitted cholera to flourish. According to Stol’kind, the government repression that prevailed since 1892 amounted to a Verdummungs-system, a dumbing down of the population in which the government diverted people’s attention from poverty through patriotic support of the war with Japan. As noted above, he cited tax increases and poor spending in the 1880s in leading to the 1891 famine and the 1892 cholera epidemic while government coffers rose.92 The government allocated 1,045 million rubles to use for the benefit of the population in 1893 and by 1904 this figure had risen to 2,178 million. Meanwhile, spending for the war reached nearly 2 billion rubles, but only 170 million, less than 10 per cent of the military budget, went toward education, improved transportation, public services, utilities and dispensation of justice.93 Such prioritisation of military objectives would come back to haunt the Tsar in 1917 when suffered by workers in Petrograd.

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The state of Russian education compounded Russia’s problems. As enrollment in universities fell, mediocre and unprincipled professors could be bribed and academic directors and teachers performed police related duties. Stol’kind blamed Konstantin Pobedenostsev, the director of the Holy Synod since 1880, for fostering an atmosphere in which the government did not value education. Even church-parish schools operated in ‘crude ignorance’ and were devoid of religious instruction.94 The tutor of Tsar Alexander III, Pobedenostsev held great influence over him and his son, Nicholas II, who supported monarchial power and Russification of minorities.95 Noting that cholera epidemics were underway in Persia and Asia, Stol’kind cautioned that physicians should take steps to protect themselves from cholera riots.96 E. Ia. Stol’kind raised many issues and recognised many problems related to cholera. A lack of education and poor living conditions, including famine, poor sanitation and insufficient medical care in the peripheries of the Empire caused cholera epidemics. While Stol’kind’s conceptualisation was broad, the government’s failure to educate and raise the material conditions for people in the borderlands of the Empire left them susceptible to cholera, endangering the central provinces due to transportation networks. Some Pirogov physicians wavered from the cause of battling cholera, but the majority brought up relevant points.

Zemstvo Physicians versus Koch While not all Pirogov physicians supported the 1905 Revolution, many were furious with the government. If their medical orientations were based primarily upon politics, they might have lambasted the administration for not pursuing aggressive actions on the borders and lines of communication and for the extreme environmentalism of the Railroad SECs. Yet, many Pirogov physicians still energetically supported localism and the movement of commerce, defying assumptions that their resistance to contagionist measures was an attempt to ingratiate themselves with the government. Their papers were balanced, reflecting scientific considerations and concern for the safety of physicians, dignity and rights of passengers, and conserving time and resources in a country where both were scarce. Perhaps most strongly, their opposition to these measures, which included quarantine, expressed their distaste for the scientific methodologies and strategies of Robert Koch.

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Disinfection was a hot topic. Dr V. L. Pentkovskii of Lublin asserted that travellers on the railroad cleared themselves of suspicion of carrying the cholera vibrio only after undressing and bathing to prove their cleanliness. Inspectors disinfected their clothing and baggage in specially constructed moving or stationary disinfection chambers, subjecting them to pressurised steam that deteriorated furs, leather garments and hats. Pentkovskii complained that the railroad often avoided enforcing the laws regarding disinfection in order to placate passengers and to avoid paying them recompense for damaged articles.97 Clearly, this last concern was intended to promote cholera prevention, not commerce. Pentkovskii asserted that disinfection took considerable time, effort, money and was unevenly performed. He noted that a well-known method of disinfection promoted by the German bacteriologist Carl Flu¨gge was effective, but required nearly four hours to complete, and was expensive to administer. Another technique involved only 30 minutes using formaldehyde steam in a depressurised chamber, guaranteeing sterilisation without destruction, spoilage or damage. This method left difficult and expensive items, such as dresses, to the responsibility of quarantine stations and required less technical and administrative oversight. The process was easily applied on passengers during epidemics and also on the items of migrants, leather and rags for example, during periods of heavy epidemic disease.98 One of the humorist immunologists who opposed Mechnikov, Flu¨gge was a senior student of Koch.99 Many Russian physicians held no love for Koch, the Berlin Institute or their methodologies. S. V. Konstansov of Astrakhan’ was even more critical of Koch, asserting that his preferred method of disinfection was not working according to theory. Theoretical and applied knowledge generally progressed slowly, Konstansov asserted, but sometimes science made abrupt advances that appeared capable of resolving important questions. However, internal contradictions in such theories created problems when they were applied. According to Konstantsov, the prevailing method of disinfection constituted such an example. Koch invented the technique in the 1880s and endorsed a series of chemical agents, touting mercuric chloride as strongest for disinfection, which bacteriologists accepted without proper scrutiny, began using without critical thought and which had remained in use ever since.100 Konstantsov also argued that

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various scientists used formaldehyde and other chemicals for 25 years without proper analysis, describing them as a ‘panacea’. Various disinfectants that Koch endorsed, he noted, were less effective than he had claimed due to experimental errors. For example, he used a bacterial culture that was tainted with disinfection matter and was not full strength, subsequently claiming that mercuric chloride at a concentration of 1:5,000 killed spores in a few minutes. However, a scientist named Frankel had used a far stronger concentration which did not produce such results in 20 minutes. Another investigator named Nocht waited for four hours without any result and other scientific work supported these findings.101 While Konstantsov’s view of Koch’s work was undoubtedly coloured, his criticism reflected genuine and valid scientific concern, including the rejection of a methodology that had not passed rigorous testing. Konstantsov turned his attention to the localist theory of the Pettenkofer prote´ge´, Rudolf Emmerich.102 Emmerich was one of Koch’s most ardent critics, arguing that cholera outbreaks occurred through ‘poisoning by means of nitric acid, which works its way to the intestinal tract’ through ‘the activities of the cholera vibrio’. Emmerich surmised that the bacteria derived its virulence from its ‘capacity to transfer nitric acidic salts into nitrous acid’. Therefore, ingesting vegetables and fruits, which were full of nitric acid salts, was dangerous. According to Emmerich, the vibrio lost potency as it passed through human intestines and it thus exited without the capacity to cause infections. However, when it contacted soil at a specific time it could regain its potency.103 Noting that Emmerich had come to these conclusions by conducting independent tests, Konstantsov stated that Emmerich had discovered that cholera bacilli coming into contact with nitric soils were three times more potent than in normal soil. He proposed that this process was a decisive factor in producing sufficient virulence in cholera to result in infection.104 When faeces and nitrous soils met at very specific times they caused an outbreak. While Konstantsov did not express a cast iron belief in Emmerich’s theory, he noted that scientists should test the feasibility of the hypothesis and complained that ‘it is as if [this theory] does not exist’, acknowledging its logic due to the local origins of many cases.105 Indeed, like many Russian physicians, Konstansov felt that the cholera vibrio required specific conditions to spark an epidemic. While we now know that the vibrio was most often neutralised by stomach acid,

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fecal discharges still had the capacity to start an epidemic and nitrogen in estuaries plays a definite role in sparking epidemics, particularly after tidal, temperature and other changes due to extreme weather. Emmerich’s theory appeared feasible. Konstansov’s main point was that, due to Koch’s prestige, bacteriologists were ignoring it.

Conclusion The lifting of the sea quarantine resulted in greater social stability, but coordination of response to epidemics was still far from desirable in the tsarist Russia of 1902. Tsarist physicians formulated hypotheses that were theoretically sound, based upon the environment and conditions in which they were working. These circumstances discouraged the use of contagionist measures that might have slowed the spread of the disease, but would not have prevented it and which certainly would have provoked violence. The Cholera Rules of 11 August 1903 included unjust provisions and privileged the railroad, but provided a foundation for constructing public health, becoming the basis for local and state cooperation over the coming years. As mentioned before, these Cholera Rules gave the government a great deal of power over anti-cholera operations in Russia while giving the responsibility and expense to local authorities. However, while it created division and short term problems, it succeeding in forcing a dialogue which addressed serious issues previously ignored. Russian physicians sorted out problems in disinfection techniques and understanding cholera’s aetiology, but still seemed obsessed with besting Koch. Russian physicians’ insistence upon raising social conditions proved to be the biggest lost opportunity in the struggle with cholera while the government was preoccupied with pursuing great power status. The Pirogov physicians’ push for famine relief and better conditions on behalf of poor and disenfranchised peoples in peripheries reflected zemstvo preventive medical principles that would prove critical in years to come. The burgeoning, but disorganised interest in race and Eugenics furthered insistence on addressing famine, economics and social conditions, issues which seemed trivial when everyone else was obsessed with bacteriology, would prove prescient. The government’s refusal to permit Pirogov physicians to address famine was one of the greatest mistakes that tsarist officials would ever make, one which likely

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contributed to fall of the monarchy. One must assign much of the blame to the interference of the nobility in local zemstvos and other areas of government and society, but Russian physicians’ rebellion against the Cholera Rules, no matter how understandable, damaged short term cooperation as well. The October 17 Manifesto to form a progressive, constitutional monarchy never succeeded, nor did tsarist public health ever quite perfect a comprehensive response to cholera epidemics. As the country faced an uncertain future, Russian physicians reconciled themselves to the inevitability of future cholera epidemics.

CHAPTER 4 CHOLERA RETURNS TO RUSSIA, 1907—13

In the first two decades of the new century Russian scientists were taking steps to modernise their institutional and practical capacities along the same lines as scientists elsewhere in Europe, a shift that one prominent historian of Russian science calls ‘little science’ to ‘big science’. The Russian sugar trade and other commercial and industrial expansion promoted development of scientific institutions, including St Petersburg’s Imperial Institute of Experimental Medicine. Pursuit of knowledge and power status had led to the establishment of ten major universities and more than 80 related institutions reflecting all aspects of science in the Russian Empire. Scientific associations were established, including the Society for Promoting the Advancement of Experimental Sciences and their Practical Application in 1909 and the Society of the Moscow Scientific Institute, which was modelled after the Royal Society in London, in 1912.1 By 1907, Russia’s period of social crisis appeared to have passed and the Tsar rescinded his promise of a constitutional monarchy. N. F. Gamaleia and the ‘Rein Commission’ wrestled with considerations related to industry and commerce, while striving to build a centralised system of public health based on science.2 Charlotte Henze argues that Russian physicians, like those in Italy, used localist theories as a basis of wielding power, pandering to commercial interest between 1907 and 1913, making them even less effective than in 1892.3 Indeed, environmentally oriented physicians such as Gamaleia, V. A. Taranukhin

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and G. V. Khlopin were becoming influential during this period, but there is no evidence that they altered their theories or findings to garner privilege. Historians often form an erroneous interpretation of bacteriology as an undifferentiated field, one which is entirely synonymous with Koch’s theories, and overestimate the capacity of this scientific paradigm to stop cholera in Russia during this period. This blurs the issue. In 1907– 13 the outlawing of land quarantines, pursuit of industry, railroad construction and tsarist incorporation of the hajj into the Empire (all complications which reflected the reality of the Russian situation), made physicians who considered the role of the environment useful to the government. While this seems to have helped their careers, their articulate presentations of cholera aetiology reflected their training, experience and the highest tenets of contemporary science. V. A. Taranukhin, M. M. Gran and other physicians who were allied with N. F. Gamaleia, D. K, Zabolotnyi, G. E. Rein and other scientists were simultaneously rising in stature by pushing for a system based solely on scientific method. Their articulations of cholera epidemics were acceptable by contemporary European standards of public health and for the period were in reality quite advanced.

Cholera Reappears in Russia: Samara, 1907 Despite the threat of a cholera epidemic in 1905, the disease failed to appear, and was almost non-existent in 1906. Russian physicians hoped that the threat had passed but, unbeknownst to them, the accumulation of events that predisposed a particular time and place to cholera, was rapidly coming to pass. The El Nin˜o cycled again in 1905–6 and famine reached the Lower Volga in the latter year.4 Emergency room physicians began seeing the usual disturbing symptoms. On 3 July 1907, two people entered the same hospital in Samara, a city on the Volga River north of Saratov. The first patient lived on Nikolaev Street in the centre of town and worked as a plumber in a boiler room near Samara Bay. Physicians treated him for ‘sharp gastroenteritis’, but he died in 24 hours. Investigators found that he had no contact with migrant workers or travellers. The second patient worked in a boiler room among metal workers in the Sherstneva factory and resided in the soldiers’ quarters on the outskirts of town. Like the first patient he had not had contact with travellers. Medical personnel isolated him in a separate

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barracks, watched him for three days and released him. On 6 July, a nurse who had attended to the second patient fell ill and on 8 July she died. Then, a watchman who worked in the waiting room where the first two patients had entered the hospital became ill. He experienced severe diarrhoea, then tremors and became debilitated due to loss of dexterity in his limbs. By 11 o’clock the next morning he had died. Investigators in the hospital laboratory discovered comma-shaped bacteria among the faeces of the nurse and a coroner found the cholera vibrio in the bowels of the security guard. Attending physicians evaluated the cases, resigning themselves to make a declaration that all four patients suffered from cholera and that an epidemic was imminent.5 Having discovered an epidemic, Samara physicians must have been at loss over the precise manner in which to combat it. Considerable theoretical disunity obscured discovery not only of the origins of epidemics, but whether or not to use preventive vaccination. Despite conducting apparently successful experiments with vaccination for cholera in Persia and Japan, Russian medical scientists failed to achieve a consensus that would permit them to use the procedure on a mass scale. The Moscow-based L. A. Tarasevich, one of the founders of Soviet immunology, later observed that, as opposed to other diseases, cholera in 1907–10 was connected with ‘many theoretical controversies regarding the pathogenesis of the disease’.6 Even I. I. Mechnikov, the scientist whose work had helped construct the foundation for vaccination, now considered it ineffective for cholera. In 1909 as deputy director of the Pasteur Institute, Mechnikov, travelled to Russia and met with D. K Zabolotnyi, S. I. Zlatogorov and P. Maslakovets. Noting that in laboratory tests at the Pasteur Institute large numbers of vaccinated rabbits had died of cholera, he suggested that sanitation would prove more important to battling cholera than vaccination. Zabolotnyi disagreed and engaged the Nobel Laureate in a heated argument in front of students and faculty at the Women’s Medical Institute, countering that cholera vaccinations lowered morbidity and mortality.7 That same year, at the first All-Russian Congress of Factory Physicians, another dispute erupted over vaccination. The opponents of the practice emphasised that economic and labour conditions and ‘raising the cultural and economic level of the working masses’ was imperative in battling cholera.8 Zabolotnyi’s argument proved prescient, but the issue was not resolved for years, leaving tsarist medicine at a loss. The same

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homogeneity of thought did not exist within medical circles regarding cholera immunology as for typhoid, smallpox and other diseases. The failed pursuit of an effective cholera vaccination for civilians and the military seemed, once again, to verify that the disease was an alien affliction that followed few rules of logic. Beginning with the investigation of the 1907 cholera epidemic in Samara, this chapter surveys some of the events that transpired concerning how tsarist physicians perceived and resolved to deal with cholera epidemics in 1907– 13. Subsequent events included Professor G. V. Khlopin’s investigation of sanitary conditions in the Lower Volga region, N. F. Gamaleia’s investigation of the 1908 epidemic in St Petersburg and two large meetings held in the aftermath of the 1910 cholera epidemic, the largest of the twentieth century in Europe. The first three investigations reveal the complicated interplay between environment and cholera that investigators dealt with, while the meetings reveal how these individuals, along with stakeholders in business, industry, commerce and the government, were sorting them out. As usual, these events reveal a dreadfully slow, but steady progress in Russia’s struggle with cholera.

The 1907 Cholera Epidemic and Investigation in Samara A web of intrigue surrounds the 1907 epidemic and its subsequent investigation. The cholera outbreak in Samara is generally cited as the first of a five-year wave of cholera epidemics that resulted in at least 279,614 cases and 143,849 deaths.9 However, there is evidence that earlier cases occurred. In his 1935 memoirs, the top tsarist physician G. E. Rein wrote that the first cases in 1907 occurred near the Black Sea in March, in one of the corners of Ekaterinoslav Province.10 The entry of cholera epidemics through the coastal regions of the Black and Caspian Seas was becoming increasingly common. Rein’s status as the premier figure and innovator in tsarist public health lends credibility to his report, but these cases were not reported in St Petersburg newspapers such as Rech and the physicians investigating the Samara epidemic were unaware of them. The local zemstvo in Ekaterinoslav produced no literature about the 1907 epidemic, but compiled a massive dossier in 1908, concurring with the St Petersburg bacteriologist, V. A. Taranukhin, a leader on the tsarist SEC, that the first cases in 1907

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occurred in Samara.11 Tsar Nicholas II later sent Rein to Ekaterinoslav Province to investigate cholera riots among coal miners in 1910.12 Indeed, cholera carriers on the railroad or on watercraft on the Samara River could have brought the vibrio to Samara from Ekaterinoslav. While Rein was likely correct, Taranukhin apparently did not have this information. His position on the SEC, outstanding analytical and communicative prowess, knowledge of most intricate nuances of science, rising influence in tsarist medicine and status as a native of Ekaterinoslav, are enough to make the most hesitant conspiracy theorist salivate. By all accounts, he was unaware of any earlier cases and destined to play an important role in an even more intriguing drama concerning cutting edge epidemiological theory. The Samara SEC’s investigation polarised around interpretations of the disease that were proposed by V. A. Taranukhin and another important government bacteriologist, N. N. Klodnitskii. The latter directed the MVD’s Bacteriological Laboratory in Astrakhan’ and worked closely with the Samara zemstvo.13 Klodnitskii argued that travellers on a steamship from Persia carried the disease into the city.14 Taranukhin, a mid-level professor at the Women’s Medical Institute in St Petersburg, formulated an articulate analysis of the epidemic, identifying weather conditions and Samara’s unhealthy local environment as the cause. He postulated that leftover bacteria from the 1904 outbreak, when carriers had brought the disease from Persia, regained virulence and sparked the outbreak, and he completed an indepth report for the MVD.15 The next year, the MVD sent a second St Petersburg physician, G. V. Khlopin, to lead an exploratory expedition charged with advising measures and expenditures for improving local sanitary conditions in the Volga River cities of Astrakhan’, Tsaritsyn, Saratov and Samara. Khlopin found a number of problems in the local environments that supported Taranukhin’s theory and proposed the same reasoning to explain the origins of a larger outbreak that followed in Astrakhan’.16 In 1909 Gamaleia, who had published similar interpretations regarding the 1904 cholera epidemics in Saratov and Odessa, cited localist causation for the epidemic that followed in St Petersburg in 1908.17 Here one can understand some historians’ assumption that these physicians were fudging their theories to ingratiate themselves with the government. Indeed, the government might have intentionally chosen

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environmentally oriented investigators to probe the epidemic to protect commerce.18 The MVD might have had several motivations to nurture an environmentalist viewpoint. One might view such motivations as a government counter offensive against the zemstvos after their actions during the 1905 revolution. As mentioned above, by 1907 the government had broken its promise of providing a constitution, marshalled its forces and was flexing its muscles. Localist arguments casted responsibility on physicians in local zemstvos, some of whom had agitated for the downfall of the monarchy in 1905. Blaming epidemics on local conditions in cities enabled the MVD to sidestep taking responsibility. Assuming Rein’s memoirs are correct, the MVD would have faced discredit if it were known that cholera lingered in Russia for four months without proper notification of authorities and initiation of anti-cholera measures. Klodnitskii, who also represented the MVD, was not the only medical official to question the MVD’s version. On 7 November 1910, an article in The Physicians’ Gazette mentioned that there were no known cases of cholera in Russia in 1906 and that ‘in 1907 Samara served as the first source (?) of cholera in Russia and from that time to the present cholera has not abated in the country’.19 The question mark is telling. Clearly, not everyone believed the MVD. Yet, however sinister the MVD appeared, the two interpretations of the investigation amounted to a classic case of contagionist versus localist thinking, in which investigators cited evidence in a manner that reflected their training and two perfectly legitimate epidemiological concepts. Klodnitskii had worked in Western Europe in the laboratories of both Pasteur and the German bacteriologist and Koch associate, Paul Ehrlich. He helped the Samara zemstvo organise and publish the journal Cholera Slate.20 Emphasising the water route up the Volga River as key to the epidemic, he insisted that cholera must have entered Samara by human carriers from Persia, asserting ‘the water routes and their arrangement along the cities play a major role in the spread of epidemic cholera. In a very short time, they compose the breeding grounds of the disease and from there it instantly spreads, achieving the greatest extent of its diffusion’.21 Conceding that there were no communications verifying the presence of cholera in the Middle East, he reasoned that the presence of patients in Samara ‘permits the supposition that there are already cases in Persia’. Steamships made the journey from Caspian seaports in Persia to Samara in six to seven days and the vibrio could have

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stowed away in the linen supplies on board a ship. Klodnitskii observed that it was necessary to identify the human carriers, whom he referred to in German as Bacillentra¨ger, who appeared healthy but transmitted the cholera vibrio, or were patients in Astrakhan’ and other places along the routes to Samara. Yet, he expressed ‘no doubt’ that carriers brought the disease south from Samara to Astrakhan’, where the Lower Volga meets the Caspian Sea.22 The problem with Kloditskii’s theory was an absence in identification of the carriers that he conceded were required along the route to Samara. Klodnitskii’s primary reason for disbelieving Taranukhin’s theory is that he doubted that the vibrio could have survived a year or more in ice and snow, and then break out in epidemic form.23 He argued that Astrakhan’ served as the conduit for transmission of disease to other places, including Saratov Province, which was located between Astrakhan’ and Samara, and that the supposition that the vibrio remained buried in Samara for a year or longer was ‘difficult to prove’ because it ‘dies easily in the presence of other more numerous microbes’ and was only capable of transmission through ‘the organisms of people’. He rejected the possibility that, during a particularly fortuitous moment, a member of the population might just suddenly fall ill or that the degree of virulence to spark an epidemic might have lain dormant in buried organisms and then become active.24 He was in fact drawing on Koch’s contagionist theory. Like Klodnitskii, Koch had recognised that cholera might live for a short period in certain environments, but emphasised the primacy of individual carriers in cholera transmission, stating, ‘[I]f one carefully examines the origin of individual epidemics, it is clear that the disease is always transported by people’.25 Klodnitskii was a government investigator who had been trained in the tradition of Koch and his school. His analysis counters the theory that Russian physicians, even those who worked for the MVD, used environmental theories to support commerce. Klodnitskii’s theory contained a number of holes. As he acknowledged, his argument depended upon detection of cases or carriers between Astrakhan’ and Samara, but none were identified, and he agreed with Taranukhin that a carrier was responsible for bringing the vibrio south from Samara to Astrakhan’. He asserted that cholera’s presence in Samara entailed that it was in Persia, that it died in the presence of other microbes, and could only be transmitted through the organisms of

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humans. Klodnitskii, who was clearly honest and quite competent, worked for the Ministry of the Interior and while he was based in Astrakhan’ rather than St Petersburg, he held an enviable position. In supporting the localist theory, Taranukhin put forth a forward thinking analysis of cholera aetiology. On the third page of his report Taranukhin acknowledged that the objective of the SEC was to ascertain whether Samara was responsible as the source and for the broad spread of the epidemic in Russia in 1907 or ‘the first victim of the usual movement of the epidemic’, declaring it an open question.26 Armed with Klodnitskii’s report and new data, Taranukhin noted that the Samara Anti-plague Commission (the SEC) first suspected a group of Muslim pilgrims and then approximately 100 Persian acrobats as the carriers of the epidemic, but these leads turned out to be false.27 Muslims constituted easy targets, but Taranukhin cleared them of blame. He might have feared cholera riots, or was simply following the tsarist protocol on incorporating Muslims into the empire, but he also had a more convincing lead. Taranukhin cited research that had been carried out in the years since Koch’s discovery and took great pains in explaining how cholera might have survived for over a year in Samara before starting an epidemic. Investigators had proven that cholera could live in water for up to two to three months in certain environments. For example, the vibrio could survive in plumbing for 32 days, in canals for 38 days, on the open seas for 64 days and in harbours for up to 81 days.28 He observed that Koch’s experiments had made it clear that cholera was passed by drinking water and waste products, citing three probabilities regarding the origin of a cholera epidemic: (1) That it would be carried by cholera patients to far-away places. (2) That it originated from human wastes in public dumps. (3) That people ingest the vibrio through drinking infected water. Noting the absence of cholera in Samara in 1905 and 1906, Taranukhin maintained it was improbable that cholera could have remained inside the bowels of patients for two years, but surmised that sanitary conditions in the city made it probable that cholera had survived in the local environment.29 Taranukhin was pushing this argument to its limits and beyond in terms of 1907 sanitary theory.

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Composing a list of problems in Samara’s environment to support this argument, Taranukhin observed that there were no sewers in Samara and that the city dumps were located in some of the most elevated places in town. Workers transported large barrels of wastes to these dumps and deposited them. From these pits, sewage seeped into a ravine, ran into a tributary of the Samara River, flowed into the Samara itself and continued several miles along the city’s shores.30 Referring to a report from the governor of Samara Province to the MVD in late August 1907, he estimated the amount of sewage that flowed from the garbage dumps on the hills into the city. Residents unleashed 1,674,000,000 pounds of water into the city each year after gardening, farming and firefighting, which mixed with 92,592,000 pounds of human waste in the city, amounting to 1,766,000,000 pounds of sewage necessary for removal every year. The governor acknowledged that a lack of barrels and limitations on work hours reduced the city’s removal capacity to approximately 163,200,000 pounds, leaving 1,602,000,000 unattended, of which workers dumped as much as possible into inactive wells that were impossible to destroy or incinerate.31 Taranukhin’s explanation clarified why drinking water in what the Russians often referred to as ‘Persian wells’ was hazardous to the health of inhabitants on the Volga. V. A. Taranukhin was using Pettenkofer’s techniques to make his case. When he was cleaning up Munich, Pettenkofer had calculated the total weight of faeces, urine, kitchen and house refuse, compact wastes and liquids that entered the ecosystem after cleaning. These waste products, he argued, could only be cleansed through proper sewage disposal.32 Sewage in Samara seeped into the city’s groundwater and spread its infection underneath the city, pooling in ravines where apartment communities were later built and creating a hazard for local residents.33 Like other tsarist physicians, he was using an established European paradigm. Russian physicians often cited Pettenkofer’s theory, but this hardly constituted backwardness. At least one modern epidemiologist has argued that Pettenkofer came closer than other nineteenth-century medical thinkers to explaining the actual aetiology of cholera.34 Few Russian physicians were miasmatists in the sense that they believed that a vapour in the atmosphere caused cholera, but many justifiably argued

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that the vibrio could live in the soil for long periods of time along the Volga River and in other environments. Most Russian physicians believed that the vibrio arrived from Asia but disagreed on how long and in what form it might survive in the environment and still spark an epidemic. Whenever cholera appears disagreements between contagionists and localists ensue, which epidemiologists’ responses to the 2010 epidemic in Haiti recently revealed.35 Legitimate scientific disagreements may have afforded an industrial, trade-oriented government the opportunity to embrace physicians who favoured environmentalist theories, but there is little evidence that the opposite was true. One must also question the likelihood that tsarist bacteriologists, seeking to ingratiate themselves with the government, created spurious theories that later turned out to anticipate much of what we know about cholera. The logical explanation is that Taranukhin, like Gamaleia in 1904, was following the evidence. Using local bacteriological experiments, Taranukhin elaborated on how the cholera vibrio survived locally after the epidemic in Samara in 1904. In August of 1907, government investigators took samples from a branch of the Samara River known as the Samarka, which they believed contained the cholera vibrio.36 The cultures were much weaker than most cholera bacteria, yet Taranukhin and others agreed that they were cholera while Klodnitskii concluded the opposite. Taranukhin brought the matter to the attention of the St Petersburg Microbiological Society and the members unanimously agreed with him. Locating even stronger samples in local reservoirs, Taranukhin argued in favour of the possibility that the vibrio travelled some distance in the water and regenerated upon finding favourable conditions in the summer of 1907.37 In asserting such a long survival rate for the vibrio, Taranukhin was challenging the principles of Koch, using instead Pettenkofer and Pasteur’s idea that germs existing in infected and putrefied environments might find the correct conditions to become harmful to living persons. Ironically, Klodnitskii uncovered the most damning piece of evidence against his own position. Upon returning to Astrakhan’, he taught a course on detecting cholera at the MVD laboratory, taking samples of suspected cholera from the Volga River. He noted that the most dangerous water was found in areas near the banks, attributing it to less water traffic and its stationary state. Taking samples from a hole in the deep waters of the middle of the river, he found no sign of cholera while

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those taken from the shoreline and close to the Kutuma and Tsareva Rivers produced positive results. Here ‘literally swarmed the cholera vibrio’ in me¨rtvie prostranstva . . . ‘dead spaces’.38 Klodnitskii did not contest that cholera could not survive in the environment, but rather focused on how long it might live and still present a hazard. From what we know today, there is little question that the estuaries of Astrakhan’ could have unleashed an epidemic under such conditions. Taken along with Gamaleia’s investigation in 1904 and findings in Odessa on the Black Sea and the banks or ravines along the Volga in Saratov and Samara, Taranukhin might well have been correct. Moreover, Klodnitskii even called the place in the river where cholera swarmed a ‘dead space’, which scientists call such areas today. Both Klodnitskii and Taranukhin were tremendous scientists, who interpreted the epidemic according to established European paradigms in which they had been trained. Most Russian physicians were content with Taranukhin’s version of the 1907 epidemic. Investigators in the Ekaterinoslav Province Zemstvo put together a 340 page collection containing 19 articles relating to cholera the following year. Few of the articles mentioned 1907 and those that did disclosed little about the epidemic’s origin. The author of the first article, A. L. Smidovich, mentioned Taranukhin’s environmental theory. Agreeing with Taranukhin, Smidovich concluded that in 1908, ‘the first cases of cholera came on 8 July in Tsaritsyn’ and ‘again as in 1907, the Volga was revealed as the breeding ground of cholera’. ‘Cholera again’, he stated, ‘was homegrown’ and ‘not Asiatic’. Smidovich mentioned Pettenkofer’s theory of a connection between low groundwater and humid, exposed soil as a causative factor. A chart noted that the first cases of cholera in Ekaterinoslav Province in 1907 occurred on 9 September, not in March as Rein later stated.39 It is possible that the Ekaterinoslav zemstvo, like the MVD, may have wished to avoid the responsibility for the import of the germ through its district or the zemstvo may have preferred not to challenge the MVD. Ekaterinoslav was Taranukhin’s home town and one of the MVD’s elite bacteriological laboratories was located there. Yet, the theories of Smidovich and Taranukhin were viable. Given the ambiguity that still prevails, it is easy to understand the confusion of Russian scientists over cholera in 1907. Koch’s discoveries actually in some ways made understanding and combating cholera in Russia more difficult.

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The MVD Returns to the Volga, 1908 – 9 On 3 October 1908, officials of the MVD formed a commission to determine problems in the municipal environments of Astrakhan’, Tsaritsyn, Saratov and Samara. The group was charged with constructing a plan for cleaning up the cities, particularly Astrakhan’, estimating expenditures and eliciting thoughts on appropriation. The commission departed St Petersburg on 22 October and remained on the Volga until May of 1909. The St Petersburg Professor G. V. Khlopin, who would become one of the foremost advocates of extending hygiene to include social conditions, headed the efforts in all four cities.40 Khlopin linked the topographical features of the region to the development of the cholera epidemics. As mentioned above, he noted the low topography in Astrakhan’, which was located beneath the waterline of the Volga River, its streams and river channels, as the most dangerous to the health of local residents. While the city’s ‘defending bank’ was approximately 14 feet high, providing some protection against flooding; water had poured into the city in 1908. Astrakhan’ was not protected by safe elevation like Moscow and some other cities. The construction of a levee between the Buzan and Boldo rivers crossed two lakes formed by Volga floods in the spring, which formed dangerous water pools in the lower-elevated districts. The levee supported the new Riazan-Urals railway, which ran from Astrakhan’ to Saratov. Unfortunately, the Astrakhan’ City Council had tabled a motion to construct an embankment. Without an obstacle, the high waters permeated the city’s defenses, therefore the lowest parts of Astrakhan’ were infested with standing polluted water in the spring, creating dampness in the lowest floors of nearby homes. Rising water uprooted garbage dumps and cesspools, which rose to the surface and poured out among citizens in streets and courtyards, flowing alongside debris from elevated districts. After a strong rainfall, large puddles, swamps and marshes appeared, infrequently flooding homes. Stagnant water from reservoirs and various sources later dried in the sun, creating ‘sunbaked’ and ‘sulphuric’ soil without sufficient air in areas where it was constantly humid. This lack of oxygen, Khlopin argued, would not permit decontamination for long periods, perhaps even decades.41 G. V. Khlopin’s description of Astrakhan’ in ways mirrored Taranukhin’s observations of Samara. Pettenkofer had observed that cholera appearing

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in low-lying river valleys was not due to river traffic, but their status as ‘regions of natural soil drainage’.42 In his observation of the anaerobic condition of the sunbaked soil, Khlopin was drawing upon Pasteur’s work on germs and fermentation, which the famous Frenchman defined as ‘respiration in the absence of air’.43 Khlopin’s fear that sufficient heat could encourage the development of microbes in soil in such a state was not farfetched. He was using Pettenkofer and Pasteur’s theories in an attempt to fuse germ theory and the climatological and topographical phenomena that he observed in the environment at Astrakhan’, where cholera is able to self-generate. His analysis amounted to a coherent formula that, for the period, was fairly advanced. Khlopin did not emphasise the routes of transportation nor Volga River traffic as one of the principal causes of cholera epidemics, but recognised that many sick workers had migrated by steamboat to Astrakhan’. These included the suspected first patient, Sevastianov. The esteemed epidemiologist, D. K. Zabolotnyi, had identified Sevastianov in Astrakhan’ as what we might call ‘patient zero’ today, fully accepting Taranukhin’s version of events.44 Khlopin, however, argued that ‘the first cases of cholera in Astrakhan’ were not brought by carriers, but in all likelihood, initiated from within the city itself. Khlopin noted a report by the senior physician of the city’s United Hospital stated that the first cases were mistakenly identified as severe gastroenteritis, a diagnosis that remained uncorrected even after carriers arrived from Samara in July.45 Khlopin did not deny the contagious aspect of cholera, nor its ability to precipitate an epidemic, but found further problems with the official version. The events along the Volga in 1907 presented tremendous epidemiological complexity. Russian physicians viewed the events through the lens of sophisticated European theories, understanding that cholera could have entered Russia along newly constructed railroad lines, or formed a semi-endemic niche in the temperate climate of southern Russia.

The Tsarist Railroad and Cholera Khlopin mentioned railroad construction, which was moving along at a furious pace between 1904 and 1908, but neither Klodnitskii nor Taranukhin paid much attention to this new mode of transport. Many Russian physicians in 1907 still feared the river was the primary conduit

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for cholera transmission. The Kazan’ military district, for example, established a series of floating cholera checkpoints on the Volga River for detection and isolation of patients.46 The military’s role in combating Russian cholera was traditionally strong, having developed a checkpoint system dating back to Pirogov. Cholera is a waterborne disease and the inclination of these physicians to focus on the river was understandable, but the movement of railroads was diffusing the vibrio throughout wider expanses of the country.

The Threat of Cholera on the Russian Railroad and the Muslim Hajj, 1907– 9 Physicians in local zemstvos and SECs were well aware of the danger that the railroad presented. In a joint medical meeting of the Balashov SEC and district physicians on 3 August 1907, the participants expressed concern about the possibility of transmission of cholera along the railroad lines in Kuznetskii district, which was located close to Samara. Water traffic also threatened to bring cholera over the Volga on the route south from Samara to Khvalinsk in the northeast section of the province, but I. P. Chernikh and M. V. Ivanov urged observation of a stretch of railroad known as the Muratovka– Begeevo line. They stressed that the most dangerous point was where the railroad crossed the Volga River near the village of Chernavka in Volsk district ‘where cholera, each time it is present, weaves a nest for itself within the outer borders of the government’.47 N. A. Zviagintsev explained that it was necessary to isolate every cholera patient that they extracted from a train, complaining that ‘the railroad administration always tries to hand off the sick to the trustees of the zemstvo’.48 In a meeting of the Balashov zemstvo council in Saratov Province on 5 August 1907, the director M. M. Obukhov opened the proceedings by confronting the threat of cholera from Samara (to the north of Balashov), stating, ‘If we look at the map, here we see that two routes are capable of bringing us epidemics: along the Saratov and Kamyshin lines. The most dangerous route of transmission [. . .] is the railroad’.49 Indeed, areas where the railroad intersected major water arteries had become breeding grounds for cholera. Even in the relatively light year of 1909, physicians paid attention to the railroad lines. Between 4 August and 27 October in Saratov Province there were 101 cases of cholera, from which 63 people died.50 Single

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cases appeared inside the city limits on 4 August, at Uleshi on 7 August and Uvek the next day. Local personnel verified the cases through bacteriological investigation.51 Railroad officials denied association with the epidemic. On 12 September, Saratov Governor Tatishchev sent a telegraph to the Urals –Riazan Railroad Council requesting the locations of patients who had been removed from trains and the location of all sanitary wagons.52 Nine days later the boss of the Railroad Medical Service responded that they had not removed any patients from trains, neither within Saratov Province nor over the entire Urals –Riazan railroad.53 He added that sanitary wagons were located in Saratov Province at Uvek, Balashov, Kamyshin and Rtishchevo.54 The executive’s assurance that his personnel ‘had not removed’ any patients from the cars likely reflected a lack of action rather than an absence of the disease. Cooperation along the railroads remained a problem. Battling cholera required cooperation between all sectors of society, not merely within the government. The government was still moving toward the incorporation of Muslim pilgrims into the Empire, but these individuals were notorious for spreading cholera and considered a powder keg for cholera-related violence. The 1907 cholera epidemic had killed approximately 20,000 people in Arabia. Hajj travellers routinely went without proper food, often eating spoiled meals that they carried with them. Hungry, underfed and less than well-hydrated, they were ideal targets for cholera bacterium. In the epidemic’s aftermath, Russian Prime Minister P. A. Stolypin passed new rules for Muslim transportation by steamboat to the Hejaz and extended railroad services to include Central Asia, Orenburg, Samara, Penza, and Kharkov to Odessa, which was a key point in travel to the hajj.55 Thus, Russian modernity not only demanded free communications for commerce, but also for the new expansive policy toward Muslim pilgrims. On 28 April 1908, during the Eighth Session of the Volga Regional Oblast’s Anti-Cholera Meeting in Samara, physicians discussed Muslim pilgrims on the railroad. One report addressed Muslims using the European-Russian railway system to travel to and from Mecca, noting the poor sanitary conditions and services on cars and at stations. N. K. Galler of Saratov noted that on every train with pilgrims, migrants and workers, toilet seats must be held in reserve and distributed for use only after cleaning and bacterial inspection. Another Saratov physician, the

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highly respected zemstvo doctor, N. I. Teziakov, complained that the railroad commission was not complying with the law. He cited Section 9 of the addendum of the Cholera Rules of 19 August 1903, which prohibited wagons carrying sick passengers to travel beyond the next station. Also, arguing that Paragraph 9 required the railroad to have proper hospital facilities at every station, he noted that large number of travelling workers, migrants and religious pilgrims gathered at these places. He suggested that the railroad build facilities to feed fourth-class passengers and keep them healthy. The zemstvos, he complained, had communicated this necessity to the railroad commission and were awaiting an invitation to collaborate.56 These were legitimate concerns, and Teziakov was a figure who was impossible to ignore. Once again, zemstvo physicians were leading the way in building effective local cooperation. They used the tsarist Cholera Rules both as a guide and legal mandate for improvement. V. A. Taranukhin was present and responded that the railroad commission directors recently met in St Petersburg and expressed the opinion that it was not their duty to provide medical treatment to passengers, but only to provide transportation. He added that necessity demanded the passing of an order requiring transfer stations to have the proper bacteriological facilities and disinfection closets.57 Whether Taranukhin was sidestepping the issue or proposing a serious mandate is difficult to determine, but Teziakov had raised the issue, put it in the government’s court and was unlikely to let it rest. Later, physicians discussed a report addressing special measures for Muslims during cholera epidemics, which was clearly designed to clear the way to support Muslim travel and tsarist assimilation of the hajj into the empire.58 The topics were designed to familiarise Russian physicians with Muslim customs and practices, and how to avoid volatile circumstances. The first block of instruction considered ‘Misinterpretation of the Muslim masses’ interference with physicians who are performing their duties in the healing of patients in hospitals’.59 Later sessions dealt with Muslims’ preference to ‘heal themselves according to the mandates of their leaders’ and ‘fatalism’ regarding recuperation. Other topics included understanding Muslim medical literature, empathetic response to Muslim corpses that were disfigured by cholera, special instructions for building Muslim cholera barracks, proper protocol for burial of Muslim cholera victims and distribution of special

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brochures to Muslim populations.60 Russian officials were stressing empathy and understanding of Muslims to avoid cholera riots. Considering that zemstvo physicians had argued for greater physician safety the government was responding in a rational manner. The MVD prohibited travel to Mecca and Medina in times of cholera, but only the tsarist Anti-Plague Commission and the Medical Council in coordination with the Muslim Clergy Assembly could revoke these privileges with the approval of knowledgeable physicians. Yet another passage counselled that Muslim hygienic practices inhibited cholera diffusion and that their religious views did not conflict with scientific methodology to the degree that it hindered ‘the struggle with cholera’.61 These messages conveyed to physicians to leave these matters in government hands, but also tend to emphasise common sense practices to reduce violence. The Samara physician M. M. Gran, an associate of Taranukhin, noted that the oblast’ meeting marked the first serious government effort to deal with issues related to Muslim practices, foreign peoples, and cholera epidemics. The ever present Taranukhin suggested forming a commission including the government, Muslim physicians, religious leaders and the population. Gran and Taranukhin suggested creating a department for this purpose, but the minutes did not reflect who else might be invited.62 One certainly understands the argument that St Petersburg afforded certain environmentally oriented physicians to wield authority. These environmentalists, including the Rein Commission member, N. F. Gamaleia, were beginning to assert themselves.

Gamaleia and the Great 1908 Epidemic in St Petersburg The ‘Great 1908 Cholera Epidemic’ in St Petersburg, as some Russian physicians referred to it, resulted in nearly 7,000 cases within the city districts alone.63 In the wake of the epidemic, the noted bacteriologist, N. F. Gamaleia, was called upon to form a plan for the city’s defenses, undoubtedly in connection with his past work and efforts with Rein to reform public health.64 Gameleia’s anti-cholera work included a doctoral dissertation on the 1892 epidemic and investigation of the 1904 epidemic in Saratov.65 He had consistently emphasised the environment in his work, supporting Pasteur and Mechnikov against Koch and due to his persistence, had lost an appointment as director of the Kronstadt

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Plague Fort.66 Gamaleia followed the evidence. In an 1899 article he had concluded that the theories of Koch and Pettenkofer could not be reconciled under one doctrine.67 He then used Pettenkofer’s principles to explain the 1904 epidemics in Odessa and Saratov, and his study of St Petersburg in 1908 suggested a return to the roots of Russian and European hygiene. Recounting the history of anti-cholera measures in Europe, Gamaleia asserted that after 1866 English physicians had constructed a plan based upon waterworks, systems of floatation and fields of irrigation, enabling them to quell epidemics.68 Soon, the entirety of Western Europe used this system and cholera epidemics persisted in 1870–1900 only in countries suffering ‘deficiencies’ such as Russia, Spain, Naples, Hamburg and St Petersburg. He stated that first English hygienists, then Pettenkofer, had employed a system that stopped cholera and typhoid in Western Europe. Based upon this work, Gamaleia formed a theory that cholera epidemics originated in ‘saprophytic breeding grounds [. . .] not along the routes of contact’ between the sick and healthy, but through multiplication of bacteria in water, soil or other natural environments and then into the stomach and intestinal tract.69 Gamaleia’s articulation of cholera aetiology bore much in common with modern theories discussed above in Chapter 1. Gamaleia was drawing upon not only Pettenkofer and Pasteur, but alluding to earlier English reformers such as Michael Faraday, Edwin Chadwick and others. Justus Liebig, the chemist whose theory of putrefaction Pasteur had refuted, was Pettenkofer’s mentor. This was the paradigm in which Pasteur had worked, making breakthroughs in immunology and bacteriology. A saprotroph is an organism that feeds on organic and inorganic compounds such as dead bodies, tissues, or excrement. Gamaleia, who was a bacteriologist associated with Odessa and Paris, was proposing that a saprotroph, residing in various environments, accomplished the nutrient replenishment that served as the missing element in cholera epidemics; natural conditions that ultimately brought cholera from the environment into the gut tract of humans. While he did not understand the role of copepods and other shellfish in estuaries, considering his earlier identification of coastal regions, he was not far off the mark. Robert Koch emphasised contact between individuals, Gamaleia now asserted that it was possible for cholera to originate from local

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conditions, even identifying an epidemic of this sort in the Peresyp district of Odessa. There were no waterworks or sewer system in this area, and people used wells to procure water that was neither chemically nor bacterially safe. The residents in this district suffered disproportionately high numbers of cases of typhoid. Dumps, sewage and unclean conditions surrounded the home where the case originated. Gamaleia concluded that this case originated locally, linking it with climate and living conditions. The primary factors causing the epidemic did not involve contact, but ‘time of year, humidity and infection of the soil [. . .] ripening in soil, sufficient warmth, humidity and rich organic matter’.70 Gamaleia concluded that cholera diffusion worked differently in Russia than in Western Europe. He observed that the routes of contact did not play as precise a role in cholera diffusion in Russia as they did in Germany and Western European countries, which nonetheless had made their nations safe by focusing on ‘saprophytic breeding grounds’.71 He continued, stating that the German influence in Russia, undoubtedly referring to Koch’s Russian followers, caused St Petersburg officials to formulate ‘a backward plan for the spread of cholera along the contagious routes’. Blaming the 1908 epidemic on this plan, he asserted that the prevailing defensive organisation of St Petersburg was ‘incorrect’.72 Gamaleia noted that some physicians believed that cholera epidemics only subsided by themselves, that they must run their course. Disagreeing, he argued that paying attention to saprophytic breeding grounds could inhibit epidemics in Russia, stating that he had arranged such measures in Baku, Erivan and Saratov and that Gran and Taranukhin were pursuing such work.73 Gamaleia was essentially a bacteriologist and immunologist who had become an epidemiologist. Having investigated cholera for 20 years, he understood the influence of climate, local environment and social conditions. The places he mentioned, Spain, Italy and St Petersburg, had all suffered epidemics after 1900 in port cities and Hamburg in 1892. The knowledge he gained likely benefitted from his epidemiological work in Odessa and St Petersburg, both ports, but in vastly different climates.74 He based his doctrine on a combination of factors, including his training and belief in the dictums of his school and, most importantly, observable data. Germany was a comparatively small nation with a large population and the human resources to administer an effective quarantine. Russia was a large country with wide open borders

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in closer proximity to endemic centres of cholera, vulnerable seashores and river basins and crossroads for trade and pilgrimages. It is worth remembering that Gamaleia was financially independent, had dedicated his life to bacteriology and was following legitimate, European scientific dictums. Whatever his weaknesses, politics were unlikely to have influenced him.

The 1910 Epidemic The 1910 epidemic began when cholera once again broke loose among coal miners in the corner of the Don River Basin, where it had likely smouldered for years. G. E. Rein observed in his memoirs that the outbreak ‘took an extremely dangerous turn’ as workers fled from the mines, coal extraction fell, factories and shops shut down and railroad operations were threatened.75 Ironically, a railroad stoppage might have saved the country, as the vibrio employed the railway network to penetrate distant corners of the Empire. In some places cholera riots began with the usual destruction of cholera barracks and rioting that Rein linked to the terrorist group The People’s Will, but these were in reality related to cholera and probably labour issues.76 Representatives of the coal miners began to arrive in St Petersburg and appeared before Prime Minister P. A. Stolypin and other high officials to appeal for a solution.77 The Council of Ministers sent Rein to the Donbass, and Stolypin was named Director of the Medical Council by approval of the Tsar and one of his ministers, Krizhanovskii. Rein noted with irritation that he had to interrupt his vacation and drive to St Petersburg, where he was briefed and sent to the Donets Basin to organise the anti-cholera campaign. The Red Cross acknowledged Rein’s authority, and provided him with an undisclosed credit. He sent mobile leaflet detachments of physicians, student-medics, senior medical students and nurses south to distribute literature about cholera.78 The activities to inform and advise local residents through leaflets followed the zemstvo tradition of communicating with and educating the public, a practice that Western European physicians had long used. The cholera riots and threats to commerce in the aftermath of the 1910 epidemic brought about the slow, steady progress that tsarist physicians were constantly pursuing. The largest cholera epidemic of the twentieth century in Europe, this outbreak consisted of 230,232 cases, of

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which 109,560 were fatal.79 As a prominent medical geographer observed, the outbreak was the first truly national epidemic in Russian history, spreading to virtually every province in the geographically largest country in the world.80 Attempting to respond to the concerns of stakeholders, including zemstvo and city physicians and representatives of the mining, railroad and steamboat industries, the MVD held meetings in 1910 and 1911 to quell dissatisfaction with tsarist management of the epidemic. According to the physician N. I. Kovalevskii, who had recorded the events in Saratov in 1904, the first meeting on 24 November 1910 began inauspiciously and accomplished virtually nothing. The attendees included provincial governors, members of local and zemstvo councils and mayors who addressed questions such as the payments that zemstvos and cities were forced to make to the SECs. Local authorities argued that the SECs suffered from deficient organisation, subordinating local sanitary supervision by forming alternate arrangements and anti-cholera zones. They complained about the high-handed behaviour of the railroads and other matters related to mercantile interests.81 Communications at the conference did not begin in an auspicious manner. The Main Medical Inspector, Malenkov, was not averse to interfering or stopping speakers in mid-sentence to obstruct the decision making process. A feeling quickly emerged that if participants did not agree with something they might as well remain silent. The members of the council agreed to alterations in the conference agenda, but protected existing legislation. Soon, communications in many of the proceedings became chaotic and business was obstructed by over-numerous sections and poor coordination. Kovalevskii concluded that the conference did not resolve anything.82 Similar problems plagued the second conference on 23 February to 1 March 1911, but the conferees passed resolutions on some concerns. There were approximately 350 participants, representing agencies like the Ministry of Trade and Industry, the Main Council of Land Construction and Farming, the Ministry of Education, engineers and physicians from the Ministry of the Ways of Communication, the Maritime Ministry, the main prison council, the Red Cross and the financial section of the Imperially Proclaimed Commission for Measures of Prevention with the Struggle with Plagues. A small host of individuals represented the MVD, including almost the entire medical

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council, members of the council of the Main Medical Inspector and the Primary Council for Agricultural Work, the Inspector of the Naval Medical-Observation Stations of the Northern Shores of the Black Sea, and members of the Medical Council of the Caucasus. There were medical inspectors present from 47 provinces and oblast’s. There were also physicians from the zemstvos and city councils and finally, individuals who were present upon special invitation of the MVD’s Main Council of Medical Inspectors, which included N. F. Gamaleia and V. A. Taranukhin, who had become the Chief Physician at the St Petersburg S. P. Botkin Municipal Hospital, and director of the St Petersburg City Bacteriological Laboratory.83 Upon arriving Kovalevskii and other participants received programmes and quickly surmised that the MVD had carefully chosen the agenda, including the questions addressed. The programme indicated that the meeting would be organised into three parts: the water and railroad ways, the factories and the mines. Kovalevskii and his colleagues were soured by the proceedings ‘from the first moment’ feeling that the agenda ‘reflected the special interests of the MVD or other participants rather than the victims of cholera outbreaks’.84 Yet, the agenda emphasised preventive measures and important aspects of medical organisation. The participants passed resolutions regarding the water routes and railroads. One resolution included a call for zemstvos and city sanitary physicians to administer and oversee the organisation of anti-cholera measures, emphasising preventive measures and medical organisation to ensure ‘constant substantive sanitary organisation by the Ministry of the Ways of Communication on the waterways’. The mandate permitted the zemstvos to activate provincial SECs, and recognised the importance of supervision on ‘vessels, rafts, wharves, and creeks’, particularly where members of the ministry were absent. The participants condemned as ‘unthinkable’ the practice of employing only one government sanitary physician on the water routes, who was also charged with carrying out measures in districts, cities and zemstvos.85 The meeting marked a step forward in the government and zemstvos’ understanding and collaboration. Just one year after the largest cholera epidemic of the twentieth century in Europe, provincial physicians were still fighting for more active intervention along the routes of transportation. They demanded the railroad commission, which was afforded vast authority under the

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1903 cholera rules, to be held responsible for disinfecting passengers, workers and residents within the boundaries of railroad property. The government, they argued, should compel the railroad SECs to employ sufficient numbers of sanitary physicians, ensure that chemicalbacteriological laboratories were stocked with the means for carrying out proper procedures and for railroad medical oversight of passengers, particularly where they congregated.86 The resolution recognised that a single observer on a train would prove incapable of detecting cholera carriers at the outset of an epidemic. Nor could the conductor carry out this task by himself.87 The participants moved ‘to compel the railroad’ to treat cholera patients within its districts.88 Rather than heeding to the will of the government, industry and commerce, Russian physicians were demanding reform on the railroads and water routes. Of course, the government did not uniformly respond with alacrity to these resolutions, but these objectives remained important issues over which zemstvo and government physicians would fight.

Conclusion Physicians in tsarist Russia developed environmental interpretations of cholera mostly due to the intellectual tradition under which they were trained and the prevalence of environmentally related problems in their country. After 1905, tsarist medical practitioners used their medical and administrative frameworks to build a system of epidemiology which recognised that contagious and other aspects of cholera, sanitation, geography, topography and issues related to climate played a role in its aetiology. While personnel in the MVD and other government bureaus may have favoured environmental approaches due to advantages it gave to industry or various other pursuits, there is little indication that physicians altered their analyses or catered to these initiatives. More often, they responded according to the paradigm under which they had been trained. For example, Klodnitskii, who had worked in Berlin, argued for a contagionist interpretation of the 1907 epidemic in Samara, even while acknowledging strong environmental influence. Teziakov and other zemstvo physicians argued vociferously in support of increased contagionist intervention on the railroad. Taranukhin, Gamaleia and others appeared to garner influence from their work, but the theories they formed adhered to accepted paradigms of Western medicine.

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Gamaleia argued for a more environmentally oriented system of defense in St Petersburg and, as he had done consistently since 1892, argued against Koch and his followers. Even as they benefitted from their work, there is insufficient evidence to claim that these physicians disregarded science to further their careers. The government’s flexible policy was not primarily based on protection of commerce. Prohibition of land quarantines, more inclusive policies for Muslim pilgrimages and flexible systems reflected the trend in the West that emphasised surveillance, prohibited land quarantines and adhered with international law. The system reduced cholera-related violence, providing greater religious tolerance and free movement of communications. The various conflicts in which Klodnitskii, Taranukhin, Tezaikov, Mechnikov, Zabolotnyi and other zemstvo physicians became embroiled, reflected efforts to iron out important rough spots in the system. The Kazan’ military district’s construction of the floating cholera barracks indicates the role that military experience of evacuating refugees, wounded soldiers and prisoners played in building the checkpoint system. The conferences in the wake of the 1910 epidemic, although disorderly, resulted in several positive resolutions as zemstvo physicians demanded more accountability from the railroad SECs. By 1912, the famine that preceeded and precipitated the five year spate of epidemics between 1907 and 1912 had subsided. A bountiful harvest in 1913, improved living conditions and greater epidemiological intelligence might have enabled tsarist physicians to quell epidemics were it not for the outbreak of World War I. Unfortunately, warfare over the next eight years presented tremendous epidemiological challenges to Russia, indeed to mankind, as it entered a global age.

CHAPTER 5 THE TROUBLES CONTINUE: WORLD WAR I, 1914—17

From the campaigns of Alexander and Napoleon to the carrying of cholera by Hasting’s army out of Maratha, military operations have a long heritage of spreading disease and changing society. The outbreak of World War I destroyed non-constitutional, multi-ethnic, monarchial rule, not only of the Tsars, but the Ottomans, AustriaHungary and Germany. Imperial Russia rivalled Germany in industry, but the noble officer corps used nineteenth-century tactics and treated peasant soldiers like serfs. Dying in scores at Tannenberg and early battles, their replacements, like the French officers of the Old Regime in 1789, came from the working class and soon joined revolutionary armies.1 Fighting around the ports of the Black Sea and on the Western Front in 1915, the twin issues of famine and climate brought cholera to Russia in World War I. The irony of the events that followed rests on the following contradiction: the monarchy’s failures to adequately respond to war, manage food supplies, or even simply cope with famine and disease, brought about influx of cholera and the downfall of the empire. All this, despite the work of progressive forces such as the Pirogov Society, the Union of Zemstvos and Union of Towns, who were making improvements by promoting interagency cooperation and assistance, organising a wartime hospital system and other measures that would eventually bring the disease under control. The Pirogov Society’s reaction to a lack of preparation for war and the work of the Union of Cities and Union of Towns at the front, combined

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with efforts to form mass vaccination units during the 1915 epidemic in Moscow all created progress, as did the continuing work on the railroads in Saratov Province and elsewhere. The unions built upon the civilian cooperation that the trustees in Saratov exhibited in 1904. Ironically, if intended to absorb the zemstvos, Pleve’s Cholera Rules helped foster social construction, as zemstvo professionals pointed out flaws and called out SEC members in collusion with the railroad or government. By 1914 Russia had achieved obshchestvennost’. Activists longed for parliamentary rule, but Nicholas II and his ministers focused on the initiative of maintaining Russia’s place in Europe.2 The functional pathologies that brought down the empire and the vibrant society that emerged after Alexander II’s reforms were evident in the battle that zemstvo physicians fought against cholera, even as Russia joined the ‘Triple Entente’ with Britain and France against the Central Powers.3

The Outbreak of World War I and Russian Public Health, 1914 The beginning of World War I forced the government to improve support for science in certain areas, but most were related to war. The government improved support for science related work in mining, agriculture and weaponry.4 Despite this institutional development, the tsarist government, did not take sufficient steps to support war casualties, refugees, the infirmed and diseased, including cholera victims. The tsarist government’s failure to plan and to quickly respond to the crises at the beginning of the war permitted accumulating problems, a flaw that it had long suffered. In 1915, the Russian army experienced defeat and Russian public health was forced to deal with a massive retreat from the front, which one scholar described as a ‘human tidal wave’.5 This defeat could not possibly have come at a worse time. The forces that would make the war years a nightmare in Russia were accumulating. Even in the stellar year of 1913, strong ENSO events occurred, continuing into 1915.6 After 1914 the railroad was forced to reroute all of the traffic in the country. The outbreak of World War I increased the necessity for rail transport, but caused a decline in capacity, decreasing its ability to haul grain by 30 per cent in 1913 – 15. In 1915, the government gave local grain dealers the authority to

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fix the price of farm products and, if necessary, requisition at a lower price. In 1916 – 17, peasants became reluctant to sell grain, keeping it for themselves or using it to make spirits. The industrial regions in Petrograd were hit the hardest, but the entire country suffered major food shortages while total grain reserves dropped by 30 per cent.7 These shortfalls undoubtedly played a role in the resumption of labour strikes in Petrograd, led by between 1,000 – 8,000 metalworkers in Vyborg District. The strikes gained impetus throughout the remaining days of the Empire, fluctuating in peaks and troughs, but more often in the former.8 The military response made matters even worse. The Minister of War V. A. Sukhomlinov and the Chief Military-Sanitary inspector A. Ia. Evdokimov both denied that the military was not prepared for World War I and refused to entertain criticism. When conditions plummeted, Evdokimov still denied that his ministry was overwhelmed, refusing support from civilian organisations.9 Tsarist economists were not concerned about the outbreak of war, even viewing it as an opportunity. Unconcerned at the outset, and weighing possibilities, the officials responsible for food distribution became concerned as prices rose, then alarmed. By February 1916, the war became a priority and tsarist policymakers fixed prices for the national government, the military and urban civilian populations, backed up by requisitioning powers for ‘visible supplies’ at distribution points.10 Tsarist economists never exercised the policy, but they had reintroduced an idea that caused long-term harm. World War I changed the balance of political power in Russia. Organisations such as the Union of Towns contributed to the war by allowing physicians, statisticians and professionals to sidestep the 1892 Municipal Statute, which had for so long deprived them of a place at the decision table. Formed to deal with the war and administered by the Red Cross, a central committee composed of the mayors of Riazan, Tver’, Vladimir, Iaroslavl’, Kiev, Tula, Kursk and St Petersburg, chaired by the Moscow mayor Mikhail V. Chelnokov, ran the Union. The Union arranged for evacuation of soldiers and civilians from the front to field hospitals, provided food and clothing to the military and even controlled state functions such as the economy.11 Cooperation between zemstvo physicians and local Sanitary Executive Commissions (SECs) in the early 1900s might be viewed as a forerunner of cooperation between the

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zemstvos and towns. The wartime activities of the zemstvo and town unions set a precedent for self-government and advancements in cooperative medicine between the central and local governments. Such prewar cooperation is crucial to this story. Much of the material and intellectual infrastructures for handling problems in public health dated back to the nineteenth century, but there is little doubt that the years 1914 – 21 marked a ‘continuum of crisis’ that became an underlying continuous force in the Soviet Union.12 The cooperation between zemstvos became so integrated with the cities that it was easy for the Bolsheviks to claim they had eliminated them. In reality, the Soviets benefitted from this work, simply absorbing it into the Soviet structure. Embryonic institutional and infrastructural development, bacteriological laboratories, zemstvos, town unions and military-medical advancements forged a path for Soviet power. Sanitationists, engineers and other professionals organised themselves, while G. E. Rein recruited N. F. Gamaleia, D. K. Zabolotnyi and other physicians in pursuit of the centralised public health apparatus that Rein believed Nicholas II had promised.13 The Union of Towns helped improve the handling of refugees during the war, wandering masses who roamed the countryside and became a population in themselves, further complicating the epidemiology of disease.14 Along with the military, the Union of Zemstvos and Towns improved evacuation, forming a land based system of checkpoints. Admittedly, tsarist public health left a great deal of work to be accomplished after the war. Soviet historians later reported that in 1914 only 204 out of the 1063 largest cities in Russia had waterworks facilities and only 145 of these plants used filters. Even worse, only 17 cities had sewer systems, and almost all served only the central parts of the cities.15 Out of the 224 most populated cities in Russia, 96 lacked significant medical organisation and 139 substantive sanitary preparation.16 Even the Tsar’s top physician, Rein, observed that in 1914 the government spent approximately only one ruble per inhabitant for public health and one and a quarter kopeck for sanitary organisation, linking recurring epidemics to such meagre spending.17 The tsarist government’s lack of commitment to the health, welfare and governance of its people was perhaps its most indictable offense.

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The Pirogov Society and the Threat of Cholera, 1914 It is now necessary to take the same measures as we would take if the epidemic had already expanded in size. It is intolerable to keep it quiet.18 G. A. Ivashentsev, 1914 The circumstances in 1914 presented considerable cause for optimism regarding infectious disease. As is well known, the harvest in 1913 was one of the best in many decades, perhaps ever. Tsarist officials were not worried about the possibility of famine due to the war. The food supply showed little sign of stress as the potential for crises mounted and tsarist authorities viewed it as an opportunity.19 Hajj related traffic in Russia had peaked at 300,000 in the early 1900s, subsiding after 1914 to ‘a trickle’ and remaining that way throughout the war.20 Both the British and Russian armies feared, however, that a jihad might mobilise forces along fronts bordering the Middle East.21 Many zemstvo physicians, however, were concerned about cholera, knowing that the mere presence of a few cases was dangerous. Tsarist overconfidence and failure to prepare extended to public health. As in 1902 tsarist public health officials seemed reluctant to take the initiative on the epidemiological front, despite the warnings of Pirogov physicians. P. V. Khavkin noted that there was only a single case of cholera in Petrograd during the first year of the war and ‘an insignificant number of breeding grounds’. However, by the summer and autumn of 1915, 600 cases appeared during an outbreak in St Petersburg, renamed to Petrograd after hostilities began to sound less Germanic.22 The government and city council failed to heed the warnings of physicians, preferring to boast of ‘the brilliant sanitary conditions’ that army administrators had ensured were in place. However, as the physician P. V. Khavkin later noted, the city had no sewer system, poor living conditions, unverified water quality and other problems.23 The city’s location and topography presented part of the problem. Southern Russia was a crossroads for travel due to Asian trade, and there remained a clear threat that border warfare would bring cholera into Russia. Residents resided along estuaries, broad rivers and ravines, in many districts dwelling near or below sea level. The newly re-christened Petrograd was vulnerable to cholera in such adverse

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environments and neither the national nor local governments were capable of making expensive improvements. The Union of Zemstvos sent squads of physicians and medical personnel to the front, freed over 150,000 hospital beds for use and organised and staffed 45 hospital trains to transport the sick and wounded to evacuation points. The agency was concerned about isolation of cholera carriers at new field hospitals, soldiers or civilians who might slip through the lines and carry diseases into European Russia.24 Community physicians sensed the looming catastrophe. Unfortunately, time would prove them correct. Four months after the outbreak of war the Pirogov Society held a meeting in Moscow between 28– 30 December 1914 to discuss preventive measures to keep their primary concern, cholera, at bay. They suggested everything from rebuilding the early-warning system and reinstating the Cholera Rules, to employing broader measures meant to improve local conditions. One of their primary concerns was the tardiness of tsarist preparation, particularly compared to their wartime enemies. G. A. Ivashentsev of Petrograd jealously mentioned that German physicians had informed him, on the very day that the war broke out, that the conflict entailed an end to their scientific work, shifting their focus to the impending epidemics of typhoid, dysentery and cholera. He lamented that the German physicians grasped the urgency that the war created, while low numbers of cases did not alarm officials in Russia into taking measures. Both morbidity and mortality were low, but Ivashentsev observed that these cases were sufficient to cause concern, yet the government was keeping it quiet. He asserted that they should undertake action with the same sense of urgency as if a full-blown epidemic was in progress.25 As they so often did, Russian physicians gauged themselves by the actions of their counterparts in Western Europe. They knew that a faster response was required. Cholera carriers and local conditions were already threatening Russia. Cases had appeared in Galicia, sprouting from small water sources such as infected lakes and streams. None of the first four patients had taken a drink of water from an infected well. Ivashentsev reasoned that even ‘the excellent sanitary conditions of Germany’ could not guarantee that carriers were necessary to bring an epidemic into that country. The ‘heavy struggle’ was imminent and no one could guarantee that cholera

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carriers would prove unable to enter the city, providing cause immediately to sound the warning. Ivashentsev called for ‘broad openness’ through circulation of instructional articles to the public to explain the measures they should take to resist the disease.26 Russian physicians understood that fighting cholera was first and foremost a ‘struggle’ against disease. They knew that assistance from the public was necessary. Ivashentsev’s words reflected a frustration in playing catch up to Germany. He would later perform forward thinking work regarding famine and bacteriology.27 However, at present, he recommended a programme that followed the staples of Pirogov medicine, including broad preventive measures and education of the population. His point regarding openness, his admiration of German colleagues, and endorsement of spreading leaflets to the citizens reflected Pirogov and Western principles of public health. Other Pirogov physicians echoed Ivashentsev’s concerns. V. P. Iakovlev of Petrograd noted that cholera had already ‘advanced to the second stage in its movement to the population’, that is, had begun to affect medical personnel assisting patients in the emergency room.28 S. I. Zlatogorov of Petrograd, who had performed experiments with vaccination in Persia in 1904, conducted a tour of the hospitals in cities along the north-west and south-west fronts, observing that multiple epidemic diseases were present and that sanitary preparation was primitive. Bacteriologists in tsarist Poland had detected the cholera vibrio and concluded that it had entered Russia as well and urged quick action and reconstruction of the system of warning.29 However, there was little time to rebuild the cholera rules, which were clearly not the problem. The tsarist government’s failure to take initiative and the exigencies created by war made dealing with cholera in 1914 a daunting proposition. Zemstvo physicians knew that certain locations were more vulnerable than others. In addition to the front, the city of Rybinsk posed a threat. Merchants moved large tonnages of freight and produce north-east from Rybinsk over the Mariinskaia System and railroad to Petrograd. Complications related to the war made Iaroslavl’ Province vulnerable through multiple avenues of transmission. Observing that the Volga River cut through Iaroslavl’ Province, the local physicians worried that the province’s location made it highly vulnerable to cholera. In Rybinsk, the Volga’s facility for diffusing cholera was heightened by the

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movement of refugees over dry routes by railroad, wagon and horse. The Rybinsk Caravan accommodated tens of thousands of workers who supported the shipment of produce and goods along the Sheksna and Molog Rivers to Petrograd. The Petrograd and Moscow railroad lines also ran through Iaroslavl’ Province as did one of the busiest stretches of railway between European Russia and Siberia.30 As the distribution centre for goods and produce destined for Petrograd, Rybinsk was a crossroads for carriers of dangerous pathogens. The mass movements of refugees, evacuation of prisoners and casualties and other factors related to World War I complicated the situation.

Organisation of the Russian Military-Medical Apparatus, 1914 –15 The age of bacteriology permitted physicians to understand problems related to the spread of disease, caused primarily by evacuation of prisoners and wounded from the front, but the complications of dealing with the logistics of this problem were enormous. Along with the military, the Zemstvo Union was vital in developing checkpoints or observation posts. As mentioned in the last chapter, in the cholera epidemic of 1907 –10, the Kazan’ Military District had built floating observation points on the Volga River to search for carriers. At these points, medical officials attended to the sick and wounded and provided them with food and clean water to drink. They also educated the public on how to avoid disease. At the Pirogov Conference for Bacteriologists, these scientists undertook the task of dealing with this issue. V. I. Ivanovskii noted that the Iaroslavl’ Zemstvo had been developing its sanitary organisation for two years, retaining the services of four sanitary physicians and a directing bureau, but that this was not enough. He reiterated the need to distribute knowledge regarding hygiene to the population, to organise places to feed starving people and perform other neglected measures.31 The number of hospital beds for gastro-intestinal diseases was less than one for every 5,000–7,000 inhabitants and the provincial hospital no longer had an infections department. Even larger cities like Iaroslavl’ and Rybinsk suffered from poor sanitation. Moreover, the waterworks in the Iaroslavl’ hospital was unfiltered and, two years earlier, the system in the Rybinsk hospital caused a typhoid epidemic.32

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Suffering from marginal resources even during normal times, Iaroslavl’ Province was unprepared for war. Military obligations made matters worse. Promising replacements, the military had activated two of the four local sanitary physicians and almost half of the Iaroslavl’ zemstvo physicians, but often reneged on its promises. One district, Liebimskii, operated with just one zemstvo physician.33 Ivanovskii’s analysis brought to light the challenges that Russian cities and governments faced in 1914. Shortages of personnel, threats based upon geography, inadequate services, thirst, hunger, homelessness and other problems created by war, left under-staffed physicians struggling to cope with multiple problems. As opposed to sanitation and bacteriological testing, Ivanovskii proposed education, nutrition, better communications and more personnel as key to solving the problem. Coordination between officials and organisations in various locations was less than effective. S. I. Igumnov of Kharkov and P. N. Diatropov examined this problem. Diatropov, who had worked in the Odessa bacteriological laboratory in the late nineteenth century, addressed the role that local councils such as the zemstvo should play and the relevance of its medical directives. The prevailing circumstances were unusual in that they demanded simple decisions and there was little time for uniformly planned preventive measures nor distribution of written orders from the Union, agreements with military authorities or authorisations from the governor to begin evacuation. Diatropov complained that the formation of a written plan did not ensure a uniform response. Such plans were often poorly followed, as local authorities responded to mandates according to their own interpretation, often sidestepping them. These problems hindered organisational, medical and hospital reform.34 Indeed, Diatropov had put his finger directly on the problem. Not only did directives seldom appear, but local officials failed to react when they did. The war required initiative and a willingness to take responsibility. The lack of such action reflected not only the failure of an inflexible government to lead, but to get out of the way and permit the initiative of others. This hesitation and interference haunted tsarist Russia, both in the refusal to permit Pirogov physicians to feed hungry citizens in 1900 – 4, during the epidemic in Siberia in 1902 and now at the outbreak of World War I.

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However, progess was continuing. S. I. Igumnov observed that in Kharkov Province, officials assembled a committee in consultation with the military commission to assist with the wounded and other issues. Forming the committee publicly, two professors served as consultants, monitoring the medical functions of distribution points. The Kharkov District committee worked under the direction of the leader of a medical council who regularly conducted meetings and communicated vital information to hospital personnel. This arrangement provided social cohesiveness and significance that did not exist in other organisations of the zemstvo union. Hospital trustees and zemstvo personnel helped evacuate the wounded from various localities.35 Battling cholera required community cooperation and civic involvement. Medical officials in Kharkov Province had even produced a sufficient number of hospital beds. The Union of Zemstvos in Kharkov arranged for 1,500 beds for the evacuation checkpoints and also appropriated over 18,000 beds for local citizens. The checkpoints were equipped with steam-formaldehyde chambers and other technologies related to disinfection. Only a few cases of infectious disease occurred among the wounded in the district hospital, which medical officials isolated in the zemstvo infection barracks. A few of these cases prompted medical workers to open special barracks for the hospitals. The number of patients remained small, and Igumnov felt that the situation in Kharkov was under control. His optimism however had limits. Stopping short of guaranteeing absolute prevention, he declared ‘but even if it [the epidemic] widens we have our own unions with means and energy, they are afraid of nothing’.36 The Kharkov zemstvo displayed the community involvement, self-reliance and confidence required to deal with cholera even in wartime. Such examples indicate that the progressive forces of public health were making headway in tsarist Russia. This type of organisation and collective spirit surfaced again during the Soviet period. Igumnov was worried about outbreaks in the populated locations due to shortages of medicine and personnel in the zemstvos. Self-reliance in such locations had limits. Local authorities employed medics, senior students and residents, but even these medical personnel could not fill the void. The problem was particularly acute during typhus epidemics which, due to crowded quarters and general uncleanliness, were increasing in alarming proportions.37 The functional nature of field

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hospitals and distribution points in Kharkov reflected how zemstvo officials were improving inter-agency communication. While insufficient to stop cholera completely during war, they diligently isolated potential carriers, inhibiting disease with confidence in the face of crisis. V. V. Favr’ expounded on Igumnov and Diatropov’s account. In the beginning of the war, Kharkov Province was unprepared to receive the wounded due to too few hospital beds, which was resolved with the support of strong local municipalities, zemstvos and their societies. The members of these organisations responded quickly, opening distribution points and emergency rooms with large numbers of beds. The military responded later, opening eight emergency treatment points with 3,000 beds. The zemstvo, towns, military evacuation and cooperating commissions proved energetic and ‘friendly’ in solving problems.38 Favr’ felt that the Union of Zemstvos and Union of Towns and other local societies were the leading local alliances against infectious diseases. The military assisted. Favr’ commended the Kharkov city committee for its competence in directing local public health and the suppression of disease. The committee operated under the leadership of a public physician, who directed the trustees of the city hospitals and in other places where the sick and wounded were treated, including the hospital of the Union of Towns. Senior physicians of the sanitary bureau issued bulletins and other communications. The significance of these medical commissions and necessity of organisations working together with public medical personnel was obvious. In other cities, incompetent officials inhibited progress.39 Long relied upon as indispensable in times of epidemics, local trustees were valued members of tsarist public health communities. Such public cooperation was important in cholera control. According to Favr’, the zemstvo medical committee in Kharkov built, equipped and supervised 1,200 distribution points. Workers sorted the sick from the healthy at the railroad station and ordered them to the city hospital. Those exhibiting general symptoms such as vomiting or who were suspected of carrying typhoid were examined in the military observation hospital, which was located near the train station in a large makeshift complex in the city schools. Personnel screened sick and wounded patients for cholera and placed suspected carriers in a special wagon, where they remained under observation throughout the incubation period. Complications emerged when the large city hospitals

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became overcrowded, endangering the integrity of the isolation and containment process.40 Favr’ noted that it was necessary to move regular patients when opening emergency checkpoints and hospitals, but the number of beds for local residents was not reduced by the military necessity.41 West of Kharkov in Poltava, the central committee of the Union of Towns began to build an infections barracks. However, officials carried out an investigation and instead decided to open several barracks in Kharkov. Kharkov had a disinfection chamber, a mechanical medical laundry, a bacteriological laboratory and more orderly anti-epidemic organisation than Poltava, which did not even have a city hospital. Favr’ stated that personnel at the infection hospital in Kharkov were building three wooden barracks with approximately 200 beds.42 He noted that the waste that occurred from the initial construction in Poltava illustrated the need for a better strategy to avoid useless expenditures and extend assistance to the districts. He suggested that the Union of Zemstvos and Union of Towns should direct medical activities, so as to ensure that the military had proper sanitary necessities without reducing local provisions and labour. Improvement in the extremely poor sanitary conditions that prevailed in cities and rural villages constituted yet another necessity.43 Favr’s observations illustrate the immensity of combating cholera in Russia during wartime. The construction of effective public health in cities, counties and rural areas, was almost impossible given the circumstances of World War I. Tsarist physicians feared cholera more than other diseases, but in the first year of war Russia suffered only 1,800 cases and 761 deaths.44 The mortality rate was rather normal, 42.27 per cent. The minutes of the Pirogov Conference of Bacteriologists illustrated how community physicians and personnel in the Union of Zemstvos and Union of Towns were addressing problems and forming a bond with local committees and a viable system of response to cholera in the first year of war. This planning and coordination occurred mostly between provincial and district medical organisations and such local administrations would assist in combating epidemics in the future. The railroad and military were operating at increasing levels of cooperation. This type of coordination would be useful later in inhibiting cholera under the Soviets, but the conditions of war kept cholera alive and well. The union of Zemstvos and Union of Towns had

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constructed a foundation that supported the logistics of evacuation, observation and other important services. The most significant of these programmes were those related to mass vaccination. The checkpoints were ideal for carrying out vaccination in conjunction with monitoring patients and the isolation and vaccination of individuals at locations where the risk of spreading the disease was greatest. Yet, the efficacy of preventive vaccination against cholera was a subject of debate that was expedited in response to the war. Many physicians were unconvinced of the effectiveness of the process, but few published their objections. Some of the first efforts to apply vaccination against cholera, including Ferran’s work in France, had not succeeded in proving that the practice was effective, but the majority of the medical literature favoured the practice. Physicians who argued in favour of using vaccination against cholera cleverly used the more proven track records of typhoid and smallpox vaccination. Their reasoning was simple: even small successes were better than taking no action. The most important proponents of immunology in Russia were Mechnikov’s old colleagues at Odessa, particularly L. A. Tarasevich, who spent 1914 and early 1915 pursuing ‘propaganda’ in pursuit of government clearance.45 There were several obstacles to gaining permission. Many individuals in medical and other circles were opposed to cholera and typhoid vaccination. Publishing an article in the Pirogov Society’s journal The Community Physician in May 1915, Tarasevich used the results of typhoid vaccination to bolster his case. He argued that the basis for vaccinations during wartime had been proven by several armies, including the British, who had used vaccinations for typhoid in colonial conflicts in India, the Japanese Navy’s efforts against paratyphoid fever in 1908 and the United States Army during the Spanish-American War. The English formed a special commission in 1902 which gained the attention of the Germans who, according to Tarasevich, had previously ignored vaccination as an anti-cholera measure.46 Tarasevich was wellinformed about medical activities in the West and felt that using them as examples would help his cause. However, arguing a case for vaccination against cholera was difficult. Unlike typhoid, cholera epidemics did not afford a period of warning, allowed less time for observing patients and were associated with more diverse conditions and complications arising from its rapid and unexpected development. Theoretical controversies had derailed its use

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in 1910.47 Cholera’s origin, unpredictability, and diverse methods of diffusion made it difficult to understand, but the fear it provoked, especially in the medical community, made it play a major role in progressing Russian and European medicine. The difficulty of producing immunity to cholera seemed once again to verify that this was an abnormal and illogical disease. Not easily discouraged, the intrepid L. A. Tarasevich argued that physcians’ poor track record in inducing immunity in the public against cholera did not merit discarding the practice. The German Army had received outstanding results in using vaccinations against both typhoid and cholera within the country’s borders on military personnel and prisoners of war. The latter were vaccinated for smallpox, typhoid and cholera, until physicians exhausted their supply of serum.48 Such excessive vaccination against the enemy likely reflected experimentation as much as cholera control. More than 1 million persons had been vaccinated against cholera in 1912 during the Balkans War between Romania and Greece. When World War I broke out, Austrian and German soldiers disproportionately suffered. After 1 September, the Austrian Army in Galicia (Poland) encountered scores of cholera patients and began to vaccinate thousands, some twice and others just once. Soldiers who were vaccinated once suffered a morbidity rate that was 7.5 times greater than those who were vaccinated twice, while those who were not vaccinated fell ill 25 times more often.49 Tarasevich noted that the Austrian Third Army suffered some cases of cholera between October and November, but medical officers began vaccinating soldiers on 8 November and there were no further cases. Of the remaining patients, there were 2,167 cases. Of those stricken, 1867 were unvaccinated with 545 deaths, a 29.3 per cent mortality rate, while 299 patients were vaccinated and of those only 1 per cent died.50 According to Tarasevich, the declining morbidity and mortality rate reflected the usefulness of vaccination.51 He argued that ‘if vaccination is necessary in the West, where sanitary and practical means for the struggle with epidemics are undoubtedly better than our own, then it is an even greater necessity for us’.52 This logic carried significant authority in a nation where members of the intellectual community and government desired parity with the West. There was also perhaps the realisation that if the military did not carry out anti-cholera vaccinations, their enemies would gain an advantage. Fear of defeat boosted experimentation.

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Tarasevich suggested that Union of Zemstvos carry out the logistics of the programme.53 He observed that, over the last two to three months, zemstvo personnel in Moscow under the supervision of the female physician E. V. Glotova, had been carrying out vaccinations and that everything was progressing well.54 Russian physicians were striving to find an effective ‘one-time’ or single vaccination. Tarasevich argued that the military should proceed with carrying out vaccinations, advising that they should target large, populated areas, the homeless, refugees and other people in war districts. He also suggested a public relations campaign to familiarise the public with the benefits of voluntary vaccination.55 The government gave official clearance for this in August 1915.56 Tarasevich and his colleagues were worried that the late start would hamper the preventive aspect of vaccination. At the end of April, there had been a call for a conference of Union of Zemstvos and Union of Towns to address carrying out broad and systematic vaccination among medical and military personnel and in some cases, the citizenry, preparation of vaccines and the establishment of special outpatient services. Tarasevich noted that a sense of urgency expedited these measures. The zemstvo union in Moscow was a model organisation, but the work took off slowly. In many places, there were long waiting lines to receive vaccinations and the efforts were uncoordinated. Propaganda campaigns helped garner popular support, but there prevailed a greater need for the development of facilities to meet demand. Finally, on 6 and 7 August in Kiev, a committee of the Zemstvo Union of the Southwestern Front held a conference that included the directors of bacteriological institutes, laboratories and leaders of military-sanitary sections. After ‘prolonged and lively debate’, they passed orders to prepare anti-typhoid and anticholera vaccines for use in ‘all sections of the military and medical personnel’ under the direction of the Military-Sanitary Department, the Union of Zemstvos and Union of Towns and other organisations ‘working under the flag of the Red Cross’.57 The Red Cross, a favoured organisation in the administration of Nicholas II, came to provide support for anti-cholera operations. The members of the convention decided to place special vaccination commissions under the authority of the military in war zones and military district sanitary commissions behind the lines. All sectors of the population would receive vaccinations for cholera and typhoid, with priority for refugees and individuals in

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war-torn districts. Members of the conference expressed hope for assistance from ‘strong social organisations’ in carrying out vaccination programmes among civilian populations.58 During World War I, Russian society built upon the zemstvo legacy, providing a voice for the middle class and self-government under the Western model. The participants of the conference also passed resolutions regarding the logistical and technical preparation of vaccines. The Union of Zemstvos made arrangements with glass factories to prepare sufficient quantities of dishes and the chemicals to assist in producing the vaccines. They provided guidelines for their preparation, touched upon matters relevant to obtaining materials and described the locations and institutes that would be essential in carrying out the process. Many of these laboratories already existed, including the Women’s Medical Institute, which was part of the Bacteriological Institute of the Physicians Belonovskii, Maslakovets and Liberman in Petrograd, and the laboratories of Doctors Gabrichevskii and Blumenthal of the Institute of Immunology, which were located in Moscow. Other important facilities included the Bacteriological Institute of the Society for the Struggle with Infectious Diseases in Kiev, the Bacteriological Institute of the Medical Society of Kharkov, the City Bacteriological Station in Odessa, the Fort of Emperor Alexander III in Kronstadt and the Bacteriological Institute of the Provincial Zemstvo in Ekaterinoslav. The participants expressed a desire to incorporate the records of other laboratories with those that were mentioned.59 These laboratories predated World War I and the actions of the congress in consolidating them marked a significant step toward unifying tsarist medicine. The Soviets would later use this network of institutions, ideas and even leftover materials to boost widespread immunity and curtail cholera. Conference participants went into great detail, establishing guidelines for preparing and carrying out vaccinations, providing instructions regarding the temperatures at which cholera and typhoid vaccines should be prepared, discussing the size of a dose and the quantity of cultures required for each disease. They adopted the preparation standards of the Gabrichevskii Bacteriological Institute in Moscow and those in Kharkov and Kiev. Medical officials were to administer no less than three doses of vaccine to personnel behind the lines in military districts and twice to army personnel at the front. The waiting period between doses was five to seven days. Individuals with

(6–11 Months) 1, (1–4) 3, (5–9) 3, (15 –19) 2, (20 –9) 9, (30–9) 4, (40–9) 2, (50 –9) 7, (60 –9) 3, (70–9) 1, (80 þ ) 1 (15–19) 2, (20 –9) 5, (30 –9) 3, (40–9) 2, (60– 9) 1, (70–9) 1, (Unknown) 1 (1–4) 2, (20 –29) 1 (20–5) 2, (40–9) 1, (60 –9) 1, (80 þ ) 1 (1–4) 1, (20 –9) 1

1 39

36

15

3 5 2 0 1 122

30 Aug. –5 Sept. 6–12 Sept.

13 –19 Sept. 20 –26 Sept.

27 Sept. –3 Oct.

4–10 Oct. 11 –17 Oct. 18 –24 Oct. 25 –31 Oct. 1–7 Nov. Overall

Traveller (1) Travellers (78) Residents (37) No Address (5)

Travellers (2) Travellers (2)

Travellers (11), No address (1),

Travellers (22),

1 Travellers (27), No address (1)

No address (3) Travellers (13)

Status

Source: Gosudarstvennyi Arkhiv Saratovskoi Oblasti (GASO), F. 79, op. 1, d. 1538, 1, 2, 4, 6, 7, 12, 18 – 20, 23 – 26, 28 –30, Vrachebnoe otdelenie Saratovskogo gubernskoro pravleniia: Statisticheskie svedeniia ob epidemicheskikh zabolevaniiakh v Novgorodskoi gubernii i v gorode Odesse i svedeniia ob umershikh v gorode Moskvy za 1915– 1916 gg.

(80 þ ) 1

(1–4) 1, (30 –9) 1, (40–9) 1, (50–9) 1, (60 –9) 1 (1–4) 3, (5– 9) 1, (15 –19) 1, (20–9) 3, (30 –9) 1, (40–9) 4, (50–9) 2 (80 þ ) 1 (6–11 months) 1, (1 –4) 3, (10–14) 1, (20–9) 9, (30–9) 6, (40–9) 7, (50–9) 7, (60 –9) 2, (70 –9) 2, (Unknown) 1

5 15

16–22 Aug. 23 –29 Aug.

Ages

Total

Deaths from cholera in Moscow in 1915

Dates

Table 5.1

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sharp fevers, intestinal bowel disorders, tuberculosis or nephritis were prohibited from receiving vaccinations, but persons having contact with these patients were not exempt.60 The physicians who administered vaccinations in military districts were responsible for filling out a registration card for every vaccination they performed, but were also permitted to keep their own detailed lists. Soldiers carried registration books with stamps reflecting their vaccination history. The statistical division of the Army of the Southwestern Front maintained registration of the vaccinations performed on military personnel. Records related to vaccinations on people behind the front lines and on refugees were distributed to civilian societies.61 Refugees were of particular importance.

The Tsarist Retreat and Moscow Cholera Epidemic of 1915 The deteriorating situation at the front in the summer of 1915 undoubtedly played a role in the government’s decision to permit vaccination in August. In July and August massive numbers of civilians fled into the heartland of European Russia after a German counter offensive forced the Russian army to retreat. This ‘human tidal wave’ carried the disease into Russia’s population centres.62 Three types of individuals fled the front. The first were wounded soldiers, invalids who returned to their villages and towns; the second were German and Austro-Hungarian prisoners of war and; the third were refugees, Russian citizens who had fled the war zones for the security of the centre of the country. Congregating in urban areas, these refugees created the biggest problem. By 1916 they composed over 10 per cent of the population in urban centres, and almost 30 in Samara, on the Volga River.63 Consequently, epidemics broke out in the large cities in Belorussia.64 By December 1915, Russian refugees numbered more than 3.3 million.65 An examination of the deaths during the 1915 cholera epidemic in Moscow reflects the role that refugees played in spreading the disease (see Table 5.1). Out of 122 deaths, authorities identified 78 victims as travellers and listed five as homeless.66 Yet, even these numbers are misleading, as 16 of the first 20, 44 of the first 59, and 66 of the first 95 victims were either homeless or travellers. The predominance of these individuals among the earliest patients reflects the role that mobility

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played in carrying the disease into the city. The number of deaths according to age group is less conclusive though it is worth mentioning that individuals who were most likely to be travellers (those between 20 and 60 years of age) accounted for 79 of 122 total deaths.67 The Russian army’s retreat in 1915 and the massive number of refugees fleeing the front brought cholera into the Russian heartland. Russian physicians’ experiences during prior epidemics had not prepared them to deal with such huge numbers of mobile disease carriers. Even Moscow, with its high ground, excellent zemstvo, and sanitary facilities, could not prevent an epidemic from developing. However, these factors likely prevented a full-scale waterborne epidemic. Also, considerations related to nutrition and immunity likely assisted in keeping the epidemic mild. Vaccination and a relatively mild famine, particularly considering what lie ahead, almost certainly helped limit the deaths. In 1915, there were 34,582 reported cases of cholera, but statistics indicate that only 859 deaths occurred.68 The mortality rate that these numbers imply, 2.48 per cent, was unusually low. This new disparity between cases and deaths in 1915 might be written off as grossly inaccurate if the largest part of the epidemic had not appeared in Moscow simultaneously with the inception of vaccination in the city. The work of Glotova, Tarasevich, the Union of Zemstvos and Union of Towns provided the groundwork for progressive work in public health and the success that the Soviets would later achieve.

The Progressive Bloc German successes in Poland in the spring of 1915 led to concerns regarding shortages of weapons. The chair of the Union of Towns was the respected liberal from Tula, Prince Georgii Lvov, who supervised and recruited labour forces and saw that the military received supplies. The industrial elite in Moscow strove to outdo their business rivals in Petrograd and in the state weapons plants. Moscow businessmen, especially Pavel Riabushinskii, established committees for war industry with representation from all spheres of society, including the government, Union of Zemstvos and Union of Towns, owners, employers and labourers. Such widespread representation for workers marked a first in Russian history, with the exception of the Duma. As medical authorities in Moscow battled cholera in August, centrists in the Duma

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and State Council formed the Progressive Bloc, which supported many of the aims of former Prime Minister Pe¨ter Stolypin, prohibiting discrimination on ethnic or religious grounds, the inclusion of Jews and full citizenship status for peasants. This was precisely the type of cooperative government that Alexander II had foreseen, but his grandson, Nicholas II, took a non-civic view of patriotism centring on state service, the supremacy of the monarchy and the Orthodox Church. Dismissing the Duma, he fired the ministers who supported the progressive Bloc.69 Nicholas’ unbending dedication to an anachronistic model of government essentially ensured the fall of the monarchy. While Union of Zemstvos and Union of Towns handled the 1915 cholera epidemic rather well, the advances the Russians made came at a steep price. The retreat in spring 1915 was disorderly, with soldiers often plundering and deserting. Working class soldiers filled in for the disappearing officers of the noble class and replacements at the front were expected to procure weapons from the dead. Peasant soldiers understood that the upper classes considered them an expendable commodity, whose lives and welfare meant little.70 After the Russian retreat in 1915 cholera was liable to enter the country from any front, but the situation in the south was particularly bad. New railroad networks facilitated the transport of the cholera vibrio. The German Kaiser wooed the Ottomans, who were seeking to provoke a Jewish revolt against Russian pogroms and a jihad against Great Britain. Despite the seemingly hare-brained nature of this scheme, the Kaiser raised massive capital, constructing a Berlin– Baghdad Railroad with lines across Persia and Turkey. German banks invested the equivalent of over 1 billion dollars, 125 billion in today’s currency, into construction. These railroads facilitated Ottoman and German troop movement from Anatolia to the fringes of the Steppe in Baku. In 1915, the Ottoman Turks occupied Tabriz and fighting ensued between Russia and its traditional enemy.71 Despite the success in Moscow, Russian public health had been slow to react to the retreat. On 28 July 1915, there was a meeting of the Saratov Sanitary Executive Commission (SEC), chaired by Saratov Vice-Governor A. S. Rimskii-Korsakov and composed of physicians, the police chief and other local officials. N. I. Teziakov, who was the main medical inspector, chastised the members for insufficiently publicising the appearance of cholera while neighbouring provinces

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had sent out the proper communique´s.72 Teziakov represented the new Russia. Born into serfdom in the Urals in 1859, he graduated from the gymnasium in Ekaterinburg and came to study statistical investigation of social hygiene in medicine at the University of Kazan’, graduating in 1884. Beginning his career as a local physician in Perm, he moved to Kherson, Voronezh and by 1903, having gained broad experience in agricultural medicine, childhood disease, typhoid, trachoma, plague and syphilis, Teziakov was one of the first physicians to administer vaccination for diphtheria. He was well known for helping create the medical-sanitary structure in Saratov, establishing the local MedicalSanitary Chronicle and emphasis on economic and broad demographic conditions. The latter included refugees and construction of checkpoints for distribution of food to factory workers. He had been active in the Pirogov Society since 1893.73 Teziakov knew that any number of cases of cholera, no matter how small, were sufficient to merit alarm. He also understood that poor preparation, response time, and communication all allowed cholera to flourish. To its last days, tsarist public health had difficulty responding rapidly to epidemics as the Cholera Rules mandated. Teziakov and his colleagues weighed up the intelligence regarding the cholera in Saratov and surrounding provinces. Prior to July, physicians in Zemlian District of Voronezh Province had conducted bacteriological investigations of patients with sharp-intestinal bowel disorders, but the death rate was low and tests did not disclose the cholera vibrio. By the end of June, the number of patients rose considerably and investigators discovered the vibrio in 40 patients, nine of whom died. Between 17– 30 June, seven of the 11 confirmed cholera patients in Schatskii District in Tambov Province also died. A patient in Kozlovskii District, Saratov Province, arrived from an active war zone and three of the next seven patients were refugees from the front.74 Cholera was arriving from the front. The cases began to mount. On 2 June, a report of physicians and scientific societies and correspondents noted that a prisoner of war named Shpring among other prisoners in transport between Penza and Tsaritsyn, was isolated at the train station in Balashov, a prominent city in Saratov Province. Nine days later, an individual at the railroad station in Tsaritsyn fell ill from cholera and died. On 6 July two cholera victims, citizens of Khvalinsk District in northern Saratov Province, fell ill, and

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then regained their health. On 18 July two residents in Tsaritsyn fell ill. Then came a shock. On 21 July, personnel at the Hundredth Evacuation Hospital in Saratov reported that they discovered cholera microbes that were far more virulent than those they detected earlier, and their colleagues at isolation points in the railroad town of Rtishchevo made similar discoveries. Overall, there were 13 cases of cholera and seven deaths since 30 May.75 The railroad was obviously the conduit for spreading cholera.76 Meanwhile, the Saratov Railroad SEC responded by concentrating its efforts on three slaughterhouses including one close to the Rtishchevo railroad station. The commission focused on uncovered ditches into which workers had thrown the intestines of animals and then filled with water, tar and oil, causing an unpleasant odor. The council of the Riazan– Uralsk railroad sent a communication on 14 July to the main headquarters of the Saratov Province Commission. The message stated that as the nearest point of the slaughterhouse sat more than 1,125 feet away, medical inspectors concluded that ‘the Rtishchevo slaughterhouse was in satisfactory condition and did not present a danger of infecting the surrounding areas’.77 There is little question that the Railroad SEC might have concentrated on more fruitful endeavors, particularly conducting measures and or providing aid to refugees along its tracks. Railroad physicians in Saratov were still a problem. On 12 August 1915, Vice-Governor Rimskii-Korsakov chaired a meeting with the directors of the Saratov Province Zemstvo in order to address taking precautions along the borders of the province to prevent the spread of disease. The issue, he said, was the most pressing problem in the province. He announced that Saratov Province would house approximately 60,000 refugees, 20,000 of which would reside in the city and 40,000 in the surrounding counties. He also noted that 75 per cent would be unemployed and therefore dangerous to the trustees.78 Rimskii-Korsakov raised the possibility that violence might break out. Saratov Province was a traditional hotbed of protest and cholera epidemics often created an excuse for violence related to unemployment and poor living conditions. The cost to house and feed one refugee for one month was approximately ten rubles.79 On 16 September, RimskiiKorsakov announced that most districts, depending on their size, would hold between 3,000 and 5,000 refugees. The city of Saratov would hold 20,000 and 500 would travel south to the small Volga river village of

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Dubovka.80 Finding accommodations for refugees in diverse areas of the province was hardly a perfect solution and physicians searched for a way to deal with the problem. On 15 August, the Saratov Zemstvo Council considered the refugee issue, noting that observers who scanned the railroads for carriers of disease were no guarantee that these individuals would not slip through. The members suggested attaching sanitary wagons and special railroad cars with disinfection capabilities and other necessities to every train with refugees. The local trustees assumed the responsibility of logging the time of destination and number of refugees expected, two to three days in advance of arrival. The council recognised the need to build facilities to feed people, conduct medical observation and isolation and to ensure sufficient housing.81 The concept of checkpoints was helpful. The Union of Zemstvos carried the responsibility for directing the work regarding refugees in Saratov Province, allocating 35,000 rubles to local zemstvos. From these funds, 3,000 went to the Saratov District zemstvo council, 5,000 to Balashov, 3,000 to Kamyshin, 1,000 to Serdobsk, and 200 to Tsaritsyn.82 The Saratov Province Zemstvo also distributed 500 rubles to every district to distribute clothing to refugees.83 The monetary relief from the Union undoubtedly helped limit casualties. Despite the numbers of refugees flooding Saratov Province, local authorities did their best to limit the spread of cholera. The railroad towns of Rtishchevo and Balashov were most vulnerable due to the number of refugees passing through them. Another point of concern was Kozlov, where Rimskii-Korsakov had sent a large number of refugees. By 7 September 1915, 19,141 refugees had passed through Balashov; 13,151 from Kharkov and 2,655 from nearby Tambov. From Balashov, 11,430 refugees travelled to Rtishchevo, 2,003 to Kamyshin, and 1,800 to Tsaritsyn.84 The epidemic developed most strongly in Kamyshin and Saratov. The Saratov provincial council prudently requested Kamyshin and Serdobsk, both suffering disproportionately, excluded from the plan.85 Neither city received refugees (See Figure 5.1). Despite efforts to contain the disease, the number of travellers proved overwhelming. Between 14 August and 1 September there were 83 cases of cholera in the areas of Saratov Province that excluded the city and 49 people died. All of the patients were refugees. Out of 65 cases that developed within the city of Saratov, 60 were refugees. In the remaining districts there was only one case.86 By 7 September, however, there were

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Figure 5.1 The railroad and cities west of Saratov c.1915. Source: Professor Richard Gibreath, Department of Cartography, University of Kentucky.

approximately 37,000 refugees and 330 cases of cholera.87 The victims included 123 in Saratov, 102 in Kamyshin, 43 in Atkarsk District, 17 in Turkakh in Balashov District and 12 in Serdobsk.88 Authorities in Kozlov isolated 59 refugees between 28 August and 11 September while the numbers for Balashov and Rtishchevo were 61 and 16 respectively on 6 September to 1 October.89 Public officials in Saratov knew they had a problem with the railroad and feared that its physicians were not following the proper protocol.90 These concerns were well founded. On 21 September 1915, L. P. Serdobov of the Serdobsk SEC complained that railroad personnel were routinely taking cholera patients to railroad feldsher stations without providing them with adequate medical attention. When these employees actually did transport cholera patients, they reportedly drove them ‘through the entire city’, which presented a hazard of transmitting the disease. Serdobov requested that railroad workers transport patients directly to the well equipped cholera barracks at Rtishchevo. The SEC, which included railroad bosses, moved to send a petition ordering all patients on the lines to be transported to the nearest railroad hospital.91 Established by the 1903 Cholera Rules, the railroad’s

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statutory power over its own property contributed to these problems, but the inclusion of railroad bosses on the Serdobsk city SEC and the objections of competent physicians like Serdobov fostered cooperation and reform. In Saratov Province, these issues were most problematic at Balashov station, which was a crossroads for traffic entering the province from the southwest front (see Figure 5.1). Between 20–27 September, authorities at the station isolated 266 victims of infectious disease, including 43 with cholera, 48 with dysentery, 69 with typhoid, 59 with sharp intestinal disorders, 8 with smallpox and 34 children suffering age-related diseases.92 Teziakov and his colleagues were most concerned about a typhus epidemic at the front and travelled to Balashov and Rtishchevo to observe the incoming trains. Arriving on 19 September 1915, they encountered an arriving train with 870 Turkish prisoners of war from the southern front, including 35 victims of disease (especially typhus) and sent them to isolation barracks. Several individuals in the cars had expired prior to arrival at the previous station where personnel had likely ignored them.93 The incident indicated that greater diligence in observing incoming patients was required. Local zemstvo physicians were sorting out the problems. Under the supervision of Teziakov and I. A. Dobreitser, who would soon direct the medical operations of the ways of communication for the Soviets, medical authorities and civilian volunteers in Saratov performed the wide variety of services that would later define Soviet public health. In the 137th Evacuation Hospital there were 420 beds and 11 barracks for isolating patients. Medics placed the Turkish prisoners in two barracks, the first and eleventh, reserved the third for typhus and scarlet fever patients and the fourth for measles. The fifth barracks held children with sharp intestinal disorders, the sixth, individuals with typhoid and the seventh, smallpox patients. The eighth barracks held victims of cholera and dysentery. On 28 September the hospital held 365 patients, of which 14 were military personnel, 42 were prisoners of war and 309 were refugees.94 All of the patients had travelled from the front. There were four buildings for isolating the families of patients with the capacity to hold between 100 and 120 persons, which Teziakov and Dobreitser cited as ‘entirely insufficient’.95 The families had been in close contact with cholera patients and presented a danger to local populations. They were isolated and provided adequate nutrition. In Rtishchevo workers prepared hot food in local kitchens. When trains

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arrived, soldiers distributed meals consisting of oatmeal and cabbage soup. Travellers arriving at night were provided with bread, tea and sugar. The families of patients could purchase lunch for 20 kopeks.96 While feeding passengers may seem insignificant, the practice became an important part of cholera prevention as authorities sought to keep passengers well fed, particularly in places where they might pass germs. Russian physicians knew from experience, as the WHO now recognises, that hunger predisposed citizens to cholera. In 1915, with some exceptions, most early reports from bacteriological laboratories were encouraging. The director of the Saratov Province Zemstvo, Dr I. P. Vaile, reported that lab workers carried out 43 cholera investigations in September, and 7 in the city of Saratov. Investigators found the cholera vibrio in only one patient, a refugee who had been admitted to the Hundredth Evacuation Hospital.97 Saratov authorities were making a heroic effort to prevent the spread of cholera, but soon darker news arrived. A report from the Tsaritsyn bacteriological laboratory for September reported that the vibrio had appeared in five of eight water sources along the river in Saratov Province, including the facilities at Saratov, Kamyshin and the three sources in Tsaritsyn. The water supplies of Samara, to the north in the Middle Volga region and Kazan’ on the Upper Volga were also polluted.98 Engineers in these cities had proven unable to secure adequate water filtration, in large part due to low elevation and high expense, proximity to the river and migrant labourers in the peripheries. The water supplies spread the disease throughout the city. While tsarist officials might have earmarked more funds toward improving waterworks, this situation was not satisfactorily resolved even in the Soviet period despite an enormous push for sanitation. The flexible system that the Cholera Rules established served as the infrastructure for the Soviets’ implementation of broad measures. Surveillance, immediate attention to threatened populations and prevention of disease proved the best means of combating cholera in Russia. The SEC in Balashov made efforts to form observation points to detect refugees for scarlet fever, cholera, typhus, dysentery and ‘undetermined infection’. The council equipped each location with boilers for water, stoves for burning refuse, heated bathhouses, chemical agents for disinfection of linen and clothing and fresh water. Workers on observation details strove to keep refugees away from the railroad

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stations. The SEC also made plans to construct 25 latrines. At Balashov the commander of the garrison stationed guards to discourage refugees from exploring the local area.99 Checkpoint personnel detained refugees to ensure that they were not healthy carriers of the vibrio, viewing anyone having contact with refugees as subject to isolation until proven safe. This type of containment discouraged refugees from passing germs to local inhabitants. Consuming boiled water prevented many from falling ill, partially compensating for the limits of the waterworks. The SEC undertook efforts to strive for the objectives outlined in the cholera rules, a system of advanced notification that would keep populations safe even when large numbers of refugees appeared. Under the plan, the director of transportation of the military district would write to the commandant of the Povorino Railroad Station and ascertain information regarding the refugees that had exited the trains there. This sort of advanced warning would have helped officials in Saratov to be prepared to deal with new arrivals. They also requested the council of the Southwest Railroad to direct administrators to notify personnel at Balashov of arrivals of refugees. With advanced notification, they could make heated cars available to use in sorting out the sick from the healthy.100 Clearly, communications were problematic. Many locations were caught off guard, a fatal miscalculation that cost many lives. The response to the crisis of war in Saratov Province, while not yet perfected, provided a significant step in the formation of effective anticholera measures along the railroad. Saratov zemstvo authorities, in conjunction with the SECs, were working together. Zemstvo leadership was exemplary, if not always effective. Planning for the reception of such massive numbers of refugees strained human and material resources, and exposed weaknesses in local responses and their sanitary systems. Railroad medical personnel too often engaged in actions, or inaction, that threatened to spread disease. On the other hand, Teziakov, Dobreitser, Serdobov and other physicians were not averse to pointing out problems and demanding reform and, considering the extreme hardships that the retreat caused they kept the casualties much lower than they otherwise might have. The statistics for the final 15 months of the Romanov Dynasty indicate progress against cholera. Statistics for 1916 indicate only 559 cholera victims and 134 in 1917 (see Table I.1). Even if all of the cases in 1917 occurred in the two months prior to the

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February Revolution these statistics, on the heels of the 1915 epidemic, seemed to indicate relative stability in a period of war. By 1916, the Tsar’s military rebounded from initial setbacks on the southwestern front. Repeating 1877, the Russian Army of the Caucasus pushed into Erzerum, crushing the Turkish Third Army, annihilating an entire division and inflicting 15,000 casualties.101 On 18 April 1916, the Caucasian army captured Trabzon and an Ottoman port on the Black Sea, occupying several cities by August and inducing panic in Constantinople and Ankara. The Ottomans were on the verge of defeat.102 The fighting in Anatolia, Persia and the Caucasus was extremely bitter. Religious hatreds provoked expulsions and deportations. The Ottomans had exiled 100,000 Christians to Greece in 1915 and continued in 1916, also expatriating Kurdish Muslims suspected of disloyalty. Muslim refugees bound for the Caucasus massed along the Erzerum Road.103 Persian loyalists blame the Russians and British for the Great Famine of 1917– 19, in which as much as 40 per cent of the population in Persia perished.104 Undoubtedly accelerated by the El Nin˜o in 1918– 20, the Persian famine’s effect on subsequent events in the twentieth century have not been properly analysed. However, the simmering effect of such an epoch and some of its specifics, dealt with in the next chapter, correlate all too well to the ongoing accumulation of social deficits that led to similar disasters in Russia.

The Beginning of the End, 1916 Even with an upturn in fortune on the battlefield the sense of doom in tsarist Russia seemed to get worse on the home front. By February 1916, there were fixed food prices for the national government, the military and urban civilian populations, backed up by requisitioning powers for ‘visible supplies’ that were prominently located at distribution points.105 Tsarist officials would not get an opportunity to exercise the policy, but tsarist economists had reintroduced the idea of requisitioning. The reason for an extreme policy was simple. The economy was breaking down.106 Recriminations over religious loyalties fanned the flames, but with famine rampant in battlefields in semiendemic areas of cholera, it was inevitable that the disease would reappear. The massive German expenditure in Ottoman railway construction contributed to Russian cholera epidemics as did the

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migration associated with warfare. Preoccupied by war and other problems in their country, Russian physicians could hardly have guessed at the disasters to come, but were still trying to resolve issues on the railroad up to the last days of the Empire. The government collapsed after grain shipments failed to appear in Petrograd in 1917 and the breakdown of the food market was cause and effect of railroad and larger failures of political and social institutions.107

Conclusion At the beginning of World War I tsarist Russia was experiencing stable social conditions and cholera was waning. While the war gave impetus to advances in public health, nascent intellectual and material infrastructures such as the bacteriological laboratories were long present. Cooperation between the unions and tsarist governing bodies improved, as did railroad medicine and cooperation throughout World War I, not only in Moscow but in Kharkov, Saratov and other places. Teziakov, Dobreitser, Serdobov and their colleagues paved the way for the Soviet system. Rein, Gamaleia, Taranukhin, Zlatogorov and Khlopin performed essential work in furthering bacteriology and hygiene. The population still suffered from insufficient water supplies, lack of sewer systems and other difficulties. The Union of Zemstvos and Union of Towns coordinated the practical means for mass vaccination, evacuation of military personnel, sorting, isolation and observation of refugees and suspected cholera carriers, but diseases such as cholera and typhus were inevitable during the period of war.108 The response of Unions to the necessities of World War I served as a model during early Soviet medicine. These organisations handled evacuation and care of thousands of refugees, prisoners of war and wounded and cholera-stricken soldiers and laid the groundwork for government and inter-agency cooperation. The cholera rules created an administrative basis for dealing with epidemics. Zemstvo medical officials like Teziakov held local physicians responsible for responding promptly, exposing the limitations of the system and providing their successors with a blueprint for improvements. L. P. Serdobov used the SEC to draw attention to the improper tactics of railroad physicians who sought to avoid responsibility. The government had built the laboratory infrastructure that provided and contained the material basis for coping with epidemics. Tarasevich,

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Glotova and other immunologists gained knowledge from carrying out mass vaccination and probably contributed to the low mortality rate in 1915. Like other European states, the tsarist government made the mistake of entering World War I, which brought an end, or the beginning of the end, of European empires. Human suffering, famine and disease brought down the regime. The reversal of fortunes that began accumulating with the outbreak of war and ENSO events in 1913– 15, with military defeat and the massive retreat, food deficits and resumption of labour strikes in 1915, ended with ruinous government controlled grain policies. Petrograd required 12,000 or more wagons of food monthly to feed its citizens, but achieved this total once in the final six months of the monarchy.109 The metalworkers in Vyborg District who had engaged in economic protest in 1915– 16, merged with social and political protesters in December 1916.110 The Russian people had grown tired of a government that asked them to shoulder the burden of Russia’s attempts to become an industrialised power in the European tradition. The same forces that brought cholera to Russia in 1915 would prove sufficient to topple the Romanov Dynasty.

CHAPTER 6 THE REVOLUTIONS, CIVIL WAR AND WAR COMMUNISM, 1917—21

Russia’s Second Bloody Sunday: The February Revolution, 1917 There comes for Russia that black year When the tsar’s crown will fall; The dark masses will feel no love, no fear . . . Death and blood will feed them all . . .1

Mikhail Lermontov Prediction, 1830

Written on his grandmother’s estate after witnessing the cholera riots of 1830, the violence that 16-year-old Mikhail Lermontov saw was the same manifestation of black rage that in 1917 made his Prediction appear prophetic. In February, workers’ grievances and a fear of famine provoked demonstrations around the steel factories in the Vyborg District of Petrograd. Women waiting in bread lines mixed with striking workers, and protests began occurring. Placards called for a general strike and the overthrow of the government. Cossacks were hesitant to provide crowd control.2 On Sunday 26 February, crowds of workers and women protesting for food in the industrial districts converged on the Nevskii Prospekt and clashed with police. Commanding the Volynskii Regiment on Znamenskaia Square, an officer compelled his hesitant soldiers to fire on the protesters, killing more than 50, including two of the regiment’s

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own soldiers. Breaking into the barracks of the Pavlovskii regiment, protestors confronted soldiers, who joined the fray on the Nevskii, screaming that the police were ‘shooting at our mothers and sisters’. Back in their barracks, the Volynskii regiment mentally digested the events. A soldier swore that he had seen his own mother among the people they had shot. Back in the line the following morning and instructed to fire, the soldiers shot their commander. Along with other regiments they joined the revolution.3 Despite the Tsar’s shortcomings, the government with the most experience dealing with food issues no longer existed. A severe economic crisis developed, and the new Provisional Government fixed the price of grain in a misguided effort to ensure sufficient food. The breakdown of the food market was a cause and effect of both railroad failures and wider interruptions of political and social institutions. The crisis that occurred before the February Revolution became more severe, leading the Provisional Government to declare in March that all grain in the forthcoming harvest would be subject to requisition. However, the government could not secure grain at the requisite price; they proceded to double it and subsequently collapsed.4 On 24 October 1917 the Provisional Government fell to the Bolsheviks, as the movement of armies brought epidemics to Russia. Inheriting the responsibilities that had toppled two governments, the brash, confident newcomers asserted their authority with great vigour, enjoying a brief reprieve in the climatic conditions that permtted a relative absence of cholera in 1916– 17. However, their luck did not hold out; the mounting social tensions included strong El Nin˜o events in 1918–20.5 The Bolsheviks pursued a policy called War Communism, which included government centralisation and requisitioning of grain, causing the food deficit to decline further. Born in a period of war, these revolutions quickly devolved into a bitter civil war between the Bolsheviks or ‘Reds’ and remnants of the tsarist army, the ‘Whites’. Contributing even more to this misery, an unprecedented onslaught of epidemics began to develop that included the continuation of the sixth cholera pandemic, the Great 1918 Flu Pandemic and perhaps the largest typhus pandemic in history. The eminent epidemiologist L. A. Tarasevich observed that the typhus progressed with ‘a rapidity which recalls the great epidemics of mediaeval times which people thought had disappeared for ever from the civilized world’.6 ‘General Typhus’ as it

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was known (due to its role in defeating Napoleon), killed approximately 2.5 to 3 million Russian citizens in 1918– 21, another 4 million in Poland and thousands of others on the battlefronts of World War I. The Soviets suffered between 22.5 and 30 million cases of typhus and another 8– 9 million of the closely related ‘relapsing fever’.7 Even the destruction of human life caused by typhus could not distract Russian physicians from their primary fear, cholera. The most dreaded pathogen of the nineteenth century, the cholera vibrio’s reappearance was virtually assured as El Nin˜o helped mobilise the natural processes which routinely boosted the vibrio’s strength. Reappearing in 1918 (and dwarfed in numbers by flu and typhus), the contagious microbe wreaked disproportionate havoc. The accumulation of the usual events that spurred cholera epidemics began to develop as the monarchy was overthrown in the February Revolution in 1917 and became more complicated during the Russian Civil War in 1918– 21. These conditions degenerated even further during the Bolsheviks’ pursuit of War Communism, resulting in two major cholera epidemics despite vigorous anti-cholera efforts. This period produced some of the worst epidemiological conditions in history, rendering the intense contagious measures that the Bolsheviks fervently applied an abysmal failure. Centralisation of government and a contagionist response did not provide an answer to Russia’s cholera problem. The disease proved every bit as destructive as it had been in 1892, 1908 and 1910.

Lenin Returns to Russia, 1917 On 3 April 1917 the exiled V. I. Lenin returned to Russia, arriving at the Finland Station in Vyborg district. He was met by a representative of the Petrograd Soviet, which had formed an All-Russian Central Committee composed of 72 members with departments for the food supply, foreign affairs and economics. Set up as a bureaucracy for the entire republic, the Soviet was supporting the Provisional Government. Denouncing the Soviet’s position, he was given a ride in an armored car to headquarters and gave a rousing speech. The next day, he elaborated on his ‘April Theses’ at another meeting of the Petrograd Soviet in the Tauride Palace. Russia’s ineffectual middle class was incapable of carrying out the bourgeois-democratic revolution required (under Marxist doctrine), necessitating an expedited, proletarian-socialist version. Lenin became a

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legend for his stance, but the Mensheviks, allied with the Constitutional Democrats or ‘Kadets’ and Socialist Revolutionaries or ‘SRs’, argued that the revolution was liberal and feared that radicalisation might provoke a counterrevolution as in 1905– 6.8 None of these developments however discouraged Lenin, or the Bolshevik faction. With 1,000 hardcore activists and 25,000 members, Bolshevism was becoming a mass phenomenon in Petrograd, particularly on the Vyborg side and northern sectors surrounding Petrograd. The Party consolidated ties with the Baltic Fleet, shipyards and military industrial factories such as the Putilov Works. Their influence extended to Kronstadt Island and as far north as Helsinki, but they were weak in the Ukraine and the Black Sea fleet, where their agenda failed to resonate with the masses.9 The Provisional Government, on the other hand, was not flourishing. In November 1916, the Western allies had forced a promise from the Tsar to assist the war effort. The Provisional Government upheld this promise, attacking the Central Powers in June 1917, hoping to spur army morale and quell domestic strife. However, morale dipped at the front and one out of every six to seven Russian soldiers, 1 million all told, deserted. Even worse, starvation from unproductive agricultural practices and requisitioning increased.10

The Provisional Government and Public Health, 1917 The scientists of Russian public health supported the February Revolution, which they viewed as opening the doors to scientific freedom. The Academy of Science elected Aleksandr Karpinskii, a geologist, as president. Scientists associated with the Kadet Party including S. Ol’denburskii, the Secretary of the Imperial Academy of Sciences and V. I. Vernadsky, of the Ministry of Enlightenment, supported the pursuit of knowledge. I. P. Pavlov and V. I. Vernadsky formed the ‘Free Association for the Development and Distribution of the Positive Sciences’, basing its organisation on American and British academies. While neither devoid of ideas nor partisan feelings, the continuity of prominent physicians, bacteriologists and sanitationists indicate that they kept their focus on science and felt more freedom to pursue their chosen vocation.11 The efforts of tsarist reformers in attempting to improve services along the railroad lines had exerted a clear effect. In 1912, the railroad

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had begun publishing the Herald of Railroad Medicine and Sanitation in St Petersburg. Edited by Dr S. P. Roshchevskii, the first four editions of 1917 ignored cholera, showcasing instead technologies related to bacteriology, including a disinfection chamber invented by V. A. Taranukhin.12 In one of the last editions, V. I. Zemblinov, the senior physician of the Moscow– Kursk Railroad, called for cooperation in constructing more proactivee public health along the railroad lines, especially regarding cooperation and assistance between railroad and local government personnel and extension of railroad medical services. Zemblinov discussed the need to unify the local medical and railroad activities and services. Dr A. A. Gruzlovym had distributed a questionnaire in Vladimir Province which indicated that approximately 50 per cent of local inhabitants were completely isolated from the railroad.13 Approximately half of local populations were subject to transmission of infectious diseases over the lines. Zemblinov suggested unifying medical strength along the railroad lines, water routes and local highways, particularly ‘in junctions’, or where the railroad met other roads of transportation. He suggested that government organisations should serve the roads of human travel, the ‘localities along which the roads lie’ and the ‘outer extremities’ of these areas.14 He added that zemstvos, municipal, local and other organisations should unite for uniform strength and means to service social necessities. Siberia, which had no zemstvos or supporting organisations, was especially weak, and required enhanced service in both the krai (large autonomous administrative districts similar to an oblast’) and the railroads. The latter, Zemblinov asserted, should extend their aid to the districts adjacent to the roads, uniting with existing organisations, factory departments and prospectors of gold, silver other ventures.15 Responsible railroad physicians were pursuing a more active role in public health. Junctions, peripheries and areas of capital venture were problem areas. Zemblinov endorsed the zemstvo principle of ‘free medical service’ for railroad workers, their families, local citizens and others who were unable to pay, as well as inspection of drinking water, sewage disposal and vaccination.16 Zemblinov also mentioned the strain placed on the railroads in dealing with these demands. The heavy movements and continual work of medical personnel, the incidence of disease in workers engaged in surveillance, the service on commissions and other duties of railroad

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physicians all forced services to be restricted to the closest settlement outside of its zone of responsibility. He called for increases in physicians and resources.17 Zemblinov was essentially arguing that the Provisional Government should move ahead with improvements that zemstvo reformers had long suggested, including more centralised services. An influential group of physicians in the Provisional Government, bacteriologists, epidemiologists, hygienists and others, favoured sanitary reform. These individuals were influential in tsarist organisations, particularly P. N. Diatropov and Z. P. Solov’ev in the Union of Zemstvos, and L. A. Tarasevich and A. N. Sysin in the Union of Towns, both of whom became leaders of Bolshevik public health. As mentioned previously, Diatropov and Tarasevich, along with N. F. Gamaleia, D. K. Zabolotnyi, I. I. Mechnikov and others, began their careers in the Odessa bacteriological laboratory. According to one of the most prominent accounts of the period from the beginning of the Provisional Government through the Bolshehik period of War Communism in 1918–21, Diatropov, Tarasevich and Sysin felt that ‘the populist vision’ of a peasant zemstvo or self-governing council was rendered unnecessary due to improvements in bacteriology, immunology and epidemiology.18 Indeed, technical specialists were rising during this period and the Bolsheviks pursued a centralised style of command that correlated to War Communism. Attempts to divorce scientists from the social and material support that civil society provided, however, are misleading. Historical analyses of the Soviet struggle with cholera require an examination of the NEP and an understanding how the Soviets understood the material relationship between technology, social factors and disease. For example, they used vaccination as an epidemiologic tool, understanding the relationship between immunity and microbial evolution and the wider humanenvironmental interactions that served as the ‘breeding grounds’ of disease. This doctrine of prevention began with Pirogov himself. Shortages and famine were imperative in causing cholera epidemics and local initiative and agency was equally important in battling it. Created by warfare and public policy, substandard social conditions made increases in sanitation, which were far from adequate in many places, entirely insufficient. The leading physicians of this period were undoubtedly working out their worldview within the prevailing political paradigm. The Pirogov

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member, D. N. Zhbankov and others advocated a decentralised system and Zhbankov called the February Revolution a ‘cleansing hurricane’ that had washed away the power of the Ministry of the Interior (MVD) and influence of the Rein Commission.19 He was wrong. There was no cleansing hurricane during the Provisional Government nor, for that matter, in 1918– 21, the Bolshevik era. While the Soviets approached their work with ideological and military zeal, the development of Soviet public health constituted an evolution of tsarist ideas that were steeped in the European tradition of research schools based on the works of Pasteur, Pettenkofer and Pirogov and involved broad populism. Bacteriology and sanitation progressed slowly as part and parcel of the broader programme of Russian public health, one that emphasised environmental processes and relied on measures such as vaccination, nutrition and immunology, as epidemiological tools. Slowly conceived under conditions of war and famine, this approach failed utterly in 1918–22. After the February Revolution, liberal tsarist bureaucrats such as A. I. Guchkov, who had led the Central War Industries Committee and Prince L’vov, who was the leader of the Union of Zemstvos, remained in charge of important organs of public health. On 7 March Guchkov called a meeting and ordered the formation of a joint Sanitary Organisation for Petrograd and the Northern region, excluding the territories of war. He appointed Professor N. N. Burdenko of Ur’ievsk University, an advocate of centralisation, as head of the field hospitals that had been organised by the Union of Zemstvos. On 3 March, the Red Cross declared loyalty to the Provisional Government and assumed the responsibility for managing and coordinating public health. Prince Alexander Ol’denburgskii was dismissed. The Provisional Government chose the Kadet deputy and physician V. I. Almazov to lead the Sanitary and Evacuation Section. Almazov conferred with experts including Zhbankov and the Rein Commission, calling for a meeting to which he invited the Moscow Union of Zemstvos and Union of Towns. This group, including the immunologists Diatropov and Tarasevich, rejected Zhbankov’s plan and drew up a counter proposal, calling a Pirogov meeting between 4 – 8 April 1917. At the meeting, a ‘special committee of three’, including Solov’ev, Sysin, and V. M. Bogotskii, appealed to reformers in Moscow, proposing a centralised organ of medical and sanitary affairs.20 The tsarist system clearly required more systematic

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control and this push coincided with better sanitary controls, but their adoption in 1918–21 together with the approaches of War Communism failed miserably. N. Sysin and P. N. Diatropov disassociated themselves from the unions, which they felt were tainted by ‘pre-revolutionary lineage’ and an association with both the Constituent Assembly and volost’ zemstvos. The two mavericks argued that the unions were temporary due to the war and had acted in complicity with the Tsar in prioritising military victory over revolution. Many members of the Moscow group were present at the conference, whilst Zhbankov and other Pirogov reformers failed to appear. The participants heard proposals until 8 April, when a representative from Moscow advocated forming a temporary central council for the Provisional Government, to be composed of two members from the Pirogov Conference and one each from the Moscow and Petrograd hospital organisations. Diatropov and his committee approved what became the final version, which differed from the original Moscow proposal by calling for a larger council and smaller executive committee. This ‘Pirogov council’ included representatives of the Military-Sanitary Administration, the Fleet Sanitary Administration and the Office of the Chief Medical Inspector, subordinating centralisation to local initiatives, as opposed to the Moscow proposal, which sought to unify all groups or organisations related to medicine and sanitation under a central commission to coordinate local activity at the expense of the zemstvos, municipalities and hospital funds.21 On 8 April, when the meeting took place, Lenin had been in Russia for a mere five days. Moscow civic leaders had been active during the war and Tarasevich was a former Pirogov physician who worked with the Moscow zemstvo on vaccination and with the Unions, known collectively as Zemgor after spring 1917, at the front. Rather than reform from below, as per the Pirogov proposal, the counter-scheme called for top-down planning, leaving only evacuation in local hands, thereby combining Rein’s emphasis on centralised planning with Ol’denburgskii’s priority of military needs.22 However, the Provisional Government did not approve the plan and a new council, which included Tarasevich, Diatropov and other important physicians, also failed to gain approval. The community physician G. I. Dembo successfully argued that physicians worked for the Russian people, not the military.23 Clearly, these initiatives did not have adequate support.

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In addition, other events began to unfold. The Union of Physicians of the Army and Fleet was formed on 9 April 1917. The Union was dominated by physicians at the front, but suffered from logistical problems. Senior physicians stood to lose rank if mobilised and many refused to go. Reformers could not prevent the creation of new councils as they awaited the ratification of the Central Medical Sanitary Council, or CMSC.24 Authorised on 16 July 1917, this CMSC addressed finances, formed a standing council to replace tsarist institutions such as the SECs and took steps to consolidate power under the Provisional Government. As expected, not everyone was happy with this. The prospect of creating new organs of public health brought complaints of bureaucratisation. V. A. Kiriakov, a former Moscow zemstvo physician, was named Chief Medical Inspector in May. On 28 June, he had pragmatically argued that traditional institutions needed to be temporarily retained. The CMSC convened in Petrograd on 26 August and the members discussed creating new organisations, asserting that the new government should not pass measures or reforms for public health without prior discussion with the council. The CMSC requested that its president should be admitted as a full member of the Council of Ministers of the Provisional Government. However, rumours regarding an invasion by General Kornilov abounded. Kyriakov’s initiatives effectively precluded funding for local Soviets or councils, and the CMSC declared that only the unions and the Red Cross could assist the Army. One week before the August meeting of the CMSC, Sysin and other physicians started a new Pirogov publication named Medical Life, arguing that the Provisional Government and zemstvos had to be liquidated as remnants of tsarist medicine that continued to support the war.25 As the following chapters will explain, there was considerable resistance to cutting away tsarist institutions and principles and, while the Bolsheviks increased centralisation of public health, the ‘liquidation’ of the zemstvos occurred in theory only.

The Bolsheviks, War Communism and Unification of Soviet Public Health, 1917 –18 When the blaze of war is burning infectious diseases come out from their corners, rise high [. . .] and destroy everything that

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stands in their path. War and the fate of the people are decided by infectious diseases, proud armies are completely destroyed.26 Robert Koch, quoted by P. V. Khavkin, 1918 During the implementation of War Communism, the Bolsheviks’ all too familiar amassing of social debts began to accumulate. They shifted toward government controlled agriculture and industry, which resulted in mass disorder. Requisitioning grain from farmers caused peasant uprisings, while new state controlled economic policies created further resentment within the middle classes.27 Food detachments, nationalisation of industry and trade restrictions were consequences of Bolshevik policies immediately following the October Revolution and the drought that characterised these years. Poorly-run small farms replaced the larger estates and failed to produce sufficient crop yields. This condition declined further when the Bolsheviks lost the main food producing provinces through fighting in Ukraine, the upper Caucasus, the Kuban and Don, Siberia and the Volga region. The Bolsheviks confiscated food in various localities in the winter of 1917 – 18, seizing factories and looting Russian plants. On 9 May, the Bolsheviks declared a Food Dictatorship. State run organisations and food detachments seized peasant food stockpiles and gave nothing in return.28 The Bolsheviks were hardly winning over the populace in southern Russia. In March 1918 Pirogov physicians refused to cooperate with the Bolsheviks and convened their own congress. However, they soon realised that leading Bolsheviks such as N. I. Semashko and Z. P. Solov’ev espoused a similar medical platform to their own. Learning that they would in fact keep their jobs, they decided instead to cooperate with the Bolsheviks. The desire to preserve zemstvo culture survived in their work, but not as an explicitly political force. The Bolsheviks also gained Pirogov support by supporting physicians who were struggling to prevent nurses, feldshers and other lower tier medical professionals from becoming a powerful force in Bolshevik medicine. The top tier status of physicians corresponded to Lenin’s emphasis on a technical intelligentsia. Had the Soviets not retained the old programmes that had combated epidemic disease, Russian community physicians would have faced the stark choice between practising privately or unemployment during an economic breakdown. By the spring of 1919, the leadership of

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the Pirogov Society encouraged their members to support the Bolsheviks.29 Lenin moved forward with the construction of public health, but there was less restructuring than the literature suggests. As the Soviet physician, L. G. Veber, later observed, one of the primary tasks of the new People’s Commissariat of Health of the Russian Republic (hereinafter referred to as Narkomzdrav RSFSR), was to coordinate, administer and ‘unify’ all activities and efforts occurring under the auspices of the previously existing organs of public health.30 Indeed, ‘unification’ is a more apt sobriquet than centralisation to describe how these forces coalesced under the Soviets. Lenin appointed N. A. Semashko as the new Commissar of Public Health and emphasised the combating of cholera as one of the central focuses of consideration. To address cholera epidemics and other infectious diseases, the Bolsheviks formed the Central Epidemics Committee under Semashko and the Health and Epidemics Department under A. N. Sysin.31 The physicians of Narkomzdrav RSFSR (Russian Soviet Federated Socialist Republic) pursued a programme that paid broad attention to the environment and the perfection and expansion of preventive vaccination.32 The implementation of these programmes facilitated wider bureaucratic and administrative control and they were compatible with other propaganda programmes.33 They were also sufficiently broad and technical to please most factions within Bolshevik medicine, adhering to the principle of preventive medicine that Pirogov physicians lauded whilst also fulfilling the Soviet penchant for technology and specialisation. Narkomzdrav RSFSR was inaugurated on 11 July 1918 and charged with administering all of the sanitary and medical organs in the new country.34 This was not an auspicious time for the Bolsheviks’ political organisation. Strong ENSO events in 1918–20 undoubtedly mobilised the environmental components that would bring famine and epidemics, which were worsened by the movement of armies and war.35 Over the next three years, social conditions plummeted to an all-time low. A large cholera epidemic was unfolding and in October and November, Russian prisoners of war brought the Spanish flu from the West. The former Pirogov and top Bolshevik physician, L. A. Tarasevich, lamented that the typhus epidemic was rapidly developing.36 Fortunately, Zemgor had left large stocks of vaccines, which allowed the Bolsheviks to continue the Commission on Serums and Vaccines and vigorously pursue mass

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vaccination.37 From its very outset, Soviet medicine drew upon tsarist medical, material and social development. From their tsarist experience, the Bolsheviks knew that the best places for concentrating measures were along the routes of transportation, particularly railroad stations and wharves, where people carried germs from endemic regions, crowded together and transferred them to other humans and the environment. Personnel started conducting even more prolonged observation of the railroad lines, adopting minimum numbers of physicians, sanitary specialists, feldshers and other personnel positioned at railroad stations. They deployed sanitary wagons at nearly every station to transport patients to hospitals and isolate them and their families. When possible, gubzdravotdely, local health workers similar to tsarist trustees, built cafeterias and ensured that everyone was fed. They provided passengers exiting trains with chilled, boiled or treated water. Soviet public health personnel educated the public, fed citizens, and attempted to sort out and isolate both suspected carriers of disease and their family members. Bolshevik medical planners made beds available for cholera patients and anticipated emergencies in places where people congregated. Workers policed the surrounding environment, cleaning up cesspools, rubbish dumps, ditches, open water sources and public restrooms, taking steps to quell transmission of disease. This type of organisation marked a continuance of work of Zemgor and other zemstvo reformers, but the Bolsheviks faced overwhelming odds due to El Nin˜o, famine and war. Lenin made appointments based upon Bolshevik political affiliation, but this arrangement was tenuous, as the leaders of the newly formed republic struggled to formulate their world view. Marxist doctrine provided no set cultural template for socialist life. The new leaders were left to create their own norms for ‘punctuality, hygiene, sexual behaviour, child rearing, and consumption’ and for ‘artistic and literary values’. Lenin was a traditionalist, a lover of classical Russian literature who in 1919 expressed disgust with ‘all kinds of intellectual inventions, all kinds of proletarian culture’. He believed in using tsarist cultural mores and achievements.38 The Bolshevik approach to epidemics reflected European medical tenets specifically altered to Russia’s geography, scientific development, economy and culture. The Bolsheviks held their first conference on 15 – 18 June, sorting out the organisational structure and foundation of the new anti-epidemic

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system. The Soviet physician, L. G. Veber, later recalled that the people and ‘local organs of power’ greatly assisted Narkomzdrav RSFSR by organising ‘epidemic control units, disinfection and vaccination centres’, ambulatories, hospitals, maternity wards, dispensaries, feldsher and other medical posts, rural hospitals in small districts and ‘sanitary and epidemiological establishments’.39 While it is easy to write off such statements as mere Bolshevik rhetoric, these medical constructs ultimately helped stop cholera. For political reasons, Veber did not mention that the zemstvos and SECs had constructed a practical basis for these activities. In 1918– 21 the Bolsheviks attacked cholera with a military-like zeal, giving detailed attention to the railroad stations and wharves, pursuing public education promoting hygiene and mass vaccination and applying broad measures, concentrating them in places where cholera was most likely to strike. However, War Communism extended the tsarist and Provisional Government’s policy of controlling the grain supply, causing mass suffering. In the 200 years since Peter the Great, tsarist bureaucrats had kept decisions regarding food distribution and famine regulation at the local level, avoiding requisitioning.40 Lenin was well aware of the effects of War Communism on the public and the Bolsheviks were extending the military discipline of the Civil War into public life, which almost caused their downfall. By 1921, several million Russians had perished.

The 1918 Epidemic in Russia The current cholera epidemic is in no small part little more than a war indemnity [. . .] the people enter payment [. . .] by microbes of infectious disease.41 P. V. Khavkin, 1918 Emerging from the famine and conditions created by war and revolution, the 1918 cholera epidemic proved a wakeup call for the upstart Bolsheviks, proving in many ways worse than its predecessors. Like tsarist physicians before them, the Bolsheviks were tardy in their preparation. Neither late preparation nor denial were the exclusive province of either government. Arriving before Narkomzdrav RSFSR

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even met, the first cases began to emerge on the Volga on 29 April 1918. By 24 May there were 34 confirmed cases of cholera, including 18 on watercraft in Astrakhan’. As the epidemic ascended the Volga, the vibrio appeared in northern Saratov Province in Khvalinsk, further upriver in Chistopol and then in Kazan’.42 The first Red Army volunteers, approximately 10,000 individuals, began signing up between May and June of 1918. In June, the Red Army General Kumich announced conscription, adding another 10,000 soldiers to his ranks.43 Cholera probably began appearing more due to El Nin˜o-induced climate than mobilisation, but the appearance of both at once was crippling. The vibrio soon occupied the usual places, including Petrograd, Saratov, the Astrakhan’ and Iaroslavl’ provinces, Tambov and Kursk.44 Public health officials in Moscow claimed that they were not alarmed, although a number of articles began appearing in newspapers. The Informational Section of the Council of Water Transport compiled collective media contents into a report. A reliance on the news media for reports about cholera, seven months after seizing power, hardly constituted a centralised intelligence system. On 4 May in ZARIA the Moscow physician P. N. Diatropov observed that individual cases involving soldiers did not yet present a danger to the city, but feared epidemics ‘in the south and east, in Tashkent, and on the Volga’, where ‘carriers of cholera present a danger [. . .] as the epidemic travels higher [. . .] then of course it threatens Moscow’. He noted that carriers could bring cholera to Moscow along the railroad, or over the Oka River from the Volga, and insisted upon initiating anti-cholera measures on the river.45 F. M. Blumenthal agreed, stating that the war did not pose a great threat of cholera to Moscow because, over the previous 100 years, epidemics appeared in Moscow due to ‘breeding grounds such as Astrakhan’ and Tsaritsyn.46 A conference of Soviet deputies in the Volga province of Simbirsk, Lenin’s hometown, emphasised the ‘construction of observation points on the Volga and at railroad stations and creating a series of isolation hospitals’, voting to activate provincial sanitary bodies.47 The implementation of observation points and the activation of provincial emergency commissions had, of course, evolved from the activities of the Kazan’ military district during the tsarist period. Confidence then gave way to fear. An article entitled ‘On the Eve of Cholera’ noted ‘widening numbers of epidemic patients’ and asserted that the new capital’s sanitary state made it ‘suitable soil for the

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development of cholera’. Growing numbers of citizens were carrying sacks of food along the railroads, advancing the spread of both typhus and relapsing fever, the latter being a recurring version of the former. The author of the article warned that not only were the suburbs vulnerable, but also the central districts, where the sewer systems were ‘polluted to the fullest degree’.48 This statement was telling. Even in Moscow, which was built on high ground for fortification and defense and where sanitary services rivalled those in Western Europe, canal systems were vulnerable to runoff. Even more problematicly, famine precipitated increased movement and weakened the population for easy transmission of disease.

Cholera Comes to Petrograd, 1918 Translucent spring has broken above the black Neva’, Immortality’s wax is melting. Petropolis, your city – if you are a star – Your brother, Petropolis, is dying.49 Osip Mandelstam, March, 1918 The poet Mandelstam’s warning that Petrograd was dying and his appeal to the heavens for divine intervention was understandable. In November 1917, the daily caloric intake per resident in the city fell to 1,395, then 1,039 and, in January 1918, a paltry 698 calories.50 Communal dining rooms served ‘watery soup and thin gruel’. The Bolsheviks rationed bread and one meal ticket bought a portion that included various substitutes, providing only 306 calories. As people starved, factories shut down from a lack of fuel and raw materials and half of the railroad’s locomotives were not fully operational. Two-thirds of the city’s mill hands were jobless. ‘Starving Petrograd [. . .] terrible place’, wrote the novelist Aleksei Tolstoi.51 Geographical isolation was a large part of the problem. Since the October Revolution, 28 governments formed in the territories of the former tsarist Empire and 27 of these were enemies of the Bolsheviks.52 The Bolsheviks lost key food producing regions in Ukraine, the Don and Kuban regions, the Caucasus, Volga, the Baltic provinces, and the Urals, causing famine in Petrograd and surrounding areas. Holding on to the

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large region surrounding Petrograd that their enemies mocked as ‘Sovdepia’, short for ‘Soviet Workers and Peasants’ Deputies’, the Bolsheviks held 30 provinces, 60 million people and nearly 1 million square miles. The people in this area, the largest country in Europe, suffered famine from the summer of 1918 to spring in 1920.53 Petrograd’s population, 2.3 million in January 1917, fell to just 720,000 in January 1921, due to hunger, disease and (understandable) emigration.54 The chances of survival for the new country appeared slim, and the Bolsheviks’ enemies used the poor state in Petrograd to induce panic. The journal Early Morning, a Moscow based newspaper sympathetic to the more conservative Kadet party, reported that Petrograd would experience epidemics with 100 per cent mortality.55 The paper and its proprietors served as a barometer of civil society in Russia, but the report was sensationalist propaganda designed to cash in on cholera’s fear. Later that year, the Bolsheviks shut down the journal.56 Petrograd’s financial situation gave cause for concern. A memo on 18 June from the Hospital Department of Narkomzdrav RSFSR to its technical department noted that an estimate of the Petrograd City Council in 1917 regarding a credit for repair of hospitals, sanitary facilities and departments and other projects earmarked for 1918, could not be transferred. The document warned that necessary credits for hospital repair during the second half of 1918 could not be overlooked. To clarify the size of the credit required, the Hospital Department requested the Technical Department ‘to expediently carry out supervision of all hospital and sanitary establishments, to prepare the necessary paperwork and to arrange for the carrying out of the repairs’.57 The city needed strong institutional support to deal with cholera, as Bolshevik medical officials expected a busy year in Petrograd hospitals. Building on the activities of Zemgor during World War I, the administration prepared for epidemics in vulnerable places and where they expected the heaviest fighting. In June, the Red Army attempted to draft large numbers of soldiers and formed worker detachments in Moscow, sending both groups east to provide security on the Volga, particularly in the Ural Mountains and places where their popularity was weak.58 Almost simultaneously, on 7 June a memo circulated in the Institute of Experimental Medicine, formerly the Imperial Institute of

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Experimental Medicine, regarding a proposal of the acting Director of the Logistics, D. K. Zabolotnyi. This proposal involved sending an exploratory commission to gather intelligence on the characteristics of cholera microbes in the Upper Volga region. The request, addressed to the female Director of the Vaccination Section, Dr E. Kolesnikova, emphasised efforts to develop an anti-cholera serum and instructed Kolesnikova to: ‘1. Help identify the origin of a collection of water and intestinal vibrios, cholera and cholera-like, in our district; 2. To routinely submit a monthly report regarding the diffusion of the epidemic;’ and ‘3. To communicate statistical material for [use in preparing] anti-cholera vaccinations’.59 In seeking data regarding the microscopic properties of cholera, Zabolotnyi and his colleagues were not content to know whether Koch’s V. cholerae 01 was present, but wanted concrete details of the variations of the vibrio and related bacterial agents within this crucial region, a traditional breeding ground of cholera where combat was to be expected. Since 1892, when he braved Pavlov’s disapproval, Zabolotnyi was seeking specific, microscopic intelligence on the vibrio in its native environment for personnel at the Bolsheviks’, formerly tsarist, main laboratory, in order to develop a serum. These objectives reflected the principles for which tsarist bacteriologists and Pirogov hygienists had stood.

An Impending Crisis Yet even before Zabolotnyi sent the memo to Kolesnikova, the prospect of war, epidemics and material shortages all threatened the work of the Institute. Dr F. M. Blumenthal had in 1901 translated Tuberculosis as a Disease of the Masses and how to Combat it from German to Russian for the Pirogov Society.60 An immunologist by trade, Blumenthal understood the social aspects of disease. On 12 June 1918, he sent an internal memo warning of an ‘impending crisis’ in the Institute’s capacity to provide high quality vaccination serums as diseases approached in the summer and autumn. Blumenthal mentioned chronic diseases such as ‘dysentery, diphtheria, typhus’ and sudden epidemics such as cholera. Shortages, he observed, would make it difficult to carry out anti-cholera vaccinations and the Institute lacked the materials to make serums and vaccines.61 The large institutes that supplied Russia’s physicians with vaccination serums for military and surrounding sectors had performed

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well, but they were reaching their capacity and had difficulty sustaining previous levels of production. Smaller laboratories lay in ‘general ruin’.62 Large central labs such as the Institute of Experimental Medicine and the Moscow Institute (named after Gabrichevskii) were operating at their highest capacity and would soon exhaust their reserves, leaving the population vulnerable to ‘imminent seasonal diseases’ like cholera.63 Preparing vaccines required horses, and these needed fodder to stay healthy. Laboratory personnel needed chemicals, specialist operating instruments, dishes, droppers, thermostats, rubber tubes and other accessories to carry out the production process.64 Blumenthal’s warning was not premature. The pre-cholera symptoms began to appear in Petrograd, then the disease itself. Bolshevik physicians helplessly observed the warning signs. P. V. Khavkin described the three months prior to the epidemic as steps in the progressive vulnerability of human intestines to the vibrio. Early in 1918, sharp intestinal illnesses appeared and by April the number of cases widened. By May, emergency room physicians were observing more severe intestinal disorders such as ‘sharp toxic enteritis’ that caused several deaths. Bacteriological diagnoses of cholera were not confirmed until 4 July.65 As Khavkin viewed it, first the human organism became vulnerable to light intestinal disorders, then more severe afflictions caused a few deaths, then cholera appeared.66 Physicians such as Khavkin discovered that increasingly severe intestinal disorders signified that cholera was imminent. Their recognition of this physiological progression ultimately aided them in amassing intelligence and preparing emergency responses, but resource shortages and the sheer number of cases they would face in 1918 rendered an effective reaction impossible. As cholera entered Petrograd and the Bolsheviks prepared for war in the Middle and Upper Volga regions, priority was given to requests for money relating to transport and communication. On 18 July, the Director of the Sanitary Section of Military Communications for the Eastern Front requested that Narkomzdrav RSFSR set aside credits for battling cholera on the railroads.67 Seven days later, the Supreme Military Council of the Red Army began sending military personnel to the Eastern Army Group.68 On 30 July, the Central Committee for Port Reform paid explicit attention to trading ports and the bay area around the Kronstadt Plague Fort, assigning 8,200 rubles for immediate

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measures.69 Lab personnel prepared serums at the fort and its operation was vital in attempts to combat the spread of cholera. Yet, already, cases were appearing in Petrograd en masse. Within a 24-hour period in 9 – 10 July, the Epidemics Sanitary Bureau registered 149 cases of suspicion of cholera, with 34 confirmed and 67 cases of ‘bloody cholera vomiting’ identified in Petrograd hospitals. Maintaining the frenetic pace of the epidemic became a problem. Beginning on 6 July, the number of cases per day took on what one official called ‘an almost catastrophic character’. On 7 – 10 July, the daily number of cases in hospitals numbered 302, 595, 825 and 714. By the end of the week there were 3,229 cases and 1,019 suspected totalling 4,247 of which 1,284 proved fatal. The mortality rate was 32.5 per cent and the recorded weekly average was 607 patients. The real number of deaths was far greater, because registration was almost impossible; those who died at home or in the streets generally went unregistered.70 One must remember that this was in the midst of both the Great Flu Pandemic and what was probably the largest typhus pandemic in history. The mounting numbers of corpses presented huge logistical problems. The coroners, responsible for examining deceased patients in their districts, were overwhelmed. The Petrograd Workers Commune expected them to investigate the dead bodies of individuals who had died from cholera within 24 hours, including the time involved in responding to private residences and conducting autopsies where necessary. Coroners were also expected to liquidate the corpses expediently so that the dead did not remain unburied for over two days, which was considered a sanitary hazard. The emphasis on decisiveness and speed of action was designed to avoid waiting periods for notification of families and proper authorities, a task in which coroners were also charged. Their job demanded that they arrange for immediate transport to the cemetery and write the reports detailing the circumstances of death.71 As the epidemic reached its apex, coroners dealt with countless corpses and fulfilling these obligations was a terrible burden. Fighting in the Upper Volga Region continued. On 7 August, Kazan’ fell to the White Army and three days later Lenin ordered all available units transferred east. Combat broke out in Simbirsk, the Urals, Saratov and Kazan’, where the Red Army Commander, Colonel Kappel,

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attempted to capture the giant Romanov Bridge over the Volga River on the Moscow-Kazan’ line. After cutting the railroad line and attacking on 28 August, Kappel’s army group withdrew. However, on 10 September, the Bolshevik Eastern Army Group successfully entered Kazan’. By 15 September there were more than 70,000 soldiers on the eastern front.72 Health officials in Petrograd took preventive measures along the routes of transportation connecting the city and Moscow to the Eastern Army Group. On 24 August, a report entitled ‘for cholera’ by the administrative section of the Commissariat of the Ways of Communication in the Petrograd military district noted that Narkomzdrav RSFSR had set aside 5,000,000 rubles ‘for the protection of the province from diffusion of related diseases [. . .] on the territories of the railroad routes’. Narkomzdrav RSFSR paid a 1 million ruble advance on 15 July and half of this sum was put to use along the tracks surrounding Petrograd. The Commissariat of Public Health of the Petrograd Workers’ Commune submitted a breakdown of expenditures for sections of railway, including 250,000 rubles for the Nikolaevskii Railroad, which connected Moscow and Petrograd, 125,000 for the Northwest, 50,000 to the Moscow-Vidavo-Rybinsk-Petrograd network and 150,000 to the Murmansk Railroad.73 Out of a total of 565,000 rubles put into practical use, the Bolsheviks used 90,000 for railroad construction; 25,000 to construct lines to a hospital on the Chudovo and Mga-Rybinsk-Volkhov system near Petrograd; and 65,000 to build new lines to outer regions of the oblast’ such as Sestroretsk, which was located in Kyrotnyi District on the Gulf of Finland between Petrograd and Vyborg.74 The Bolsheviks were using their resources in a manner that, but for the condition of the population, might have produced results. On 19 September, the local Central Committee in Petrograd reported back on the expenditure on the local ports. Workers used 1,500 rubles for cleaning the extreme pollution at a point in the bay near the shoreline used by fishermen; 500 for tearing down an old public latrine and cleaning pollution at the wharves used by the steamboat ‘Obnovka’, and 1,500 on a latrine near a reinforcing wall on the north side of the harbor where the Obnovka transferred passengers. They spent 1,500 and 2,200 rubles respectively on procuring boiled water at the harbour during August and September and as compensation for medical personnel, but

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did not provide specifics regarding the 1,000 rubles reserved for unforeseen expenditures.75 Soviet medical personnel were cleaning up vulnerable environments in places where the most at-risk individuals congregated as their predecessors in the zemstvos suggested and were spending more money on these tasks.

Applause from the West While Khavkin complained that English language sources did not accurately report the strength of the new Soviet government, he cited an article in the London Times on 20 August 1918 entitled ‘The Destruction of Cholera’. Recognising the presence of famine in Russia, the reporter noted that it was possible to ‘celebrate for cholera’, noting: ‘As the epidemic first widened, the Soviet Government carried out very energetic sanitary measures. The population was supplied with boiled water and in many places food and cholera vaccinations. Preventive measures under the Soviet Government were better organised than during the tsarist regime [. . .testifying] to their organisational talent’.76 Indeed, the Bolsheviks applied a military discipline and esprit d’ corps that pre-war, tsarist society never matched. The article verified the efforts the Soviets were applying toward sanitation, but the Times’ report was premature. The presence of famine in Russia, along with the ENSO events, entailed that vigorous sanitation would not stop cholera. Despite the remarkable energy of the Bolsheviks and the praise of Western admirers, the epidemic was not under control, and the response was far from adequate. By November, the cholera epidemic that had begun in July rivalled ‘The Great Petersburg Cholera of 1908– 10’.77 Reports from other Western news sources painted a grim picture of the epidemic. The New York Times recorded the reports of German newspapers. On 24 August, the Weser Zeitung of Bremen received a dispatch from Petrograd regarding the cholera and typhus epidemics, stating ‘the populations of entire villages are dying in great numbers’. On 25 August, a New York Times headline read: ‘Epidemics in North Russia: Starving Population Swept by Cholera and Typhus’.78 A disruption in services and transportation resulted in devastating shortages; as usual famine was the catalyst for the epidemic. In various locations people did not have bread and were subsisting on oats. The Moscow correspondent of the Du¨sseldorf

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Nachrichten sent a dispatch stating that the railroad between Moscow and every province except Tver’ and Tula was out of service. The Bolsheviks controlled the lines, but encountered ‘passive resistance’ from railway workers, while counter-revolutionaries blew up bridges and destroyed tracks.79 Greater Petrograd remained cut off. In such conditions, cholera carriers were perhaps less of a problem than famine and temporary reservoirs of the disease, such as the water channels, ports and estuaries. The epidemic continued to build up momentum. By 7 September, statisticians had recorded 31,402 cases of cholera.80 A. N. Sysin presented these figures at a meeting of the Central Committee of Narkomzdrav RSFSR on 17 September to Tarasevich, Dobreitser, Diatropov, and representatives of the Main Military-Sanitary Council and Sea Commission. The new Commissar of Public Health, N. A. Semashko, a former Pirogov member, longtime Bolshevik and Lenin associate, and other physicians were present. They discussed the diffusion of the epidemic, payment for and distribution of vaccines and produced an estimate on the costs of anti-cholera measures and the organisation of a Museum of Social Hygiene in Moscow.81 Semashko and his deputy A. V. Mol’kov, were the proponents of Social Hygiene. The Central Committee emphasised sanitation and hygiene since World War I had caused so much neglect.82 The report said little however about the social deterioration caused by War Communism. The statistics of the Soviet statistician I. G. Fedorov indicate that the 1918 Cholera Epidemic in Petrograd was in some ways even worse than the epidemics in 1892 and 1908 (presented in Tables 6.1 and 6.2). The worst districts in the city limits in total cases and death rates per 1,000 residents in 1918 were Vasilevskii Island and Aleksandro-Nevskii. Narvskii and Rozhdestvenskii occupied third and fourth places for the total cases, but Vyborg district claimed third place in regard to morbidity. Of the 12 major districts in the city, all but three suffered from higher morbidity rates than they had in 1908 and 1892. The only improvement since 1908 occurred in the Petrogradskii and Spasskii districts, which experienced less morbidity than in the previous epidemics.83 Although the statistics in Rozhdestvenskii District were lower than in 1908, this was due to the extreme number of cases and morbidity that it had suffered in that earlier year. The highest degree of improvement probably occurred in Petrogradskii district. In 1892, only

Table 6.1 Cholera cases and suspicion of cholera by district in St Petersburg/Petrograd, 1892, 1908 and 1918 1892 District Vasilevskii Vyborgskii Petrogradskii Al. Nevskii Rozhdestvenskii Narvskii Spasskii Kolomenskii Moskovskii Liteinyi Kazanskii Admiralteiskii

Absolute Number

Coefficient per 1,000 population

719 319 480 450 414 325 317 164 274 116 71 35

7.8 7.0 6.2 5.8 5.4 3.7 3.0 3.0 2.1 1.4 1.3 0.9

Absolute Number

Coefficient per 1,000 population

1,247 1,267 1,027 555 960 365 724 377 784 374 167 74

9.2 7.4 5.4 5.1 5.0 4.3 4.2 3.9 3.7 3.0 2.9 1.9

1908 District Rozhdestvenskii Al. Nevskii Vasilevskii Spasskii Narvskii Kolomenskii Moskovskii Vyborgskii Petrogradskii Liteinyi Kazanskii Admiralteiskii

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Continued

1918 District Vasilevskii Al. Nevskii Vyborgskii Rozhdestvenskii Kazanskii Moskovskii Kolomenskii Narvskii Admiralteiskii Liteinyi Spasskii Petrogradskii

Absolute Number

Coefficient per 1,000 population

1,483 1,132 509 781 238 778 353 886 121 455 296 629

12.1 9.5 8.5 7.4 6.2 6.1 5.7 5.7 5.6 5.2 4.2 3.4

Source: I. G. Fedorov, ‘Epidemiia kholery v Petrograd v1918 g: Po predvaritelnym Statisticheskogo Podotdela Mediko-Sanitarnogo Otdela Komissariata zdravookhraneniia’, Izvestiia Komissariata zdravookhraneniia soiuza kommun sev. Oblasti, no. 1 (noiabr’ 1918): 87.

Vasilevskii Island suffered a higher number of cases and it had the third highest morbidity coefficient in the city, suffering 480 cases and .62 per cent morbidity. By 1918 the so-called ‘Petrograd Side’, which was located across the Neva from Admiralteiskii district, had a lower morbidity rate, 0.34 per cent, than any central district.84 One of the problems for officials in Petrograd was how to avoid the disease spreading to outer districts of the northern parts of the oblast’ and to other Soviet Republics.85 In the suburbs of Petrograd there were 1,830 cholera victims and 535 suspected of falling ill, amounting to 2,365 cases.86 Three suburbs, Novoderevenskii, Petergofskii and Okhtenskii suffered more than seven cholera patients for every 1,000 inhabitants (0.7 per cent).87 The suburb of Novoderevenskii, which was in Primorskii District, had the worst morbidity rate in Petrograd Oblast’, suffering 21.2 cases of cholera for every 1,000 residents (2.12 per cent).88 Other suburbs such as Poliustrovskii and Shlisselburgskii received little service from the Petrograd waterworks.89 Poor water sources caused certain districts to suffer a disproportionately.90

Table 6.2 Daily numbers of cholera cases and deaths in Petrograd for July, August and September, 1918 July

August

September

Date

Cases

Deaths

Cases

Deaths

Cases

Deaths

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Total

7 6 14 30 44 53 302 595 825 714 527 639 525 422 454 424 322 331 333 244 196 193 181 209 199 154 150 143 159 135 105 8,625

2 1 2 1 10 12 31 88 166 221 213 183 197 216 200 177 155 141 134 127 110 68 88 71 82 93 49 56 59 75 44 3,072

138 98 118 103 106 121 129 125 98 94 84 100 77 88 76 69 60 59 53 62 51 59 36 47 28 43 28 35 40 55 48 2,331

44 47 35 41 57 48 52 48 36 35 38 36 26 26 22 30 23 18 17 13 21 18 15 16 18 14 15 4 15 12 11 851

47 45 60 47 40 32 61 34 35 61 46 33 46 34 34 43 39 42 22 43 32 42 18 24 21 23 18 31 25 25 – 1,091

20 15 17 18 11 16 12 20 12 8 15 13 16 19 15 14 11 10 16 8 10 10 7 13 7 4 8 9 6 12 – 372

Source: I. G. Fedorov, ‘Epidemiia kholery v Petrograd v1918 g: No predvaritel’nym Statisticheskogo Podotdela Mediko-Sanitarnogo Otdela Komissariata Zdravookhraneniia’, Izvestiia Komissariata zdravookhraneniia soiuza kommun sev. Oblasti, no. 1 (noiabr’ 1918): p. 82.

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A breakdown of the water system in Novoderevenskii in Primorskii District, provided the vibrio with a major boost. The population of Staryi Derevni of the Novoderevenskii suburb in Primorskii district was using polluted water, taken from the lower Great Nevka River and sections of Che¨rnaia Rechka (Black Creek). In 1916 – 17, during the height of World War I, the city sanitary council erected a series of simple constructions along the shoreline of the Great Nevka designed to chlorinate the drinking water. Residents procured water in buckets or barrels from these branches, but in the summer of 1918 (the height of the epidemic), a station broke down, spreading the vibrio and causing a number of casualties.91 Improvement in sanitary engineering was a gradual process, particularly in places stressed by poor geoepidemiology, intense demographic movements and famine. Khavkin noted that by the time of his article in November the epidemic had been ‘localised’, meaning that it was no longer spreading to adjacent districts.92 However, containing the outbreak in November, when seasonal cholera epidemics generally lost impetus, was not a great accomplishment. Khavkin soberly observed that the 1918 epidemic served as a test for medical-sanitary work and social construction. Predictably, he condemned tsarist medicine and the Petrograd city commission for the spread of earlier epidemics, but did not reserve criticism to the previous government. Admitting that the 1918 epidemic had claimed many lives and required huge expenditures in labour and medical personnel, he lamented the wasted materials and medicines that might have been used for other purposes. He conceded that Narkomzdrav RSFSR should have taken advantage of the rare peace in April 1918 to prepare. As conditions deteriorated, war broke out, and the city was left undefended; it was then that the vibrio struck Petrograd during the rebuilding of its ‘medical-sanitary apparatus’. Khavkin traced the epidemic to migration from the front in 1917, which saturated the city (particularly the downtown districts) with smallpox, typhoid, relapsing fever, intestinal bowel disorders and bloody vomiting. He commented that Petrograd was predisposed to unsanitary conditions, and admitted that Narkomzdrav RSFSR ‘should have been anticipating and preparing for the worst’. The city was plagued by hunger, filth, disruption of transport services and the labour force. Khavkin lamented that this state was altogether too usual for Petrograd.93

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Khavkin, it should be remembered, was one of the firebrands of the Pirogov Society who had castigated the tsarist government for its failure to act at the outbreak of World War I. His continued leadership and willingness to criticise the Bolshevik regime and its failure to take sufficiently quick action, as in 1914, marked a continuation of pre-war problems. In 1918, the epidemic even broke out before the army had started to mobilise. The famine came about due to continuation of the policy of food requisitioning, first ordered by tsarist administrators, then carried out in the Provisional Government and continued with even greater vigour by the Soviets. This only succeeded in disrupting the local government markets that had long fed the Russian people. The breakdown of water sources in Novoderevenskii District was more of an accelerant than a cause of the epidemic. Figure 6.1 illustrates how these conditions made the Petrograd 1918 epidemic even worse, in some ways, than the St Petersburg epidemics of 1892 and 1908. The disorder in 1918 somewhat altered the pattern in which cholera generally attacked the suburbs. The microbe did not spare the central districts in 1918, particularly Kazanskii and Admiralteiskii District, which ranked fifth and ninth respectively in mobidity in 1918. Admiralteiskii District was the most prestigious and perhaps wealthiest district in the city. Meanwhile, on the northern side of the Neva River, both Vyborg District and Vasil’evskii Island, which had improved in 1908, now suffered greater numbers of cases and fatalities than in 1892. Housing thousands of working class citizens, the revolution had in fact only brought these citizens greater suffering (see Figure 6.1). When one considers the plethora of diseases that flourished in 1918, there is little doubt that grain requisitioning both under the Provisional Government and Bolshevik War Communism brought widespread suffering to the city. In other respects, the Petrograd cholera epidemic of 1918 was little different than the epidemics of the past, characterised as an ‘explosive’ waterborne epidemic. Beginning with a rapidly accelerating numbers of cases, the epidemic continued at full impetus for a short time, peaked, then lessened by the third week, when the daily average fell to approximately 329 cases; this amounted to a 50 per cent decrease. This abatement continued until the end of September, when 160 cases occurred over the final seven days (see Table 6.2).94 As Fedorov reported, when charted by a line graph these figures created ‘a sudden rising at the beginning, development over a few days to the apex’, where

Figure 6.1 Cholera in St Petersburg/Petrograd, 1892, 1908 and 1918. Source: Professor Richard Gilbreath, Department of Cartography, University of Kentucky.

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it remained for a short period before descending into ‘a long tail of sporadic cases’.95 In this regard, the 1918 cholera epidemic in Petrograd was a ‘classical’, nineteenth-century style epidemic, of the type that struck Hamburg and St Petersburg in 1892 and the latter again in 1908. In 1918, cholera did not spare the central districts, neither Kazanskii nor Admiralteiskii District. Both had the least concentration of cases in 1892 and 1908, but were struck harder in 1918. The concentration of cases in the areas surrounding the Nevskii Prospekt in Admiralteiskii District and the Vyborg factory district, perhaps reflect the revolution’s role in the epidemic. St Petersburg/Petrograd experienced three classical cholera epidemics within a 30-year period. The measures that Russian physicians advocated were designed to prevent or limit the spread of the disease. They isolated patients, their families and their ‘circle’ of associates in special hospital rooms, conducted bacteriological examinations of their feces and attempted, as one Soviet physician observed, ‘to kill the infection at the very place where the onset of the disease was detected’. They boiled linen, disinfected rooms, cleaned courtyards and cesspools and closed down wells.96 This intense application of measures would indeed become a vitally important component of the Soviet anti-cholera strategy, but could not hope to counteract the effects of famine in 1918. Increased contagious measures, no matter how strictly applied, would have proven impotent in stopping cholera in 1918. The Bolsheviks regularly reported their activities, an indication of an increased sense of autonomy and progress in communications. Due to its status as a Bolshevik base, the Vyborg District Medical-Sanitary Department Emergency Commission for the Struggle with Cholera took a leading role and proved particularly adept at communications. On 29 July 1918, the Commission sent a dispatch to the Council of Chancelleries of Narkomzdrav RSFSR describing the measures that its physicians had taken in 12–28 July. ‘In Vyborg’, the report began, ‘the Medical-Sanitary department shows concern for all of the commissions and proceedings of the central organs of medicine. Moreover, it oversees the organisation of sanitary conditions and sanitary work in its own district’. The commission elaborated that its sanitary-medical department coordinated the work of sanitary physicians who served the commune, urban residents, workers at places where cholera prevailed, housing directors, cultural educators and the Commission of

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Labour, carrying out ‘general measures to improve the organisation of sanitary and medical work’.97 This report reflected the Bolsheviks’ broadening approach to cholera and general public health, which included coordination with civil authorities and educating the public. Every ten days, personnel distributed notifications to sanitary physicians regarding concerns such as homes and apartments that were condemned. These observations were presented to the Soviet’s Department of the Local Population at meetings where party officials planned and carried out the logistics of moving people from undesirable locations to suitable living quarters.98 This work required cooperation with both civil authorities and the general populace, stressing both geographic and demographic threats in various locations. This reflected the type of public interaction that zemstvo and European authorities had routinely espoused. The continued improvement in government-public cooperation and regional communication were important in stopping cholera in the Soviet Union. Responding to Logistics Director Zabolotnyi’s request to gain microbiological intelligence in the upper Volga region and on the Kama River, the physician E. Kolesnikova and her colleagues at the Institute of Imperial Medicine chose a propitious place to begin.99 On 15 September 1918, another female physician, A. I. Belousova, reported that the task force had begun their work in the laboratory in Rybinsk. The first cases of gastroenteritis had appeared there at the end of June, providing the investigators with material for study. They detected the presence of the vibrio on 5 July and by 1 September there were 50 cases. Investigations later in September turned up negative results. From Rybinsk, Belousova and her colleagues travelled to a cholera conference for the oblasts of the Upper Volga in Kostroma. The discussion revolved around preventive vaccination and bacteriological investigations. Belousova carried out her investigations in the laboratory in Kostroma, isolating several types of microbes, then the group moved to Iaroslavl’ and Uguche. Planning to move on to the Kama River, Belousova was forced to cancel the trip, noting her intention however to soon resume study on ‘water and bowel vibrios: related to cholera victims’.100 Zabolotnyi, Kolesnikova, Belousova and other laboratory specialists at the Institute of Experimental Medicine were taking a leadership role against cholera by gathering and distributing vital, geographically specific intelligence. A cholera conference during the early period of war

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reflected the influence of the Pirogov Society and zemstvo medicine on the development of Soviet public health. Consolidation of governments permitted fuller cooperation and participation. Planning and concentrating on the Upper Volga River valley and surrounding districts, which were central points of cholera diffusion and warfare, reflected a continued commitment to improving a system that had been adopted in 1903 and developed in the latter years of tsarist rule. The use of surveillance rather than extensive quarantine adhered to accepted international practices since 1903. Personnel observed checkpoints, isolated patients and suspected cholera carriers, disinfected wharves, and performed related measures along the ways of transportation. Following his instincts, Zabolotnyi had pursued the link between the environment, natural conditions and disease since 1892. The contribution of Zabolotnyi and the female scientists of the Institute in furthering epidemiological intelligence cannot be quantified, and their goal of producing an immunised population against cholera would soon be come to fruition. Local medical departments worked with citizens in their districts, concentrating on feeding starving people, hydrating them with clean water and other sanitary concerns, particularly in extreme situations such as those caused by climate or poverty. As in Saratov in 1915, the Vyborg Medical-Sanitary Department issued directives for opening cafeterias and bakeries to help feed people and requested that citizens report any case of cholera among workers in the district to their sanitary physician and medical-sanitary department, who initiated directives to prevent an epidemic. As the Saratov SEC had done in 1904, officials in Vyborg district discussed measures for improving sewer systems and plans for supplying clean water to inhabitants on the outskirts. The representatives of residence committees and other local organisations assisted these efforts and found people appropriate housing. The Medical-Sanitary Department opened outpatient facilities and distributed flyers offering to assist patients along the borders of the district.101 They knew that they needed broad public cooperation, particularly in the outskirts of municipalities where migrants gathered, to compensate for limited municipal services by promptly responding to immediate threats. Greater numbers of personnel operated at new checkpoints and used new technologies. The medical-sanitary department in Vyborg District

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opened three cholera check points where medical personnel were available on a 24-hour basis. At each check point, there was at least one physician, two disinfection specialists, three sanitation specialists and a ‘telephonist’. Personnel used automobiles and two-wheeled carts to transport patients and their belongings to cholera hospitals. Flyers provided the telephone numbers for locations where workers carried out cholera vaccinations.102 Reports increasingly listed telephone numbers.103 In 1918 the Emergency Assistance Department for Narkomzdrav RSFSR in Petrograd listed at least eight telephones, two numbers for the telephone bureau, one for the payment section, three for emergency assistance and two for response and transport of patients.104 A report of the medical-sanitary section in Petrogradskii District in 1919 noted that the division had a telephone and planned to begin 24-hour reporting through three telephonists.105 The Soviets employed more personnel and technology, resulting in better communication and response. The technologies were only recently available, but the Soviet’s love of technology helped improve a system of checkpoints and notification that had evolved from the tsarist military and administration. The intelligence gathered by Fedorov and local reports such as those in Vyborg district facilitated the formation of effective plans, such as proposed construction of new stations in the suburbs of Poliustrovskii and Lesnoi, which had high cholera rates.106 In 1918 Poliustrovskii suffered 119 cases of cholera and a 0.64 per cent mortality rate, while Lesnoi experienced 68 cases and 0.18 per cent mortality rate.107 The Vyborg Cholera Commission hired medical assistants to construct isolation apartments in Lesnoi, but insufficient equipment caused delays. The commission also planned to place additional isolation apartments near the Finland Railroad Station and on B. Samsonievskii Prospekt; the railroad station required maximum efforts and extra facilities.108 Using tsarist legislation, the Bolsheviks tried to compensate for shortages with stricter measures along the railroad. Citing a 1912 order, on 3 August 1918 the Administrative Department of the Commissariat of the Petrograd Military District Ways of Communication communicated its intention to enforce strict anti-cholera measures along the railroads: With the appearance of the first suspicion of cases in Petrograd, the Commissariat of the Petrograd Military District of the Ways of

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Communication as proposed by the local councils of the railroad are to prepare all means in anticipation of the struggle with epidemics, as it applies to the Rules for prevention and spread of cholera and plague along the railroads (enacted between) 30 July and 16 August 1912.109 By citing a set of orders for preparation on the railroads and adaptating the Petrograd military district of the Kazan’ military district’s points along the Volga River in 1908, the Bolsheviks were still effectively operating under the tsarist administrative apparatus. Both evolved from the tsarist Cholera Rules of 1903, a strategy in which authorities were expected to respond post haste. Designed as a preventive measure, the system’s success depended upon early detection. The adoption of the rule by the Soviets in an unmodified form indicates that they used both the tsarist legal and administrative infrastructure for anti-cholera legislation and emergency response measures not merely as a guide, but as established administrative law. The firm hand used in enforcing these measures reflected the increasing militarisation of Soviet society. The railroads were excellent places for the Bolsheviks to conduct checkpoints, education, vaccination and other programmes related to medicine, health and politics. They conducted propaganda programmes in close proximity to ‘towns, garrisons or railways’.110 Such places, where multitudes of citizens routinely came together in close proximity, promoted the viability of the Party, its health system, its vaccination programme and slowed down cholera transmission. A memo of the Petrograd Commissariat of the Ways of Communication noted that there would be boiled and chilled water available at every station during the arrival and departure of passengers, and that local societies would conduct strict supervision of any produce that was loaded or unloaded. Additionally, personnel would carry out the disinfection of garbage dumps, outhouses, cesspools and other potentially hazardous places along the railroad lines, carry out mass vaccinations, conduct lectures and distribute literature. The memo listed measures and equipment that would be available at various lines. For example, on the Nikolaevskii Railroad, the main line between Petrograd and Moscow, every station had two heated freight cars available, one for transporting and isolating patients, the other for family members.111 The Soviets opened pharmacies where travellers purchased medicine and bandages and

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received medical advice. Well trained medical assistants, the aforementioned feldshers, ensured disinfection of linens and organised two or more disinfection detachments for patient needs, including cleaning infected wagons.112 The militarisation of medical workers and societies in staffing and inclusion of pharmacies ensured better health care along the lines. Nevertheless, the epidemic continued to widen. The Commissariat planned to have sufficient beds along the routes, providing 30 for the hospital of the American built Aleksandrovskii factory, which was located near Petrograd, 50 in other sections of the hospital and 30 in a newly constructed, second cholera barracks in the courtyard; a total increase of 110 beds.113 The 50 general beds were immediately available to receive cholera patients, and the Soviets planned the construction of cholera barracks at other stations, including Malaia Vishera, which had 20 beds and Bologoe and Tver’, which had 15 each. The Commissariat composed contingency plans in case patients turned up at unexpected points on the railroad and could open barracks with 15 beds each at Moscow Station, Ostshkov and Velikie Luki and ten at Toropets.114 Such in-depth planning mirrored the work of Teziakov, Dobrietser and the trustees in Saratov during World War I. In order to assist in the detection of cholera carriers, the Commissariat placed physicians’ observation and isolation points at stations where they expected gain the most patients, who were primarily treated in the district hospital of Petrograd and Bologoe I or II, Moscow Station or Velikie Luki. The agency also planned to build a cholera barracks at Chudovo or Volkhov to observe passengers on the Nikolaevskii and Moscow-Vidavo-Rybinsk railroad networks (see Figure 6.2 below).115 Understandably, Petrograd officials were concerned about threats from large urban centres like Moscow and Rybinsk. On the Nikolaevskii line, the Commissariat arranged for chlorine treated water to be given to passengers, and carried out anti-cholera vaccinations at both physicians’ observation points and hospitals in all medical sectors.116 These activities were designed to detect cholera carriers and prevent travellers from falling ill; the agenda was even more intense than the one carried out in Saratov Province in 1915. The Commissariat pinpointed locations they considered problematic, which included the Novyi Derevnyi or Novoderevenskii suburb. Located along the Gulf of Findland, the Primorskii District Petrogradskii-Sestroretsk Railroad posted personnel

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on 24 hour duty at stations, to supervise and aid exiting and entering passengers with two sanitary wagons reserved for isolation and anticholera vaccinations, with the same duties being implemented at the Okhta Station.117 Every railroad station in Petrograd retained means for transporting and placing patients in the hospitals.118 Unfortunately, none of these preparations stopped cholera from moving freely in Soviet Russia in 1918. By 17 August, the MedicalSanitary Section of the Commissariat of the Ways of Communication reported 1,010 cases along the nation’s railroad lines.119 The lines that crossed or ran adjacent to water routes such as the Volga and Mariinskaia system between Rybinsk and St Petersburg were particularly dangerous. Between 9– 15 August there were 32 reported cases of cholera, with 28 occuring on the Nikolaevskii and Uralsk– Riazan lines, which serviced the Petrograd and Lower Volga regions respectively. Authorities detected 14 cases on the latter at the stations Ershov, Kozlov, Rtishchevo, Saratov, Riazan and Penza, while the same number occurred along the former at the Aleksandrovskii factory, Bologoe, Tosko and

Figure 6.2 Railroad network between Petrograd and Rybinsk/Iaroslavl’. Source: Professor Richard Gilbreath, Department of Cartography, University of Kentucky.

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Farforovnyi Post.120 By 27 August there were 1,232 documented cases of cholera along the nation’s railroad lines.121 Despite their knowledge of the vulnerable locations, Bolshevik efforts to stop the disease were insufficient. Physcians in northern cities knew that cholera from the Lower Volga threatened them. An article in the Nizhnii Novgorod Leaf expressed with trepidation that sanitary conditions at the Tsaritsyn railroad station were ‘truly tragic’ and the Tsaritsyn wharves ‘in no better condition’.122 During a meeting of Narkomzdrav RSFSR on 17 September, a certain Dr Abramov presented a diagram of the deaths and mortality in Tsaritsyn. Located between Astrakhan’ and Saratov, the city had experienced 36 deaths and 41.5 per cent death rate in May, 91 deaths and 33.3 per cent death rate in June, 584 deaths and a 45.5 per cent death rate in July and 237 deaths with a 54.4 per cent death rate in August.123 Cited as the location where the first cases turned up in 1908, the vulnerability of the city troubled physicians. Narkomzdrav RSFSR increased the observation of passengers and the gathering of intelligence on all railroads. During the Moscow meeting, a doctor named Lysakovskii observed that there was significant development of cases along the railroad lines in Tula Province. The greatest number occurred where passengers arrived from agricultural provinces.124 This movement was likely due to the famine. On 7 September, the Briansk District Commissariat of Public Health sent a telegram to the Council of the Moscow-Kiev-Varozhozhskoi Railroad in reference to a resolution passed during a meeting on 31 August. The Commissariat ordered feldshers to inspect railroad passengers to prevent ‘the carrying of cholera into the district and city by individuals who enter at the junction of the stations of Briansk, where masses of passengers gather’.125 The Soviets pursued intervention along the lines with their customary military vigour, but in 1918 the vibrio was unstoppable. Narkomzdrav RSFSR matched this energy by distributing large sums of money for measures along the railroads and sought accountability. On 13 September, the Director of the Council of Chancelleries of Narkomzdrav under the direction of the social hygiene advocate, Mol’kov, requested the administrative division of the Petrograd Military District Ways of Communication to submit ‘a report on the expenditure of one million rubles to the district for anti-cholera measures along the ways’.126 This spending and measures did little to stop cholera, as the

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vibrio thrived on a weakened populace in population centres, particularly Petrograd.

Moscow versus Petrograd The disparity in the susceptibility to cholera of Moscow and Petrograd marks a chapter in the rivalry between the two cities. During the first 15 days of July, Petrograd experienced 2,663 cases of cholera as opposed to only 25 in Moscow. Over the next 6 days there were 1,497 cases in Petrograd, 45 in Moscow and during the next eight days there were 966 cases in Petrograd and 63 in Moscow.127 Altogether, Petrograd suffered a collosal 5,126 cases in July as opposed to only 133 in Moscow.128 Moscow’s better water facilities, high ground and organisational structure (which were the legacy of the excellent Moscow Zemstvo), unquestionably played a role in this disparity; but, as we shall see in the next chapter, the famine in Petrograd added much to the disparity. Petrograd also suffered more geoepidemiological risks that increased its vulnerability. Low elevation, the annual influx of merchants and products due to seasonal trade, low water channels running through the city, combined with its status as the so-called ‘Window to the West’ contributed to the city’s fate. Therefore, the disparity between casualties in the capitals was not entirely due to inequities in municipal and medical services. The Volga-Mariinskaia water system and railroad lines from Iaroslavl’ Province presented a grave threat to the Petrograd while, detached from the Volga, the ground in Moscow (chosen centuries earlier for defense by the Grand Prince Iuri Dolgorukii), was higher with an abundance of springs, ideal for creating fresh waterworks. Suffering 41,289 cases in 1918, the Bolsheviks experienced only 3,998 cases the following year.129 The medical service directors of the railroad sent a telegram to Narkomput (the commission that administered communication routes) and Narkomzdrav RSFSR, detailing the measures needed to procure high quality drinking water for the population. The telegram also suggested that it was necessary to circulate a weekly report detailing the bacteriological investigations of suspicious water sources and to increase invitations offered to specialists in assisting with sanitary oversight.130 Another telegram in late July 1919 addressed the need for even more beds at cholera barracks along the railroads.131 In combating a disease that struck quickly, the speed of response was essential.

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Unfortunately, by April 1919 shortages had derailed the Soviet vaccination programme. On 10 April Narkomzdrav RSFSR passed a decree ordering local establishments to assist the Institute of Experimental Medicine with issues relating to nutrition, fuel, agriculture and other activities, to facilitate the unhindered pursuit of its immunological work. On 29 July, the Institute complained that it was not receiving enough assistance and was inundated with Spanish flu, dysentery, cholera and other diseases. Laboratory workers called upon local institutions to supply firewood to heat their building. They lacked pens and paper, needed food to feed laboratory animals, preparative materials and medicine for experiments. The staff resolved to meet the needs of the medical establishments of the Russian Republic and Red Army; social support was imperative in stopping cholera.132 These precautions went for naught as cholera was already moving along the railroad lines. On 9 July 1919, cases began springing up along the stations of the Nikolaevskii Railroad and then in the populated areas around railroad settlements. On 22 August, a report from Novgorod of the Commission of Finances of the Northern Oblast’ stated that an epidemic was advancing from the outskirts of Petrograd Oblast’ and spreading to populated counties in nearby Novgorod Oblast’. As predicted, the vibrio entered the Kresetskoe and Valdaisko-Bologoe districts before it arrived at the final railroad station of Bologoe, which was located on the outskirts of Novgorod.133 Stopping cholera on the railroad lines was proving almost impossible and the Soviets were suffering the same frustration as their tsarist forbears, despite increased sanitary measures. In 1920 there were no confirmed cases of cholera on the water routes of the Northern Oblasts, except for a single suspected patient on the river in Totma who soon regained health. Physicians warily monitored sharp intestinal sicknesses and dysentery, which numbered 876 and 226 cases respectively.134 Workers continued to build observation points along the water routes where cholera was expected. These included floating sanitary barges around the wharves in Vologda and in the factories of Pechatkino in Sukhona District, Uste-Kubenskoe in the Kubna District of the Kubna system of Virtembergskaia, Totma of Sukhona District, the Ustiugskom, Kotlasskaia, Arkhangel’sk and Belomorsko-Arkhangel’skii medical districts.135 The observation of key points and monitoring of symptoms that cholera might be imminent, including sharp intestinal

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disorders and dysentery, a tsarist medical practice, had become an integral part of the Soviet early-warning system. The usual reduction in cases by the third year was a hollow victory and there was every reason to believe the disease would return.

Bolshevik Vaccination As mentioned above, the tsarist and Soviet obsession in pursuing vaccination was due, in part, to the influence of Pasteur, whom Russian physicians lauded. In 1920, S. I. Zlatogorov noted (incorrectly) that people did not know about immunisation or the cause of disease until Pasteur showed that the introduction of a weak infection into the body can gradually train the organism to acclimatise to a disease.136 Stating that modern science was capable of inducing immunity in animals against any disease, Zlatogorov observed that microbes introduced into an organism through repeated interactions cause bodily processes to work against microbes and their poisons, thereby providing a natural defense.137 In fact, as noted above, there were exceptions. Mechnikov had learned that cholera could not be introduced to frogs which, he believed, had a natural immunity to the disease.138 While Pasteur had not invented vaccination, the Russians had come to idolise him much in the same way as had the French.139 Zlatogorov was perhaps unaware that Lady Wortley Montagu, the wife of a British ambassador in Turkey in the early eighteenth century, brought the process of ‘engrafting’ or vaccination (for smallpox in this case) to the attention of English science.140 Sir Edward Jenner formalised a scientific method for vaccination for smallpox, ushering its use into the West.141 Yet, Zlatogorov’s eagerness in promoting Pasteur as the founder of immunology was not wrong, as the French genius had produced tremendous advances in the process. The struggle for ideas between adherents of Pasteur and Koch over epidemiology and between Paul Ehrlich and Mechnikov over vaccination had often caused Russian physicians to attack Koch’s work. By 1919 the flames of these theoretical wars were cooling, but not dead. The Samara physician, M. M. Gran, who had allied with Gamaleia and Taranukhin in 1909, observed that Koch’s experiments never adequately answered the question of why one person becomes ill while another does not. He noted that scientists had discovered that human

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blood matter contains natural defences; the white corpuscles that could consume and digest bacteria. When these particles entered the blood, the organism began defending itself from bacteria. Gran added that this defense worked not only through white blood cells, but also the body’s ‘liquid section, in serums’. Blood serum, the part of the blood that is not a cell nor associated with clotting, contained both an innate and acquired capacity to kill bacteria in the body. Acquired immunity occurred naturally, but could also be induced artificially to protect people from infectious disease.142 The two processes that Gran described, cellular and non-cellular immunity, represented the respective theories of Mechnikov and Koch’s colleague, the German Paul Ehrlich. Immunity explained why one individual became ill during a cholera epidemic while another did not.143 As with Koch’s vibrio, Soviet bacteriologists were incorporating Ehrlich’s theory with Mechnikov’s ideas. They viewed vaccination as the best chance for stopping cholera epidemics. Without mentioning Koch, Zlatogorov noted that ‘the discovery of the cholera microbe immediately sparked a great deal of thought about using Pasteur’s ideas to battle the disease’.144 He observed that to induce immunity against cholera, the immunologist must introduce living or dead bacteria into the human system, noting that Russian physicians had injected 70,000 people in Japan with two cubic centimetres of dead cholera microbes. These individuals universally failed to develop the disease while those who received one cubic centimetre often fell ill and died. Zlatogorov had performed experiments in Persia in 1904 in which 10 per cent of individuals who were not inoculated fell ill and 72 per cent died while the number for inoculated persons was 2 and 15 per cent respectively.145 His point was that vaccinations kept the number of cases small during World War I. By 1920, millions of people had been vaccinated in European nations, producing excellent results.146 The Soviets used tsarist experiments and experiences to verify the efficacy of vaccination. However, the practice was not a panacea. Acknowledging their limitations, vaccination programmes were becoming the bulwark of the Bolshevik anti-cholera programme, which was based upon the zemstvo principle of prevention. In the prerevolutionary period, tsarist physicians organised mass vaccination programmes against smallpox resulting in considerable decreases in the disease by the mid-1870s.147 In 1920, the Soviets produced 30,000 litres of cholera vaccine and, the next year, 27 million doses of cholera

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and typhoid vaccine and 2,144,000 for diphtheria.148 During the first ten months of 1920, nearly 4 million people attended lectures related to sanitation.149 The idea of protecting the public and quelling panic with one procedure reflected how the Bolsheviks used European medical concepts, building on tsarist construction of public health and propaganda to win public approval during the Civil War. Russian physicians’ experiences with vaccination led to new knowledge. Like Tarasevich earlier, Zlatogorov asserted that cholera vaccinations presented no harm to humans and were worthwhile even if they prevented one case in ten. He stressed that vaccination against cholera did not protect the patient over a lifetime, but only for one year. However, if physcians vaccinated someone ‘as soon as the first cases of cholera are detected’, the patient developed immunity in five to seven days.150 Zlatogorov suggested vaccinating very young children then working through the population by age to the elderly. Individuals suffering fevers, he observed, should not be vaccinated.151 The idea of targeting the most vulnerable populations and those imminently threatened was compatible with the emergency response strategy. Noting that the Bolsheviks were building good sanitary and cultural conditions to improve people’s lives, Zlatogorov’s main point was that vaccination, along with a broad public education, helped to subdue mass fear. Vaccination proved compatible with propaganda in controlling fear and avoiding cholera riots.152 During the first ten months of 1920, nearly 4 million people attended lectures related to sanitation.153 Russian physicians understood that vaccination, even if imperfect, worked to stop disease and prevent panic, rioting and the flight that spread cholera during the tsarist period. Disciplining and pacifying the public was an important aspect of cholera control.

General Shortages and Other Problems Despite increasing financial endowments and progress in sanitation and communications, logistical and material problems continued to materialise. Medical officials were, for example, unable to comply fully with a circular of Narkomzdrav RSFSR from 9 February 1920 concerning the organisation and deployment of detachments for vaccinating targeted populations. Unable to staff these detachments, they feared that emergency one-time vaccination to passengers and crews

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in transit would be insufficient and lacked the means to administer a second. Some local councils did not have enough emergency rooms at checkpoints and instructions for dealing with patients along the water routes went undistributed.154 In absence of improved local and economic support, Narkomzdrav RFSFR was helpless against cholera.

Conclusion Absolutely every citizen must be supplied with brochures, attend lectures and otherwise become familiar with cholera, its causes, and the measures for resisting it [. . .] every citizen must at least take an active part in the struggle with cholera, especially now that the working masses have taken power into their own hands.155 M. M. Gran, 1918 Whether rhetoric or sincere, socialist ideology was helpful in motivating a disciplined public, but technical prowess and the intelligentsia proved impotent against cholera in the face of insurmountable social obstacles. In 1918– 21, the Bolsheviks had vigorously pursued massive sanitation efforts, increased surveillance, vaccination and education, but were not successful in creating stable epidemiological conditions. Grain requisitioning had proven disastrous. The lack of food and onset of disease in various regions rivalled the Time of Troubles in the sixteenth and seventeenth centuries, derailing the Empire, then the Provisional Government and now seriously threatening the Soviets. The Party improved the system of check points, increased hospital beds and sanitary measures along the railroads and wharves and contagionist measures along railroads and water ways, partially fulfilling the vision of zemstvo and railroad reformers, but these actions had not stopped cholera and the years ahead proved some of the worst in Russian history Resistance to the Bolsheviks mounted. During the White Offensive in the winter of 1919 peasant bands known as Greens emerged and by mid-1920 were rebelling in Tambov, Saratov and other Volga Provinces. Economic conditions plummeted and, by winter 1920– 1, the famine became catastrophic.156 The effects of famine and threat to the new order convinced the Bolshevik political elite to concentrate on improving social conditions. Helpless against disease during war and faced with

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multiple crises, Lenin gave his medical chiefs autonomy to rid the nation of disease, but unlike in the tsarist period, held them accountable for the job. Henceforth, the government pursued all practical measures to improve the condition of the country, an approach that continued throughout what Lenin called the New Economic Policy, or NEP. The government permitted limited private ownership of the means of production, markets and food sources. They continued to rely upon the framework provided by the tsarist Cholera Rules and pursued more strongly than ever every resource in their power to prevent further cholera epidemics. Bacteriologists and immunologists explored the connection between the cholera vibrio and what they understood as the greater nemesis, famine. They viewed the development of epidemics as a complicated process involving factors beyond human ingestion of the cholera vibrio. Gran echoed a common refrain: physicians, scientists, societies, activists and every person in the new workers’ republic must participate in eradicating cholera. Gran observed in 1919 that citizens needed to educate themselves to keep from falling ill, but also asserted that the government needed to wipe out hunger and other conditions that weakened society. They needed to keep homes, outhouses and courtyards free of conditions that might cause cholera multiplication and to clean and disinfect wharves. Physicians needed to monitor populations, stringently enforce isolation and control human migration, particularly those arriving from places where cholera prevailed. Physicians needed to find more effective disinfection means to kill bacteria in dresses, linen and other items.157 Such measures were technical, but included public education and cooperation. Infighting between factions in public health remained, but the theoretical divisions that had prevented a consensus before World War I were disappearing. Soviet bacteriologists almost universally accepted Zabolotnyi’s view that they needed to examine the environment and gather intelligence about relationships between microbes, nature and built environments. Environmentalists and hygienists knew that various types of microbes affected the human organism differently. Russian physicians were increasingly considering the human organism as a component of cholera aetiology, understanding that increases in the severity of certain intestinal disorders was a sign that cholera was imminent. They monitored bloody vomiting, sharp intestinal disorders

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and gastroenteritis. Vaccination provided limited immunity, but contributed to lower morbidity and mortality. The practice used technology, involved mass segments of the population and was preventive in nature, pulling the tenets of Odessa and Moscow bacteriologists together with Pirogov and zemstvo advocates. The opportunity to engage the population also presented more sinister possibilities. If social and human conditions might be scientifically controlled, then perhaps a group of elite specialists or a political faction might use the technology to amass and hold power. Examination of the documents of the early 1920s and the benefits of hindsight reveal the origin of darker objectives, masked by the admirable intentions of eradicating a dreaded disease.

CHAPTER 7 THE NEW ECONOMIC POLICY (NEP), 1921—8

The programme which Lenin and the Bolshevik leadership put together to control cholera in the Soviet Union, after the Red Army’s victory in the Civil War, must be considered in view of the New Economic Policy (NEP). At that point, social and economic conditions in the USSR were at such low ebb that national survival depended upon improvement. The political crisis that faced the Bolsheviks in 1921 was ‘far-reaching and systemic’. And while the NEP, which permitted limited private markets, was effective in some locations, the Lower Volga region, Saratov, and other cities suffered until 1924. Having previously experienced the lowest population decreases in the country in 1917 –20, the populations in the Lower Volga and Urals provinces now experienced heavy losses, including 7.7 per cent in Saratov Province. Dependency on state-run institutions jumped to 16.9 per cent after the famine in 1921– 2 and three waves of refugees descended on the province. Internecine struggles in Saratov and other places resembled the border struggles in the United States after the Civil War in Missouri, but were larger, broader, more complex and much more violent. The Reds struggled for supremacy against the Whites, the Bolsheviks against fellow socialists and local populaces. They drew soldiers into their ranks and workers formed militia units.1 The Russian republics knew no reprieve, as the strife that had begun during the 1905 Revolution turned into war in 1914, and subsequently into civil war and a continuation of ideological conflict.2 Both social hygienists and general hygienists

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struggled over control of public health, but more importantly, ideological, revolutionary and military conflicts brought ideas long dormant in public health bubbling to the surface. This began to forge a system of public health based upon raising the material and social circumstances of the Russia people, an approach consistent with Lenin’s New Economic Policy.

The Troubles in Saratov Province, 1921 Despite grain requisitioning, the food supplies in Saratov Province were reasonably good until a low crop yield in 1920 spurred a crisis. By February 1921, there was nearly 30 per cent less available food than the previous year. The government then curtailed requisitioning, restricting rationing to soldiers and industrial workers in the north, and permitting local markets to resume. The government imposed only a modest sales tax. Suddenly, in April, the price of rye flour rose drastically and a serious drought made it obvious that the harvest would fail. Panic ensued, prices rose and food consumption sharply declined. The free market price of rye flour in Saratov, which had previously been lower than in Moscow, sharply increased and became higher, an imbalance that continued until August 1922.3 These high produce prices in Saratov would prove disastrous. The military and epidemic campaigns in Petrograd had forced some improvements and people in the port on the Baltic Sea were beginning to enjoy a slight reprieve, but in the Lower Volga River region, where the Bolsheviks were attempting to consolidate their power, the native Russians suffered horribly. Many were furious with the Communists for the starvation that grain requisitioning had brought, peasant bands roamed the countryside engaging in theft and vandalism and some fled the province. Parents abandoned their children, who gathered at local Soviets searching for food. Workers searched Communists whom they suspected of hiding grain. Some Soviet officials enriched themselves at the expense of the peasants, who at times curtailed cultivation and production to avoid losing even small surpluses to the Bolsheviks. In October 1921, the Bolsheviks appropriated nearly 90 per cent of the harvest in Saratov Province. In Moscow, with its formidable facilities and favourable location, Soviet officials denied the first reports of famine, but suffered from drought and unusually hot weather.4 These imbalances

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caused citizens of the Volga region and Moscow to suffer famine and cholera. Understanding that famine and social conditions influenced disease, nearly all physicians agreed on an agenda emphasising prevention, a variety of anti-cholera measures, technological improvements and addressing weaknesses. Tarasevich and other physicians tried weakening the vibrio through a systematic elimination of both the breeding grounds that permitted it to thrive, and increased immunity in human hosts. They targeted vulnerable locations through massive vaccination campaigns, addressing famine and making select improvements in sanitation and water provision. In the Lower Volga and in other areas, the Soviets were not able to build public facilities that permanently elevated the living conditions of the people, but used the knowledge gained through epidemiological intelligence and statistics to more effectively employ the prior tsarist system of response. The years 1921–4 saw continued famine and disorder on the Volga, but the Soviets prioritised the struggle against cholera, which paid some dividends. The number of cases could have been much worse. They began turning their attention to social problems, public education campaigns, measures along the railroads and water routes with tremendous zeal and many bacteriologists, immunologists and hygienists began embracing social hygiene.

Social Hygiene and General Hygiene The new Commissar of Public Health, N. A. Semashko, was an advocate of a broad approach to medicine known as social hygiene, a practise which considered connections between social problems and their relevance to hygiene, sanitation and disease. Social hygiene shared much in common with the platform of general hygiene that physicians such as Erismann and Khlopin had espoused. The concept of social medicine was not new in Russia. As noted above, tsarist physicians had viewed hygiene broadly. The prevailing theory holds that advocates of social hygiene in tsarist Russia failed to define the areas of the theory that fell outside the parameters of general hygiene, including everything ‘that had a vaguely social cast’.5 Indeed, interest in social hygiene and eugenics coincided with one another since 1905 and neither had blossomed due to loose definition.6 In 1921, proponents of social hygiene such as Semashko and

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his deputy, A. P. Mol’kov, both former Pirogov members, emphasised that social hygiene was an independent discipline based upon German soziale Medizin.7 This almost certainly amounted to an effort to distance this concept from any connection with tsarist roots. In the early 1920s, Soviet public health drew upon these intersecting concepts of European social and tsarist zemstvo medicine. The real struggle between general and social hygiene concerned bureaucratic survival. The sources fail to reveal Semashko’s exact conception of social hygiene. In his textbook, the Principles of Hygiene, the primary proponent of general hygiene (St Petersburg Professor G. V. Khlopin) invoked the names of Erismann and A. P. Dobroslavin. Dobroslavin had taught at the Military Medical Academy in St Petersburg from 1871 to 1889. A hygienist, like Erismann he had emphasised analysis of social conditions in investigations of disease. Khlopin argued that severing social concerns from general hygiene would limit his discipline to laboratory investigation by removing ‘the protection of labor, community nutrition, reform of housing, and sanitary legislation’.8 Semashko, on the other hand, did not mention any tsarist roots and proudly emphasised the distinctly German origin of the methodology, stating that the discipline was new to Russia.9 He noted that the old formula, ‘microbe þ organism ¼ (physical) environment ¼ disease’ was outdated and should be replaced with analysing social factors.10 In fact, the theory that Semashko considered ‘invalid’ is clearly a descendant of Max von Pettenkofer’s ‘x þ y ¼ z’, which the Bavarian chemist/physician had used to explain cholera aetiology. As we have seen, as something of a mentor to Erismann, Pettenkofer had exercised considerable influence over the formation of zemstvo medicine. Semashko’s rejection of the formula probably stemmed from an attempt to separate Soviet and tsarist medicine. Pettenkofer had long emphasised the social aspects of medicine, having conducted a survey of Bavarian citizens in his efforts to battle cholera.11 Indeed, Semashko apparently changed his mind after Stalin removed him from leadership in the 1930s, when he wrote a tribute to Erismann and called for a return to the methodology that this ‘social hygienic’ approach had inspired. Recalling an early debate between Erismann and Dobroslavin, who argued that hygienists could come from the ranks of chemistry and other disciplines and not require a medical degree, Semashko lamented recent attempts to limit the field

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of hygiene to more technical measures such as sanitation. He referred to Erismann’s 1872 – 7 manual: The immediate goal of hygiene [. . .] to investigate the influence on man of all phenomena of nature to the action of which he is subjected, and furthermore the influence of the artificial environment in which he lives as a result of his social condition, and finally to find the means of mitigating the action of the organism of all harmful conditions from the part of nature and society.12 This definition bore much in common with zemstvo medicine itself. No matter how the Soviets tried to split hairs, zemstvo medicine clearly influenced the Soviet approach. Other scholarship asserts that social hygiene evolved from zemstvo medicine.13 Proponents of the philosophy expressed sentiments that hunger, economic conditions and poverty caused disease and were concerned with developing socio-economic statistics, investigations of peasant agriculture and sanitation as a manifestation of social issues.14 Rural Soviet medicine retained the uchastok, or ‘precinct’ into the 1970s, and though far more multifaceted, it functioned and remained ‘strikingly similar’ to model that the E. A. Osipov conceived a century before.15 Erismann brought the theory from Western Europe and developed it in the Moscow zemstvo, which influenced other provinces on the primacy of social factors in medicine, surviving to become a principle in Soviet medicine.16 The counter-argument posits that although social hygiene had tsarist and German roots, the approach was essentially a Soviet innovation. In this version of events, social hygiene rested between biology, i.e. bacteriology and epidemiology on one side and sociology on the other. Social hygiene, as developed by the Soviets in the 1920s, relied upon specialists in statistics and other fields rather than just the generalists that characterised zemstvo medicine, arguing that the tsarist government had missed an opportunity to adopt social hygiene.17 According to this school of thought, Stalin discontinued the programme because of its foreign origins, and failure of proponents to define and solve issues that were outside the realm of medical specialisation.18 These are excellent points. The Soviets emphasised technology and applied it with a military-like discipline. Social hygiene covered far

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more ground than just dealing with cholera epidemics; in fact, articles on the subject quite often did not even mention cholera while keying on tuberculosis and alcoholism. Thus, this debate will undoubtedly not end here, but the broad range of factors involved in social hygiene was not the exclusive province of either hardcore specialists or sociologists, but the terrain of opposing sides within a broad gamut of social sciences with basis in preventive medicine. Emerging from intersections of Russian public health and the social and economic strife of three revolutions, three military defeats and 12 years of continuous war and ideological struggle, social hygiene represented a unique Soviet modernity intersecting the principles of zemstvo and European medicine. Flourishing through the NEP, social hygiene was doomed however when Stalin consolidated power. While Stalin loved technology, he could not afford anyone criticising social conditions during the collectivisation and political purges of the 1930s. Soviet ideology rested on class and also officially eschewed zoological categorisations of human beings, which was likely also a factor in the failure of eugenics to flourish. The differences between social medicine and the form of general hygiene that Erismann and Khlopin practised were less important to resisting cholera epidemics than their similarities. Social hygiene’s heyday in the USSR, while physicians were conceptualising a broad agenda to deal with cholera and while Lenin permitted limited capitalism, was a matter of political survival. The period of war and revolution brought conditions that drove home these messages. Advocates of social medicine included Semashko’s Deputy Commissar Z. P. Solov’ev, A. V. Mol’kov and general hygienists such as Diatropov and Sysin.19 As Commissar, Semashko was responsible for ensuring cooperation among Soviet physicians and by most accounts exercised the type of diplomacy that was well suited for this task. As military strife and conditions on the Volga spiralled downward, the Soviets readied for a final putsch to rid targeted locations of the cholera vibrio and the conditions (biological, chemical, social, ecological and physiological) that were conducive to the development of epidemics. Between 1921 and 1927, the Soviets drew upon the tsarist penchant for administrative legislation and emergency response, as well as the zemstvo/Pirogov tradition of raising the cultural level of the populace. Science and technology played a crucial role in shaping these improvements, as did improved communications between individuals

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and agencies. A unified leadership and paramilitary command issued clear communications that increased the initiative of local physicians in their administering anti-cholera measures. Local organisations also remained important. The republics administered and coordinated Soviet public health, but the oldest and most influential organisation was Narkomzdrav RSFSR, which, operating under Semashko since 1918, functioned as a centralised headquarters with autonomous branches throughout the country. Narkomzdrav RSFSR formed a clear and comprehensive plan for approaching public health, and had an experienced staff in 1928. Prior to that time, much of the nuts and bolts of daily operations were carried out by local agencies, provincial health sections or zdravotdely and in the districts.20 Soviet medical personnel continued to expand the mass vaccination programme and sought to patch up the holes in the system, striving to improve water supplies where they could and increasing sanitation measures. Advances in bacteriology played an important role in this process, as did hygiene in targeted clean up programmes, public education and epidemiology. However, the primary goal of the NEP was to eradicate harmful social circumstances, particularly famine. The suffering continued in many places however and the primary issue was a lack of food. Approximately 5 million people died of malnutrition in the Soviet Union in 1921– 2.21 In 1920, harvested grain totalled only 54 per cent of the mean for 1909– 13 and the aggregate for 1921, 37.6 million tons, composed just 43 per cent of pre-war totals.22 A fuel crisis shut down manufacturing and transportation systems. Wages lost relevance as rations and assistance, when available, were provided free of charge.23 As noted above, the NEP helped some provinces more than others and the Volga Region suffered particularly badly. Approximately 23 million people in the country were designated victims of famine and 2.1 million of them lived in Saratov province. Then the largest city on the Volga, Saratov had 228,000 residents in 1916, but by 1921 the population fell to 185,000, creeping back up to 211,000 in 1926. In July 1921, at the peak of the cholera epidemic in Saratov, a ‘stampede of refugees’ made it impossible to register cholera deaths and only a fraction was recorded. Local registers counted only 379 deaths with local newspapers recording 1,476, but the reality was closer to 1,476 than 379. The provincial department of health estimated the total number of cases in the city alone at 3,500.24 In the Don Cossacks

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Territory, 5 per cent of the population vanished and 2.5 per cent were disabled. Deaths in the region were three times greater during the Civil War than they had been during World War I and the region lost its status as the nation’s granary. By 1922, production on small peasant farms fell to less than one-third of 1917 levels. The number of livestock in the Don region, the most bountiful in tsarist Russia in 1917, became perhaps the smallest, plummeting four-fold by 1921.25 Peasant uprisings blighted the countryside, the most serious occurring in Tambov Province and workers’ strikes broke out yet again in Petrograd. As famine gripped the nation, an imminent threat to Bolshevik power emerged on 1 March as sailors and soldiers who had helped the Reds gain victory in the Civil War set up their own commune on Kronstadt Island. Lenin and Trotsky sent forces under General Tukhachevsky to quell the rebellion, but the ‘free soviets’ at Kronstadt resisted for 16 days before soldiers crushed the uprising.26 This threat may have been the last straw. Fearing ruin, Lenin decided to implement limited capitalism in a communist workers’ state. This decision effectively marked the beginning of the end for the cholera vibrio.

Lenin Confronts Cholera, 1921 The famine and crises in 1921 caused cholera cases to increase tenfold to 204,228.27 At least 176,885 of these cases occurred in the civil sectors, the military suffered 5,837 and 20,017 appeared on the railroad. The disparity between the military and civil society was due to vaccination, better food and provisions; war had created the social disparities that caused unrest. Amid the chaos a bright spot appeared, as Petrograd experienced only six cases. Otherwise, the vibrio occupied the same places as it had the previous year, in the Donbass and Rostov, but arrived early, in January.28 The early arrival caught Narkomzdrav RSFSR off guard, but Soviet officials drew on the expertise of the former Pirogov physician, I. A. Dobreitser, who worked the railroad in Balashov with Teziakov in 1915, to form a plan. The Soviets named Dobreitser Director of the ‘United Conference of the Epidemiological Subdivision and Department for Formulation of a Plan of Measures for the Struggle with Cholera Patients on the Railroad Ways of Communication in 1921’. By 15 February he and his committee released an agenda containing activities and special instructions, which addressed ‘general circumstances’,

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‘registration and reports’, ‘organisation of bacteriological investigations’ and ‘improvement of water quality’.29 This last measure reflected an emphasis on concern for the condition of water sources. While the first three objectives were listed ‘to be carried out’, the fourth specified that distribution of water would be ‘combined at two to three [check] points, changing the [original] drafting of the idea that chlorinated water be provided at each point with a guarantee of an acceptable level of competent oversight’. The checkpoints were vital because individuals were likely to introduce the disease into a new location over the railroads and waterways. The remaining discussion included a proposal to the Department of the Ways of Communication to consider the chlorination of water to be vital at all locations.30 The notes regarding water provision reveal that in 1921 the USSR was still suffering from qualitative and quantitative issues in this area. This condition reflects not a bacteriological revolution, but rather improvisation, by rationing water and distributing it at railroad stations, wharves and prioritised places. Water quality and sewage disposal remained weak in many places of the Soviet Union in 1921, particularly on the Lower Volga. The report reflected the weight of importance that each category presented. Bacteriological investigations (third on the list) were critical to detecting infected water supplies, while ‘provision of good quality water’ (fourth on the list) prioritised making clean water available and preventing people from drinking infected water. A mandate regarding ‘division of sewage’ and ‘cleaning of the soil’ followed, noting that sanitary physicians and engineers would collaborate at small stations to address construction of cisterns and other practical difficulties regarding sewage removal.31 For water, they made do with small, makeshift facilities and alternative methods. Other measures included hospitalising patients, vaccinations, disinfection, hot baths and laundries, education of the public, checkpoints for isolation and surveillance and servicing passengers in places where crowds gathered.32 As one might expect from a committee chaired by Dobreitser, this was mostly the same agenda that personnel in Saratov had used in 1915. Despite concern about cholera, Dobreitser and his colleagues in the 1921 document ‘Instructions for anti-cholera measures on the interior waterway’ explicitly declared that ‘the water routes even in the very worst conditions due to cholera must remain free for navigation’.33 This

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policy was a continuation of the 1903 Cholera Rules and the tsarist military’s discontinuation of the sea quarantine in 1904. Like their predecessors, physicians in Narkomzdrav RSFSR sought to maintain free passage of river traffic while conducting surveillance through the checkpoint system. The second point directed workers on watercraft to concentrate on patients removed from any vessels in the areas surrounding the water routes, to carry out disinfection on watercraft and apply other measures as directed by oblast’ physicians at the outset of the epidemic. When necessary, they were to open floating physician observation points.34 However, obstructing transportation to battle cholera was no more practical under the Soviets than it had been under the tsars. The directors of public health anticipated the arrival of migrant labourers in the extremities of provinces and relied upon the activation of measures in the interior of the Empire when a threat existed. After laying out general duties, the orders became more specific. Order Three mandated that after activating the floating physicianobservation points on steamboats and barges personnel should distribute circulars, continuing the Oblast’ Council’s directives. Command personnel were charged with immediately reporting when their point was operational.35 Order Four required every boat to contain an equipped sanitary cabin for workers with sufficient medicine and chemicals to keep the crews healthy.36 In contrast to tsarist workers in 1903, individuals on board ships now knew that they were responsible for adhering to orders, taking action and reporting their activities. The Soviets adeptly deployed personnel and equipment in the places that were most heavily stricken, including the Northwest provinces and Volga and Don River regions, by tracking the number of sanitary steamboats, ships, personnel and assignments. In 1921, there were a minimum of 3,418 workers employed on the rivers and ports of the Soviet Union and at least 85 watercraft, of which 12 or more were sanitary steamboats. Each oblast’ had one sanitary steamboat at its disposal except for the Don-Kuban council, which had two.37 A high percentage of sanitary personnel were assigned in the Northwest Regional Oblast’ Council, which included Petrograd and surrounding areas, and in the Volga region. With 18 and 17 respectively, these councils contained the highest number of medical-districts and deployed the most workers: 525 in the Volga Oblast’ Region and 630 in the

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Northwest. These 1,155 workers composed more than one-third of the personnel on the entire water system.38 From the tsarist experience, the Soviets knew these regions presented a great threat and correspondingly gave them the most resources. While Russian physicians had long understood the vulnerability of the Don due to ports on the Black Sea, they generally gave it lesser importance than the Volga region. The disease once again entered through the Don-Kuban region in 1921. The reports of Gamaleia, Arkhangel’skii and others exposed the Black Sea ports as the greatest threat. The Soviets conducted intense surveillance and anti-cholera measures in this region. As Tarasevich later noted, by April 1921 cholera had spread to Ukraine and the Northern Caucasus in the Kuban region and was diffusing along the railroad.39 A report of the Central Commission of Narkomzdrav RSFSR in 1921 confirmed Tarasevich’s observations.40 Local oblast’ councils formed vaccination detachments.41 Cholera had resided in the country since January and was now a year long guest. Stopping a disease that had become semi-endemic through quarantine would have proven impossible. Their only means of halting cholera was for local agencies to monitor year-round the areas in which it appeared. Unlike in tsarist times, Lenin took an interest in cholera control. On 19 April 1921, Lenin dispatched a letter to Semashko asking if ‘cases of cholera and other infectious diseases’ had appeared in Moscow in ‘the last few days’ and if so, the number and strength relative to prior epidemics and the measures that were being ordered and applied.42 A cholera epidemic in the new capital would have provided the enemies of the Soviets with ammunition to discredit the new government. Moreover, the letter revealed how Soviet leaders viewed cholera as the primary epidemiological threat and something of a general term for disease. Physcians inevitably followed the phrase ‘struggle with cholera’ with ‘and other infectious diseases’, as if stopping the former would quickly precipitate the fall of the latter and to some degree this is what in fact happened. The Soviet historians A. S. Dremov, A. P. Kyropotov and M. I. Barsukov, directors of the medical-sanitary section of the Military Revolutionary Committee in the first ministry of public health, described the role of famine and priority that Lenin and the Soviets gave to the anti-epidemic campaign:

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After the end of the Civil War there was hunger in both the nation and the army, which brought on outbreaks of typhus and relapsing fever. The situation soon became worse causing the development of other infectious diseases, primarily typhoid and cholera. In a few regions of the nation these outbreaks became very serious. Therefore, the struggle with cholera and typhoid became highly important government tasks.43 Barsukov and his co-authors commented that ‘for a short period of time the government conducted a wide complex of varied prophylactic measures in the nation and the army [. . .] shaped by a series of special decisions published in orders of the highest priority’. The authors emphasised that Lenin paid close attention to the campaign against cholera and typhoid, staying informed of every undertaking and engagement.44 The paramilitary approach to the struggle with cholera required a chief executive and Lenin fulfilled the role in a manner that Nicholas II could not. The primary breeding grounds of the vibrio were the same as in past years. By May, cases on the border with Persia crossed into territory. On the heels of the Great Famine and cholera epidemic in Persia in 1917–19, these reports were quite serious. Almost simultaneously, cholera was detected in the Volga Region. Laboratory bacteriologists in Tsaritsyn verified the presence of the vibrio in their city on 16 May. Soviet officials in Saratov Oblast’ undertook preparations on the water routes, receiving a telegram that a patient with cholera on board watercraft entered Astrakhan’ from Tsaritsyn. Medical officials in Tsaritsyn received regional assistance as cases appeared upriver in Saratov.45 By the end of the month, Voronezh Province was experiencing a serious epidemic.46 In June, the epidemic grew stronger, spreading along the Volga River to the Samara, Astrakhan’ and Saratov provinces.47 On 7 June, workers removed a suspected patient from the Steamboat ‘Vladimir Ulianov’ (Lenin’s proper name), in Samara. A second passenger on the boat fell ill and two days later, a third was removed from the steamboat ‘Grazhdane’ (‘Citizens’). A fourth victim appeared on the Samara wharf. Further north, on 19 June authorities encountered two suspected cases in Vasilsursk in Nizhegorod Province. Three days later, Narkomzdrav RSFSR received a telegram confirming 27 cases in Rostov-on-Don, 4 in Tsaritsyn, 12 in Saratov, 128 in Samara, 18 in Vasilsursk, 25 in Nizhny

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Novgorod, five in Kostroma, three each in Iaroslavl’ and Iurevets, two in Rybinsk and Puchezh, four in Murom, which was the oldest town in Vladimir Province and 123 in Astrakhan’.48 All of these cities had a connection with the Volga. Puchezh was a port city on the river, Murom was located in Vladimir province on a Volga tributary, the Oka. Vasilsursk and Penza were located on the Sura, also a Volga tributory. The epidemic appeared to be a classic case of the vibrio securing transportation through passengers on the river, but there were other similarities with prior outbreaks. Just as Rein had reported regarding 1907–10, the first case appeared in the Don Basin and the vibrio was either immediately transported to the Volga or appeared independently from another source or through nature. As in 1908 and 1910, the first patient on the Volga appeared in Tsaritsyn. From there, as in 1907, a passenger on board a steamboat carried the disease south to Astrakhan’. Though laboratory specialists verified the first case on the Volga in Tsaritsyn, as in past epidemics Astrakhan’, Saratov and Samara quickly developed many more cases than the source city. Meanwhile, cholera ascended the river to the Upper Volga Region and gained a foothold in the traditional strongholds of Kostroma, Nizhny Novgorod, Iaroslavl’ and Rybinsk. Cities such as Saratov, Samara and, particularly, Astrakhan’ remained susceptible. Information regarding past epidemics reveals a possible explanation for this pattern. Carriers from the Black Sea routinely threatened the Don region and, as the last chapter indicated, by 1918 Narkomzdrav physicians feared the vulnerability of the railroad station in Tsaritsyn. The railroad had long connected the Don and the Volga region and, as established, lower Volga cities such as Saratov, Astrakhan’ and Samara suffered poor sanitary conditions, particularly in coastal and outer districts. The revelation of cases on the Don in January make it likely that, as in tsarist times, the vibrio entered the nation well before it was widely known if indeed it had left at all.49 There is little wonder that Russian physicians considered cholera endemic or semi-endemic to certain regions. They were likely correct as the vibrio simultaneously appeared in numerous locations and exploited interior environments and conduits of transmission making the prospect of conducting an effective quarantine unfeasible. Sanitary conditions in the Lower Volga remained poor at best, invalidating historical accounts that improvements in sanitation

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stopped cholera in Russia. While officials in the Lower Volga Region had made small improvements, the situation had worsened due to war, revolution and famine. In Saratov, refugees remained a problem, which the Saratov Gubzdravotdel addressed on 15 July 1921.Forming a refugee city near the Volga shore on the grounds of Degtiarnaia Square, the council directed local health officials to identify the measures that were necessary.50 In 1921, Saratov was, in the words of one of the city’s most prominent chroniclers, ‘a community in disarray, but a community in the making’.51 The city was emerging from the Civil War as a new community and would struggle from its effects through the next few years. Suffering another wave of refugees due to the famine in 1921, the refugee camp reflected this transformation. Conditions in the camp bred cholera and to be sent there was a nightmare. Between January and July 1922, 9,405 refugees entered the camp: 1,184 of them perished and 82 per cent of all the ‘town’s’ inhabitants fell ill in some manner or another.52 The camp reflected the city’s, indeed, the country’s specific European modernity, a manifestation of military organisation akin to imperial concentration camps in South Africa, isolation and contagionist medical sorting and also the work of Dobreitser, who had worked with Teziakov on the Balashov railroad in World War I. As ruthless as it was the refugee city perhaps prevented local contagion better than Rimskii-Korsakov’s plan during World War I. Dealing with large numbers of displaced persons was part of the unspoken residue of the twentieth-century surveillance state, a prelude to the forced assemblage of humans based on political ideology and race, occurring under the Soviets and Nazis respectively.53 Lenin followed the epidemics in Russia closely. As the Saratov Gubzdravotdel was completing a journal entry regarding the refugee city, Lenin telephoned Semashko requesting that he send a physician to the Kashirskaia electric station where he feared that a large gathering of workers created a ‘possibility’ for the development of cholera.54 Lenin was undoubtedly more interested the negative effect of an epidemic on the opening of the electrical plant than the lives it might cost, another example of the modern body politic. Electrification of the Soviet Union was an important Soviet imperative for achieving parity with Western Europe, but so was stopping cholera and Lenin took keen interest in Narkomzdrav RFSFR’s day-to-day work. Ten days later, Lenin and his ministers of public health issued their most important document regarding cholera, ‘Memo 1689’, the ‘Decree

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of the Soviet of Peoples’ Commissars of the RSFSR for Measures against Cholera Epidemics’. The document was composed of a set of directives that amounted to a comprehensive plan for dealing with cholera. The preface stated its objective: ‘In view of the strong diffusion of cases of cholera in separate districts of the republics, which have developed in places into strong epidemics, especially in the provinces that have been damaged by crop failures the Soviet Peoples’ Commissars have ordered [the following].’55 Local agencies retained much authority. The responsibility for communications fell on Narkomzdrav RSFSR, which was the Health Commissariat of the Russian Republic, an organisation to coordinate the work of the Russian provinces. The first instruction recognised the importance of the work at hand and the second, the flow of paperwork related to the anti-cholera campaign, the authority of directors of provincial executive commissions, of provincial departments of public health and communes, such as in northern Petrograd, ‘or their designees . . . to create orders for all executive committee emergency commissions for cholera’. The provincial sections of public health controlled the paperwork and the logistical sections of districts distributed all written documents pertaining to cholera to the provincial section.56 There were vast similarities with the tsarist system. The supreme commander of public health at the local level was the director of the Guberniia, or provincial executive committee who, during cholera epidemics, basically fulfilled the same role that provincial governors carried out under the 1903 Cholera Rules. The Guberniia ispolnitel’nye komissii, ‘Provincial Executive Commission’, or ‘Gubispolkom’, performed almost precisely the same leadership role as the combined tsarist provincial SECs and zemstvo councils. District gubzdravotdely replaced the zemstvo councils and tsarist SECs that had operated at that level. Emergency cholera commissions at the provincial level with semiautonomous subordinate commissions in the districts held a great deal in common with the tsarist arrangement. The Soviets benefitted from a reduction in duplication by combining the zemstvo and tsarist government functions, a move that was already occurring under the tsarist system. Though the Soviets claimed to have liquidated the zemstvos, they essentially incorporated these institutions, which had been designed as instruments for self-government, into the functional government entities they were already becoming when the Soviets came

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to power in 1917. The work of Zemgor during World War I had laid the groundwork for cooperation. For most practical purposes, the Soviets built on the tsarist structure. The similarity with the Cholera Rules did not stop there. The third and fourth points of Memo 1689 concerned the railroads and waterways which the People’s Commissariat of the Ways of Communication RSFSR, an obvious replication of the tsarist ministry, exercised great authority. Directive Three announced that ‘on the railroads and water routes are posted orders of representatives of the gubernii sections of public health for the struggle with cholera’ and that ‘individuals must unquestioningly execute [these orders] through local organisations’.57 This directive was an order for any individual, directors of local organisations such as schools, jails, stores and other firms down to their lowest ranking worker, to use the resources at his or her disposal to carry out anti-cholera directives associated with the railroad lines and waterways. The Soviets were drawing upon the civil society that tsarist Russia had constructed and with military-style command that constituted an order, not request. This concept was not really new. In tsarist and Muscovite Russia, every individual had a duty to serve the autocracy. The Soviets were drawing upon a sense of duty with roots that had spread over several centuries, along with a new militarised ardour reflecting the ideological zeal of the socialist ideologues of a working class, many of whom believed they were occupying an important place in the new order. This fervour was not so different than the civic-minded enthusiasm of the trustees who worked for P. N. Sokolov in Saratov in 1904, except that the Soviets were able to draw upon a deeper and even more vigorous sector of the populace. Muscovite and tsarist traditions, now ingrained in the minds and hearts of militarised socialist ideologues, laid the foundation for Soviet power. In the same vein, Mandate Four stated: The People’s Commissariat of the Ways of Communication is regarded as absolutely the highest [organ] of leadership in [ensuring] the wellbeing of passengers at the stations and on the ways [of communication and for ensuring] sufficient quality and quantity of local water, for reinforcing the work of those who boil the water and for properly organising the cleaning up of garbage and filth from the routes.58

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The practice of boiling water and providing it to people during cholera epidemics dated back before the 1904 epidemic in Saratov. The terse nature of this directive implied that the Commissariat not only had the duty, but also the authority to ensure that clean water was available along the ways and the responsibility of overseeing the tasks of those who engaged in such work. As part of Directive Ten, the decree ordered the ‘councils of the railroad and water routes to carry out. . .measures for cleaning and repairing their own medical-sanitary establishments’.59 The order for cleanliness implied that such locations would be subject to inspection. All of these directives corresponded to similar edicts in the tsarist Cholera Rules but their tone, combined with the short, violent history of the Bolsheviks in Russia, indicated that they would be strictly enforced; a manifestation of tsarist administrative law, military spirit and ideological zeal. The Soviets provided administrators of the Ways of Communication autonomy over their jurisdictions, but unlike the railroad physicians under Nicholas II, they were held accountable. The routes of transportation were just as important to the Soviet economy as they had been in Imperial Russia and the intense application of sanitary measures in the wake of the October Revolution continued, including the same system of checkpoints and concentration on breeding grounds. By 1911, the Kazan’ military district had documented these efforts.60 Under the zemstvo reformer Dobreitser’s direction, the pragmatic Soviets continued to emphasise them. The groundwork for vaccination had been laid by tsarist physicians, but under the Soviets such technology became increasingly vital. Commanded by Tarasevich and many of the same personnel, the power the Soviets bequeathed to the individuals in charge of vaccination, as well as the increased importance of their task, constituted a break with the past, although key command personnel remained mostly the same as under the tsarist system. Mandates Five and Six authorised the continuation of mass cholera vaccinations, again emphasising the railroads and water routes. Mandate Five acted ‘to forbid the entry of passengers without preventive anticholera vaccinations on railroads and water routes (also for suburban transportation) [. . .] in districts and provinces that were stricken with epidemics and also for passengers who are travelling there’.61 Mandate Six required that all workers of Narkomzdrav who were engaged in the

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process of vaccination and workers on the railroads and waterways would receive vaccinations.62 Vaccination was becoming more of a key component in the Soviet system Mandates Eight and Nine addressed controlling migrant populations, which was still a major problem, particularly in the Lower Volga Region. Mandate Eight ordered that the People’s Commissariat of Agriculture monitor and take steps to control the movement and settlement of migrants. Mandate Nine forbade mass eviction of civilians from districts suffering from cholera epidemics.63 Limiting the movement of populations and inhibiting transmission of the vibrio was one of the essentials of twentieth-century European modernity. Mandate Ten ordered the communal sections ‘according to the first demand of public health’ to ensure that buildings at hospitals, sanitary facilities, other institutions and populated locations were adequately cleaned, freeing the public health departments from these duties in order that they might pursue their anti-epidemic work during cholera emergencies. Mandate Ten granted the councils of the railroads and waterways the same freedoms of action and authority.64 By drawing on the labour of the population, Soviet officials were able to alleviate some of their problems with human resources. Tsarist physicians had long understood the link between famine and cholera. Drawing on this knowledge, the decree ordered the People’s Commissariat of Nutrition and its local agencies to provide for nutritional demands in institutions related to healing and sanitation and at ‘isolation nutrition points’ to feed travellers who were isolated and held under quarantine.65 Soviet recognition of the need to feed the country, long a bone of contention of Pirogov physicians, marked another link between these old and new administrations. Also, the People’s Commissariat of the Post Office and Telegraph retained the authority under the decree ‘to transfer to the People’s Commissariat of Public Health by expedited order every written article regarding cholera and plague’.66 The decree made the necessary monetary credits available to conduct cleaning operations, including an account reserved for equipment, special clothes and soap and funds for ensuring water provision.67 The emphasis upon increased communication was important, in that it sent a message to local organisations that they should expediently carry out anti-cholera measures to prevent the spread of disease. Emergency nutrition, better communications and

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widely available clean water were measures that would result in lower morbidity and mortality rates. The mandates authorised local authorities to take necessary and prompt action, but the potential for abuse was obvious. Practically any communication could be seized as cholera-related. The Soviet surveillance state proved a boon for cholera control. The decree sought increases in provisions and personnel. The third and fourth sub-points of the Mandate Seventeen retained the authority ‘to put an end to a high exodus of medical personnel and to free them from the attraction’ of engaging in labour obligations that were outside the realm of their specialties. The Soviets took steps to ensure that this would not occur ordering that all medical personnel would receive fair pay when working against cholera epidemics.68 This directive was yet another method of directing the medical resources of the country toward inhibiting cholera epidemics rather than moonlighting or even tending their own gardens. Physicians’ work against cholera was obligatory. The fifth sub-point stressed familiarisation of medical personnel at all distribution points with directives that had been passed out to workers in bacteriological institutions. Mandate Eighteen sought to strengthen efforts of local workers and peasants’ councils and encourage ‘broad activity and participation in all anti-cholera measures’.69 Here was an overt call for the population to assist in battling cholera epidemics. As the following pages will illustrate, the primary break with the past was that the Soviets would demand compliance. This language was not rhetoric. Lenin’s deputies were making extensive preperations and backing them up with the authority and funds to achieve success. They ordered the expedited movement of mail and gave local public health services the autonomy to perform their duties, obtain provisions, disinfect locations, vaccinate and feed at-risk inhabitants and provide them with clean water. There was an element of coercion involved, in that the officials could inhibit population movement and detain and isolate people at stations and wharves even for suspicion. The Soviets could utilise local institutions and resources and force individuals to assist in carrying out anti-cholera measures. Shortages of personnel and provisions and economic deficits were problems in tsarist Russia and the Soviets dealt with these same issues. Political ideology, military-like zeal and authority amounting to martial law drew on traditional Russian notions

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of duty to the state. This intersection between the traditional and modern involved mandatory and enthusisastic participation. Lenin’s 1921 decree was designed to prevent cholera epidemics and, like the 1903 Cholera Rules, was crafted for a rapid emergency response. The directives did not mention any intentions to develop permanent waterworks or sewer systems and, while the Soviets improved these areas, they did not achieve parity with Western European governments.

Weaknesses in the NEP, 1921 –2 In a large, geographically diverse country, the Soviets were inevitably more successful in some regions than others. The economic weaknesses of the NEP ensured that people on the Volga were dying every day. On 2 August 1921, an article appeared in the New York Times under the headline: ‘Wandering Humanity, The Saratov Government is one vast gypsy camp of weak, starving, sick and dying people’.70 Westerners reported that Russians in cholera-ravaged districts were engaging in acts of superstition and resisting cholera vaccinations and sanitary precautions due to evil spirits. They buried cholera victims at night and whispered to one another that the Bolsheviks were torturing and killing patients in cholera barracks. Peasant women reportedly uttered incantations, ploughed furrows around villages and built fires, hoping to prevent cholera from entering their village.71 These reports painted a picture of Russia as wild and untamed, with a superstitious, undereducated population and a government that was unmodern, which still permitted cholera epidemics. Much of the disorder related to climate. The results of ENSO-related drought were everywhere. Two articles in the New York Times on 28 September 1921 noted that Western railroad passengers travelling through the Volga river valley observed that every inch of the earth was ‘singed by drought’. At each station, travellers encountered crowds of dying Russians who held out their hands and begged for food. The masses of refugees fleeing hunger included peasants, workers and starving demoralised Red Army soldiers who deserted their ranks, fleeing along the railroad lines. The Red Guard closely monitored the tracks. Another article declared: ‘Cholera in Russia Wanes. 150,000 Refugees Reach Petrograd from Famine District’. Dr Rupert Blue, who was directing an investigation for the United States Immigration Service

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into the condition of emigrants bound to the US from Riga, reported that only 5,000 of the 150,000 refugees arriving in Petrograd could be offered employment. Once again Petrograd inherited the problems of the Volga Region, as the ‘Window to the West’, but this time the influx of civilians exerted little effect and Blue noted that the epidemic was declining.72 The refugees had undoubtedly been fed, vaccinated and had undergone stringent observation. The restriction of cholera to the famine districts on the Volga indicate that, as usual, the disease followed hunger and drought. However sanitary conditions in Saratov remained underdeveloped and had even deteriorated during the war years, thereby accelerating the epidemic. The Saratov physician N. N. Rozanov lamented that the local executive committee had ordered the complete cleaning of the city, but conditions were even worse than before World War I, declaring that at the current rate of development the city would never improve. The capacity to remove wastes had deteriorated. The sewage transport system devised by local officials in the tsarist era had worked ten times faster than the new sewer system, permitting a buildup of sewage and garbage ‘so great that [it was] incapable of disposing of not only all, but even a significant part of it’.73 Soviet sanitationists adopted an alternate system of waste removal quite similar to the tsarist transport system that personnel had used in Samara in 1907.74 The break with tsarist sanitationists lay in their use of more advanced machinery. They claimed to have copied this system, calling it assenizatsiia, from the French, assainissement, which was essentially a more mechanised version of the tsarist system.75 The adoption of the French name and system, the use of the tsarist sanitary methodology and European-style machinery were trademarks of Soviet modernity. As Taranukhin had in 1907 in Samara, Rozanov used Pettenkofer’s methodology for calculating the sanitation problem in Saratov. To cleanse the city, where more than 150,000 people lived in 1922, it was necessary to remove more than 10.8 million pounds of sewage annually. Calculating agricultural and other wastes into the equation, Rozanov observed that the sewer system removed approximately one tenth of the waste, which ‘does not improve the sanitary conditions of the city and leaves a danger of the development of epidemic cholera, typhoid and other intestinal disorders’. Large piles of sewage measuring seven feet or more in width lay in the soil and mixed with water in large

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public squares. This water flowed into other areas and presented a danger for neighbours and distant inhabitants.76 These sanitary conditions were nearly identical to those that prevailed in Samara in 1907. Rozanov noted that these conditions resembled those he had observed in Baku. Multi-story buildings and homes were built on top of places where someone years ago had dumped sewage. Studies of the soil verified Rozanov’s observations and that ‘we live in our own filth’.77 The local waterworks was barely producing one bucket of water per person. The city sewer system was constructed before the war and deteriorated due to a lack of maintenance. By 1920, only 847 out of 12,079 properties in the entire city of Saratov were connected to the sewer system and only 624 (5.2 per cent) were receiving active service.78 Rozanov constructed a graph illustrating the poor coverage of city services within the city (see Table 8.3). The figures showed that Saratov’s city services deteriorated during the period of War Communism although sewer services improved in select areas. Rozanov’s article indicates that some districts made very poor progress regarding municipal services and, in some cases, they actually regressed. Rozanov also presented statistics regarding the spread of cholera in the city districts. Many of the problems that existed in Saratov in 1904 remained unsolved. As usual, the Glebuchevskii Ravine proved to be the worst place in the city and the neighbouring ‘Old City’ was also poor. Only parts of the first and third districts Table 7.1 Percentage of properties with active waterworks and sewage systems and the percentage of cholera patients per 1,000 residents in the Saratov city districts, 1921

District 1 2 3 4 5 6

Per cent of properties with active waterworks

Per cent of land with active sewer systems

Number of cases of cholera per 1,000 population

66.3 11.6 66.2 11.6 27.0 9.8

24.0 1.4 16.0 0.4 7.3 0.8

11.5 10.6 17.4 17.4 10.1 9.2

Source: N. N. Rozanov, ‘Otchistka goroda Saratova’, Saratovskii Vestnik Zdravookhraneniia (iiul’-avgust 1922): p. 18.

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possessed significant sewer services and most of the city was undefended.79 Statistics related to cholera in Saratov in 1921, when compared to St Petersburg/Petrograd in 1908 and 1918, are telling. For a city which at least one historian has accurately described as having the best anti-cholera organisation in the Lower Volga region during the twentieth century’s first decade, cholera morbidity for Saratov in 1921 was poor. Of the six major districts, the one with the lowest degree of morbidity equalled the shockingly high rate that Rozhdestvenskii District in St Petersburg experienced in 1908. In fact, the 17.2 per cent morbidity rate that the Third and Fourth Saratov Districts suffered in 1921 was higher than in any district in Petrograd in 1918, except for the suburbs of Vasil’evskii Gabanskii (17.9 per cent) and Novoderevenskii (21.2 per cent, see Table 8.3).80 The latter outbreak, as we have seen, was accelerated by the breakdown of a water filtration unit. War Communism and civil war created a difficult situation that the Soviet leadership could not change overnight. Socialist economics, World War I, ideological struggles and civil war in 1918–22 had proved disastrous. By 1921, Lenin was forced to make concessions or risk the fall of the republic. In response he developed the NEP and permitted physicians to pursue sociological medical approaches to disease in order help raise the cultural and material level of the population. The success of the programmes proved uneven however, as famine and cholera capitalised on the widespread disorder in Saratov. Cholera epidemics in Saratov and Moscow illustrate the connection between famine and cholera even in cities like Moscow which was located on high ground and had advanced sanitation. Lenin’s order for action against cholera indicates that he was determined to curtail infectious diseases. Soviet physicians drew on the tsarist model to accomplish this task. Semashko and Mol’kov emphasised social hygiene’s tie with Germany, use of technology and French methods of sanitation, but their approach retained the tsarist infrastructure. Social and general hygienists shared emphasis on improving social conditions and both approaches were amenable to Lenin’s NEP.

Conclusion Lenin’s plan to raise the cultural and material level of the Russian people, Soviet scientific advancements and bureaucratisation had roots in tsarist

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practices. Lenin’s Memo 1689 bore much in common with the 1903 tsarist Cholera Rules and the Soviet and tsarist administrative structure functioned in much the same manner. The formation of Narkomzdrav RSFSR resulted in better communications, but provincial public health departments bore the brunt of the responsibility for battling cholera, depending largely upon the support of local societies and citizens to operate and function well. The Commissariat of the Ways of Communications, Narkomput RSFSR and a duplication of the tsarist ministry of the same name, all attempted to continue the reforms that zemstvo physicians such as Teziakov, Dobreitser and others had begun. The agency maintained a focus on railroad stations, wharves and other places where people congregated. Physicians continued to hope that they could sap the strength of the disease and this theory would be tested in the years immediately ahead. Yet, in Lenin’s tersely worded memo, one can detect intersections of European and tsarist modernity. This was present in the new machinery, the increased emphasis on vaccination and other technologies, the adoption of social hygiene and concentration on social conditions (even as the principles of general hygiene were retained), the emulation of French technology regarding sanitation (backed by nineteenth-century theories of Pettenkofer and tsarist efforts), the detention of refuges in large encampments, which was a step toward twentieth-century one-party rule. These developments fused the ideology of socialist political parties with the practices of modern militaries and the application of European scientific ideas, setting the stage for the final attack against cholera in Russia.

CHAPTER 8 `

THE END OF CLASSICAL' CHOLERA EPIDEMICS IN THE SOVIET UNION

In 1922, the top medical officials of Narkomzdrav RSFSR were still embracing and advocating the application of a broad range of measures against the disease and improving social conditions, but cholera persisted. At first it appeared that cholera might continue indefinitely. Tarasevich noted that cholera spread with alarming speed during the first five months of 1922, exceeding the pace of the disease for the previous two years. The forecast appeared bleak.1 Cholera followed the famine, as a shortage of seeds and agricultural workers decreased the amount of land sewn in 1922.2 Tatars and Bashkirs suffered disproportionately from famine and cholera, which spread from Samara east over the railway to Ufa. According to Dr Krijanovsky, Director of the Bacteriological Institute in Ufa, by 27 May conditions in the town accelerated the spread of cholera and left it without resources for defence.3 The city had suffered 17,560 cases in 1921, but there were more than 20,000 cases in 1922, numbers which Tarasevich alarmingly estimated as being ‘much lower than the real figure’.4 This was an alarming report from Tarasevich, which was not unexpected, as he believed that such alarm precipitated better preparation, but the situation appeared genuinely bleak. The epidemic’s resurgence was however a prelude to success, as its grip progressively weakened over the next four years. Cholera’s withdraw from the European continent occurred through the same regions from which it had emerged, reflecting both a waning of natural forces in India

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and a weakening of the vibrio in southern Russia. This was a natural termination that resulted, at least in part, from Soviet physicians’ efforts to assist this dissolution via a programme based on Darwin’s theory, one that included applying mass vaccination along with attention to nutrition and other broad measures that tsarist physicians had used for years. Soviet military discipline and Bolshevik zeal had facilitated expedient and effective execution of these measures.

Cholera Wanes in Southern Russia, 1921 Soviet administrators and engineers began slowly improving railroad communication which had been nearly inoperable the year before. Employers resumed paying cash wages and, most important, the government abolished rationing on 10 November 1921.5 Soviet public health officials continued to concentrate on improving famine, providing clean water and attacking the vibrio at its point of development. The change in economic policies, along with relentless Soviet measures, paid a dividend as, despite the five-month spate in Ufa, the vibrio weakened. As Tarasevich reported to the League of Nations: The most interesting aspect of this example is that, in spite of the extremely difficult condition in which the population was situated, and circumstances favourable to the spread of the epidemic, cholera only developed to a very limited extent, especially when compared with typhus and relapsing fever, which accounted in these same districts for tens of thousands of cases. We must therefore seek for the explanation of this slight development and rapid cessation of the epidemic, not merely in the action taken, but in certain epidemiological conditions connected most probably, in the first place, with the properties of the vibrio itself.6 The Soviets were better able to track cholera due in part to a surveillance state that was intercepting not just mail, but every type of correspondence, but there is evidence that they were efficient at pursuing traditional methods as well.7 According to I. A. Dobreitser, there were 86,178 confirmed cases of cholera in 1922 and 4,945 suspected cases, amounting to approximately 91,123 cases. When comparing 1922 with the previous year, morbidity appears to have decreased from 15.9 cases per 10,000

Table 8.1

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Cholera in the Soviet Union in 1921, 1922 and 1923

January February March April May June July August September October November December Month Not Indicated Overall

1921

1922

127 64 72 661 1,654 32,870 93,343 53,670 14,741 5,186 486 326 2,018 204,228

Cholera 382 429 1,530 2,772 8,444 12,714 20,749 10,749 963 38 15 4 27,340 86,178

1923 Suspicion 9 9 183 398 669 717 1,851 959 149 – – 1 1 4,945

4 2 1 1 – – – – – – – – – –

Source: N. Dobreitser, ‘Kholera v 1922 godu’, Gigiena i sanitariia putei soobshcheniia 3-4 (iiun’-iiul’ 1923): p. 85.

inhabitants to 7.1. There were 4,701 cases along the railroads as opposed to 20,017 the year before and only 60 along the water routes, a figure down from 1,111 in 1921. However, only 32 places in the country were completely free of cholera, as opposed to 338 the year before.8 A Narkomzdrav bulletin indicated that ‘the epidemic began one half of a month earlier in 1922 and was again observed by January’.9 The implications of the data seemed clear. As the bacterium lost its breeding grounds, it decreased in strength in order to survive in absence of available hosts. In January 1922, there were even more cases than in the same month the year before, but the spread of cholera over the two-year period indicated that the microbe had taken up permanent residence in the country. The number of cases became smaller, particularly along the railroad lines. Cholera’s extended presence reflected its ability to adapt and sustain itself for reasonably long periods in the Soviet environment, but Soviet bacteriologists focussed on this adaption as its primary vulnerability. Having played a role in Mechnikov’s successful formulation of phagocytic immunity so many years ago, Darwin’s theory again emerged as the locus under which vaccination and Soviet epidemiology operated.

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The vibrio persisted in places such as Penza Province, which was located just north of Saratov Province. While the outbreak in Penza never became large, the city suffered 187 cases and 137 deaths distributed over 3 districts. The epidemic appeared due to refugees, then followed the general seasonal trend. A sporadic distribution of 14 cases in January led to particularly light months in February and March, when there were approximately 7 cases, then 6 in April. Almost all of the first cases occurred among refugees then, in May, began appearing ‘among the population of the city’. That month there were 42 cases, then 47 in June and 131 in July, but in August the epidemic began finally to subside.10 The data in Penza reflected the changing nature of epidemics in the Soviet Union (see Table 8.1). Cholera was present on a more consistent basis than in the past, prompting health officials to theorise that the pathogen was evolving. Narkomzdrav RSFSR confirmed cases during every single month of 1921 and 1922. Bacteriologists were likely encountering the El tor vibrio, which had been discovered in 1905 in Egypt, or another weak microbe, but almost never referred to it by that name, generally referring to microbes that were difficult to identify as either ‘less virulent’ or ‘cholera- like’. In 1922 Narkomzdrav RSFSR documented 811 such cases, but only two of them, both travellers from Siberia, were confirmed as cholera victims.11 Physicians credited reduced virulence and mortality to vaccination. A memo summing up the ‘special anti-cholera measures’ that Narkomzdrav RSFSR carried out in 1922 noted the necessity ‘to single out anti-cholera vaccinations which in 1922 were administered many times more than in 1921’. In 1921, the agency carried out 10,404 vaccinations and, in 1922, increased this effort more than tenfold to 112,881 people.12 There were 204,228 cases of cholera in the Soviet Union in 1921, a figure that fell to approximately 91,123, including suspicion of cholera, in 1922 (see Table 8.1). While it was predictable that cholera would subside in the second year of an epidemic, Narkomzdrav RFSFR’s prophylactic measures, which relied heavily on vaccination, undoubtedly played a role in the reduction. With a more effective economic policy that was alleviating famine, more widespread use of vaccination, surveillance and identification of threats, explosive epidemics would soon be a thing of the past in the Soviet Union. The origin of the disease in the Donets Basin was by now obvious. Soviet officials paid more attention to Black Sea ports in southern Ukraine and Crimea.

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Sanitation in the Ports of Southern Russia Sanitation remained a vital part of the Soviet programme. On 1 March 1922, the Military-district Interagency Sanitary Commission for the Struggle with Epidemics on the Black Sea-Azov Routes of Transportation, hereinafter OChVSU, began preparing to deal with ‘sharp infectious diseases, especially cholera [. . .] in the ports of the military district’. The commission directed its attention to areas adjacent to the ‘ports, various filthy wastes, garbage, corpses and other’ harmful or vulnerable environmental conditions. The OChVSU agreed to dispatch all significant information regarding the development of disease to the main office of the Sanitary Department of the Seas, or Morsannadzora. In the vicinity of the wharves they marked public restrooms for repair, engaged in cleaning and disinfection, which was ‘carried out according to specific requirements for the sea’, inspected drinks and produce in small stores and ensured that boiled water was freely available for public consumption.13 These organisations attempted to prevent the development of the disease by concentrating on its origin, choosing places where intelligence indicated that it would strike and applying the broadest measures possible, including vaccination. A report submitted by the OChVSU on 30 June 1922 recounted the development of epidemic diseases in the region up to that time, noting that there had been five cases of cholera in Odessa, three in Kherson and one in Feodosiia. The ports at Skadovsk, Kerch, Nikolaev and Ochakov were declared hazardous for the transmission of cholera and other diseases that were appearing. At that moment, the Soviets were dealing with a plethora of diseases. In the port of Sevastopol, for example, there were ten cases of typhus, two of relapsing fever, four cases of dysentery and 19 of sharp intestinal sickness. Yalta suffered one case each of typhus and relapsing fever. Feodosiia dealt with five cases each of typhus and relapsing fever and six sharp intestinal disorders.14 Detection and past knowledge regarding the importance of sharp intestinal disorders assisted the Soviets in pinpointing important locations. With only two steamboats, limited personnel and multiple epidemics, keeping cholera out of the Black Sea ports was likely impossible in 1922. The Soviets continued the flexible system that the tsarist MVD had begun in 1903, but their better communications and experience in detection, the knowledge of what to look for and sharpness of response anticipated modern relief efforts.

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Disinfection on the Soviet Railroad As the lines once again became operational, the work of keeping the railroads free from cholera became difficult and disinfection was an important measure. The director of the work at the stations, V. A. Iakovenko, was an assistant in the hygiene laboratory at the MilitaryMedical Academy of the general hygienist, G. V. Khlopin. The latter had written The Hygiene of Cities in 1903.15 Iakovenko described how cleaning was carried out at a Sanitary Disinfection Station, or Sandezstantsiia, showcasing the Barshava railroad disinfection facility, which was located four kilometres from the main track of the Petrograd– Pskov line. At this location, four wooden platforms lay parallel to four railroad lines and were capable of rising to the level of the field wagons expressly for the purpose of disinfecting wagons and movable equipment. At the end of the fourth podium, there was an adjoining wooden structure and stand, which held four steamformaldehyde chambers. The last chamber was in need of repair at the time of his article. At the end of one of the railroad lines sat buildings with permanent disinfection chambers, or ‘steam P 51’, which provided the station with hot water and steam. Near each chamber, small wooden structures supported boilers.16 Residing opposite the main track of the Petrograd-Pskov line was a series of simple buildings, including one for firefighting, a storeroom for disinfection chemicals and equipment, an office for the railroad ministry and one for assistants. Some distance from the storerooms there was another series of wooden buildings for the chancellery of Sandezstantsiia, the assistants of various orderlies, steam rooms and disinfectors who carried away buckets from the sanitary trains. On 15 October 1922, the personnel of Sandezstantsiia were divided into general sections by their job functions: one director, two instructors, three disinfectors, one orderly, 27 janitors, one labourer, three machinists and two security guards. Workers of cleaning detachments were divided into two groups, with one engaged in disinfection and the other, composed mostly of women, cleaning and washing the wagons and beds after the disinfectors were finished.17 The teams used a soap and water preparation and, infrequently, sulfuric gas to spray down wagons and clean them of bacterial agents. They hosed down all interior surfaces of the ‘hard’ wagons, or those

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without pillows, linens or luxuries, with a liquid that was tailored to the suspected degree of infection. All wagons were considered infected and the first person to enter was an instructor or disinfector in special clothes, who applied water pressure to the surfaces. Then, workers in detachments removed the trash and garbage, but only after irrigation of the interior surfaces with approved liquids. To ensure workers’ health, the stations prohibited dry sanitary cleaning of wagons without prior irrigation with disinfection liquids. The second part of the work, the cleaning and washing of floors, was administered after irrigation.18 To perform irrigation, workers moved platform carts that held approximately 40 buckets of water with hot disinfection liquid and a large pressurised hose alongside the wagon. The hose suctioned a liquid chemical mixture with a soap preparation from the bucket and sprayed it from just over 46 feet.19 The disinfector put on protective gloves, entered the wagon and began irrigating the interior areas of the wagon, including the ceiling, walls, corners and floor. The strong jets of water and disinfection liquid washed away dust, filth and, most important, germs.20 Iakovenko’s description of the work at the Sandezstantsii illustrates the elaborate preparations that Soviet workers put into disinfection on the railroad. They knew that intense cleaning reduced the chance that the cholera vibrio might be carried further into the country. Such disinfection was among a number of measures that the Soviets applied against cholera. Their use of advanced machinery, brigade-like organisation, barracks, leadership, focus and broad, intense application by workers under general hygienists who obviously held important positions and used advanced technology, reflects an organisational capacity absent before the war; an improvement of tsarist concepts that forged Soviet modernity. The problem of procuring treated water in Petrograd presented difficulties. The output of pure water had spiralled in 1917 and, by 1922, was lower than in the previous nine years (see Table 8.2). Z. G. Frenkel’, one of the foremost proponents of social hygiene, published a study of the effects of war on Petrograd in 1923, studying the link between cholera and water provision. The breakdown of the water system at Staryi Derevnyi in 1918 costed many lives, but Frenkel’s study indicated that it was an aberration. The amount of clean water produced from all sources during the tsarist period actually increased during World War I, before beginning a slow

8,357,351 8,570,342 8,873,242 9,023,162 9,960, 390 10,244,560 8,540,176 8,275,882 8,166,162 7,814,081 6,230,420

6,839,797 7,042,393 7,318,099 7,496,218 8,177,020 8,603,687 7,200,181 6,093,870 5,716,313 5,188,579 –

81.8 82.1 82.3 83.1 82.1 84 84.3 73.7 70 66.4 –

22,834 23,482 24,360 24,721 27,214 28,000 23,000 22,700 22,967 21,414 –

9.4 11.5 10.9 10.6 11.2 11.6 15.6 20.8 31.8 28.3 27

– 38 38 37 37 33 30 23 23 27

– 2,078 2,364 2,706 2,726 2,846 2,679 2,781 2,351 2,341

Source: Z. G. Frenkel’, Petrograd perioda voiny i revoliutsii: sanitarnye usloviia i kommunal’noe blagoustroistvo (Petrograd, 1923), p. 102.

1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922

Year

Provision of treated water in Petrograd, 1912 – 22

Yearly quantity of Average daily Annual Overall water provided provision of Average daily Coal use Quantity of water as calculated % of water buckets of water in 1,000s provided (in 1,000s by water metres calculated (in 1,000s consumed per Level raised of pud of buckets) (in 1,000s of buckets) water of buckets) individual in metres (36 lbs.)

Table 8.2

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decline in 1918 and a rapid downward spiral during the civil war. Water production in Petrograd dropped sharply in 1918, declining through 1922. The amount of water provided to homes, estimated in metres, followed a similar pattern as did daily water provision, but the buckets per individual increased, likely due to out-migration and other factors. After the incident at Staryi Derevnyi, the authorities terminated work on temporary stations. The facility was then neglected until 1921. Station No. 2 in Staryi Derevnyi took its water from the Greater Neva River, providing only 1.88 buckets a day in 1921, but 2100 buckets daily the following year. Workers cleaned it with five grams of chlorine per three cubic metres of water in summer and winter.21 According to the statistics of the social hygienist, Frenkel’, the Soviets were making improvements in water provision. The work of general hygienists told a different story however, about the state of sanitation and water provision in Petrograd. In 1923, I. N. Lastochkin, an assistant to Khlopin in the Department of Hygiene at the Military Medical Academy, studied the conditions affecting water provision to workers and residents at the Aleksandrovskii mechanical factory. The main mechanical factory of the Russian Railroad, the plant was located on the Nikolaevskii railroad in the extremities of Petrograd on the left bank of the Neva River just north of where it received the Okhta. The industrial significance of the factory made it vulnerable to epidemics. Steamboats and railroad wagons travelled to and from the workshop and the factory apartments housed the inhabitants of two Petrograd districts. The factory settlement received water from the Neva in two intake pipes, channelling it into a water tower and distributing it throughout the factory settlement for drinking and agricultural use. The pipes were located approximately 42 feet from the bank and the system stretched for approximately 3,000 feet along the river, beyond the location of the fenced water tower.22 This structure was plagued by a number of problems. The left bank of the Neva River was subject to extreme pollution. Drainage ran downstream from the Farforovnyi factory through a pipe which was seven feet in diameter and contained the discharges of some 40 different systems, including the steam baths of a ceramics institute. Just beneath the drainage pipes of the Farforovnyi factory, local people cleaned their dirty linen in the Neva, causing bacterial agents from the linen to flow downstream. The left bank was also the avenue of drainage for another factory, nearby apartments,

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cesspools and a 500-person hospital. Between seven in the morning and ten at night, steamboats and other vessels departed and arrived at the nearby Torntonovskii wharf. Upriver from the fenced pipes of the water tower of the Aleksandrovskii factory there was, on the shoreline of the Neva, a 63 by 95 foot space where foresters worked. Logs floated downstream, gathering in a receiving station where the pump of the water tower dispersed drainage. The water in the receiver was polluted and malodorous, with large splotches of oil floating on the surface.23 The forestry factory, which was located near the water tower and used to make repairs on it, created splinters, heaps of sawdust and other debris that was carried off by winds and heavy rains, often finding its way into the river. Approximately 20 or more feet from the Neva shoreline, the receiving pipe was fastened to the walls of a well, which performed water intake. A wooden cesspool extended from the walls of the well and its clay layer was cracked and splintered to the degree that it was penetrated by water 21 feet or less from the shoreline, the most polluted in the river. ‘Sediment, sewage and pollution’ floated in the water and leaked through openings into the water supply where it was procured from the river.24 Also, less than 50 feet beneath the fenced water tower the Neva met the River Basseika, where a canal accommodated freight barges. In the unfilled chambers of the canal there was ‘green, turbid acid’, while the water in the filled chamber ran past two collectors that served as drains for polluted water from the Aleksandrovskii factory and hospital, which housed 100 beds for patients of infectious disease. The chambers also received drainage from the government factory ‘Neftegaz’.25 The drainage held so much pollution that the water 50 feet upriver surrounding the receiving well had a ‘rancid odour’. Finally, approximately one to one and a half kilometres upriver from the Aleksandrovskii Factory, drainage from the Obukhovskii factory flowed along the left bank of the Neva past the Aleksandrovskii water receiver.26 In 1922, the water in the Aleksandrovskii factory contained significant microorganisms (see Table 8.3). A number of cases of typhoid and dysentery occurred among the factory population in 1921, but there were no reported cases of cholera. This same population had suffered 416 cases of cholera and 9.6 per cent morbidity in 1918 (see Table 8.4). Unlike Frenkel’s report, Lastochkin’s observations hardly reflected a stable state of affairs concerning sanitation in Petrograd. On the contrary, even though the settlement was cholera free, many conditions prevailing

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Table 8.3 Tests of water quality at the Aleksandrovskii Mechanical Factory, 1922 Time the sample was taken from the water 14 June 6 September 10 September 19 September 10 October 20 October

Living organisms per cubic centimetre

Number of colonies per cubic centimetre

7.9 8.5 8.1 7.6 8.2 8.4

714 1365 1172 635 1210 1380

Source: I. N. Lastochkin, ‘Zabolevaemosti rabochikh po Aleksandrovskom zavode Nik. Zhel. Dorogi v Petrograd v sviazi s vodosnabzheniem i kanalizatsiei’, Gigiena i sanitariia putei soobshcheniia, no. 1 (aprel’ 1923), p. 76.

in and around the factory might easily have caused an outbreak of infectious disease. While cholera was absent among the factory population, typhoid and dysentery were well-represented. The study of the Aleksandrovskii factory reveals that unacceptable sanitary conditions still prevailed on the Neva in the outskirts of Petrograd in the early 1920s even though cholera was relatively absent. Noting the new inequality between Moscow, which experienced 312 cases in 1921 and Petrograd, which had nine, the Moscow-based Tarasevich tried to explain this disparity as due to Petrograd’s chlorinated water and the good water supplies at Nizhnii Novgorod and Tver’. In other words, that these water systems retarded the movement of infectious agents on the ways from India to Petrograd. Tarasevich admitted that his reasoning ‘seems paradoxical if preceding epidemics are borne in mind’, but that Petrograd, located at an extreme end of Russia, entertained only ‘a few travellers and for that reason it receives fewer germs than Moscow’.27 For one of the few times in his career, Tarasevich’s meticulous reasoning ability perhaps failed him. Petrograd had always suffered far more casualties than Moscow and, perhaps influenced by his association with the latter, Tarasevich rationalised the new disparity. The chlorination of the Petrograd water supplies dated back at least to 1916 and did not save the city from cholera in 1918, nor did the Tver’ waterworks. One must question why the superior water supplies and sanitary conditions in Moscow did not save it from cholera in 1921.

17,678 17,673 16,516 16,853 16,333 16,831 16,831 16,831 13,818 11,791 12,813

1910 1911 1912 1913 1914 1915 1916 1917 1918 1920 1921

Total 20 – – – – – – – 416 – –

Absolute 75 66 105 144 322 304 220 280 22 3 17

Per 10,000 42.4 37.3 67.3 85.7 197.1 180.6 130.7 166.4 15.9 2.5 13.3

Cholera

Typhoid Per 10,000 11.3 – – – – – – – 301.1 – –

Total 17 20 – – 22 103 106 97 13 95 75

Dysentery Per 10,000 9.6 11.3 – – 13.5 61.0 63.0 57.6 9.4 80.6 58.5

Source: I. N. Lastochkin, ‘Zabolevaemosti rabochikh po Aleksandrovskom zavode Nik. Zhel. Dorogi v Petrograd v sviazi s vodosnabsheniem i kanalizatsiei’, Gigiena i sanitariia putei soobshcheniia 1 (aprel’ 1923): p. 77.

Pop.

Year

Table 8.4 Cases of typhoid, cholera and dysentery among the population of the Aleksandrovskii Mechanical Factory on the Nikolaevskii Railroad, 1910– 21

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Also, if improved sanitation curtailed cholera in the city and suburbs of Petrograd in 1921, it did not stop typhoid and dysentery, which are also waterborne diseases. The Soviets attempted to compensate for water shortages by rationing it. Tarasevich criticised ‘disinfection week’ and ‘water week’ programmes designed to provide clean water and disinfection on a regular basis. He argued that they ‘only produced results in certain places’, particularly failing along the Volga, where poor municipal services had ‘fallen out of repair or in some cases [. . .] completely destroyed and all intercourse with foreign countries was prevented by a blockade’.28 The NEP and reduction of famine probably saved Petrograd from cholera in 1921. Sanitation was important in that Moscow, which had excellent services and water sources, experienced only 312 cases in the midst of famine. The new disparity between the cities was due to the NEP’s short-term limitations and continuation of warfare, which caused famine in Moscow, Saratov and nearby Volga cities in early 1921.29 Cholera failed to materialise in Petrograd in 1921, a shift due more to adequate nutrition and perhaps the vibrio’s weakening and general retreat toward India than increased sanitation. A blockade and reduced numbers of traders and shiploads of freight up the Volga undoubtedly helped, but, as noted above, the city received 150,000 refugees from the Volga famine districts without an increase in cases. Transmission of the contagion in humans was more widespread in the presence of starving hosts. The Soviets made incremental improvements in all areas, including execution of the emergency response system. As Tarasevich observed, in October 1922 Soviet authorities were carrying out anti-epidemic efforts ‘under the broad headings of:’ health propaganda, the most precise and rapid registration possible, vaccination, hospitalization and isolation of confirmed or suspected cases, attempts to improve the water supply and sewer [systems], disinfection, etc. The execution of the majority of these measures encountered, and still encounters, difficulties which are sometime insuperable [. . .] and their application has therefore, speaking generally, been imperfect and unequal at different times in different places.30

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As cholera was disappearing from Petrograd and other locations in 1922, the Soviets were still struggling to improve sanitation. Lowered economic conditions in some places made dealing with cholera more difficult than in others. The comparison between Petrograd and Moscow indicates how various forces could alter geoepidemiology, a reminder that the presence of cholera epidemics, while disclosing much about a country, is unreliable in assessing the progressive nature of a society. Moscow possessed a more efficient waterworks system, geographical protection and perhaps even better leadership but, as in 1915 and 1921, the city’s advantages did not spare the city in the presence of famine.

Soviet Microbiology, Epidemiology and Famine during the NEP, 1922 –7 The gravity of our epidemic situation, the number of its victims and the suffering it occasions are as nothing to the horrors of the famine and the extent of evil which it has already caused, which it is still causing and will continue to cause.31 L. A. Tarasevich, October 1922 In the early to mid-1920s, literature dealing with cholera become less abundant while a new body of scholarship regarding the ‘struggle with famine’ emerged in journals such as Red Night.32 Lenin’s order of 25 July 1921 provided for the necessity to feed personnel who were working at isolation or quarantine stations and patients who were detained.33 Soviet physicians knew that malnourished individuals were more likely to fall ill than those who were well fed. General hygienists such as Khlopin and social hygienists such as Semashko, Mol’kov and others shared a concern for famine. Some epidemiologists began examining not only famine’s effect on immunity but how it might affect the virulence and structure of the vibrio. Eight years of war and famine caused physicians to view cholera more as a symptom of adverse social issues than as the primary concern. Attention to famine would lower the rates of cholera and other diseases. Movement of populations during famine was a major culprit in spreading cholera.34 Yet, the effect that malnutrition had on the organism was also a factor and Russian physicians considered the role of this relationship. V. A.

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Liubarskii observed that the factors that would prove most important ‘in determining the origins, course and dying out of an epidemic’ included ‘not only micro-, but also macro-organisms’. Noting that hunger was present at the time of his article in 1927, he maintained that ‘the origins and character of diseases are determined not only through available causes, but by macro-organisms’. In Petrograd, renamed Leningrad in 1924, G. A. Ivashentsev and other professors discovered a new and complicated disease, which was caused by a ‘special microbe’ with similar, but not precisely the same qualities as paratyphoid. A worker in the Krasnodar laboratory of Zabolotnyi’s former partner, I. G. Savchenko, analysed the microbe and an investigating physician hypothesised that it had mutated in the intestine due to changes in the nutritional regimen. The origin of the infection, Liubarskii observed, occurred under ‘abnormal conditions’, which affected its nature and characteristics. This investigation ‘splintered like a meteor’ causing numerous studies related to macro-organisms.35 Macro-organisms were, as opposed to micro-organisms, large plentiful substances or matter that might facilitate the onset of cholera such as, in this case, famine-related changes within human intestines. Liubarskii pondered why in the past cholera disappeared for some time and suddenly returned, reasoning that the change involved the conditions under which the disease originated. Studies undertaken by V. A. Levetskii and his colleagues discovered that such conditions often involved locations that were conducive to ‘easy multiplication of cholera victims owing to the development of immunity in the carrier’.36 Liubarskii noted that a physician named V. A. Barykin had theorised that the aetiology of cholera permitted it time to enter collectively the intestines of the Russian population. Through frequent visits and sustained presence in individuals, the human organism might adapt to living with the microbe and ‘the population gradually, but steadily builds an immunity to it’.37 He cited investigations of tuberculosis in which investigators recognised that chronic hunger appeared to weaken or destroy the acquisition of immunity.38 These microbiologists had mostly been trained under the tsarist system. While cholera does not live for long periods in humans we know today that famine lowers immunity of individuals to disease and that climate strengthens its spread in ocean and river estuaries, where it remains for long periods. According to Liubarskii, such studies applied to cholera in that famine rendered the human organism susceptible to the disease. Studies

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by S. S. Kazarnovskii and N. I. Krich revealed distinct changes in the characteristics of the stomach in absence of proper nutrition, altering the intestines when cholera was present and weakening antibody formation. Such studies further motivated government efforts to improve nutrition, particularly in places threatened by epidemics.39 Liubarskii’s study of famine was an outgrowth of his years of research that linked bacteriology with epidemiology, further consolidating the efforts of the Odessa group (Tarasevich, Diatropov, Zabolotnyi and Gamaleia with Khlopin) and earlier hygienists such as Erismann and Osipov. Admittedly, Soviet science advanced this ball further down the field, but much of the work that influenced the general Russian medical framework is traceable to Mechnikov in Odessa and Pirogov at Sevastopol. The Soviets included many of the same scientists who been there from the beginning, bringing these elements together in a manner that reflected their particular modernity under the concept of immunology and the technological fulcrum of vaccination.

The Role of Soviet Vaccination in Cholera’s Withdrawal Soviet physicians viewed vaccination as a preventive tool that had produced the results to justify its use, but the procedure still faced opposition. One of vaccination’s proponents, A. M. Bezredka, noted that 30 years of experimentation with anti-cholera vaccinations had still resulted in divided opinions. By 1922, widespread use of the cholera vaccine had earned it a reputation as a ‘weak prophylactic’. Laboratory experiments had not provided definitive data verifying its effectiveness and many considered it of little value. Bezredka disagreed, arguing that ‘those who witness epidemics and the practice of vaccination become partisan to the method’.40 Acknowledging the importance of establishing the effectiveness of anticholera vaccination with more certainty, he admitted that immunologists owed their knowledge not to laboratory observation, but 30 years of ‘practical experiences in the field (that) provided observations that could not be obtained in a laboratory’. These ‘epidemiologists [. . .] removed the sowing of doubt and mistrust’ in the practice, expressing confidence that laboratory work would prove the efficacy of cholera serum.41 While not foolproof, vaccination was a valuable epidemiologic tool. Zabolotnyi’s old partner, I. G. Savchenko, made considerable progress in his Krasnodar laboratory. In an October 1922 report,

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Tarasevich noted that investigators working under Savchenko’s supervision had evaluated the effects of mass vaccination on broad immunity among the population. In 1920 in Krasnodar, a mild epidemic of cholera materialised under conditions in which physicians feared a larger outbreak. Savchenko’s investigators conducted a study utilising the Pfeiffer-Isaev Phenomenon and a technique invented by the Belgian, Jules Bordet.42 They discovered that of 1247 vaccinated individuals, 814 (65.3 per cent) developed some kind of immunity, while 433 (34.7 per cent) did not. Comparing groups of vaccinated and un-vaccinated individuals, Savchenko’s workers concluded that 56.2 per cent of those who were not vaccinated developed immunity while 43.8 per cent did not, as opposed to 87.2 and 12.8 for those who were vaccinated.43 The immunologists concluded that two-thirds of the population in Krasnodar possessed some immunity against cholera, including 50 per cent of those who were not even vaccinated.44 Tarasevich cited studies in Kharkov and another by A. M. Bezredka, who was working against smallpox, dysentery and paratyphoid, that indicated that a lowered virulence in the cholera vibrio was resulting in ‘abortive forms’ in carriers of the disease, producing ‘relative immunity, so that the epidemic, if it breaks out at all, rapidly disappears on its own accord, through the progressive decrease in its virulence and through natural immunisation’.45 Working with epidemiologists, Soviet immunologists did everything they could to help this natural process along. Liubarskii also wrote that biological studies of the cholera vibrio showed ‘the significance of the role of immunisation of the population as an epidemiological factor’. E. V. Voronin, a scientist in Savchenko’s lab, studied 259 cultures of the cholera vibrio in which three were agglutinative, or capable of initiating an epidemic, while 198 were non-agglutinative, or ‘cholera-like’. Liubarskii hypothesised that similar waterborne microbes were responsible for producing natural immunity in the population. Investigators were aware that there were variations of ‘cholera and para-cholera’ microbes and sought to find the role they played in the development of epidemics.46 They understood that each microbe held varying capacities and sought to use them to prevent epidemics. Soviet immunologists concentrated their work in vulnerable border regions. Dobreitser published an article in Hygiene and Sanitation on the

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Ways of Communication in 1922, observing it was ‘obvious’ that vaccination lowered the number of cases of cholera.47 While statistics were incomplete, Soviet physicians had vaccinated at least 9,228,000,968 people in the border regions of the Soviet Union, 5,452,424, three times, 2,658,674, twice and 1,117,871, once.48 The Soviets in 1922 vaccinated one million four hundred and ninetyfour thousand five hundred and five people in Ukraine, three million four hundred and seventy-nine thousand eight hundred and seventy-seven in the Caucasus, 177,786 in Siberia and one million nine hundred and eighty-seven thousand three hundred and fifty-seven in other places of the Empire.49 The morbidity rate of vaccinated individuals was one-third that of the unvaccinated. In Arkhangel’sk, 4,649 people were vaccinated, 79 cases materialised and only four of them were vaccinated. In Rostov-onDon only 89 of 1620 people who had been vaccinated fell ill and most of the stricken had received their shots over a year prior to onset. Physicians vaccinated 37,669 individuals in Penza and none of the 275 patients who fell ill had been vaccinated.50 Savchenko’s and other experimenters’ work paid remarkable dividends. These statistics indicated that vaccination exerted influence in preventing cholera. By studying the field, bacteriologists such as Savchenko and Bezredka, both veterans of the tsarist system, understood that results in the field showed progress that laboratory investigations did not. These results stemmed from the persistence of bacteriologists such as Savchenko and his partner, Zabolotnyi, who emphasised field work even in the face of opposition from I. P. Pavlov. Dobreitser undoubtedly understood this concept from his work in Saratov Province. Morbidity rates in the USSR indicated that people who were vaccinated within 12 months of an epidemic were far less likely to fall ill. Studies also indicated that those who received vaccination suffered lowered mortality, or death rates. In one cholera barracks holding 368 patients, the death rate among unvaccinated occupants was 60.6 per cent, while only 25.7 per cent of the vaccinated died. Among the population in Rostov-on-Don, comparable percentages were 51.3 and 22 per cent.51 While it is always possible to cast doubt on statistics and some sampled populations were small, there was evidence that mass vaccination achieved success. On the other hand, the number of individuals who were vaccinated and still fell ill indicates that these programmes were not ‘wiping out’ cholera. Documented successes

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amounted to small but significant victories in a battle of attrition that physicians and the Soviet people were waging against the cholera vibrio. Soviet vaccination worked well in tandem with broad measures, the manifestation of the preventative system for which zemstvo physicians had longed. Even Tarasevich, one of the strongest proponents of vaccination, admitted that the process had encountered setbacks, but argued that plans for continuing the practice were based on sound logic. In general, efforts to vaccinate the civil population had been minimal and the results were ‘negligible’. The army was vaccinated time and time again and the soldiers ‘nevertheless showed a certain number of cases of cholera’. To those who cast doubt on the practice, Tarasevich pointed out that mortality was two times lower among those who had been vaccinated than in those who had not in places such as Rostov, where cholera mortality was 20.6 and 43.5 per cent respectively. In Kharkov, 12 patients who had been vaccinated and fell ill survived. In January of 1922 in Kiev, only 38 of the 170 soldiers who had been vaccinated fell ill as opposed to more than 119 who had not.52 The soldiers’ survival was also probably due to the better food and living conditions that made the military an excellent career for many Russian males. In fact, increased recovery was also partly due to the broad measures that personnel administered at checkpoints, such as emergency hydration and nutrition. Soviet success in the struggle with cholera owed much to alleviation of famine and dehydration as well as bacteriology and immunology. In this sense, the Soviets’ use of vaccination was more a triumph of applied science in relationships between human physiology and broad sociological phenomena than of the technology itself. Indeed, one of the strongest arguments against vaccination was that it created huge numbers of cholera carriers who were capable of transmitting the disease to others. Tarasevich acknowledged that statistics confirmed this argument, but countered that it was better for those who developed the disease to do so through vaccination and remain a carrier with immunity rather than to fall prey to the vibrio. Medical personnel in the West today might cringe at such an argument, but in a country that suffered such cruel privations in 1918–24 as the Soviet Union, it undoubtedly seemed more logical. Soviet methodology developed within a framework of militarisation and emergency circumstances, in many cases equivalent to

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martial law, a circumstance of time and place that privileged military personnel. Soldiers were vaccinated at least 95 per cent of the time, but civilians, far less often, therefore, the former fell ill approximately 50 times less frequently than the civilians.53 Mass immunity in soldiers, who often spread the vibrio, undoubtedly curbed morbidity. Better food, water and other benefits among army personnel also undoubtedly contributed to the disparity, but it is clear that vaccination facilitated the development of immunity in the Soviet Union and that targeting areas under imminent threat paid dividends. Vaccination was a tool from the tsarist era that, without the ideological warfare and militarisation of society in 1905– 24, would likely never have developed as it did. Soviet hygienists during this period evaluated the effects of famine, sanitary precautions and defences, water quality and other conditions relating to the development of cholera epidemics as part of the larger process of eliminating breeding grounds and creating broad immunity. They confronted the disease where it was likely to develop, at railroad depots and wharves and anywhere people congregated. They cleaned these areas, the vessels that passed through them, constructed special stations for disinfection, restricted refugees to isolated areas and administered hundreds of thousands of vaccinations, making select repairs and improvements on waterworks, sewage and sanitation systems, improvising when technology failed. Their setbacks were formidable and progress, incremental. Soviet physicians made improvements in public services such as waterworks and sanitation, but their system of cholera control remained based upon intelligence gathered through epidemiology (i.e. surveillance), laboratory research and improved detection and response. They fed citizens, boiled water, vaccinated citizens, educating them about hygiene and retaining the tsarist administrative structure and system of emergency response. The Soviets used advancements and reforms that zemstvo physicians, epidemiologists and the tsarist military had pursued since 1892 rather than just extensive quarantine.

The Sixth Pandemic Departs Europe: 1923 –7 Cholera cases dropped considerably in 1923 and were scattered individually across the country, causing great optimism. There were a few cases south of Moscow in Perm, which was located east of the Volga

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ESTH

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UKR AINE K i r g h i z

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KHIVA

TURKEY

OKH

Pekingo

A RA

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MA LIL A

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Madras

S

KENYA

L I TA

SIAM

Cholera in British India Annual Death Rate Per 100,000 pop. 7 – 14 23 – 27 46 – 51 81

INA CH DO IN

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CH

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Hong

EN

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FR

EN

AN

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UGANDA

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SUDAN

T I B E T

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A RL

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PE R SI A

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UNION OF SOUTH AFRICA

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MA

WEST

MOZ A

SOUTH

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RH OD E

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ANGOLA

Mountius

O

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Cholera Under 30 cases 50 – 100 cases 310 cases 1500 cases

Figure 8.1 Distribution of cholera between India and the Soviet Union, 1923. Source: Epidemiological Intelligence, No. 8, 1923 (Geneva: League of Nations Health Organization, 1923).

on the border of European Russia and the Urals Mountains. Some cases materialised on the southern border in Central Asia and others appeared around the Sea of Azov (see Figure 8.1).54 The disease retreated along the outskirts of the Volga region, indicating that measures along the river were effective and local populations were not as prone to the disease. In regional Volga cities, the evidence is overwhelming that sanitation and waterworks systems did not cause cholera to withdraw.

242 Table 8.5 Month January February March April May

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Cholera in the USSR in 1923 up until 24 September Number of cases Month 7 2 1 2 14

June July August Without a definite time

Number of cases 18 46 20 4

Source: ‘Infektsionnaia zabolevaemost po SSSR v 1923 g.’ Gigiena i sanitariia putei Soobshcheniia, no. 7 – 8 (noiabr’-dekabr’ 1923 g.), p. 74.

One of the earliest reports of 1923 came on 15 January from the Ninth All-Russian Conference of the Departments of Public Health, which boldly proclaimed: ‘this year the cholera epidemic was liquidated’. Essentially true, scattered cases remained. The report stated that 9 million vaccinations had been administered in the border regions, but, unfortunately one-half were performed only one-time.55 There were seven cases in January, including one in Moscow, one in Aleksandrovsk in Kremenchugsk Province and four in Central Asia in Tashkent. In February, there were two cases in Ekaterinoslav Province, one in March in Elizavetgrad, one in April in Yalta, two in Rostov and one in Perm.56 By 15 October, the Sanitary Epidemic Service, or Sanep, reported that there had been 30 cases in Rostov and the Don gubernii, or provinces, five cases in Tashkent, three at the railroad station in Iuzovka, which had experienced so much cholera-related turmoil, two in the Perm, KubanBlack Sea and Ekaterinoslav governments and one each in Moscow, Kremenchugsk and Novgorod. By 23 July there were only 48 registered cases of cholera.57 Cholera was stubbornly struggling for existence in the Black Sea-Azov region (see Figure 8.1). By 24 September Soviet officials had documented 114 cases and 16 individuals suspected of cholera and compiled statistics relating to the distribution of these cases over an eightmonth period (see Table 8.5). The greatest number of cases in 1923 once again occurred in Rostov, which suffered 73 cases and in the in the Donets oblast’ where there were ten.58 The Soviets used advanced intelligence, keeping an eye on events in the Middle East. A report on 20 December noted that there was a cholera epidemic in Persia. Between 10 August to 6 September there were 802 cases, of which 754 massed at Abad, a village in Azerbaijan and 44 at

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Mohammad. Public health officials in Persia reported the unusually high mortality rate of over 90 per cent, which as one might hope, quickly subsided, probably due to its own strength and a scarcity of human hosts. Authorities in Persia formed a quarantine at the border of Kasur– Shiri for travellers returning from Bagdad.59 Despite the outbreak in Persia, reports related to cholera became less regular in 1924 as investigators focused on the extremities of the Soviet Union. The number of confirmed cases in European Russia amounted to only nine, with one in Central Asia.60 Cholera diffusion was almost precisely the same as in 1923 (see Figure 8.2).61 Cholera-like cases caught the attention of investigators who, by the middle of the year, detected such cases in the border regions. In the July/August issue of Hygiene and Epidemiology an intelligence report noted ‘this year choleralike (cases) were once again concentrated in the vicinity of Rostov-onDon’. The first cases appeared on the Don approximately 20 kilometres from Rostov at the station of Ansa on 2 May. By 11 May laboratory workers verified six cases and by 15 July there were eight registered cases. August brought approximately 11 more cases in the borderlands of the Kazakh Republic and Dagestan and there was one case in Voronezh.62 Cholera clung to life in the areas between the Black and Caspian Seas and due south in the borderlands of the Arabian peninsula, undoubtedly due to social conditions, poor sanitation and drainage, but perhaps also to the abundance of shorelines and intersecting waterways. Cholera’s initial and continued entry in Russia over this route during the preceding 98 years likely reflected an environmental predisposition to the disease. Soviet epidemiologists understood this susceptibility well. On 1 October 1924, Soviet immunologists of the Sanitary Epidemic Department of the Serum-Vaccination Commission of Narkomzdrav RSFSR observed: ‘At the current time the opinion exists that the tributaries of the Don River present one of the world breeding grounds of cholera equal to the branches of the Ganges River’. This may have been an overstatement, but this area had proven itself time and again to be a veritable reservoir for cholera and the Soviets wisely chose to pursue vaccination in this area. The Rostov Microbiological Institute and Moscow based Microbiological and Sanitary Hygiene Institute (GINZ) assumed the leading role.63 By 20 June 1924 at the Eighth All-Russian Conference of Bacteriologists, Epidemiologists and

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POLAND

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HUNG

ROMANIA Belgrade SLAVIA

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GREECE

I LGA R BU

K HAR

PER SI A

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Aden MA LIL A

ABYSSINIAN

A

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T

TERRITORY

adesh

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LI

SIAM

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U

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ITA

Cholera in British India Annual Death Rate Per 100,000 pop. 15 – 20 20 – 50 70 – 145 195 and over

S

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A

INA CH DO IN

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Bombay ER

EGYPTIAN

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I N D I A

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F

C H I N A Foochow

IA

Mecca

ANGLO-

SUDAN

T I B E T

AFGHANISTAN

A

EL Z JA

HE

EGYPT

Pekingo

A

AR

Cairo

M O N G O L I A

A S I A

SI N KIANG T U BOR K E S T A N

KHIVA

TURKEY

RANEAN SEA

LIBYA

TIME OF CHOLERA

Mountius

O

C

Cholera Less than 20 cases 20–80 cases 180–300 cases

Figure 8.2 Distribution of cholera between India and the USSR, 1924. Source: Epidemiological Intelligence No. 9: Statistics of Notifiable Diseases, 1924 (Geneva: League of Nations Health Organization, 1924), p. 25.

Sanitary Physicians, there were more than ten reports dedicated to vaccination and experimental work on animals. Most of the reports indicated that vaccinations for smallpox, typhoid and dysentery resulted in an immunity, which was ‘absent in regard to cholera’.64 Reporting on the conference, Dobreitser did not elaborate on the disparity and vaccination, nonetheless, assumed an increasing role in

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cholera prevention. Anti-cholera vaccination still had opponents, but the results in places such as Krasnodar gave the Serum-Vaccination department confidence that they could singlehandedly cope with the bacterium. A relative dearth of opposition to cholera vaccination in primary sources likely reflects the formidable development, organisation and strength of the established bacteriological laboratories and institutes that dated well into pre-revolutionary times. Soviet authorities better understood and traced the connection between cholera in India and the Soviet Union. Reports were not always timely. An article on the death rate in India in 1924 indicating that it was four times higher than the previous year and twice as high as in 1922, did not appear until 1926. The tsarist bacteriologist and immunologist (now ‘epidemiologist’) N. F. Gamaleia featured this article as the main editorial in the first edition of Hygiene and Epidemiology. The epidemic encompassed ‘all of India’ and the north-west provinces of the country, producing mortality of up to 22.1 of every 10,000 inhabitants.65 As the epidemic became less volatile, the editors in the League of Nation’s Epidemiological Intelligence Number 10, reported that cholera epidemics ‘in all of the remaining parts of Asia’ besides Korea ‘have begun to subside’. In the French Indies there were 168 deaths and Indo–China experienced 180 cases. The cases in Asian countries in 1924 included 17 in Ceylon, 97 in Siam, 31 in the Philippine Islands, 22 in the Malaysian states, 12 in the Establissements des Detroits, two in China and a single case in Shanghai. Other places in Asia experienced scattered cases.66 Such reports often came too late to allow for preparation, but Tarasevich’s work with the League and Gamaleia’s later publication in 1926 indicate that the Soviets’ panEurasian intelligence was a manifestation fusing nineteenth-century tsarist bacteriology with twentieth-century international initiatives in epidemiology. By 1925, cholera was mostly confined to the tropical zones and Asian provinces from which it had emerged in 1817 and departing the temperate zones through which it diffused six times over the last century. A small outbreak involving approximately 11 cases occurred north and east of the Azov Sea and west of the Caspian and one in Central Asia. There were no cases on the Volga, even in Tsaritsyn or Astrakhan’ (see Figure 8.3).67 This absence was not due solely to better sanitation, but vaccination and better overall conditions including the cessation of

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TIME OF CHOLERA Number of deaths in each district of British India. 1–300 300–1000 1000–2000 and over

Cholera in 1925 Less than 10 cases 10–50 cases 50–200 cases 200–500 cases 500–1200 cases

1076 Pondicherry (Fr) Karaikal (Fr)

320

Figure 8.3 Distribution of cholera between India and the Soviet Union, 1925. Source: Epidemiological Intelligence No. 10: Statistics of Notifiable Diseases, 1925 (Geneva: League of Nations, 1925), p. 20-1.

warfare and increases in the food supply. The vibrio departed first the Volga, then the Don oblasts and Black Sea-Azov coasts and the Aral Sea in Central Asia, areas in which the vibrio stubbornly persisted for a century. In 1926 there were 25 cases in Central Asia and just one in European Russia.68 Considering cholera’s entrance and exit from the Soviet Union it is possible to understand the historical significance of the vulnerability of the Donets Basin to cholera. As Tarasevich had informed the League of Nations in 1922, ‘As regards Rostov, it may be noted that this town and its district come as one of the first on the list in severity of the cholera epidemics from 1830 to 1872; after that they hand over this gloomy precedence to the regions situated along the Lower Volga’.69 However, despite this shift, the Don region remained important. The shift occurred as a consequence of Russian industrialisation in the 1880s, but the Don region continued as the gateway to the Empire,

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the place where the vibrio gained a foothold before moving to the Volga due to commercial transport, migrant labourers, vulnerable natural environments, deficits in socio-economic status and drainage in these vast river valleys. If not an extension of the Ganges River, the Donets Basin was safe haven and conduit for the vibrio. From the region around the seas, cholera could move to Tsaritsyn or Samara and then downriver and upriver to Astrakhan’, Saratov and other places on the Lower and Middle Volga or, as in 1915 during World War I, other locations as circumstances dictated. Refugees, prisoner and supply transports, deployments and local social conditions such as in Saratov in 1921 determined variations in the course of epidemics. The vibrio spontaneously appeared on the Volga upriver in Tsaritsyn in 1908 and 1910, Samara in 1907 and, given Rein’s observation that the 1907 epidemic began in Ekaterinoslav Province and Gamaleia’s exhaustive investigations in 1892, 1904 and 1909, the coastal area in the regions between the Caspian and Black Sea brought cholera to Azerbaijan and the Don in every pandemic. Cholera’s sustained entry into Central Asia around the Aral Sea was equally persistant. Moreover, the disease exited the Soviet Union by almost precisely the same route it had originally arrived. Soviet scientists did not deliver a crushing blow to the disease. More admirable, the Soviet struggle with cholera was more like a battle of attrition along a broad front with a series of small encroachments that gradually weakened an otherwise unyielding enemy. After penetrating all Russian provinces in 1910 during the largest cholera epidemic of the twentieth century in Europe, the vibrio remained wellrepresented throughout the country until 1921, then grew less capable of penetrating the country and descended along its usual breeding grounds, making counterattacks, but gradually subsiding. The winter epidemics in the Don provinces in 1921 and afterwards reflected the evolving nature of the vibrio, which was weakening in an attempt to survive. This lapse in strength was undoubtedly another factor in why cholera failed to reach Petrograd in force in 1921 despite plentiful breeding grounds. Since cholera often originates in India, one might find a correlation between the strength of cholera in India and its appearance and demise in the USSR. While the total number of cases in British India during the Sixth Pandemic were unavailable for this study, the number of deaths

248 Table 8.6

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Deaths from cholera reported in British India, 1896 – 1925

Year

Deaths

Year

Deaths

Year

Deaths

1896 1897 1898 1899 1900 1901 1902 1903 1904 1905 Total All Years

491,867 570,782 153,117 171,908 850,985 282,649 125,885 314,299 193,457 442,508

1906 1907 1908 1909 1910 1911 1912 1913 1914 1915

713,664 413,180 607,278 242,848 435,077 365,157 425,192 311,127 299,174 409,328

1916 1917 1918 1919 1920 1921 1922 1923 1924 1925

300,071 277,537 571,643 602,304 131,203 459,843 125,808 74,326 306,811 96,752* 10,765,780

Source: Epidemiological Intelligence No. 10: Statistics of Notifiable Diseases 1925 (Geneva: League of Nations, 1926), p. 17. *Data for the last quarter of 1925 was incomplete.

in the source country sheds light on this relationship. As shown in Table 8.5, Russia often experienced epidemics either simultaneous or a year or two after a high number of deaths occurred in India (compare these figures with those in Table I.1). The first cases of cholera in Russia during the sixth pandemic appeared in the Far East in 1902, which was two years after deaths in India from cholera peaked at 850,985. In 1903, or a year before the disease appeared in Saratov in 1904, there were 314,299 deaths in India. After subsiding, cholera-related deaths again peaked at 713,664 cases in India in 1906, which was the year before it again arrived in Russia. Over the following years mortality in India remained relatively high, as did the number of cases in Russia, except for a sharp decrease in 1909 in both countries. Deaths in India slowly decreased from 425,192 in 1912 to 277,537 in 1917. Cholera was correspondingly moderate in Russia during these years. In 1918, the year of a major outbreak in Russia, deaths in India once again peaked at 571,643 and then at 602,304 in 1919. After a relatively light year in 1920, 1921 was a disaster. At the beginning of the last series of epidemics in Europe, which occurred almost exclusively in the Soviet Union, the number of cholera deaths in India increased to 459,843. From that time forward, the numbers of deaths in India subsided, corresponding with lighter years in Russia before rising again to

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306,811 cases in 1924 just before cholera made its final appearance in large numbers in the Soviet Union. In 1923 and 1925, the number of deaths in India were few, which correlated to light years in Russia during these same two years.70 This is, admittedly, a rough interpretation, subject to many aggravating and mitigating factors, but it indicates that cholera’s spread from India was still the primary contributor to its diffusion across the parts of the globe that were still affected. That diffusion however, was shaped by many environmental and climatic circumstances.

Conclusion The Russian Civil War in 1918 – 21 caused widespread hardship on civilian populations and created a more militarised populace. Divided by ideological doctrine and suffering conflict, these conditions improved in various locations and cholera epidemics began to wane. Famine and cholera followed the battle front to Ufa in 1922, where the last strong epidemic occurred, but reduced warfare in the following years permitted the vibrio to begin its retreat back to India. Soviet bacteriologists vigorously monitored and studied cholera’s withdraw, detecting that the vibrio was weakening. Not surprisingly, the technology-oriented Soviets gave vaccination the lion’s share of the credit, applying a massive campaign of immunisation that included the carrying out of millions of vaccinations, an indication not only of ideological zeal, but a militarised precision and ironclad confidence in the technological component at the heart of their core beliefs. Those beliefs also included a rise in living conditions for the Russian people. By 1925 many older intellectuals were impressed at the manner in which the Soviets had raised the material circumstances of the people and the freedom that the NEP had brought about.71 The reduction of cholera epidemics reflected this improvement. As Soviet physicians continued studying cholera microbes in laboratory and field settings, connecting microbiology with social and environmental concerns, alleviation of famine perhaps did the most to decrease epidemics. Agricultural advances in 1923–7 increased the amount of food that individual Soviets consumed.72 This consumption, along with general improvements in ‘hygiene, health education, and preventative medicine’, not only lowered cholera rates, but practically every

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contagious disease. During these four years, the overall number of cases of malaria in the USSR dropped from 5.7 to 3.7 million, as smallpox nosedived from 46,000 to 15,000.73 Targeted disinfection programmes, repair of broken water sources, more hospital beds, hygiene education, water provision and mass vaccination were all part of this multi-faceted approach, but the level of sanitary protection that waterworks and canalisation provided outside of Moscow left something to be desired in the newly-named Leningrad and in the Lower Volga region. Soviet public health officials mimicked their leader, V. I. Lenin, in that they were pragmatists, taking what they inherited from the tsarist system and improving upon the concepts that zemstvo reformers, the tsarist military and epidemiologists such as Zabolotnyi, Tarasevich, Teziakov, Dobreitser and others had long ago initiated.

CONCLUSION

Overcoming cholera epidemics was something of a rite of passage for European nations undergoing modernisation, but each country faced different challenges. Koch’s contagionist strategy was not the only legitimate means of dealing with cholera in Europe after 1883. A product of climate change, imperial pursuits, warfare, trade, industrialisation, social upheaval, religious pilgrimage and famine, cholera ceased appearing in a country only when its scientists developed both medical infrastructures and remedies that were adequate based upon the country’s location and difficulties. These complications repeated themselves with great success where climatic, environmental, economic and other circumstances permitted. Plagued by protest and efforts for reform, a 12-year period of revolution and warfare destroyed the tsarist Empire and created the modern Soviet state, fusing elements of the two societies. Appearing in force within the Soviet Union before subsiding, the persistence of cholera and the efforts of the two administrations to stop it, explains much about them both, particularly their administration of public health. This study has revealed the origins of a previously misunderstood, environmentally-focused medical methodology in Russia and provided an assessment of how, due to geography and climate-related issues, cholera created a more persistent and stronger threat to Russia than to its neighbours to the West. This was particularly true after 1900 when the less-deadly, but more durable versions of the vibrio began to dominate. Tsarist physicians were not only forced to deal with issues related to commercial and industrial development but also increasing

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swaths of land, due to imperialism and incorporation of Muslim pilgrims, who were often connected with bringing the vibrio to Russia. These threats, a more survivable bacterium and decreases in biological strength all meant that Russia would experience cholera epidemics more often than the nations that were located further west. The decreased diffusion of the cholera vibrio beyond Russia, Eastern Europe and southern European ports after 1900, Gottschlich’s discovery of El Tor cholera in 1905 and recent findings in epidemiology that El Tor dominated the sixth pandemic, all indicate that Tarasevich and his Soviet colleagues were correct. The general weakening of the vibrio kept cholera out of Western Europe after 1900, but the anticholera measures undertaken by Soviet public health in the end facilitated the vibrio’s decline in virulence. While cholera epidemics ultimately died out, an accumulation of factors related to climate, economic policies, warfare and other factors, could recreate the processes that fortified its strength. El Nin˜o events interrupted the monsoon and mobilised the changes in tides and oceanic temperatures that produced cholera and caused severe drought in the Don River basin, in the Volga Breadbasket and the wheat fields of Orenburg, where the first strong epidemics materialised and near where it lingered into the 1920s. Southern Russia’s agricultural regions fed the rest of Russia, and the droughts had severe implications, although policy often made these issues worse. The famines of the 1840s, of 1891 and 1921 rank among the worst in history. The long-term effects that these famines inflicted on the human organism are not known, but the reappearance of cholera in the presence or direct aftermath of famine over the course of 100 years, the changing biological characteristics of the cholera vibrio and the economic difficulties in ensuring that everyone in the massive country was fed were the primary reasons for recurring cholera epidemics in Russia. This problem was not due, as is so often thought, to the presence of a backward medical system. In addition to famine, factors such as Russia’s proximity to India along the routes of travel with Western Europe, late industrialisation and the construction of railroad tracks also put the nation in harm’s way. The large river systems hosted a huge amount of traffic and, after the 1880s, were networked by new railroad tracks. Migrant workers left the rural agricultural areas looking for work, huddling around railroad

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stations and along the outskirts of cities in southern Russia, in areas where there were no city services. These places were breeding grounds for cholera and other diseases and the probability that they might bring the vibrio along was high. Subject to the drainage of massive river basins, city services in the centre of these towns saved many lives, but could not cope with the influx of so many migrant labourers. Taken together, these influences threatened southern Russia and areas that were closely linked with it such as Rybinsk, Iaroslavl’ Province and other locations along the Mariinskaia System, including St Petersburg/Petrograd. No other European country faced such threats. With all of these complications, Russia quite logically created and applied a system of public health designed to cope with the multifaceted causes of cholera. The tsarist Cholera Rules essentially evolved into Lenin’s 1921 plan for dealing with cholera. Both systems took into account the resources and capabilities at their disposal and, increasingly, the more economic and timely application of measures due to better surveillance and the more systematic application of vaccination and other supporting measures. The methodology that tsarist physicians ultimately passed on to their Soviet successors, who were in many cases one and the same people, accounted for the difficulty, if not impossibility, of stopping cholera with quarantine. In fact, considering recent scientific studies, the investigations of Gamaleia, Khlopin, Klodnitskii and others, provided considerable evidence to suggest that after 1900 and perhaps even before, cholera appeared along the coastlines and estuaries of southern Russia through chemical processes in these environments via their food chains, rendering Koch’s discoveries and quarantine and other contagionist measures ineffective. Cholera’s appearance after 1900 in various estuaries was perhaps in an ‘autochthonist’ manner, as Pettenkofer had named it, rising from the environment into human gut tracts. Through empiricism, Pettenkofer and Erismann came as close as any other scientist to anticipating cholera’s true cause and the Russian physicians who built upon their theories were not backward, but reporting on cholera aetiology as it actually appeared in Russia. Cholera’s appearance in various locations along the coasts of Italy and Spain and in various places during the sixth pandemic likely also reflect this phenomenon and were part of cholera’s natural withdraw from Europe due to decreases in strength rather than a failure to apply quarantine. Tsarist and Soviet scientists were perceptive,

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creative and pragmatic and were primarily driven by material considerations, their training and observation. Russian physicians’ scientific orientation and strategy drew not only from bacteriology, but chemistry, zoology, immunology, physiology and botany. This menace, widespread famine and other adverse social conditions in the country and the education of its physicians influenced development of a broad scientific paradigm that emphasised bacterial and chemical interaction in soils, climate, social conditions and a variety of other factors. The research schools of Pasteur and Pettenkofer, the Odessa laboratory and a network of others in Russia all worked within this environmental-bacteriological paradigm. In the late nineteenth century, D. K. Zabolotnyi, who is widely recognised as the father of Russian epidemiology, took his investigations out of the laboratory and into the field. Zabolotnyi thought little about arguing with Nobel Laureates like I. P. Pavlov and I. I. Mechnikov when he disagreed with them. The facility of quarantine in stopping cholera decreased the closer one came to its source in India and Russian physicians believed that cholera could live in their country for long periods of time. Recent scientific studies indicate that they were likely correct. The work of Zabolotnyi, Tarasevich, Semashko, Mol’kov, Khlopin and many other scientists spanned the entire modern period of Russian cholera epidemics and their training in the tsarist system was instrumental to Soviet success. Tsarist physicians followed a native or populist avenue that touted free medical care, prevention and attention to social needs which, after Koch’s discoveries in 1883, gradually fused with bacteriological study and an emphasis on the environment. This philosophy brought together hygienists (such as F. F. Erismann, E. A. Osipov and A. P. Dobroslavin, who emphasised broad statistical investigations, hygiene and social factors) and bacteriologists. The latter were more narrowly focused, but both groups held an interest in chemistry and other disciplines that formed the basis for a medical philosophy founded upon chemical and bacterial interaction in the soil. Originating under Pasteur and Pettenkofer and brought to Russia by Erismann, hygienists and Odessa bacteriologists, the common doctrine that many Russian community physicians shared was also based upon experiences dealing with cholera epidemics and the practising of medicine in the impoverished rural populations of their native land.

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The Soviet victory was thus, as V. A. Liubarskii stressed, due more to a broad understanding of microbiology within the context of macro-organisms as opposed to micro-organisms. This realisation brought promising laboratory experimentation and field work in the mid-1920s. The degree to which the broad orientation of Soviet public health continued under Stalin and how it coexisted with Stalinist concepts of a ‘New Soviet Person’ who, in Soviet theory, could overcome and mould the environment, remains mostly unanswered. Studies of disease and famine in Soviet Russia after 1928 are, quite understandably, overshadowed by the Stalinist persecution of intellectuals, kulaks (mildly successful peasants generally accused of hoarding), the Jewish community and other Soviet citizens in the Great Terror of the 1930s. The Soviets’ defeat of the Nazis in the Great Patriotic War also looms large. However, the implications of this question within the Lamarckian paradigm of 1930’s Soviet science and how World War II might have influenced it, if there are adequate archival records, provides fruitful grounds for future scholarship. This book has broached several topics that require such scholarly research, including the enthusiasm of Russian scientists for chemistry in the nineteenth century and the discipline’s subsequent influence on the development of public health and other academic fields. The current study has illustrated how the relationship between the so-called ‘hard’ sciences and social sciences provided avenues that led to the betterment of society. Soviet epidemiology used technology such as vaccination and better sanitation to increase human immunity to disease, but by themselves these technologies were insufficient to stop cholera in 1918– 22. Ultimately, technology improved people’s lives most effectively when integrated with broader phenomena such as public education, increased food consumption and better standards of living. Espousing a system based upon specialists, the Soviet people (at least temporarily) enjoyed better material circumstances and openness during the New Economic Policy. However, the broader aspects of Russian efforts to control cholera provided, in many places, a method of overcoming poor sanitation and impure water sources, ultimately proving this aspect to be crucial in combating cholera in the USSR. With limited resources and amid overwhelming adversity, tsarist physicians fought a battle against a mysterious and deadly disease that

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returned regularly and seemingly arbitrarily, killing hundreds of thousands of their citizens. In a struggle that seemed hopeless, they devised strategies to inhibit epidemics, saving countless thousands of lives. Ironically, their work provided an infrastructure that helped the Soviets become an unqualified world power.

GLOSSARY OF TERMS AND ORGANISATIONS

Aerobic: with oxygen. Aetiology: includes the various means by which the cholera microbe is transferred or transmitted between water reservoirs and other natural environments including within and between human beings. Anaerobic: in absence of oxygen. Anti-contagionist theory: associated with environmental approaches to cholera long after acceptance of the contagious bacterial agent. Assenizatsiia (in French, assainissement): a system of waste removal in which the Soviets and French employed advanced machinery). Autochthonist: theory of cholera aetiology. Bacillentra¨ger (en): a German word used to denote someone who appears healthy, but is a ‘carrier’ of a bacillus, capable of transmitting a disease to others or into the environment. Bacillus: a word denoting a bacterial agent that is capable of causing disease such as, in the case of this book, the cholera vibrio. Copepods: shrimplike crustaceans that serve as a carrier of cholera bacteria within the brackish water of estuaries, subsequently advancing the transmission of the agent through consumption by larger shellfish such as clams, and subsequently by humans in an undercooked state.

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Copepods’ ability to survive in anaerobic and aerobic environments likely contribute to their efficiency in this role. El Nin˜o Southern Oscillation (ENSO events): includes El Nin˜o and La Nin˜a, which effect the relationship between surface temperatures in the ocean and atmospheric pressure. Feldsher: a German word used to describe a mid-level health worker who performed vaccination and other lower-tech duties. Gosplan RSFSR: the state planning committee. Guberniia: a ‘province’ or the rough equivalent of an American state. Gubzdravotdel: local health councils at the district and smaller government levels that was influenced by and essentially replaced the tsarist zemstvos. Gubzdravotdely: local government health workers under the Bolsheviks/Soviets who performed essentially the same function as the trustees under the tsars. They provided care and support for patients, usually at stops along the railroads or wharves as part of the checkpoint system. Krai: a large, autonomous government that was similar to an oblast’. Kulak: a wealthy peasant often involved in some kind of commercial activity. Narkomput: under the Bolsheviks and Soviets the Commissariat of the Ways of Communication. Narkomzdrav RSFSR: acronym for Narodnyi Komissariat Zdravookhraneniia or the People’s Commissariat of Public Health of the Russian Republic. Nevskii Prospekt: located in the central district of St Petersburg, the primary thoroughfare in the city. This boulevard was the location of much revolutionary strife including the initial clashes of the February revolution in 1917. New Economic Policy: the policy of limited capitalism, open markets and relative freedom between 1921 and 1928.

GLOSSARY OF TERMS

AND

ORGANISATIONS

259

Oblast’: the term used, though not exclusively, by the Soviets to denote a large, autonomous government or region such as the Don– Cossacks Oblast’ in the south. OChVSU: okruzhnoi mezhduvedestvennoi sanitarnoi komissii no bor’be o epidemiiami pri Chernomorsko-azovskom okruge morskikh soobshcheniia. [Military district interagency sanitary commission for the struggle with epidemics for the Black Sea–Azov military district of sea transportation]. Okrug: a military district generally found within geographical areas such as the Don Cossacks region in Southern Russia that were governed by the military. Pale of Settlement: the Jewish Pale of Settlement, created by Catherine the Great in the late eighteenth century, an area with changing borders in Western European Russia in which Jewish residents were permitted to reside permanently until 1917. Popechitelstvo: also referred to as popecheniia, these were trustees who worked or volunteered helped local public health agencies. Their activities ranged from arranging and working in soup kitchens to inspecting and repairing wells, epidemiological surveillance, tending to cholera patients and other activities. Raion: an administrative unit of government which became the equivalent of a district under the Soviets (replacing the designation uezd), but was up until that time more often reserved for designating the large districts in urban regions and large cities. Sanitary Executive Commissions (SECs): commissions created by the tsarist Cholera Rules of 1903. They were activated by provincial governors, mayors or their deputies during periods when cholera threatened. These commissions generally operated at the guberniia (provincial) level and in the larger cities of the gubernii. Sovnarkom: the Council of People’s Commissars, RSFSR. Straits: the isthmus between Anatolia and Eastern Europe that affords access from the Black Sea into the Aegean and Mediterranean Seas. Trustees: in the late tsarist period, local medical workers such as feldshers, aids and other assistants who performed lower-level medical

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tasks and procedures as part of the checkpoint system in local towns and on the railroads and water routes. Uchastok: a ‘medical precinct’ (sometimes also referred to as a subdistrict) usually within a city or in the suburbs. Uezd (y): in tsarist Russia, a small unit of government within a guberniia (province) or oblast’, generally called a ‘district’ by Western historians. Vibrio: the bacterial agent or microbe that causes cholera epidemics. Volost’: a small, often rural or peasant jurisdiction with a zemstvo, roughly equivalent to an American county. Vrach: a physician who had passed a formal course of study in a recognised medical school. In Russia, the title of ‘Doctor’ is bestowed only on someone who successfully completes a dissertation. Zemgor: after 1917, the collective name for the Union of Zemstvos and Union of Towns. Zemstvo: a local governing council often at the guberniia or uezd level. These councils were created by the Great Reforms of the 1860s and no longer used after the fall of the Romanov dynasty. Zemstvo medicine: a form of public health that emphasized the preventive aspects of disease prevention rather than treatment, emerging after the Crimean War, often performed by physicians who were employed by the zemstvos.

NOTES

Introduction 1. Fernand Braudel, The Structures of Everyday Life: The Limits of the Possible (Berkeley, CA: University of California Press, 1992), p. 80; Braudel was paraphrasing Mirko D. Grmek, ‘Pre´liminaires d’une e`tude historique des maladies’, Annales, E. S. C., 196 no. 6, pp. 1473– 83. 2. L. A. Tarasse´vitch, Epidemiological Intelligence: Epidemics in Russia Since 1914; Report to the Health Committee of the League of Nations, No. 1. (Geneva: League of Nations Secretariat Health Section, 1922), pp. 5 – 6. 3. Nancy Mandelker Frieden, Russian Physicians in an Era of Reform and Revolution, 1856– 1905 (Princeton, NJ: Princeton University Press, 1981), pp. 135 – 8. 4. Stephen Kotkin, Stalin: Paradoxes of Power, Volume I 1878– 1928 (New York, NY: Penguin Books, 2014), pp. 63– 5. 5. Peter Baldwin, Contagion and the State in Europe (Cambridge: Cambridge University Press, 2005), pp. 8, 84, 141 and others. 6. Edward Said, Orientalism (New York, NY: Vintage Books, 1979), p. 7. 7. Samuel C. Ramer, ‘The Zemstvo and Public Health’ in Terrance Emmons and Wayne S. Vucinich (eds), The Zemstvo in Russia (Cambridge: Cambridge University Press, 1982), pp. 276 – 314. 8. For just such an argument regarding Pettenkofer’s theories of hygiene see Alfredo Morabia, ‘Epidemiologic Interactions, Complexity, and the Lonesome Death of Max von Pettenkofer’, American Journal of Epidemiology 166, No. 11 (October 2007), pp. 1236– 8. 9. Olga Viktorovna Kedrova, ‘Dinamika i osobennosti epidemicheskikh proiavlenii kholery v nizhenem povolzhe period s 1892 po 1996 god’ (Dissertatsiia na soiskanie uchenoustepeni kandidata meditsinskikh nauk, Ministerstvo zdravookhraneniia Rossiiskoi Federatsii, Rossiiskii nauchno-issledovatelskii protivchumnyi institute ‘Mikrob’, Saratov, 1999), pp. 28 – 31.

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8 –10

10. Martin Malia, Russia under Western Eyes: From the Bronze Horseman to the Lenin Mausoleum (Cambridge, MA: The Belknap Press of Harvard University Press, 1999). 11. Tsuyoshi Hasegawa, The February Revolution: Petrograd, 1917 (Seattle: University of Washington Press, 1981), pp. 6–7, and; Leopold Haimson, ‘The Problem of Social Stability in Urban Russia, 1905–1917’ Slavic Review 23, no. 4 (1964), pp. 619–42; Also see Geoffrey Hosking, Russia and the Russians, A History (Cambridge, MA: Harvard University Press, 2011); Peter Waldron, The End of Imperial Russia, 1855–1917 (New York, NY: St Martins Press, 1997); and others. 12. Waldron, The End of Imperial Russia, p. 1. 13. Kotkin, Stalin, pp. 66 – 8. 14. I rely liberally on Eileen Kane, Russian Hajj: Empire and the Pilgrimage to Mecca (Ithaca, NY: Cornell University Press, 2016); see also Daniel Brower, The Russian City Between Tradition and Modernity (Berkeley, CA: University of California Press, 1990). 15. Peter Holquist, ‘Violent Russia, Deadly Marxism? Russia in the Epic of Violence, 1905– 1924’, Kritika: Explorations in Russian and Eurasian History 4/3 (Summer 2003), pp. 627– 52; Peter Holquist, Making War, Forging Revolution: Russia’s Continuum of Crisis, 1914 – 1921 (Cambridge, MA: Harvard University Press, 2002); Peter Holquist, ‘Information is the Alpha and Omega of Our Work: Bolshevik Surveillance in its Pan-European Context’, The Journal of Modern History, 69 (3), pp. 415 –50; Donald J. Raleigh, Experiencing Russia’s Civil War: Politics, Society and Revolutionary Culture in Saratov, 1917– 1922 (Princeton, NJ: Princeton University Press, 2001); Lars T. Lih, Bread and Authority in Russia, 1914 – 1921 (Berkeley, CA: University of California Press, 1990); Kotkin, Stalin. 16. Alan J. Rocke, ‘Group Research in German Chemistry: Kolbe’s Marburg and Leipzig Institutes’, Osiris 2nd Series 8 (1993), p. 77. For the seminal article see J. B. Morrel, ‘The Chemist Breeders: The Research Schools of Liebig and Thomas Thomson’, AMBIX: The Journal of Society for the Study of Alchemy and Early Chemistry IX, No. (March 1972), pp. 1 – 46; see also Gerald L. Geison, ‘Research Schools and New Directions in the Historiography of Science’, Osiris 2nd series, Vol. 8 (1993), pp. 226– 38; Kathryn M. Olesko, ‘Tacit Knowledge and School Formation’, Osiris 2nd Series 8 (1993), pp. 16 – 29; and others. This scholarship grew out of conceptualisations of science by, among others, Sir Karl Popper, The Logic of Scientific Discovery (London: Hutchinson & Co., 1959); Thomas Kuhn, The Structure of Scientific Revolutions (Chicago, IL: University of Chicago Press, 1962); Bruno Latour, Science in Action (Cambridge MA: Harvard University Press, 1988) and others. Also see the Festschrift by Imre Lakatos and Alan Musgrave (eds), Criticism and the Growth of Knowledge (Cambridge: Cambridge University Press 1970). 17. See Nikolai Krementsov, ‘Big Revolution, Little Revolution: Science and Politics in Bolshevik Russia’, Social Research Vol. 73, no. 4 (Winter 2006), pp. 1173– 1204; Regarding epigenetics and Lysenko see Loren Graham,

NOTES TO PAGES 10 –12

18. 19. 20.

21. 22. 23. 24. 25.

26.

27. 28. 29.

263

Lysenko’s Ghost: Epigenetics and Russia (Cambridge MA: Harvard University Press, 2016); See also Jenny Leigh Smith, ‘Agricultural Involution in the Postwar Soviet Union’, International Labor and Working Class History, Spring 2014, Vol. 85, pp. 59– 74. Earlier scholarly work recognised a degree of legitimacy in Lysenkoism. See Dominique Lecourt, Proletarian Science? The case of Lysenko (London: Schocken Books, 1978). Roderick McGrew, Russia and the Cholera (Madison, WI: University of Wisconsin Press, 1965), pp. 7, 10, 13, 15. Frieden, Russian Physicians, p. 79. McGrew compliments Russian physicians in many regards. Frieden, Russian Physicians; John F. Hutchinson, ‘Tsarist Russia and the Bacteriological Revolution’, History of Medicine and Allied Sciences 40 (1985), pp. 432– 7; Lisa K. Walker, ‘The Pen and the Test-Tube Revisited: Generational Identity, Scientific Innovation and Russian Reception to Bacteriology, 1890– 1914’, The Soviet and Post-Soviet Review 32 No. 1 (2005), pp. 269 –91; Hachten, ‘Science’, p. 304. John Hutchinson, Politics and Public Health in Revolutionary Russia, 1890– 1918 (Baltimore, MA: Johns Hopkins University Press, 1990). Lisa Kay Walker, ‘Public Health, Hygiene and the Rise of Preventative Medicine in Late Imperial Russia, 1874– 1912’ (Ph.D. diss., University of California, Berkeley, 2003), p. 166. Walker, ‘Public Health’, 166; Hutchinson, ‘Tsarist Russia’, p. 437; Walker, ‘The Pen and the Test-Tube’, pp. 269– 91. Hachten, ‘Science’, pp. 303 – 4. D. V. Mikhel’, ‘Rossiiskaia mikrobiologiia i kholera na rubezhe XIX – XX vv.: iz laboratorii v pole’, Aktual’nye problemy istorii Rossiiskoi tsivilizatsii. Sbornik materialov i mezhevuzovskii nauchnoi konferentsii k 100 letniiu SGU, 2009, pp. 141 –54. On zemstvo medicine see Ramer, ‘The Zemstvo and Public Health’; Nancy M. Frieden, ‘The Politics of Zemstvo Medicine’, in Terrance Emmons and Wayne S. Vucinich (eds), The Zemstvo in Russia (Cambridge: Cambridge University Press, 1982), pp. 315 – 42; and Susan Gross Solomon (ed.), Doing Medicine Together: Germany and Russia between the Wars (Toronto: University of Toronto Press, 2006) and Susan Solomon, ‘Social Hygiene and Public Health, 1921– 1930’ and others in John F. Hutchinson and Susan Gross Solomon (eds), Health and Society in Revolutionary Russia (Bloomington, IN: Indiana University Press, 1990), pp. 175– 99; on Russian eugenics see Nikolai Krementsov, ‘The Strength of a Loosely Defined Movement: Eugenics and Medicine in Imperial Russia’, Medical History (2015), vol. 59 (1), pp. 6 – 31, and others. Charlotte E. Henze, Disease, Health Care and Government in Late Imperial Russia: Life and Death on the Volga, 1823– 1914 (London: Routledge, 2012), p. 25. Ibid., pp. 125, 142. Baldwin, Contagion, pp. 8, 84, 141 and others.

264

NOTES TO PAGES 12 –17

30. Julia Adeny Thomas, ‘Comment: Not Yet Far Enough’, American Historical Review 117 (3) (2012), pp. 794– 803. 31. Edward L. Keenan, ‘Muscovite Political Folkways’, The Russian Review 45/2 (April 1986), pp. 115– 81. 32. I. M. Chuzh, A. M. Shelepov and E. I. Veselov, Istoriia voennoi meditsiny (Moscow: Meditsina, 2007), pp. 101 – 7.

Chapter 1 Cholera and its Environs: The Case of Russia 1. David Karaolis, Ruiting Lan, and Peter R. Reeves, ‘The Sixth and Seventh Cholera Pandemics Are Due to Independent Clones Separately Derived from Environmental, Nontoxigenic, Non-01 Vibrio Cholerae’, Journal of Bacteriology 177 (June 1995), p. 3191. 2. Richard Finklestein, ‘Cholera, Vibrio Cholera 01, and 0139, and Other Pathogenic Vibrios’, in Medical Microbiology 4th Edition. Availalable at ,http://www.ncbi.nlm.nih.gov.books/NBK8407/. (accessed 15 December 2015). 3. S. M. Rashed, A. Iqbal, S. B. Mannan SB, et al., ‘Vibrio cholerae O1 El Tor and O139 Bengal Strains Carrying ctxBET, Bangladesh’, Emerging Infectious Diseases. 2013, 19 (10), pp. 1713– 15. Available at ,https://doi.org/10.1111/ j.1574-695X.2009.00590.x . (accessed 25 March 2017). 4. Ibid; Rita R. Colwell and William M. Spiro, ‘The Ecology of Vibrio Cholera’, in Dhiman Barua and William B. Greenough III eds, Cholera: Current Topics in Infectious Disease (New York, 1992), pp. 107 –8, 123. 5. Nural A. Bhuiyan, Suraia Nusrin, Munirul Alam, Masatomo Morita, Haru Watanabe, Thandavarayan Ramamurthy, Alejandro Cravioto, and Gopinath Balakrish Nair, ‘Changing genotypes of cholera toxin (CT) of Vibrio cholerae O139 in Bangladesh and description of three new CT genotypes’, 2 October 2009, ,https://doi.org/10.1111/j.1574-695X.2009.00590.x . (accessed 25 March 2017). 6. L. A. Tarasse´vitch, Epidemiological Intelligence, Part II, No. 5 (Geneva: League of Nations, 1922), p. 4. 7. J. R. McNeill, Something New Under the Sun: An Environmental History of the Twentieth-Century World (New York, NY: W. W. Norton & Company, 2001), p. 192. 8. William Menke, cited in Francesca Trianni, ‘What Makes Indonesia a Hot Spot on the Ring of Fire’, Time 14 Feb. 2014. Available at ,http://world.time. com/2014/02/14/what-makes-indonesia-a-hot-spot-on-the-ring-of-fire/. (accessed 13 December 2016). 9. World Health Organisation (WHO), ‘El Nin˜o and Health: Protection of the Human Environment Task Force on Climate and Health’ (Geneva, 1999), p. 5. 10. Orlando Figes, Peasant Russia Civil War: The Volga Countryside in Revolution, 1912– 1917 (Oxford: Oxford University Press, 1989), pp. 24– 5.

NOTES

TO PAGES

18 –21

265

11. Alfredo Morabia, ‘Epidemiologic Interactions, Complexity, and the Lonesome Death of Max von Pettenkofer’, American Journal of Epidemiology 166, No. 11 (October 2007), p. 1236. 12. EPA: United States Environmental Protection Agency, ‘Basic Information about Estuaries’. Available at , https://www.epa.gov/nep/basic-informationabout-estuaries . (accessed July 11 2017). 13. Richard Finklestein, ‘Cholera, Vibrio cholera 01 and 0139, and Other Pathogenic Vibrios’. 14. Gillen D’Arcy Wood, Tambora: The Eruption that Changed the World (Princeton, NJ: Princeton University Press, 2014), pp. 89 – 90. 15. N. N. Klodnitskii, cited in S. N. Klodnitskaia, N. N. Klodnitskii, 1868– 1935: Bydaiushchiesia deiateli otechestvennoi Meditsiny (Moskva: Gosudarstvennoe izdatelstvo meditsinskoi literatury, 1956), p. 128. 16. Morabia, ‘Epidemiologic Interactions’ p. 1236; Rita Colwell, ‘Calanoid Copedpods’. Available at ,http://www.nsf.gov/news/speeches/colwell/rc02_s wedish/tsld031.htm. (accessed 15 December 2015). 17. Morabia, ‘Epidemiologic Interactions’, p. 1236. 18. Bireswar Banerjee and Jayati Hazra, Geoecology of Cholera in West Bengal: A Study in Medical Geography (Calcutta: J. Hazra, 1974), pp. 19, 20, 37 – 45. 19. G. V. Khlopin, Materialy po ozdorovleniiu Rossii: Sanitarnoie opisania g. g. Astrakhani, Samari, Saratova i Tsaristyna s ukazaniiem mer ikh ozdorvleniia (St Petersburg: Tipagrafiia ministerstva vnutrennkh del, 1911), p. 51. 20. McNeill, Something New, pp. 129 – 30. 21. Epidemiological Intelligence No. 10 (Geneva: League of Nations), p. 17. 22. WHO, ‘El Nin˜o’, pp. 23– 5. 23. Robbins, Famine, pp. 172 – 3, 24. W. Bruce Lincoln, ‘Russia’s Grim Famine History’, review of Harvest of Sorrow: Soviet Collectivization and the Terror Famine by Robert Conquest’, The World and I Online 4 (1987), n.p. 25. Ralph Turchaiano, ‘Famine alters metabolism for successive generations’, Eve’s Drift: Highlighting multagenesis research for conflict, peace or other (12 December 2016). Available at ,https://evesdrift.com/2016/12/13/famine-alters-metabolism-for-successive-generations/ . (accessed 26 March 2017). 26. Lincoln, ‘Russia’s Grim Famine History’ n.p. 27. Mike Davis, Late Victorian Holocausts. See also David S. Landes, The Wealth and Poverty of Nations Why Some are So Rich and Some So Poor (New York, NY: W. W. Norton & Company, 1999), p. 269. 28. Frank Clemow, The Cholera Epidemic of 1892 in the Russian Empire (London: Longmans, Green, and Co., 1893), p. 58. 29. G. V. Khlopin, Materialy, p. 41. 30. J. W. Crawford, Canals and Irrigation in Foreign Countries: Reports from the consuls of the United States in Answer to Circulars from the Department of State (Washington: Government Printing Office, 1891), p. 160. 31. Olga Bazanova, ‘Volgabalt Capital’, Science in Russia No. 4 (2009), p. 92.

266

NOTES

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21 – 26

32. Crawford, Canals, pp. 155– 63. 33. Ibid., p. 164. 34. G. I. Arkhangel’skii, Kholera v Peterburge v prezhnie godu (St Peterburg: Shredera, 1892), p. 4. 35. Edward Ames, ‘A Century of Russian Railroad Construction: 1837 – 1936’, American Slavic and East European Review 6 (Dec. 1947), p. 58. 36. Patterson, K. David, ‘Cholera Diffusion in Russia: 1823 – 1923’, Social Science and Medicine 38, No. 9 (1994), pp. 1179– 80. 37. Scott J. Seregny and Rex A. Wade, ‘Saratov as Russian History’, in Scott J. Seregny and Rex A. Wade (eds), Politics and Society in Provincial Russia: Saratov, 1590– 1917 (Columbus, OH: Ohio State University Press, 1989), p. 4. 38. Ol’ga Viktorovna Kedrova, ‘Dinamika i osobennosti epidemicheskikh proiavlenii kholery v nizhenem povolzh’e period s 1892 po 1996 god’ (Dissertation, Saratov, 1999), pp. 23 – 4. 39. Henze, Disease, pp. 154– 5. 40. James Bater, ‘Between Old and New: St Petersburg in the Late Imperial Period’, in Michael Hamm, The City in Late Imperial Russia (Bloomington, IN: Indiana University Press, 1986), p. 60. 41. Alexander Vucinich, Science in Russian Culture: 1861 – 1917 (Stanford, CA: Stanford University Press, 1970), p. 136; also see Vucinich, Science in Russian Culture: A History to 1860 (Stanford, CA: Stanford University Press, 1963), pp. 330, 664. 42. Rene´ Dubos, Pasteur and Modern Science (Garden City, NY: Anchor Books, 1960), pp. 40 – 9, 81 – 93; Elie Metchnikoff, The Founders of Modern Medicine: Pasteur, Koch, Lister. (Delanco, NJ: Gryphon Editions LLC, 2006), p. 30. 43. Dubos, Pasteur, p. 89. 44. Mechnikoff, The Founders, p. 30. 45. A. M. Shapiro, Gigiena vody i Saratovskie fi’ltry, Doklad doktora A. M. Shapio o bakteriologicheskom izsledovanii dei’stviia Saratovskikh fil’trov iz ochistky vodoprovodnoi vody, prochitannyi v publichnom zasedanii Saratovskago Sanitarnago Obshchestva 21-go oktiabbria 1900 goda (Saratov, 1900), p. 17. 46. See for example Henze, Disease, p. 25. 47. Fielding H. Garrison, An Introduction to the History of Medicine with Medical Chronology, Suggestions for Study and Bilbiographic Data (London: W. B. Saunders Company, 1929), pp. 270, 658– 9. 48. For an in-depth explanation of the miasma theory and the efficacy of Pettenkofer’s epidemiology see Morabia, ‘Epidemiologic Interactions’, p. 1238. 49. Evans, Death in Hamburg, pp. 237– 43. 50. Morabia, ‘Epidemiologic Interactions’, p. 1235. 51. Ibid., pp. 1235– 7. 52. Ibid., p. 1237. 53. Wolfgang Locher, ‘Pettenkofer and Epidemiology: Erroneous Concepts – Beneficial Results’, in History of Epidemiology: Proceedings of the 13th International

NOTES TO PAGES 26 –28

54. 55. 56. 57. 58. 59.

60. 61. 62. 63. 64.

65. 66. 67. 68.

69.

267

Symposium on the Comparative History of Medicine – East and West, Yosio Kawakita, Shizu Sakai and Yasuo Otsuka eds. (Tokyo: Ishiyaku EuroAmerica Inc., 1993), pp. 102 – 4. Fielding H. Garrison, An Introduction to the History of Medicine with Medical chronology, Suggestions for Study and Bilbiographic Data (London: W. B. Saunders Company, 1929), pp. 270, 658– 9. Rene´ Dubos, Pasteur and Modern Science, pp. 95 – 6. Metchnikoff, The Founders, pp. 24– 5; Jacob Henle, Pathologische Untersunchungen (Berlin, 1840). Ibid., p. 30. Norman Howard-Jones, The Scientific Background of the International Sanitary Conferences, 1851 – 1938 (Geneva: World Health Organization, 1975), p. 52. For more clarification see Richard J. Evans, Death in Hamburg Society and Politics in the Cholera Years (Oxford: Oxford University Press, 2005) and: Margaret Pelling, Cholera, Fever, and English Medicine (Oxford: Oxford University Press, 1978). Robert Koch, ‘Lecture at the First Conference for Discussion of the Cholera Question (1884)’, in Essays of Robert Koch, trans. K. Codell Carter (New York, NY: Greenwood Press, 1987), p. 164. Ibid., p. 165. R. J. Morris, Cholera, 1832, The Social Response to an Epidemic (New York, NY: Holmes & Meier, 1976), pp. 181 – 3. Charles-Edward Armory Winslow, The Conquest of Epidemic Disease: A Chapter in the History of Ideas (Madison, WI: University of Wisconsin Press, 1980), p. 317. Among others see Sandra Hempel, The Strange Case of the Broad Street Pump: John Snow and the Mystery of Cholera (Berkeley, CA: University of California Press, 2005); and Steven Johnson, The Ghost Map: The Story of London’s Most Terrifying Epidemic and How it Changed Science, Cities, and the Modern World (New York, NY: Riverhead Books, 2006). Evans, Death in Hamburg, pp. 503– 9 and others. Frank M. Snowden, Naples in the Time of Cholera, 1884– 1911 (Cambridge: Cambridge University Press, 2002), pp. 67– 9 and others. Paul Weindling, Epidemics and Genocide in Eastern Europe, 1890 – 1945 (Oxford: Oxford University Press, 2000), p. 21. Henze, Disease; Walker, ‘Public Health’; John F. Hutchinson, ‘Tsarist Russia and the Bacteriological Revolution’, Journal of the History of Medicine and Allied Sciences 40 (1985), pp. 420 – 39; and Politics and Public Health in Revolutionary Russia, 1890–1918 (Baltimore, MA: Johns Hopkins University Press, 1990). This was not the same plague that killed half of Europe between 1347 and 1349 and returned in 1700, but was another deadly form that lasted in Russia into the early twentieth century.

268 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84.

85. 86. 87. 88. 89. 90. 91. 92. 93.

NOTES

TO PAGES

28 –32

Frieden, Russian Physicians, pp. 99– 102. Ibid., p. 102. Walker, ‘Public Health’, p. 158. Daniel P. Todes, Darwin Without Malthus: The Struggle for Existence in Russian Evolutionary Thought (Oxford: Oxford University Press, 1989), p. 54. Ibid., pp. 86, 94. Dubos, Pasteur, 115. In the late eighteenth century Edward Jenner used a serum derived from cowpox to ‘vaccinate’ residents in the English countryside from smallpox. ‘Vacca’ is Latin for cow. Ibid., pp. 115 – 25. Semyon Zalkin, Ilya Mechnikov: His Life and Work (Honolulu: University Press of the Pacific, 2001), p. 107. Ibid., 108. Ibid. Ibid., pp. 110 – 11. Ibid. Ibid. Daniel P. Todes, Darwin Without Malthus, p. 86. Daniel Todes notes that William Addison in 1866 observed that ‘nature has the action of inflammation in reserve, not for the purpose of vexing mankind and shortening life, but for the purpose of repairing and healing – the cure of wounds and fractures, the discharge of dead parts and foreign bodies, and for elimination of unwholesome poisonous matters from the blood’. Todes points out that this type of reasoning dated back 1,700 years to Galen and also notes that the seventeenth-century scholar von Helmont had proposed a ’metaphorical thorn’ that bore responsibility for pleurisy. Also, Carl ‘Heinrich’ Schultz and others in the early eighteenth century had often repeated the ‘military metaphor’ that the body’s defensive processes were active in the ‘battle with disease’. For more information see Todes, Darwin without Malthus, pp. 95 – 7. Ibid., 96. Mechnikov’s notes in the Russian Academy of Sciences in Moscow appear in French, German and Russian. Zalkind, Ilya Mechnikov, pp. 108 – 9. Garrison, History of Medicine, p. 584. Behring, a leading humouralist, developed a successful diphtheria serum. Todes, Darwin Without Malthus, p. 97. Hutchinson, Politics, p. 246. Zalkind, Ilya Mechnikov, pp. 111– 12. Todes, Darwin Without Malthus, p. 97. A. Bezredka, ‘O protivokholernykh privivkakh’, Vrachebnoe Obozrenie 4 (15 aprel’1922), p. 145. Howard-Jones, The Scientific Background of the International Sanitary Conferences, p. 59.

NOTES TO PAGES 34 –39

269

Chapter 2 Tsarist Russia and the First Five Pandemics, 1817 –94 1. Brian Fagan, The Little Ice Age: How Climate made History, 1300–1850 (New York, NY: Basic Books, 2002), pp. 162– 3. 2. Roderick McGrew, Russia and the Cholera (Madison, WI: Wisconsin University Press, 1965), pp. 18– 19. 3. M. R. Smallmann-Raynor and A. D. Cliff, War Epidemics: An Historical Geography of Infectious Diseases in Military Conflict and Civil Strife, 1850 – 2000 (Oxford: Oxford University Press, 2004), p. 107. 4. Gillen D’Arcy Wood, Tambora: The Eruption that Changed the World (Princeton, NJ: Princeton University Press, 2014), pp. 20 – 1, 33 – 9. 5. Fagan, The Little Ice Age, p. 169. 6. D’Arcy Wood, Tambora. pp. 20– 1, 33 – 9. Fagan, The Little Ice Age, p. 169. 7. Peter Holquist, ‘Violent Russia, Deadly Marxism? Russian in the Epic of Violence, 1905– 1924’, Kritika: Explorations in Russian and Eurasian History 4/3 (Summer 2003), p. 634. 8. Eileen Kane, Russian Hajj: Empire and the Pilgrimage to Mecca (Ithaca, NY: Cornell University Press, 2016). 9. D’Arcy Wood, Tambora, p. 86. 10. Brian Fagan, Floods, Famines and Emperors: El Nin˜o and the Fate of Civilizations (New York, NY: Basic Books, 1999), pp. 99– 100. 11. Ibid., p. 10. 12. Mike Davis, Late Victorian Holocausts. See also David S. Landes, The Wealth and Poverty of Nations Why Some are So Rich and Some So Poor (New York, NY: W. W. Norton & Company, 1999). 13. Wood, Tambora, pp. 10, 60 – 5. 14. Roderick McGrew, Russia and the Cholera (Madison, WI: Wisonsin University Press, 1965), p. 19. 15. Wood, Tambora, pp. 10, 22, 72 – 6. 16. McGrew, Russia, p. 19. 17. John P. LeDonne, The Russian Empire and the World, 1700– 1917: The Geopolitics of Expansion and Containment (Oxford: Oxford University Press, 1997), p. 120. 18. Thomas M. Barrett, ‘Crossing Boundaries: The Trading Frontiers of the Terek Cossacks’, in Russia’s Orient: Imperial Borderlnds and Peoples, 1700 – 1917 Daniel Brower and Edward Lazzerini (eds) (Bloomingtin, IN: Indiana University Press, 1997), p. 232; McGrew, Russia, pp. 19, 23. 19. Kane, Russian Hajj, pp. 20– 3. 20. McGrew, Russia, pp. 19, 23. 21. Ibid. 22. Robbins, Famine, p. 19. 23. McGrew, Russia, pp. 39– 40, 94. 24. Ibid.

270

NOTES TO PAGES 39 – 46

25. Ibid., p. 41. 26. Kane, Russian Hajj, 23. 27. LeDonne, The Russian Empire, pp. 118, 121. See also Peter Hopkirk, The Great Game: The Struggle for Empire in Central Asia (New York, NY: Kodansha Amer Inc., 1992), p. 115. 28. K. David Patterson, ‘Cholera Diffusion in Russia, 1823 – 1923’, Social Science and Medicine 38 (1994), p. 1179. 29. McGrew, Russia, p. 43. 30. Ibid., pp. 47 – 50 31. Ibid., pp. 50 – 1. 32. Ibid., p. 100. 33. Ibid., pp. 4 – 5. 34. Ibid., pp. 13 – 15. 35. Ibid. 36. McGrew, Russia, pp. 4– 5. 37. Howard Markel, Quarantine! East European Jewish Immigrants and the New York City Epidemics of 1892 (Baltimore, MD: Johns Hopkins University Press, 1999). 38. David Arnold, ‘Cholera in the Philippines’, in David Arnold (ed.), Science, Technology and Medicine in Colonial India (Cambridge: Cambridge University Press, 2004). 39. New York Times, 10 October 1893. 40. Ibid. 41. Peter Baldwin, Contagion and the State in Europe, 1830 –1930 (Cambridge: Cambridge University Press, 2005), p. 67. 42. Ibid., pp. 67, 84 – 5. 43. Robbins, Famine, p. 20. 44. Ibid., pp. 6 – 7. 45. Fagan, The Little Ice Age, p. 169. 46. LeDonne, Russian Empire, p. 128. 47. W. Bruce Lincoln, ‘Russia’s’, 48. Henze, Disease, p. 22. 49. Ibid., pp. 25, 140. 50. Kane, Russian Hajj, pp. 38– 9. 51. Erwin Ackerknecht, ‘Anticontagionsim between 1821 and 1867’, Journal of International Epidemiology 2009 38, pp. 13– 14. 52. Ibid., p. 14. 53. Kane, Russian Hajj, pp. 38 – 9. 54. Henze, Disease, pp. 5, 19– 20. 55. Mark Harrison, Contagion: How Commerce has Spread Disease (New Haven, CT: Yale University Press, 2012), pp. 78 – 9. 56. LeDonne, Russian Empire, p. 129. 57. See Steven Johnson, The Ghost Map: The Story of London’s Most Terrifying Epidemic and How it Changed Science, Cities and the Modern World (New York, NY: Riverhead Books, 2006) and, Sandra Hempel, The Strange Case of the Broad

NOTES TO PAGES 46 –52

58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92.

271

Street Pump: John Snow and the Mystery of Cholera (Berkeley, CA: University of California Press, 2007). Smallmann-Raynor and Cliff, War Epidemics, pp. 417, 423. Ibid., p. 417. Henze, Disease, p. 20. I. M. Chuzh, A. M. Shelepov and E. I. Veselov, Istoriia voennoi meditsiny (Moscow: Meditsina, 2007), pp. 101– 6. Geoffrey Hosking, Russia and the Russians, A History (Cambridge, MA: Harvard University Press, 2011), p. 293. Robbins, Famine, p. 20. I. I. Molleson, in Frieden, Russian Physcians, p. 91. Henze, Disease, p. 21 Kane, Russian Hajj, p. 55. Henze, Disease, p. 21. Arkhangel’skii, Kholera v Peterburge, p. 4. Ibid. David Arnold, ‘Cholera and Colonialism in British India’, Past and Present 113 (Nov. 1986), p. 144. Davis, Late Victorian, pp. 269, 71. Kane, Russian Hajj, p. 64. Harrison, Contagion, pp. 146 – 8. Erwin Ackerknecht, ‘Anticontagionism between 1821 and 1867’. Ibid., pp. 154 – 5. Brian Fagan, Floods, Famines and Emperors: El Nin˜o and the Fate of Civilizations: (New York, NY: Basic Books, 1999), p. 12. Edward Ames, ‘A Century of Russian Railroad Construction, 1837 – 1936’, American Slavic and East European Review 6, No. 3 / 4 (December 1947), p. 58. Baldwin, Contagion, pp. 211– 12. LeDonne, Russian Empire, pp. 132– 3. Ibid. Davis, Late Victorian, pp. 268 – 71. Henze, Disease, p. 25. Hosking, Russia and the Russians, pp. 360–1. Ibid., p. 198. Wood, Tambora, p. 8; Fagan, The Little Ice Age, p. 169. Ibid., pp. 37, 40 – 1, 53. Davis, Late Victorian, pp. 121– 22. Ibid., pp. 124– 5; Richard G. Robbins Jr., Famine in Russia, 1891 –1892 (New York, NY: Colombia University Press, 1975), pp. 2 – 3. A particularly rich and fertile black soil, ‘che¨rnozem’, is native to this region Robbins, Famine, p. 31. Geoffrey Hosking, Russia and the Russians, p. 294. Frieden, Russian Physicians, p. 139. Ibid.

272

NOTES TO PAGES 52 –60

93. Orlando Figes, Revolutionary Russia, 1891– 1991, A History (New York, NY: Metropolitan Books, 2014), pp. 7 – 11. 94. Frieden, Russian Physicians, p. 140. 95. Ibid., pp. 140 – 1. 96. Stol’kind, ‘O merakh bor’by s kholeroi’, Pirogovskii s”ezd no bor’be s kholeroi’ (Moscow: Pirogovskii s”ezd po bor’be s kholeroi Tovarishchestvo ‘Pechatniia S. P. Iakovleva’, Petrovka, Saltikovski per., d. T-va, No. 9, 1905), pp. 170– 1. 97. Robbins, Famine, pp. 172 – 3. 98. Fagan, Floods, Famines and Emperors, pp. 8, 11. 99. Kane, Russian Hajj, pp. 47 – 8. 100. Clemow, The Cholera, p. 3. 101. LeDonne, The Russian Empire, pp. 132 –3. 102. Patterson, ‘Cholera Diffusion’, pp. 1179– 80. 103. Hachten, ‘Science’, p. 295. The epidemic struck both Hamburg and Naples in Western Europe. Hamburg experienced approximately 9,000 deaths. 104. Clemow, The Cholera, p. 58. 105. Arkhangel’skii, Kholera v Peterburge, p. 14. 106. Clemow, The Cholera, pp. 38, 40– 2. 107. Ibid., pp. 31 – 4. 108. Ibid., p. 31. 109. Ibid., pp. 32– 3. The Volga and Danube were the first and second longest rivers in Europe. 110. Kane, Russian Hajj, p. 92. 111. Jeff Sahadeo, ‘Epidemic and Empire: Ethnicity, Class, and “Civilization” in the 1892 Tashkent Cholera Riot’, Slavic Review 64, No. 1 (Spring 2005), pp. 119, 123– 4. 112. Frieden, Russian Physicians, pp. 144– 5; Theodore, H. Friedgut, ‘Labor Violence and Regime Brutality in Tsarist Russia: The Iuzovka Riots of 1892’, Slavic Review 46, No. 2 (Summer 1987), pp. 264– 5. 113. Henze, Disease, p. 25. 114. Hachten, ‘Science’, pp. 298 – 9. 115. Hutchinson, ‘Tsarist Russia and the Bacteriological Revolution’, p. 426. For information about the Kronstadt Plague Fort see Daniel P. Todes, Pavlov’s Physiology Factory: Laboratory Interpretation, Laboratory Enterprise (Baltimore, MA: John’s Hopkins University Press, 2002). 116. Hutchinson, ‘Tsarist Russia and the Bacteriological Revolution’, p. 428; Walker, ‘Public Health’. 117. F. F. Erismann, Kholera: epidemiologiia i profilaktika s obschestvenno-sanitarnoi tochki zreniia. Lektsii, chitannyia studentam starshikh kursov meditsinsago fakul’teta Imperatskogo Moskovskvogo Universiteta (vesnoiu 1893 goda) (Moscow: I. N. Kushnerev, 1893), pp. 1 –4, 20– 1. 118. Erismann, Kholera, pp. 20– 1. 119. Ibid., p. 21. 120. Fagan, Floods, Famines and Emperors, pp. 12– 13.

NOTES 121. 122. 123. 124. 125. 126. 127. 128. 129. 130.

131. 132.

133. 134. 135. 136. 137. 138. 139. 140. 141.

TO PAGES

60 – 68

273

Erismann, Kholera, pp. 1 – 4. Ibid., pp. 4 – 5. Ibid., p. 19. Ibid., p. 20. Ibid., pp. 20– 1. For more information on the Toulon epidemic see Frank M. Snowden, Naples in the Time of Cholera, p. 75. Ibid., p. 5. Frank Clemow, cited in Howard-Jones, The Scientific Background, p. 36. Erismann, Kholera, pp. 21 – 3. Bruno Latour, The Pasteurization of France (Cambridge, MA: Harvard University Press, 1988). A. M. Shapiro, Gigiena vody i Saratovskie fi’ltry, Doklad’ doktora A. M. Shapio o bakteriologicheskom izsledovanii deistviia Saratovskikh’ fil’trov iz ochistky vodoprovodnoi vody, prochitannyi v publichnom zasedanii Saratovskago Sanitarnago Obshchestva 21-go oktiabbria 1900 goda. (Saratov, 1900), p. 9. Also see A. M Shapiro, Gigiena vody i Saratovskie fil’tri (Saratov: Saratov Sanitary Society, 1910). Ibid., p. 17. Vinogradskii published his life’s work in S. N. Vinogradskii, Mikrobiologiia pochvy, problemy i metody: piat’desiat let issledovanii (Moskva: Izdatel’stvo Akademii Nauk SSSR, 1952). Also see Iu. A. Mazing, T. V. Andriushkevich, Iu. P. Golikov, Rasskazy o velikom bakteriologove S. N. Vinogradskom (Saint Petersburg: Rostok, 2002); for United States study of soil nitrification see Dean David Waynick, Variability in Soils and its Significance to Past and Future Soil Investigations: A Statistical Study of Nitrification of Soils (Berkeley, CA: University of California Press, 1918). Mechnikov and his students routinely called cholera a ‘virus’, which was a general term for disease before the invention of electron microscopes permitted the discovery of the minute agents that what we today know as a virus. Metchnikoff, Immunity, pp. 6 –7. Gamaleia, Etiologiia, p. 2. Ibid., p. 5. Ibid., p. 2. Hutchinson, Politics, p. 426. Metchnikoff, Immunity, pp. 5 –6. Ibid., p. 142. Ibid., p. 143.

Chapter 3 The Sixth Pandemic Enters Russia, 1902 –7 1. Nikolai Krementsov, ‘The Strength of a Loosely Defined Movement: Eugenics and Medicine in Imperial Russia’, Med. Hist. (2015), vol. 59 (1), pp. 6 – 8; Liudvik Krzhivitskii [Ludwik Krzywicky], Psikhicheskie rasy (St Petersburg: XX vek, 1902), pp. 54 – 73; 212 – 23.

274

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68 –74

2. Ibid., pp. 9 – 11. Krementsov argues that a lack of consensus in Russian Eugenics strengthened the movement and spread the gospel while keeping it from germinating as a science in Russia as it did in other European countries; Susan Solomon notes that tsarist physicians failed to develop social hygiene sufficiently and that the government missed out on a chance to embrace and adopt it. See Susan Solomon, ‘Social Hygiene and Public Health, 1921 – 1930’, in John F. Hutchinson and Susan Gross Solomon (eds), Health and Society in Revolutionary Russia (Bloomington, IN: Indiana University Press, 1990), pp. 175 –99. 3. See Nancy M. Frieden, Russian Physicians in an Era of Reform and Revolution, 1856– 1905 (Princeton, NJ, 1981); and John F. Hutchinson, Politics and Public Health in Revolutionary Russia, 1890 – 1918 (Baltimore, MD, 1990). 4. Krementsov, ‘The Strength of a Loosely Defined Movement’, pp. 9 – 10. 5. Mike Davis, Late Victorian Holocausts: El Nin˜o famines and the Making of the Third World (London, 2002), pp. 14– 15, 269. 6. Brian Fagin, El Niῇ o and the Fate of Civilizations (New York, NY: Basic Books, 1999), p. 11. 7. Davis, Late Victorian Holocausts, p. 7. 8. Frieden, Russian Physicians, pp. 197– 9. 9. Hans Rogger, Russia in the Age of Modernisation and Revolution, 1881– 1917 (New York, NY: Longman Publishing, 1983), p. 125. 10. Scott J. Seregny and Rex A. Wade, ‘Saratov as Russian History’, in Scott J. Seregny and Rex A. Wade (eds), Politics and Society in Provincial Russia: Saratov, 1590– 1917 (Columbus, OH: Ohio University Press, 1989), p. 4. 11. Edward Ames, ‘A Century of Russian Railroad Construction, 1837 – 1936’, American Slavic and East European Review 6, No. 3/4 (December 1947): p. 58. 12. Nancy Frieden, Russian Physicians, pp. 195– 6. 13. Ibid., pp. 195 – 8. 14. S. V. Konstansov, ‘Dezinfektsiia, eia prakticheskoe znachenie voobshche i pri kholere v chastnosti’, Pirogovskii s”ezd po bor’be s kholeroi, Moskva, 21– 23 Marta 1905 goda (Moskva: Pirogovskii s”ezd po bor’be s kholeroi Tovarishchestvo , Pechatniia S. P. Iakovleva, . Petrovka, Saltikovskii per., d. T -va, No. 9, 1905), p. 82. 15. New York Times, 28 July 1902. 16. P. Ia. Meziatsev, Vrach, no. 20 (ianvar’ 1900), pp. 745 – 6. 17. Ibid., pp. 746 – 7. 18. Russkii vrach, no. 95 (1902), p. 1369. 19. Ibid. 20. Ibid., p. 1370. 21. Ibid. 22. Frieden, Russian Physicians, pp. 286– 91. 23. Henze, Disease, p. 128.

NOTES

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275

24. Harrison, Contagion, p. 201. 25. V. P. Krasnukh, ‘Bor’ba s kholeroi v Zakaspiiskoi oblasti, Pirogovskii s”ezd no bor’be s kholeroi, p. 90; Peter Waldron, End of Imperial Russia, 1855– 1917 (New York, NY: Palgrave, 1997), p. 26. 26. Pribavlenie 1-e k svody: Pravitel’stvennykh rasporiazhenii po priniatii mer protiv zanosa i raspostraneniia kholery i chumy vnutri Imperii i po sukhoputnym i morskim granitsam (Saint Petersburg: Tipografia Ministerstva Vnutrennikh Del, 1904), p. 3. 27. Ibid., 3. ‘Dlia preduprezhdeniia rastprostraneniia kholery i chumy po zheleznym dorogam i po vnutrennim vodnym putei’. 28. Pribavlenie, p. 4. 29. Ibid., pp. 3 – 4. 30. Ibid., p. 4. 31. Pribavlenie, p. 20. 32. Henze, Disease, p. 128. 33. V. K. Vysokovich, ‘Ob antivnykh privivkakh protiv kholery’, po bor’be s kholeroi, p. 40. 34. N. I. Kovalevskii, Sanitarnoe sostoianie g. Saratova v. 1910 g: otchet sanitarnago vracha (Saratov: Parovaia Tipo-Lithografiia S. M. Panina, 1911), pp. 37–8; Gamaleia, Kholera i bor’ba s neiu, s prilozheniem kart, izobrazhaishchikh rasprostranenie kholernykh epidemii (Odessa: Tipografiia Iuzhno-Russkago Obshchestva Pechatnago Dela. Pushkinskaia sob. Dom No. 18, 1905), p. 61. 35. Ibid. 36. Kovalevskii, Sanitarnoe sostoianie, p. 39. 37. Ibid. 38. Ibid. 39. Vardugin, Vo vlago, pp. 30– 2. For maps of the city and a photo of the Glebuchevskii Ravine see Henze, Disease, pp. 35 – 6, 77. 40. Anton Chekhov, ‘In the Ravine’, in David Plante (ed.), Ward No. 6 and Other Stories, trans. Anton Chekhov Constance Garnett (New York, NY, 2003). 41. Gosudarstvennyi Arkhiv Saratovskoi Oblasti (GASO), f. 79, o. 1, 1904, d. 997, p. 9. Vrachebnoe otdelenii Saratovskago gubernskogo pravleniia: Delo o rabote sanitarno-ispolnitel’nykh komissiii protivo-kholernykh meropriiatiakh v Saratovskoi gubernii v 1904 godu. Obshchestvo Riazansko-Ural’skoi Zheleznoi Dorogi, Protokol, pp. 1, 10. 42. Ibid., p. 2. October 13, 1904, ‘Zhurnal’ zasedaniia gorodskoi sanitarnoispol’nitelnoi kommissii’, Vrachebnoe otdeleniie Saratovskoi gubernskoro pravleniia: Delo o rabote sanitarno-ispolnitel’nykh komissii i protivokholernykh meropriiatiakh v Saratovskoi gubernii v 1904 gody, 2 oktiabria do 23 noiabria (Saratov, 1904). 43. Vardugin, Vo vlago, p. 63. 44. GASO, f. 79, o. 1, 1904, d. 997, p. 3. 45. Vardugin, Vo vlago, p. 162.

276 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56.

57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72.

73. 74. 75. 76.

NOTES

TO PAGES

81 – 90

Ibid., p. 181. GASO, f. 79, o. 1, 1904, d. 997, p. 3. Also see Vardugin, Vo vlago, p. 53. Ibid. The Glebuchevskii ravine was even larger and more prone to disease than the Beloglinskii ravine. Ibid. Hutchinson, Politics, p. 307. GASO, f. 79, o. 1, 1904, d. 997, p. 3. Ibid. Ibid. Ibid., p. 4. GASO, f. 79, o. 1, 1904, d. 997, 266. 22 – 6. Zhurnal’ Zasedaniia Saratovskoi gorodskoi sanitarno ispolnitel’nyi kommissii: Rezul’taty khimicheskago izsledovaniia v probe vody iz stochnykh trub Saratov sil gorodskikh boen i Aleksandrovskoi bol’nitsy. September 29, 1904. Pelling, Cholera, Fever, and English Medicine, pp. 283– 4. Krementsov, ‘The Strength of a Loosely Defined Movement’, pp. 9 –13; see also Havelock Ellis, The Task of Social Hygiene (New York, NY: Houghton Mifflin Company, 1912). Gamaleia, Kholera i bor’ba s neiu, p. 1. Hutchinson, Politics, p. 199. Gamaleia, Kholera i bo’rba s neiu, p. 67. Ibid. Kovalevskii, Sanitarnoe sostoianie, pp. 37 – 8. V. I. Vardugin, Vo vlago narodnogo zdraviia (Saratov, 2005), p. 174. Gamaleia, Kholera i bor’ba s neiu, pp. 67–8. Ibid., p. 67 – 9. Ibid., pp. 69 – 71. Ibid., pp. 69 – 70. Gamaleia, Kholera i bor’ba s neiu, p. 71. Ibid., pp. 71 – 2. Krementsov, ‘The Strength of a Loosely Defined Movement’, pp. 9 – 10. I. M. Lepinskii and I. S. Eliashvili, ‘Kholera v. g. Baku’, Russkii Vrach 49 (1904), p. 1652; and, I. M. Lepinskii, ‘Deiatel’nost prozektorskago kabineta Bakinskoi gorodskoi Mikhailovskoi bol’nitsy vo vremia kholernoi epidemii v 1904 g. v g. Baku’, Pirogovskii s”ezd po bor’be s kholeroi, p. 87. Donald J. Raleigh, Experiencing Russia’s Civil War: Politics, Society and Revolutionary Culture in Saratov, 1917–1922 (Princeton, NJ: Princeton University Press, 2002), pp. 22–3. Geoffrey Hosking, Russia and the Russians, A History (Camridge, MA: Harvard University Press, 2001), pp. 362 – 3. Ibid. Ibid., pp. 366 – 7.

NOTES

TO PAGES

90 – 96

277

77. N. V. Kirilov, ‘(Istoriia i epidemiologiia kholery) Kholernyia epidemii Dal’nago Vostoka i mery bor’by s nimi v Kitai i v nashikh predelakh’, Pirogovskii s”ezd no bor’be s kholeroi, p. 1. 78. Ibid., p. 3. 79. E. Ia. Stol’kind, ‘O merakh bor’by s kholeroi’, Pirogovskii s”ezd no bor’be s kholeroi, p. 168. 80. Ibid. 81. Ibid., p. 168. 82. Ibid., pp. 167 – 8. 83. Ibid., p. 167. 84. Ibid., p. 168. 85. Ibid. 86. Ibid. 87. Ibid. 88. Ibid., pp. 168 – 9. 89. Ibid., p. 169. 90. Ibid., 91. Ibid., p. 170. 92. Ibid., pp. 170 – 1. 93. Ibid., p. 170. 94. Ibid., p. 171. Widely detested by liberals, Pobedenostsev was the target of at least one assassination attempt and retired later that year. For more information see Robert Byrnes, ‘Conservative Thought Before the Revolution’, in Theofanis Stavrou, Russia Under the Last Tsar (Minneapolis, MI: University of Missesota Press, 1969) and Konstantin Petrovich Pobedenotsev, Reflections of a Russian Statesman (Michegan, MI: Ann Arbor, 1964). 95. Ibid., p. 172. 96. Ibid., p. 174. 97. V. L. Pentkovskii, ‘Peredvizhnyia dezinfektsionyia kamery na more i na sushi’, Pirogovskii s”ezd po bor’be s kholeroi, p. 70. 98. Ibid. 99. Richard J. Evans, Death in Hamburg Society and Politics in the Cholera Years (Oxford: Oxford University Press, 2005), p. 267. Evans observes that Koch favoured carbolic rather than mercuric chloride. 100. Ibid., pp. 77 – 8. 101. Ibid., p. 78. 102. Pettenkofer committed suicide in 1901. For more information see among others Morabia, ‘Epidemic Interactions’, and Evans, Death in Hamburg. 103. Ibid., p. 85. 104. Ibid. 105. Ibid.

278

NOTES

Chapter 4

TO PAGES

99 –103

Cholera Returns to Russia, 1907 –13

1. Nikolai Krementsov, ‘Big Revolution, Little Revolution: Science and Politics in Bolshevik Russia’, Social Research Vol. 73, no. 4 (Winter 2006), pp. 1175– 6. 2. John F. Hutchinson, Politics and Public Health in Revolutionary Russia, 1890– 1918 (Baltimore, MA: Johns Hopkins University Press, 1990), p. 97. 3. Charlotte Henze, Disease, Health Care and Government in Late Imperial Russia: Life and Death on the Volga, 1823 –1914 (London: Routledge, 2011); see also Frank Snowden, Naples in the Time of Cholera, 1884–1911. (Cambridge: Cambridge University Press, 2001). 4. World Health Organization (WHO), ‘El Nin˜o and Health: Protection of the Human Environment Task Force on Climate and Health (Geneva: World Health Organization, 1999), p. v. 5. V. A. Taranukhin, Ocherk kholernoi epidemii v. g. Samare v 1907 g. v sviazi s bakteriologicheskimi izsledovaniiami pitevykh vod i izverzhenii bol’nykh (Saint Petersburg: Ministerstva vnutrennikh del, 1908), p. 1. 6. L. A. Tarasevich, ‘Noveishiia danniia po voprosu o predokhranitel’nukh privivkakh protiv briushnogo tif i kholery’, Obshchestvennyi vrach: zhurnal’ obshchestva russkikh vrachei pamiat’ N. I. Pirogova 5 (mai 1915), p. 221. 7. Zalkind, Ilya Mechnikov, p. 130. 8. Peter F. Krug, ‘The Debate over the Delivery Health Care in Rural Russia’, Bulletin of the History of Medicine 50 (Summer 1976), p. 240. 9. Tarasse´vitch, Epidemiological Intelligence, Part I, No. 2, p. 39. 10. G. E. Rein, Iz perezhitogo: Vrachebno-Sanitarniaia reforma i uchrezhdeniie Ministerstva Narodnago Zdraviia v Rossii. Ocherk glavneushikh politicheskikh techenii v Rossii za poslednie gody Tsarstvovaniia Imperatora Nikolaia II, 1907– 1918, Tom pervyi (Berlin, 1935), 7, p. 58. 11. Kholernaia epidemiia 1908 g. v Ekaterinoslavskoi gubernii (Ekaterinoslav, 1909). 12. Rein, Iz perezhitogo, pp. 58 and 62. 13. That same year Klodnitskii followed up on suspicions that camels in the Caspian lowlands played a role in transmitting plague to humans. This type of plague was not biologically related to the medieval version of the disease. For more information see V. N. Fedorov, ‘Plague in Camels and its Prevention in the USSR’, Bulletin of the World Health Organization 23 (1960), pp. 275–81. 14. Nikolai Nikolaevich. Klodnitskii, ‘K epidemiologii kholernikh zabolovanikh v g. Samare’, Kholernyi listok: Prilozhenie k “vrachebnoi khronikie Samarskoi gubernii, 3 (Samara, 1907), pp. 1 – 7. 15. Taranukhin, Ocherk, pp. 1 – 10. 16. G. V. Khlopin, Materialy po ozdorovleniiu Rossii: Sanitarnoe opisanie gg. Astrakhan’, Samary, Saratova i Tsaritsyna s ukazaniem mep neobkhodimykh dlia ikh ozdorovleniia (Saint Petersburg: Tipografiia Ministervstva Vennutrennikh Del, 1911), pp. 1, 151– 2.

NOTES

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103 –111

279

17. N. F. Gamaleia, Kholera v’ Odesse i plan’ bor’by s kholernymi epidemiiami osobenno v priemnenii k S. – Petererburgu (Odessa: Tipographiia Aktsionernogo IuzhnoRusskago O-va Pechatnago Dela, 1909). 18. Henze, Disease, pp. 22– 6. 19. V. I. Binshtoka, ‘Kholernaia epidemiia 1910 goda v Rossii’, Vrachebnaia Gazeta 45 (niabr’ 1910), p. 111. 20. S. N. Klodnitskaia, N. N. Klodnitskii, 1868– 1935: Bydaiushchiesia deiateli otechestvennoi meditsiny (Moskva: Gosudarstvennoe izdatel’stvo meditsinskoi literatury, 1956), pp. 127 –8. 21. Klodnitskii, ‘K epidemiologii’, p. 3. 22. Ibid., pp. 6 – 7. 23. Taranukhin, Ocherk, pp. 3 – 4. 24. Klodnitskii, ‘K epidemiologii’, p. 7. 25. Robert Koch, ‘Lecture at the First Conference for Discussion of the Cholera Question [1884]’, in Essays of Robert Koch, trans. K. Codell Carter (New York, NY, 1987), p. 164. 26. Taranukhin, Ocherk, p. 3. 27. Taranukhin was likely referring to the local SEC rather than the MVD commission on which he served. 28. Taranukhin, Ocherk, p. 25. 29. Ibid., pp. 5 – 6. 30. Ibid., p. 6. 31. Ibid. 32. Locher, ‘Pettenkofer and Epidemiology’, p. 110. 33. Taranukhin, Ocherk, p. 7. 34. Alfredo Morabia, ‘Epidemiologic Interactions’, pp. 1237 –8. 35. See Mosk, Matthew, and Rym Momtaz, ‘Report: UN Peacekeepers Caused Cholera Epidemic in Haiti’. Available at , http://abcnews.go.com/Blotter/reportcaused-cholera-haiti/story?id¼ 14904474 . (accessed 10 December 2011). 36. The Samarka River has dried up and is now known to local inhabitants as the ‘sukhoi’ or ‘Dry’ Samarka. I am indebted to Professor D. V. Mikhel’ of Saratov State University for this information. 37. Taranukhin, Ocherk, p. 7. 38. S. N. Klodnitskaia, N. N. Klodnitskii, p. 128. 39. A. L. Smidovich, Kholernaia epidemiia 1908 g. v Ekaterinoslavsk gubernii, pp. 1, 25. 40. G. V. Khlopin, Materialy po ozdorovleniiu Rossii: Sanitarnoe opisanie gg. Astrakhan’, Samary, Saratova i Tsaritsyna s ukazaniem mep neobkhodimykh dlia ikh ozdorovleniia (St Peterburg: Tipagrafiia ministerstva vnutrennkh del, 1911), p. 1. 41. Khlopin, Materialy, 51; Regarding water pools in India see Bireswar Banerjee and Jayati Hazra, Geoecology of Cholera in West Bengal: A Study in Medical Geography (Calcutta: J. Hazra, 1974). 42. Max von Pettenkofer, cited in CEA Winslow, The Conquest of Epidemic Disease: A Chapter in the History of Ideas (Madison, WI: University of Wisconsin Press, 1980), p. 315.

280

NOTES

TO PAGES

111 –116

43. Rene Dubos, Pasteur, p. 80. 44. D. K. Zabolotnyi, ‘Ocherk Razvitiia kholernoi epidemii 1907 – 1908 gg. v Rossii i protivokholernye Meropriiatii’, in Izbrannye trudy, Tom 2: Kholera, Sifilis, Epidemiologicheskie i drugie raboty (Kiev: Izdatel’stvo Akademii Nauk Ukrainskoi SSR Kiev 2 1957), p. 57. 45. Khlopin, Materialy, p. 45. 46. Kholera 1907, 1908, 1909, 1910 g. g na vodnykh putiakh Kazanskago Okruga putei Soobshcheniia (Kazan’: Lito-tipografiia I. N. Khartonova, 1911). 47. I. P. Chernikh and M. V. Ivanov, ‘Protokol sovmestnago zasedaniia Kuznetskoi uezdnoi sanitarno-ispol’nitelnoi kommissii s uezdnym vrachebno-sanitarnom sovetom’, VSKSG no. 9 (sentiabr’ 1907), p. 691. 48. N. A. Zviagintsev, ‘Protokol’, p. 691. 49. M. M. Obukhov, ‘Protokoly zasedanii sanitarnago soveta pri Balashovskoi zemskoi uprav’, Vrachebno- sanitarnaia khronika Saratovskoi gubernii (VSKSG) 9 (sentiabr’ 1907), p. 678. 50. GASO, f. 79, op. 1, d. 1241, 105. ‘Biulleten’ o dvizhenii kholery v Saratovskoi gubernii s 4 avgusta po 27 oktiabria 1909 g’. 51. GASO, f. 79, o. 1, d. 1241, pp. 62 – 4. 52. Ibid., p. 60. 53. Ibid., p. 74. 54. Ibid., p. 75. 55. Eileen Kane, ‘Odessa as a Hajj Hub, 1880s– 1910’ in John Randolph and Eugene M. Avrutin (eds) Russia in Motion: Cultures of Human Mobility since 1850 (Urbana, IL: University of Illinois Press, 2012), pp. 112 – 15. 56. The report had been submitted by I. M. Kutlurdaev, ‘Otchet iz vrachebnikh i drugikh uchenykh Obshchestv i korrespondentsii’, Russkii Vrach 32 (1908), p. 1082. 57. Ibid. 58. Ibid. 59. Ibid., p. 1083. 60. Ibid. 61. Ibid. 62. ‘Otchet iz vrachebnikh i drugikh uchenykh Obshchestv i korrespondentsii’, p. 1083. 63. I. G. Fedorov, ‘Epidemiia kholery v Petrograd v1918 g: Po predvaritel’nym Statisticheskogo Podotdela Mediko-Sanitarnogo Otdela Komissariata zdravookhraneniia’, Izvestiia Komissariata zdravookhraneniia soiuza kommun sev. Oblasti, no. 1 (noiabr’ 1918), p. 87. There were approximately 6,894 cases. 64. Hutchinson, Politics, p. 199. 65. N. F. Gamaleia, Etiologiia, and Gamaleia, Kholera i bor’ba s neiu. 66. Hutchinson, Politics, p. 492. 67. N. F. Gamaleia, Osnovy obshchei bakteriologi (Odessa: ‘Slaviankaia’ tipografiia N. Khrisogelos, 1899), p. 79.

NOTES

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116 –124

281

68. N. F. Gamaleia, Kholera v Odesse i plan bor’by s kholernymi epidemiiami osobenno v primenenii k S. – Petererburgu (Odessa: Tipographiia Aktsionernogo UizhnoRusskago O-va Pechatnago Dela, 1909), p. 8. 69. Ibid. 70. Ibid., pp. 31 – 2. 71. Ibid., pp. 8 – 9. 72. Ibid., p. 9. 73. Ibid. 74. Nikolai Krementsov, ‘The Strength of a Loosely Defined Movement: Eugenics and Medicine in Imperial Russia’, Med. Hist. (2015), vol. 59 (1), pp. 6 – 8. 75. Rein, Iz perezhitogo, p. 61. 76. This is the same group which had assassinated Tsar Alexander II in 1882. 77. Ibid. 78. Ibid., p. 61. 79. L. A. Tarasse´vitch, Epidemiological Intelligence: Epidemics in Russia Since 1914, Report to the Health Committee of the League of Nations, Part 1: No. 2 (Geneva: League of Nations, 1922), p. 39. 80. K. D. Patterson, ‘Cholera Diffusion in Russia, 1823– 1923’ Social Science and Medicine 38, No. 9 (1994), p. 1185. 81. N. Kovalevskii, Ochet o komanderovke na obsuzhdeniiu protivkholernikh meropriatii v S.-Peterburge s 23-go fevralia po 1-e marta 1911 g. (Saratov, Parovaia TipoLithografiia S. M. Panina, 1911), p. 2. 82. Ibid., p. 3. 83. Ibid., pp. 5 – 6. 84. Ibid., pp. 4 – 5. 85. Ibid., pp. 20 – 1. 86. Ibid., p. 23. 87. Ibid., pp. 23 – 4. 88. Ibid., pp. 24 – 5.

Chapter 5 The Troubles Continue: World War I, 1914 –17 1. Orlando Figes, Revolutionary Russia, 1891– 1991: A History (New York, NY: Metropolitan Books, 2015), pp. 53– 6. 2. Geoffrey Hosking, Russia and the Russians, A History (Cambridge, MA: Harvard University Press, 2001), pp. 389 –91. 3. The Central Powers were Germany, Austria – Hungary and the Ottoman Empire. 4. Nikolai Krementsov, ‘Big Revolution, Little Revolution: Science and Politics in Bolshevik Russia’, Social Research Vol. 73, no. 4 (Winter 2006), p. 1176. 5. John Hutchinson, Politics and Public Health in Revolutionary Russia, 1890– 1918 (Baltimore, MD: Johns Hopkins University Press, 1990), p. 119.

282

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124 –129

6. R. Sari Kovats, Menno J. Bourna and Andy Haines, ‘El Nin˜o and Health: Protection of the Human Environment’, World Health Organization (Geneva: World Health Organization, 1999), p. v. 7. Peter Waldron, The End of Imperial Russia, 1855– 1917 (New York, NY: Palgrave, 1997), p. 146. 8. Tsuyoshii Hasegawa, The February Revolution: Petrograd, 1917 (Seattle, WA: University of Washington Press, 1981), pp. 570– 1. 9. Hutchinson, Politics, pp. 112 – 13. 10. Lars T. Lih, Bread and Authority in Russia, 1914 – 1921 (Berkeley, CA: University of California Press, 1990), pp. 1, 20– 1. 11. William E. Gleason, ‘The All-Russian Union of Towns and the Politics of Urban Reform in Tsarist Russia’, Russian Review 35 (July, 1976), pp. 290 – 2. 12. Peter Holquist argues that World War I created organisations and infrastructures that became part of the Soviet Union. See Peter Holquist, Making War, Forging Revolution: Russia’s Continuum of Crisis, 1914– 1921 (Cambridge, MA: Harvard University Press, 2002), p. 285. 13. Hutchinson, Politics, 91; Rein, Iz Perezhitogo, 69. Rein’s account tends to indicate that Nicholas II’s reply was evasive. The project also faced resistance from powerful figures. When World War I began, the Tsar placed public health under the leadership of his cousin, Prince Alexander Ol’denbergskii, perhaps indicating dissatisfaction with Rein. 14. Peter Gatrell, A Whole Empire Walking. Refugees in Russia during World War I (Bloomington, IN: University of Indiana Press, 1999). 15. E. I. Lotova and Kh. I. Idel’chik, Bor’ba s infektsionnimi bolezniami v SSSR, 1917– 1967 (Moscow, 1967), p. 16. 16. Ibid., p. 17. 17. Georgii Rein, cited in Lotova and Idel’chik, Borba s infektsionnimi bolezniami v SSSR, p. 20. 18. G. A. Ivashentsev, ‘Soveshchaniia bakteriologov i predstavitilei vrachebnosanitarnukh organizatsii po bor’be s zarazhnymi boleznami v sviazi s voennym vremenem, Moskva, 28 – 30 dekabria 1914 g’. Obshchestvennyi vrach: Zhurnal’ obshchestva russkikh vrachei v pamiat’ N. I. Pirogova 2 (fevral’ 1915), p. 24. 19. Lars T. Lih, Bread and Authority in Russia, 1914 – 1921 (Berkeley, CA: University of California Press, 1990), pp. 1, 20– 1. 20. Eileen Kane, Russian Hajj: Empire and the Pilgrimage to Mecca (Ithaca, NY: Cornell University Press, 2015), p. 157. 21. Eugene Rogan, The Fall of the Ottomans: The Great War in the Middle East (New York, NY: Basic Books, 2015) pp. 99– 128. 22. Khavkin, ‘Epidemiia kholery’, p. 81. 23. Ibid. 24. Hutchinson, Politics, pp. 116– 17. 25. G. A. Ivashentsev, ‘Soveshchaniia bakteriologov’, p. 24. 26. Ibid.

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27. See V. A. Liubarskii, ‘Dostizheniia v oblasti mikrobiologii i epidemiologii v SSSR v gody 1917– 1921’, Zhurnal’ Mikrobiologii, Patologii i Infektsionnykh Boleznei (ZhMPIB) 4 (1927), p. 2. 28. V. I. Iakovlev, ‘Soveshchaniia bakteriologov’, p. 24. 29. S. I. Zlatogorov, ‘Soveshchaniia bakteriologov’, p. 25. 30. V. I. Ivanovskii, ‘Soveshchaniia bakteriologov’, p. 25. 31. Ibid. 32. Ibid. 33. V. I. Ivanovskii, ‘Soveshchaniia bakteriologov’, p. 25. 34. S. I. Igumnov, ‘Soveshchaniia bakteriologov’, p. 27. 35. Ibid. 36. Ibid. 37. Ibid. 38. V. V. Favr, ‘Soveshchaniia bakteriologov’, p. 28. 39. Ibid. 40. Ibid., pp. 28 – 9. 41. Ibid. 42. Ibid., p. 29. 43. Ibid. 44. L. A. Tarasse´vitch, Epidemiological Intelligence: Epidemics in Russia Since 1914, Report to the Health Committee of the League of Nations, Part 1: No. 2 (Geneva, 1922), p. 39. 45. The word ‘propaganda’ did not the same negative connotations in Europe as in the United States. 46. L. A. Tarasevich, ‘Noveishiia danniia po voprosu o predokhranitel’nukh privivkakh protiv briushnogo tif i kholery’, Obshchestvennyi vrach: zhurnal’ obshchestva russkikh vrachei pamiat’ N. I. Pirogova 5 (mai 1915)’, pp. 218– 19. 47. Ibid., p. 221. 48. Ibid., p. 220. 49. L. A. Tarasevich, Predokhranitel’nyia privivki protiv briushnogo tifa i kholery (Moskva: Tipografiia T- va Piavshinskikh Putinkovskii per., sobstvennyi dom, 1915), p. 7. Of those who were vaccinated twice, only two out of 10,000 fell ill while those who were vaccinated just once suffered 15 cases for every 10,000. 50. Ibid., p. 8. 51. Ibid. 52. Tarasevich, ‘Noveishiia danniia’, p. 221. 53. Ibid., p. 222. 54. Elizabeth Hachten, ‘How to Win Friends and Influence People: Heinz Zeiss, Boundary Objects, and the Pursuit of Cross-National Scientific Collaboration in Microbiology’, in Susan Gross Solomon, Doing Medicine Together: Germany and Russia Between the Wars (Toronto, 2006), fn. p. 191. 55. Tarasevich, Predokhranitel’nyia privivki, p. 12. 56. L. A. Tarasse´vitch, Epidemiological Intelligence, Part 1, No. 2, p. 6.

284

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137 –145

57. Peter Waldron, The End of Imperial Russia, 1855– 1917 (New York, NY, 1997), p. 148. 58. Tarasevich, Predokhranitel’nyia privivki, p. 12. 59. Ibid., p. 14. 60. Ibid., p. 15. Vaccination serums arriving at the front were believed to lose potency after three months. 61. Ibid., pp. 16 – 7. 62. Hutchinson, Politics, p. 119. 63. Gatrell, A Whole Empire Walking, p. 3. 64. Hutchinson, Politics, p. 119. 65. Gatrell, A Whole Empire Walking, p. 3. 66. GASO, f. 79, o. 1, d. 1538, 1, 2, 4, 6, 7, 12, 18– 20, 23–6, 28– 30, Vrachebnoe otdelenie Saratovskogo gubernskoro pravleniia: Statisticheskie svedeniia ob epidemicheskikh zabolevaniiakh v Novgorodskoi gubernii i v gorode Odesse i svedeniia ob umershikh v gorode Moskvy za 1915– 1916 gg. 67. Ibid. 68. Ibid. 69. Hosking, Russia and the Russians, pp. 389–91. 70. Mark D. Steinberg, Voices of Revolution, 1917 (New Haven, CT: Yale University Press, 2001), p. 51. 71. Sean McMeekin, The Berlin – Baghdad Express (London: Belknap Press, 2010), pp. 219, 312. 72. ‘Zhurnal zasedaniia Saratovskoi gubernskoi sanitarno-ispol’nitelnoi komissii po voprosam sviazannym s kholeroi’, 28 iiulia1915 goda, Vrachebno-sanitarnaia khronika Saratovskoi gubernii (VSKSG) 8 (avgust 1915), pp. 773– 4. 73. Iu. A. Rakhmanin, N. I. Lutesivich, A. I. Ziavalov and I. V. Miasnikov, ‘Vklad N. I. Teziakova v razvitie zemskoi meditsiny, sanitarnogo dela v. Saratovskoi gubernii (k-150-letiiu c dnia rozhdeniia)’, Gigiena i Sanitarnaia Moskva Nov/ Dec (6) 2009: pp. 87 – 9. 74. ‘Zhurnal zasedaniia Saratovskoi gubernskoi sanitarno-ispol’nitelnoi komissii’, pp. 773 –4. 75. Ibid., p. 774. 76. ‘Otchet iz vrachebnikh i drugikh uchenykh Obshchestv i korrespondentsii’, Russkii Vrach, no. 32 (1908), pp. 1082 – 3. 77. ‘Zhurnal’ zasedaniia’, p. 776. 78. A. S. Rimskii-Korsakov, ‘Ob organizatsii pomoshchi bezhentsem’, VSKSG, no. 9 (sentiabr’ 1915), p. 864. 79. Ibid., pp. 864 – 5. 80. Ibid., p. 866. 81. ‘Ob organizatsii pomoshchi bezhentsem’, pp. 865– 6. 82. Ibid., p. 873. 83. Ibid. 84. Ibid., p. 872. 85. Ibid., p. 871.

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86. ‘Kholernyia zabolevaniia v Saratovskoi gubernii’, VSKSG, no. 8 (avgust 1915), p. 780. 87. ‘Ob organizatsii’, p. 871. 88. Ibid., pp. 871 – 2. 89. Ibid., p. 871. 90. Ibid., p. 872. 91. ‘Protokoly Serdobskoi Sanitarno-Ispol’nitelnoi Komissii o bezhentsakh: 21-go sentiabria 1915 goda’, VSKSG, no. 9 (sentiabr’ 1915), p. 888. 92. N. I. Teziakov and I. A. Dobreitser, ‘Rtishchevskii i Bakashovskii raspredelitel’nye punkty dlia bezhentsev’, VSKSG, no. 9 (sentiabr’ 1915), p. 876. 93. Ibid., p. 880. 94. Ibid., p. 881. 95. Ibid. 96. Teziakov and Dobreitser, ‘Rtishchevskii i Balashovskii’, p. 881. 97. I. P. Vasilev, ‘Ochet o diatel’nosti vremennoi bakteriologicheskoi laboratorie Saratovskago Zemstva za sentiabr’ 1915 g’, VSKSG, no. 9 (sentiabr’ 1915), p. 895. 98. A. A. Churilinoi, ‘Otchet o diatel’nosti Tsaritsynskoi bakteriologicheskoi laboratorii Saratovskago gubernskago zemstvo za sentiabr 1915 g’. VSKSG, no. 9 (sentiabr’ 1915), p. 893. 99. ‘Protokol zasedaniia sanitarno-ispolnitelnoi podkomissii st. Balashov po voprosom sviazannym s pribytiem bezhentsev’, 28 avgusta 1915 goda, VSKSG, no. 8 (avgust 1915), p. 778. 100. Ibid., p. 778. 101. McMeekin, The Berlin-Baghdad Express, p. 313. 102. Ibid. 103. Ibid. 104. Mohammad Gholi Majd, The Great Famine and Genocide in Persia, 1917– 1919 (Lanham, MD, 2003), pp. 1, 20– 1. 105. Lih, Bread and Authority, pp. 20 – 1. 106. Steinberg, Voices of Revolution, p. 51. 107. Lih, Bread and Authority, pp. 20– 1. 108. For an account of typhus on the railroad see Robert Argenbright, ‘Lethal Mobilities: Bodies and Lice on Soviet Railroads, 1918– 1920’, Journal of Transport History 29 (September 2008), pp. 259 – 76. 109. Waldron, The End of Imperial Russia, p. 146. 110. Hasegawa The February Revolution, pp. 570– 1.

Chapter 6 The Revolutions, Civil War and War Communism, 1917 –21 1. Mikhail Lermontov, cited in Semyon Ekshtut, ‘Pushkin’s Heir’, Russian Life 42/6 (October/November 1999), pp. 19– 32.

286

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153 –161

2. Geoffrey Hosking, Russia and the Russians, A History (Cambridge, MA, 2001), p. 391. 3. Orlando Figes, Revolutionary Russia, 1891 – 1991, A History (New York, NY, 2014), pp. 70– 1. 4. Lars T. Lih, Bread and Authority in Russia, 1914– 1921 (Berkeley, CA, 1990), p. 31. 5. R. Sari Kovats, Menno J. Bourna and Andy Haines, ‘El Nin˜o and Health: Protection of the Human Environment’, World Health Organization (Geneva: 1999), p. v. 6. Tarasse´vitch, Epidemiological Intelligence, Part I, No. 2, p. 8. 7. Robert Argenbright, ‘Lethal Mobilities: Bodies and Lice on Soviet Railroads, 1918– 1920’, Journal of Transport History 29 (September 2008), pp. 259 – 76. Argenbright acknowledges the inevitability of disease in Russia during the period of war and revolution. 8. Stephen Kotkin, Stalin, Volume I: Paradoxes of Power, 1878– 1928 (New York, NY, 2014), pp. 190– 5. 9. Ibid., pp. 186– 7. 10. Ibid., p. 196. 11. Nikolai Krementsov, ‘Big Revolution, Little Revolution: Science and Politics in Bolshevik Russia’, Social Research Vol. 73, no. 4 (Winter 2006), pp. 1177– 8. 12. Vestnik Zhelenodorozhnoi meditsiny i sanitarii, 3, 4 (1917), cover, inset. 13. B. I. Zemblinov, ‘Ustroistvo vrachebno-sanitarnoi sluzhby zhel. Dorogakh s otpredeleniem otnosheniia eia k mestnym obshchestvennym vrachebnosanitarnym organizatsiiam’, Vestnik Zhelenodorozhnoi meditsiny i sanitarii, 3 –4 (1917), p. 50. 14. Ibid., pp. 50 – 1. 15. Ibid., p. 51. 16. Ibid. 17. Ibid. 18. John Hutchinson, Politics and Public Health in Revolutionary Russia, 1890– 1918 (Baltimore, 1990), pp. 8, 143. Hutchinson argued that October brought the real cleansing hurricane, that the war and revolutions prompted the rise of technical specialists in public health. See John Hutchinson, ‘Who Killed Cock Robin? An Inquiry into the Death of Zemstvo Medicine’, in. Health and Society in Revolutionary Russia Susan Gross Solomon and John F. Hutchinson (eds) (Bloomington IN, 1990), pp. 3– 26. 19. Ibid., p. 143. 20. Ibid., pp. 143 – 6. 21. Ibid., pp. 152 – 3. 22. Ibid., pp. 153 – 7. 23. Ibid., p. 16. 24. Ibid., pp. 160 – 1. 25. Ibid., pp. 162 – 8.

NOTES

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162 –168

287

26. Robert Koch, cited by P. V. Khavkin, ‘Epidemiia kholery 1918 g. v Petrograde’, Izvestiia Komissariata zdravookhraneniia soiuza kommun sev. Oblasti 1 (noiabr’ 1918), pp. 80– 1. 27. Donald J. Raleigh, Experiencing Russia’s Civil War: Politics, Society, and Revolutionary Culture in Saratov, 1917– 1922 (Princeton, N. J. 2002), p. 8. 28. Evan Mawdsley, The Russian Civil War (Boston, 1987), pp. 71 – 4. 29. Peter Krug, ‘Russian Physicians and Revolution: The Pirogov Society, 1917– 1920’ (Ph.D. Dissertation, University of Wisconsin, 1979), pp. 285– 8. 30. L. G. Veber, ‘The System of Public Health Service in the USSR’, World Health Organization Inter Regional Travelling Seminar on Cholera (Moscow: USSR Ministry of Public Health Central Institute for Advanced Medical Studies, 1968), p. 2. 31. Tarasse´vitch, Epidemiological Intelligence, Part I, No. 2, p. 8. 32. V. A. Liubarskii, ‘Dostizheniia v oblasti mikrobiologii i epidemiologii v SSSR v gody 1917– 1921’, Zhurnal’ Mikrobiologii, Patologii i Infektsionnykh Boleznei (ZhMPIB) 4 (1927), p. 1. 33. Steven Hoch, ‘The Social Consequences, of Soviet Immunization Policies, 1945– 1980’ (Unpublished paper, 1997), pp. 8 – 14. 34. L. G. Veber, ‘The System of Public Health Service in the USSR’, pp. 1 – 2. 35. Kovats, Bourna and Haines, ‘El Nin˜o and Health’, p. 5. 36. Tarasse´vitch, Epidemiological Intelligence, Part I, No. 2, p. 8. 37. Ibid. 38. David Hoffmann, Stalinist Values: The Cultural Norms of Soviet Modernity (1917 – 1941) (Ithaca, N. Y. 2003) pp. 4, 38. 39. Veber, ‘The System of Public Health Service in the USSR’, pp. 2 – 3. 40. Richard G. Robbins, Famine in Russia, 1891–1892 (New York, NY, 1975), p. 27. 41. P. V. Khavkin, ‘Epidemiia kholery 1918 g. v Petrograde’, pp. 80– 1. 42. GARF, f. A-482, o. 7, 1918, d. 29, 11, ‘Kholera Na Volge’. 43. Mawdsley, The Russian Revolution, p. 64. 44. GARF, f. A-482, o. 6, 1918, d. 7, p. 6. 45. GARF, f. A-482, op. 7, 1918, d. 29, p. 2. 46. Ibid. 47. Ibid., p. 5. 48. GARF, f. A-482, o. 7, 1918, d. 29, 13, ‘Na Kanun Kholery’, in the journal GAZ Zhizn’. 49. Joseph Brodsky ed., Osip Mandelstam, 50 Poems (New York, NY, 1977), p. 44. 50. Bruce Lincoln, Sunlight at Moonlight: St Petersburg and the Rise of Modern Russia (New York, NY, 2002), p. 243. 51. Aleksei Tolstoi, cited in Lincoln, Sunlight at Moonlight, p. 243. 52. Ibid., p. 240. 53. Mawdsley, The Russian Revolution, p. 70. 54. Lincoln, Sunlight at Moonlight, p. 252. 55. GARF, f. A-482, o. 7, 1918, d. 29, p. 12. ‘Kholera’, in Ranoe Utro. 56. Gazetnye starosti. Available at , http://www.starosti.ru. (accessed 8 November 2011).

288

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168 –172

57. TsGASPb, f. 2815, o. 1, d. 348, 1918, 18, 18 ob. 58. Mawdsley, The Russian Civil War, p. 66. 59. Tsentral’nyi Gosudarstvennyi Arkhiv nauchno-tekhnologicheskago dokumentatsiia Saint-Peterburga (TsGANTD SPb), f. 182, o. 1 – 1, 1918, d. 9, p. 13. ‘Gosudarstvennyi Institut Eksperimental’noi meditsiny. Nauchno-issledobatel’skii otdel. Ochet o komanderovke v goroda Verkhnego Povolzh’ia i Kamy i perepiska s finansoviia otdelom NKVD o finansvoovanii chumykh otriadov; komanderovnye udastovereniia satrudnikov instituta’. 60. See Sigard Adolphus Knopf, Tuberculosis as a Disease of the Masses and how to Combat it: ‘The International Congress to Combat Tuberculosis as a Disease of the Masses’, which convened at Berlin, May 24th to 27th, 1899. Awarded the International Prize to this work through its Committee on July 31st, 1900 (New York, NY, 1911), p. 2. Also see S. A. Knopf, Tuberculose al seine Volkskrankeit und der Kampf mit ihr [Russ. Uebersetzung redaktiert v. F. M. Blumenthal.] (Moskva, 1901). 61. TsGANTD SPb, f. 182 o. 1–1, 1918, d. 11, 1, Gosudarstvennyi institute eksperimental’noi meditsiny Nauchno-issledovatel’skii otdel. Dokladnaia zapiska o snabzhenii naseleniia lechebnymi syvorotkami’, Predstoiashchii krizis v del snabzheniia naseleniia lechebnymi syvorotkami: Doklad sdelannyi 12–ogo iiunia s. g. v komissi pri Glavnom Voenno-Sanitarnom Upravlenii, Dokladnaia zapiska F. M. Blumentalia’. 62. Ibid. 63. Ibid., 1, 1 ob. 64. TsGANTD SPb, f. 182, o. 1 – 1, d. 11, 1918, 1 ob. 65. Khavkin, ‘Epidemiia kholery’, p. 81. 66. Ibid. 67. GARF, f. A-482, o. 6, 1919, d. 77, 34. Zavedyvaiushim Sanitarnoi chastykh Voennykh Soobshenii Vostochnogo Fronta telegramoiu ot 18-go iiuliia. 68. Mawdsley, The Russian Revolution, p. 66. 69. TsGASPb, f. 2815, o, 1, 1918, d. 348, 157 ob. ‘Zhurnal’ Tsentral’nago Komiteta Po Portym Delam’, 23 zasedanie, 19 September 1918, no. 115. 70. I. G. Fedorov, ‘Epidemiia kholery v Petrograd v1918 g: No predvaritel’nym Statisticheskogo Podotdela Mediko-Sanitarnogo Otdel’a Komissariata Zdravookhraneniia’, Izvestiia Komissariata Zdravookhraneniia Soiuza kommun sev. Oblasti 1 (noiabr’ 1918), p. 84. 71. Tsentral’nyi gosudarstvennyi arkhiv Sankt-Peterburga (TsGASPb), f. 2815, o. 1, 1918, d. 343, 42, ‘Raport’. 72. Mawdsley, The Russian Revolution, pp. 66 – 7. 73. TsGASPb, f. 2815, o. 1, 1918, d. 348, 121. ‘Rossiiskaia Federativnaia Sovetskaia Respublika, Narodnyi Komissariat Putei Soobshcheniia, Petrogradskii Okrug, Administrativnyi Otdel, Chast’ Byta, 24 avgusta dnia 1918 g., ‘dlia kholery’. 74. Ibid. This route was the Rinovskii, Finland, and Petrograd-Belo-ostrov (White Island) line.

NOTES

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289

75. TsGASPb, f. 2815, o, 1, 1918, d. 348, 157 ob. ‘Zhurnal Tsentral’nago Komiteta Po Portym Delam’, 23 zasedanie, 19 September 1918, no. 115. 76. Khavkin, ‘Epidemiia kholery’, p. 80. 77. Ibid. 78. New York Times, 25 August 1918. 79. Ibid. 80. GARF, A-482, o. 7, 1918, d. 29, 11, ‘Kholera Na Volge’. 81. Ibid. 82. Veber, ‘The System of Public Health Service in the USSR’, p. 3. 83. Fedorov, ‘Epidemiia kholery’, pp. 86 – 7. 84. Ibid. 85. Khavkin, ‘Epidemiia kholery’, p. 80. 86. Fedorov, ‘Epidemiia kholery’, p. 87. 87. Ibid. 88. Ibid. 89. Z. G. Frenkel’, Petrograd Perioda Voiny i Revoliutsii: Sanitarnye usloviia i kommunal’noe blagostroistvo (Petrograd: izdanie Petrogubotkomkhoza, 1923), p. 107. 90. Fedorov, ‘Epidemiia kholery’, p. 87. 91. Frenkel’, Petrograd Perioda Voiny i Revoliutsii, p. 107. 92. Khavkin, ‘Epidemiia kholery’, pp. 80 – 1. 93. Ibid., pp. 80 – 1. 94. Fedorov, ‘Epidemiia kholery’, p. 84. 95. Ibid. 96. V. I. Nebizailovi, ‘Programma-konspekt dlia chtenii po zaraznym bolezniam’, Izvestiia Komissariata zdravookhraneniia soiuza kommun sev. Oblasti, no. 2 (dekabr’ 1918), p. 53. 97. Tsentral’nyi gosudarstvennyi arkhiv Sankt-Peterburga (TsGASPb), f. 2815 o. 1, d. 343, 1918, 37’.O diatel’nosti tsentro-snabzheniia pri-chrezvychainoi komissii po bor’be s kholeroi / za vremia s 12 – 28 iiulia s/g. vkliuchitelno’. 98. Ibid. 99. TsGANTD SPb. f.182, o. 1 – 1, 1918, d. 9, 13. ‘Gosudarstvennyi Institut Eksperimental’noi Meditsiny. Nauchno-issledovate’lskii otdel. Otchet o kamanderovke v gorodakh verkhnego Povolzh’ia i Kama i perepiska s finansoviia otdelom NKVD o finansivoovaniia chumnykh otriadov; komandirovnyi udostvovereniia samupravnikov instituta. Nachato: 1 iiuniia 1918, okoncheno: 27 noiabr’ 1918’. 100. TsGANTD SPb, f. 182, op. 1 – 1, 1918, d. 9, 26. ‘Kratkii ochet o kamanderovke v gorodakh verkhnego Povolzh’ia i Kama pomoshchnitsy Zaveduiushchago Epidemiologichesckim Otdelom Instituta Eksperimental’noi Medistiny’. 101. TsGASP, f. 2815, o. 1, 1918, d. 343, 37 and 38. 102. Ibid. 103. Ibid.

290

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184 –189

104. TsGASPb, f. 2815, o. 1, 1918, d. 348, 10’.Rossiiskaia Federativnaia Sovetskaia Respublika. Soiuz Kommun Severnoi Oblasti. Komissariat Zdravookhraneniia Chezvychainaia Komissiia no bor’be s kholeroi’. 105. TsGASPb, f. 9156, o. 1, 1919, d. 273, 67. 106. Ibid. 107. Fedorov, ‘Epidemiia kholery’, p. 87. 108. TsGASPb, f. 2815 o. 1, 1918, d. 343, 37, ‘O diatel’nosti tsentro-snabzheniia’. 109. TsGASPb, f. 2815, o. 1, 1918, d. 348, 133, ‘Rossiiskaia Federativnaia’. 110. Fitzpatrick, The Russian Revolution, p. 66. 111. The Nikolaevskii railroad was the second major line constructed in Tsarist Russia. Tsar Nicholas I initiated the study of a plan in 1841 to build this railroad line and the first passenger train departed Moscow for St Petersburg on 1 November 1851. For more information see J. N. Westwood, A History of Russian Railways (London: Allen & Unwin, 1964), pp. 25 – 40. 112. TsGASPb, f. 2815, o. 1, 1918, d. 348, 133, 133 ob. 113. TsGASPb, f. 2815, o. 1, 1918, d. 348, 133 ob. ‘Rossiiskaia Federativnaia’. The Aleksandrovskii works was furnished and staffed by an American firm in 1843 to build 162 twenty-five ton engines, 2500 American eight-wheel freight cars, and 70 passenger cars. For more information see Westwood, A History of Russian Railways, pp. 1 – 32. 114. Ibid., p. 134. 115. Ibid. 116. Ibid. 117. Ibid., p. 135. 118. Ibid. 119. Ibid. 120. GARF, f. A-482, o. 6, 1918, d. 78, 10, Mediko-sanitarnii otdel putei soobshcheniia: Svdeniia o kolichestvo i dvizhenii kholernykh zabolevanii na zhelezhykh gorodakh: Odvizhenii kholernykh zabolevanie s Maia 1918 po Dekabr’, Narkomzdrav Tsentral’nyi Mediko-Sanitarnyi Soviet, ‘o dvizhenii kholernikh zabolevaniia na zhel. dorogakh na ‘17’ avgusta 1918 goda. 121. Ibid., p. 18. 122. GARF, f. A-482, op. 7, 1918, d. 29, 14, ‘Narkomzdrav Vodnoi MedikoSanitaria: Otdel Gazetnyia zametki. Mediko-sanitarnoi otdel vodnykh putei i transporta v mestakh’. The term listok or ‘list’ expressed that the entire newspaper appeared on one sheet of paper. 123. GARF, f. A-482, op. 6, 1918, d. 7, 6. 124. Ibid., d. 7, 6. 125. GARF, f. A-482, o. 6, 1918, d. 7, 10. 126. TsGASPb, f. 2815, o. 1, 1918, d. 348, 154. 127. GARF, f. A-482, o. 6, 1918, d. 7, 2, ‘Narodnyi Komissariat Zdravookhraneniia: Sanitarno- epidemiologicheskaia Sektsiia, Svedeniia o khode kholernykh zabolovanii za iiul’ mesiats 1918 g’.

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189 –195

291

128. Ibid. 129. Tarasse´vitch, Epidemiological Intelligence, Part 1, No. 2, p. 39. 130. GARF, f. A-482, o. 6, 1919, d. 77, 30, Mediko-sanitarnyi otdel putei soobshcheniia: Perepiska s Narkomatom putei soobshcheniia, upravleniiami zheleznykh dorog o priniatii mer po bor’be s kholeroi. 131. Ibid., p. 32. 132. TsGANTD SPb f. 182, o. 1 – 1, 1919, d. 23, 45, 45 ob. ‘V Narodnyi Komissariat Zdravookhranenii’. 133. TsGASPb, f. 2815, o. 1, 1918, d. 348, 73, ‘Zdanie Prisutsvennykh Mest. v Upravlenie Delami Komissara Finansov Severnoi Oblasti. Novgorodskii Gubernskii Ispolnitel’nyi Komitet Soveta. 134. GARF, f. A-482, o. 7, 1921, d. 109, 11. ‘O Kholera’. 135. Ibid. 136. S. I. Zlatogorov, Chto Takoe Kholera i Kak Borots’ia s nei? (Peterburg: Z. I. Grezhebina, 1920), p. 39. 137. Ibid. 138. Zalkind, Ilya Mechnikov, p. 130. 139. See Bruno Latour, The Pasteurization of France (Cambridge, MA: Harvard University Press, 1988). 140. Modern History Sourcebook: Lady Wortley Montagu (1689 – 1762), Smallpox Vaccination in Turkey, Fordham University. Available at http://legacy. fordham.edu/Halsall/mod/montagu-smallpox.asp (accessed 20 December 2016). 141. Edward Jenner, Vaccination against Smallpox (New York, NY: Prometheus Books, 1996). 142. M. M. Gran, Kholera i bor’ba s nei (Moscow: Izdanie Narodnogo Komissariata Zdravookhraneniia, 1919), p. 16. 143. Ibid., pp. 16 – 17. 144. Zlatogorov, Chto Takoe Kholera, pp. 39– 40. 145. Ibid., p. 40. 146. Ibid. 147. Hoch, ‘The Social Consequences’, p. 1. 148. Ibid., p. 4. 149. Weisman, ‘Origins’, p. 107. 150. Zlatogorov, Chto Takoe Kholera, p. 42. 151. Ibid. 152. Ibid. 153. Weisman, ‘Origins’, p. 107. 154. GARF, f. A-482, o. 7, 1921, d. 109, 11ob. 155. M. Gran, Kholera i borba s nei, p. 21. 156. Raleigh, Experiencing Russia’s Civil War, p. 8. 157. Gran, Kholera i borba s nei, pp. 19–20.

292

Chapter 7

NOTES

TO PAGES

197 –202

The New Economic Policy (NEP), 1921 – 8

1. Donald J. Raleigh, Experiencing Russia’s Civil War: Politics, Society, and Revolutionary Culture in Saratov, 1917– 1922 (Princeton, NJ: Princeton University Press, 2002), pp. 177 – 87, 407. 2. Peter Holquist, ‘Violent Russia, Deadly Marxism? Russian in the Epic of Violence, 1905– 1924’, Kritika: Explorations in Russian and Eurasian History 4/3 (Summer 2003), pp. 627– 52. 3. S. G. Wheatcroft, ‘Famine and Epidemic Crises in Russia, 1918– 1922: The Case of Saratov’, Annales de de’mographie historique (1983), pp. 345– 6. See also Donald J. Raleigh, Experiencing Russia’s Civil War: Politics, Society, and Revolutionary Culture in Saratov, 1917– 1922 (Princeton, NJ, 2002; James W. Long, ‘The Volga Germans and the Famine of 1921’, Russian Review 51 (1992), p. 510; and, Evan Mawdsley, The Russian Civil War (Boston, MA: Birlinn Ltd., 1987). 4. Ibid., pp. 394– 6. 5. Susan Solomon, ‘Social Hygiene and Public Health, 1921 – 1930’, in Health and Society in Revolutionary Russia, John F. Hutchinson and Susan Gross Solomon eds. (Bloomington, IN: Indiana University Press, 1990), p. 180. 6. Nikolai Krementsov, ‘The Strength of a Loosely Defined Movement: Eugenics and Medicine in Imperial Russia’, Med. Hist. (2015), vol. 59 (1), pp. 6 –8 and others. 7. Ibid., p. 181. This approach had originated in Germany and was borrowed from thinkers such as Alfred Grotjahn. 8. Ibid., p. 179. 9. Ibid., pp. 179– 80. 10. Ibid., p. 178. 11. Wolfgang Locher, ‘Pettenkofer and Epidemiology: Erroneous Concepts Beneficial Results’, in History of Epidemiology: Proceedings of the 13th International Symposium on the Comparative History of Medicine: East and West, Yosio Kawakita, Shizu Sakai and Yasuo Otsuka eds. (Tokyo: Ishiyaku EuroAmerica Inc. 1993), pp. 102 –7. 12. N. A. Semashko, ‘Friedrich Erismann, the Dawn of Russian Hygiene and Public Health’, Bulletin of the History of Medicine 20 (1946), pp. 1, 5. 13. Peter F. Krug, ‘The Debate over the Delivery Health Care in Rural Russia’, Bulletin of the History of Medicine 50 (Summer 1976), p. 235. Whether this was P. N. Sokolov, who served on the Saratov SEC in 1904 and formed the Saratov Trustees, is unknown. 14. Ibid., pp. 235 – 8. 15. Ibid., p. 238. 16. Ibid., p. 240. 17. Solomon, ‘The Expert and the State’, pp. 197– 203. 18. Solomon, ‘Social Hygiene’, p. 180. 19. Ibid., p. 181.

NOTES

TO PAGES

203 –208

293

20. Weisman, ‘Origins’, pp. 115– 16. 21. Mawdsley, The Russian Civil War, p. 287. Also, Wheatcroft, ‘Famine’, p. 329. 22. Alec Nove, An Economic History of the USSR: 1917 – 1990 (New York, NY: Penguin Books, 1993), p. 86. 23. Ibid., p. 87. 24. Wheatcroft, ‘Famine’, pp. 330 – 3. 25. Holquist, Making War, p. 282. 26. Paul Avrich, Kronstadt 1921: The Uprising of Sailors at the Kronstadt Naval Base is Examined in the Context of the Political Development of the New Soviet State (New York, NY: W. W. Norton and Co., 1970). 27. Dobreitser, ‘Kholera v 1922 godu’, p. 85. 28. Tarasse´vitch, Epidemiological Intelligence, Part I, No. 2, p. 7. 29. GARF, f. A-482, o. 7, 1921, d. 93, 8. ‘Protokol soedinennogo sobshchaniia epidemiologicheskogo podotdela i otdela putei po obsuzhdeniiu plana meropriiatii po bor’be s kholernymi zabolevaniiami na zheleznodorozhnykh putiakh soobshcheniia v 1921 g’. 30. Ibid. 31. Ibid. 32. Ibid. 33. GARF, f. A-482, o. 7, 1921, d. 93, 3. ‘Instruktsiia o protivkholerniikh meropriiatiiakh na vnutrennikh vodnikh putiakh’. 34. Ibid. 35. Ibid. 36. Ibid. 37. GARF, f. A-482, o. 7, 1921, d. 93, 9, 9 ob., 10. ‘Spisok parakhodov i katerov sanitarnogo Naznacheniia na vodnikh putiakh soobshcheniia’. 38. Ibid. 39. Tarasevich, Epidemiological Intelligence, Part I, No, 2, p. 7. 40. GARF, f. A-482, o. 7, 1921, d. 93, 43. ‘Doklad v tsentral’no-Komissii NKZ ob obshchikh meropriiatiikh San. Vod. Sektsii no bor’be o epidemii kholery putei Respubliki’. 41. Ibid. 42. Vladimir Ilich Lenin, ‘(memo 161) Pismo V. I. Lenina Narodnomu komissaru zdravookhraneniia RSFSR N. A. Semashko o zabolevaniiakh kholernoi i merakh bor’by s nei,” 19 Aprelia, 1921 g.’, in Zdravookhraneniia v pervye gody Sovetskoi vlasti, 1917 – 1924: sbornik dokumentov i materialov, eds. I. Barsukov, A. S. Dremov, and A. P. Kyropatov (Moscow, 1924), 328. The letters SNK stood for Sovnarkom or Council of People’s Commissars. 43. Barsukov, Dremov, and Kyropotov, Zdravookhraneniia v pervye gody sovetskoi vlasti, 1917– 1924, p. 520; Weissman, ‘Origins’, p. 99. 44. Ibid. 45. GARF, f. A-482, o. 7, 1921, d. 93, 43. 46. Tarasevich, Epidemiological Intelligence, Part I, No. 2, p. 7.

294

NOTES

TO PAGES

208 –217

47. Ibid. 48. GARF, f. A-482, o. 7, 1921, d. 93, 43. 49. Tarasevich reported the January cases to the League of Nations by October of 1922, but it might have been reported earlier. Tarasse´vitch, Epidemiological Intelligence, Part I, No. 2, p. 7. 50. GASO, f. 521, o. 1, 1921, d. 614, 37, ‘Saratovskii Gubispolkom Sekretariat: Materialy k protokolom Gubernskogo ispolnitel’nogo komiteta, 3 iiulia 1921, 28 avgusta 1921’. 51. Raleigh, Experiencing Russia’s Civil War’, p. 176. 52. Ibid., p. 190. 53. Peter Holquist, ‘Violent Russia, Deadly Marxism? Russian in the Epic of Violence, 1905– 1924’, Kritika: Explorations in Russian and Eurasian History 4/3 (Summer 2003), pp. 627– 52 and ‘Information is the Alpha and Omega of Our Work: Bolshevik Surveillance in its Pan-European Context’. The Journal of Modern History, 69 (3), pp. 415– 50. See also Zygmunt Bauman, Modernity and the Holocaust (Ithaca, NY, 2000). 54. V. I. Lenin, ‘Telefonogramma V. I. Lenina Narodnomu komissariatu zdravookhraneniia RSFSR N. A. Semashko o komandirovanii vracha na postroiku Kashirskoi elektricheskoi stantsii’, in Barsukov, Dremov and Kyropatov, Zdravookhraneniia v pervye gody, p. 338. 55. ‘(Memo 1689), Dekret Soveta Narodnykh Komissarov RSFSR o meropriatiiakh protiv kholernoi epidemii’, in Barsukov, Dremov and Kyropatov, Zdravookhraneniia v pervye gody, p. 338. 56. Ibid. 57. Ibid., p. 340. 58. Ibid., p. 339. 59. Ibid., p. 340. 60. Kholera 1907, 1908, 1909, 1910 g. g na vodnykh putiakh Kazanskago Okruga putei soobshcheniia (Kazan’, 1911). 61. Memo 1689, in Barsukov, Dremov and Kyropatov, Zdravookhraneniia v pervye gody, p. 339. 62. Ibid., pp. 340 – 1. 63. Ibid., p. 340. 64. Ibid. 65. Ibid., pp. 340 – 1. 66. Ibid., p. 340. 67. Ibid. 68. Ibid., p. 341. 69. Ibid., p. 342. 70. New York Times, 21 August 1921. 71. Ibid. 72. New York Times, 28 September 1921. 73. N. N. Rozanov, ‘Ochitska goroda Saratova’, Saratovskii vestnik zdravookhraneniia (SVZ) (iiul’- Avgust’ 1922), p. 16.

NOTES

TO PAGES

217 –227

295

74. V. A Taranukhin, Ocherk kholernoi epidemii v. g. Samare v 1907 g. v sviazi s bakteriologicheskimi izsledovaniiami pitevykh vod i izverzhenii bol’nykh (St Peterburg: Ministerstva vnutrennikh del, 1908). 75. Bol’shaia Meditsinskaia Entsiklopediia, Tom vtoroi (ansel-baragnoz) (Moskva, 1928), pp. 395– 411. 76. Ibid. 77. Ibid., p. 17. 78. Ibid. 79. Ibid. 80. Ibid.

Chapter 8 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

14. 15. 16.

17. 18.

The End of ‘Classical’ Cholera Epidemics in the Soviet Union

Tarasevich, Epidemiological Intelligence, Part I, No. 2, p. 49. Nove, An Economic History, p. 93. Krijanovsky, cited in Epidemiological Intelligence, Part I, No. 2, p. 36. Tarasevich, Epidemiological Intelligence, Part I, No. 2, p. 36. Nove, An Economic History, p. 87. Tarasevich, Epidemiological Intelligence, Part I, No. 2, p. 8. Peter Holquist, ‘Information is the Alpha and Omega of Our Work: Bolshevik Surveillance in its Pan-European Context’, The Journal of Modern History, 69 (3), pp. 421– 3. N. Dobreitser, ‘Kholera v 1922 godu’, p. 87. ‘Kholera v Penzenskoi gub’. Biulleten’ narodnogo komissariata zdravookhraneniia (NKZ) 1 (1923), p. 45. Ibid. Ibid. Biulleten’ narodnogo komissariata zdravookhraneniia (NKZ) 3 – 4 (fevral’ 1923), p. 19. GARF, f. A-482, o. 7, 1922, d. 94, p. 228. ‘Doklad Nach. OChVSU Okruzhnoi Mezhduvedestvennoi Sanitarnoi Komissii no Bor’be o Epidemiiami pri Chernomosrsko-Azovskom Okruge Morskikh Putei Soobshcheniia’, 30 iiuniia, 1922. Ibid. G. V. Khlopin, Gigiena Gorodov: Obshchedostunnyi ocherk (Iur’ev: Tipografii K. Mattisna, 1903). V. A. Iakovenko, ‘Desinfektsiia i dezinsektsiia zh.- D. sostav na sanitary.dezinf. Stantsii Sev.- Zap. Zh. D. (Barsh. Zh. D.)’, Gigiena i Sanitariia: Putei Soobshenie nosviashchennyi voprosom meditsiny gigieny i sanitari transporte 1 (1923), p. 62. Ibid. Iakovenko, ‘Desinfektsiia i dezinsektsiia’, p. 63.

296 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42.

43.

44.

NOTES

TO PAGES

227 –237

This was equal to approximately 20 arshin (28 inches each). Iakovenko, ‘Desinfektsiia i dezinsektsiia’, p. 63. Frenkel’, Petrograd perioda voiny i revoliutsii, p. 107. I. N. Lastochkin, ‘Zabolevaemosti rabochikh po Aleksandrovskom zavode Nik. Zhel. Dorogi v Petrograde v sviazi s vodosnabsheniem i kanalizatsiei’, Gigiena i sanitariia putei soobshcheniia 1 (aprel’ 1923), p. 75. Ibid., pp. 75 – 6. Ibid. An oil and gas facility. Ibid. Tarasevich, Epidemiological Intelligence, Part II, No. 5, p. 12. Ibid. Raleigh, Experiencing Russia’s Civil War, pp. 394 – 6. L. A. Tarasevich, Epidemiological Intelligence, Part II, No. 5, p. 10. The italics are my own. Ibid. Kransnaia nov’, 1920s issues. Memo 1689, p. 341. Richard J. Evans, ‘Epidemics and Revolutions: Cholera in NineteenthCentury Europe’, Past and Present 120 (Aug. 1988), pp. 132– 4. Liubarskii, ‘Dostizheniia’, p. 2. Ibid. Ibid., p. 3. Ibid. Ibid. A. Bezredka, ‘O protivokholernykh privivkakh’, Vrachebnoe obozrenie 4 (15 aprel’ 1922), p. 145. Ibid. This procedure is often called bacteriolosis, the Isaev – Pfeiffer Phenomenon or just the Pfeiffer Phenomenon. Bacteriolosis was an infection of the blood plasma in laboratory guinea pigs that could be inhibited by heating the blood. The Pfeiffer– Isaev Phenomenon was first discovered by Richard Pfeiffer, a German groundbreaker in immunology who worked in Berlin with Koch, and V. I. Isaev, who after 1894 directed the Kronstadt Plague Fort near St Petersburg. The Belgian immunologist Jules Bordet (1870 – 1961) worked in Mechnikov’s lab at the Pasteur Institute and discovered the concept of hemolysis, a process that occurs when red blood cells are ruptured and their contents flow into surrounding fluid. Tarasse´vitch, Epidemiological Intelligence, Part II, No. 5, p. 13. Actually, the figures that Tarasevich cited in this article are precisely the opposite of what I have written above, but the information makes it abundantly clear that this is what he had intended to write. The percentages as cited above are the only possible logical scenario. Ibid.

NOTES 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73.

TO PAGES

237 –250

297

Ibid. Liubarskii, ‘Dostizheniia’, p. 4. Dobreitser, ‘Kholera v 1922 gody’, p. 90. Ibid. Ibid. Ibid., p. 91. Ibid. Tarasevich, Epidemiological Intelligence, Part I, No. 2, p. 11. Ibid. Epidemiological Intelligence No. 8, p. 13. ‘IV-i Vserossiiskii S”ezd otdelov Zdravookhraneniia’, Biulleten’ NKZ 1 (15 ianvaria 1923 g.), p. 9. Biulleten NKZ 15 (5 avgusta 1923), p. 11. Biulleten NKZ 20 (15 oktiabr’ 1923), p. 9. ‘Infektsionnaia zabolevaemost po SSSR v 1923 g.’, Gigiena i sanitariia putei soobshcheniia 7 – 8 (noiabr’-dekabr’, 1923 g.), p. 74. Biulleten’ NKZ 23 (20 dekabr’ 1923), pp. 13 – 14. Ibid. Epidemiological Intelligence No. 9: Statistics of Notifiable Diseases, 1924 (Geneva: League of Nations Health Organization, 1924), p. 5. Narkomzdrav: Gigiena i epidemiologiia 4 (iiul’-avgust 1925), p. 205. ‘Sanitarno-epidemichiskii otdel syvorotochno-vaktsinnaia komissiia NKZdrav’, Biulleten’ NKZ, no. 16 (1 oktiabr’ 1924), p. 12. I. A. Dobreitser, ‘VIII Vserossiiskii S”ezd bakteriologov, epidemiologov i sanitarnykh vrachei’, Biulleten’ NKZ, no 23 (20 iiuniia 1924), p. 15. Narkomzdrav: Gigiena i epidemiologiia, no. 4 (1926), p. 68. Ibid. Epidemiological Intelligence, No. 10, 21; and Epidemiological Intelligence No. 11, p. 51. Epidemiological Intelligence, No. 11, p. 51. Tarasse´vitch, Epidemiological Intelligence, Part I, No. 2, p. 9. Epidemiological Intelligence No. 10, p. 17. Kendall E. Bailes, Science and Russian Culture in an Age of Revolutions: V. I. Vernadsky and His Scientific School, 1863– 1945 (Bloomington, IN: Indiana University Press, 1990), p. 161. S. G. Wheatcroft, cited in Davis, ‘Economics’, pp. 147 – 8. Ibid., pp. 147 – 8.

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300

RUSSIA

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Epidemiological Intelligence No. 8: Statistics of Notifiable Diseases for 27 European countries, 15 African countries, 14 American countries, twelve Asiatic countries and for Australasia for the year 1923 (Geneva: League of Nations Health Organization, 1923). Epidemiological Intelligence No. 9: Statistics of Notifiable Diseases, 1924 (Geneva: League of Nations Health Organization, 1924). Epidemiological Intelligence No. 10: Statistics of Notifiable Diseases, 1925 (Geneva: League of Nations Health Organization, 1925). Fourth Epidemiological Report for the Year 1926 (Geneva, 1927). Frenkel’, Z. G., Petrograd Perioda Voiny i Revoliutsii: Sanitarnye usloviia i kommunal’noe blagoustroistvo (Petrograd, 1923). Mendeleev, D. I., Mendeleev on the Periodic Law: Selected Writings, 1869– 1905, William Jensen (ed.) (Mineola, NY: Dover, 2005). Klodnitskii, N. N., ‘K epidemiologii kholernikh zabolevanikh v g. Samare’, in Kholernyi listok: Prilozhenie k ‘vrachebnoi khronikie Samarskoi gubernii’ (3 Izdannie Samara: Samarskogo Gubernskogo zemstvo, 1907). Knopf, S. A., Tuberculosis as a Disease of the Masses and how to Combat it: ‘The International Congress to Combat Tuberculosis as a Disease of the Masses’, which convened at Berlin, May 24th to 27th, 1899. Awarded the International Prize to this work through its Committee on July 31st, 1900 (New York: The Survey, 1911). ——— Tuberculose al seine Volkskrankeit und der Kampf mit ihr [Russ. Uebersetzung redaktiert v.F.M. Blumenthal.] (Moscow: 1901). Kovalevskii, N., Ochet o komanderovke na obsuzhdeniiu protivkholernikh meropriatii v S.-Peterburge s 23-go fevral’ia po 1-e marta 1911 g. (Saratov: Parovaia TipoLithografiia S.M. Panina, 1911). Kholera 1907, 1908, 1909, 1910 g. g na vodnykh putiakh Kazanskago Okruga putei soobshcheniia (Kazan’: Lito-tipografiia I.N. Khartonova, 1911). Kholernaia epidemiia 1908 g. v Ekaterinoslavskoi gubernii (Ekaterinoslav: Tipografiia Torgovago Doma ‘Neite i Miasoedov’, 1909). ‘Oral Cholera Vaccine Use in Complex Emergencies: What Next?’ Report of the WHO Meeting, 14– 16 December, 2005.(Cairo, Egypt: Global Task Force on Cholera Control, World Health Organization [WHO], 2005). Pirogovskii s”ezd no bor’be s kholeroi, Moskva, 21 – 23 Marta, 1905 goda (Moscow: Pirogovskii s”ezd po bor’be s kholeroi Tovarishchestvo ‘Pechatniia S.P. Iakovleva’, Petrovka, Saltikovski per., d. T-va, No. 9, 1905). Pribavlenie 1-e k svody: Pravitel’stvennykh rasporiazhenii po priniatii mer protiv zanosa raspostraneniia kholery i chumy vnutri Imperii i po sukhoputnym i morskim granitsam (St Petersburg: Tipografia Ministerstva Vnutrennikh Del, 1904). Soveshchaniia bakteriologov i predstavitilei vrachebno-sanitarnukh organizatsii po bor’be s zarazhnymi boleznami v sviazi s voennym vremenem. Moskva, 28–30 dekabria 1914 g., Obshchestvennyi vrach: zhurnal’ obshchestva russkikh vrachei v pam’iat N.I. Pirogova 2 (fevral’ 1915), pp. 24 –9. Statistics of Notifiable Diseases For the Year 1927 (Geneva: Health Organisation, 1929). Taranukhin, V. A., Ocherk kholernoi epidemii v.g. Samare v 1907 g. v sviazi s bakteriologicheskimi izsledovaniiami pitevykh vod i izverzhenii bol’nykh (St Petersburg: Ministerstva vnutrennikh del, 1908). Tarasse´vitch, L. A., Epidemiological Intelligence: Epidemics in Russia Since 1914; Report to the Health Committee of the League of Nations, No. 1. (Geneva: League of Nations Secretariat Health Section, 1922).

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Journals

Biulleten’ narodnogo komissariata zdravookhraneniia (Biulleten NKZ) British Medical Journal Bulletin of the History of Medicine California State Journal of Medicine Gigiena i sanitariia putei soobshcheniia Gigiena i sanitariia putei soobshchenie: posviashchennyi voprosom meditsiny gigieny i sanitari transporte Gorodskoe delo Izvestiia Komissariata Zdravooxraneneniia Soiuza Kommun Severnie Oblasti Izvestiia Narodnogo Komissariata Zdravookhraneniia Kholernyi listok (Samara) Krasnyi nov’ Obshchestvennyi vrach: zhurnal’ obshchestva russkikh vrachei v pamiat N.I. Pirogova Russkii vrach Vestnik zhelenodorozhnoi meditsiny i sanitarii Vrachebnaia gazeta Vrachebnoe obozrenie Vrachebno-sanitarnaia khronika Saratovskoi gubernii (VSKSG) Vrachebnaia zhizn’ Zhurnal’ mikrobiologii, patologii i infektsionnykh boleznei (ZhMPIB)

Archives

Bibliotek Saratovskago Gosudarstvennoga Universiteta Gosudarstvennyi Arkhiv Rossiskii Federatsii (GARF) Gosudarstvennyi Arkhiv Saratovskoi Oblasti (GASO) Muzei Gigiena Sankt Peterburga Rossiiskii akademyi nauka (RAN) Tsentral’nyi Gosudarstvennyi Arkhiv Sankt-Peterburga (TsGASPb) Tsentral’nyi Gosudarstvennyi Arkhiv Nauchno-tekhnologicheskago Dokumentatsiia SanktPeterburga (TsGANTD SPb)

Websites

Bhuiyan, Nural, Nusrin, Suraia, Alam, Munirul, Morita, Masatomo, Watanabe, Haru, Ramamurthy, Thandavarayan, Cravioto, Alejandro and Gopinath Balakrish Nair, ‘Changing genotypes of cholera toxin (CT) of Vibrio cholerae O139 in Bangladesh and description of three new CT genotypes’, 2 October 2009.Available at ,https://doi.org/10.1111/j.1574-695X.2009.00590.x. (accessed 25 March 2017). Colwell, Rita ‘Calanoid Copedpods’. Available at ,http://www.nsf.gov/news/ speeches/colwell/rc02_swedish/tsld031.htm. (accessed 20 December 2016).

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EPA: United States Environmental Protection Agency, ‘Basic Information about Estuaries’. Available at ,https://www.epa.gov/nep/basic-informationabout-estuaries. (accessed 11 July 2017). Finklestein, Richard. ‘Cholera, Vibrio Cholera 01, and 0139, and Other Pathogenic Vibrios’, in Medical Microbiology 4th Edition (Galveston TX, University of texas medical Branch at Galveston, 1996) Available at ,https://www.ncbi.nlm.nih. gov/books/NBK8407/. (accessed 15 December 2015). Gazetnye starosti. Available at ,http:/www.starosti.ru. (accessed 8 November 2011). Lincoln, W. Bruce. ‘Russia’s Grim Famine History’ review of Harvest of Sorrow: Soviet Collectivization and the Terror Famine by Robert Conquest’, The World and I Online 4 (1987), n.p. Available at ,https://www.worldandischool.com/public/1987/ april/school-resource11749.asp. (accessed 15 December 2015). Modern History Sourcebook: Lady Wortley Montagu (1689 – 1762), Smallpox Vaccination in Turkey, Fordham University. Available at ,http://legacy. fordham.edu/Halsall/mod/montagu-smallpox.asp. (accessed 20 December 2016). Mosk, Matthew, and Rym Momtaz, ‘Report: UN Peacekeepers Caused Cholera Epidemic in Haiti’. Available at ,http://abcnews.go.com/Blotter/report-caus ed-cholera-haiti/story?id¼14904474. (accessed 10 December 2011). Trianni, Francesca, ‘What Makes Indonesia a Hot Spot on the Ring of Fire’, Time 14 February 2014. Available at ,http://world.time.com/2014/02/14/whatmakes-indonesia-a-hot-spot-on-the-ring-of-fire/. (accessed 13 December 2016). Turchaiano, Ralph, ‘Famine alters metabolism for successive generations’, Eve’s Drift: Highlighting multagenesis research for conflict, peace or other, 12 December 2016. Available at ,https://evesdrift.com/2016/12/13/famine-alters-metabolism-forsuccessive-generations/. (accessed 26 March 2017).

Secondary Sources Books

Ackerknecht, E. H., Rudolph Virchow: doctor, statesman, anthropologist (Madison, WI: Arno Press, 1953). Avrich, P., Kronstadt 1921: The Uprising of Sailors at the Kronstadt Naval Base is Examined in the Context of the Political Development of the New Soviet State (New York, NY: W. W. Norton & Company Inc, 1970). Barua, D. and Greenough III, William B. (eds), Cholera: Current Topics in Infectious Disease (New York, NY: Springer Publishing, 1992). Bailes, K. E., Science and Russian Culture in an Age of Revolutions: V.I. Vernadsky and His Scientific School, 1863– 1945 (Bloomington, IN: Indiana University Press 1990). Baldwin, P., Contagion and the State in Europe: 1830– 1930 (Cambridge: Cambridge University Press 2005). Banerjee, B. and J. H., Geoecology of Cholera in West Bengal: A Study in Medical Geography (Calcutta: J. Hazra, 1974). Bater, J., The Soviet City: Explorations in Urban Analysis (Beverly Hills, CA: Hodder & Stoughton, 1980). Bauman, Z., Modernity and the Holocaust (Ithaca, NY: Cornell University Press, 2000).

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Braudel, F., The Structures of Everyday Life: The Limits of the Possible (Berkeley, CA: University of California Press, 1992). Brodsky, J., Osip Mandelstam: 50 Poems, trans. Bernard Meares (New York, NY: Persea Books, 1977). Brower, D., The Russian City Between Tradition and Modernity (Berkeley, CA: University of California Press, 1990). Brower, D. and Lazzerini, E. (eds), Russia’s Orient: Imperial Borderlnds and Peoples, 1700– 1917 (Bloomingtin, IN: Indiana University Press, 1997). Chevalier, L., Laboring Classes and Dangerous Classes: In Paris During the First-Half of the Nineteenth Century (New York, NY: Howard Fertig, 1973). Cracraft, J. and Rowland, D. (eds), Architectures of Russian Identity: 1500 to the Present (Ithaca, NY: Cornell University Press, 2003). D’Arcy Wood, G., Tambora: The Eruption that Changed the World (Princeton, NJ: Princeton University Press, 2014). Davis, M., Late Victorian Holocausts: El Nin˜o famines and the Making of the Third World (London: Verso Books, 2002). Dubos, R., Pasteur and Modern Science (Garden City, NY: Anchor Books, 1960). Engelstein, L., The Keys to Happiness: Sex and the Search for Modernity in Fin-de-Sie`cle Russia (Ithaca, NY: Cornell University Press, 1992). Evans, R., Death in Hamburg: Society and Politics in the Cholera Years (Oxford: Penguin Books, 2005). Fadeeva, T. D., Kholera i bor’ba s nei (Moscow: Medgiz, 1959). Fagan, B., The Little Ice Age: How Climate Made History, 1300– 1850 (New York, NY: Perseus Books, 2002). ——— Floods, Famines and Emperors: El Nin˜o and the Fate of Civilizations (New York: Basic Books, 1999). Frieden, N. M., Russian Physicians in an Era of Reform and Revolution, 1856– 1905 (Princeton, NJ: Princeton University Press, 1981). Field, M. G., Soviet Socialized Medicine (New York, NY: Free Press, 1967). Figes, O., Peasant Russia Civil War: The Volga Countryside in Revolution, 1917– 1912 (Oxford: Oxford University Press, 1989). ——— Revolutionary Russia, 1891 – 1991, A History (New York, NY: Metropolitan Books, 2014). Fitzpatrick, S., The Russian Revolution. (Oxford: Oxford University Press, 1994). Fitzpatrick, S., Alexander Rabinowitch and Richard Stites (eds), Russia in the Era of NEP: Explorations in Soviet Society and Culture (Bloomington, IN: Indiana University Press, 1991). Garrett, L., Betrayal of Trust: The Collapse of Global Public Health (New York, NY: Hachette Books 2000). Gatrell, P., A Whole Empire Walking: Refugees in Russia during World War I (Bloomington, IN: Indiana University Press, 1999). Graham, L., Lysenko’s Ghost: Epigenetics and Russia (Cambridge MA: Harvard University Press, 2016). Hachten, E. A., ‘Science in the service of society: Bacteriology, medicine, and hygiene in Russia, 1855–1907’ (Ph.D. dissertation: University of Wisconsin, 1991). Hamm, M. F. (ed.), The City in Imperial Russia (Bloomington, IN: Indiana University Press, 1986). Harrison, M., Contagion: How Commerce has Spread Disease (New Haven, CT: Yale University Press, 2012).

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Hasegawa, T., The February Revolution: Petrograd, 1917 (Seattle, WA: University of Washington Press, 1981). Hempel, S., The Strange Case of the Broad Street Pump: John Snow and the Mystery of Cholera. (Berkeley, CA: University of California Press, 2005). Henze, C. E., Disease, Health Care and Government in Late Imperial Russia: Life and Death on the Volga, 1823– 1914 (London: Routledge, 2011). Hobsbawm, E. J., The Age of Empire: 1875– 1914 (New York, NY: First Vintage Books, 1989). Hoffmann, D. L., Stalinist Values: The Cultural Norms of Soviet Modernity [1917 – 1941] (Ithaca, NY: Cornell University Press, 2003). Holquist, P., Making War, Forging Revolution: Russia’s Continuum of Crisis, 1914– 1921 (Cambridge, MA: Harvard University Press, 2002). Hopkirk, P., The Great Game: The Struggle for Empire in Central Asia (New York, NY: Kodansha Amer Inc., 1992). Hosking, G., Russia and the Russians, A History (Cambridge, MA: Harvard University Press, 2011). Howard-Jones, N., The Scientific Background of the International Sanitary Conferences, 1851– 1938 (Geneva: World Health Organization, 1975). Hutchinson, J., Politics and Public Health in Revolutionary Russia, 1890 – 1918 (Baltimore, MA: Johns Hopkins University Press, 1990). Hutchinson, J. and Solomon, S. G. (eds), Health and Society in Revolutionary Russia (Bloomington: Indiana University Press, 1990). Johnson, S., ‘The Ghost Map’: The Story of London’s Most Terrifying Epidemic – and How it Changed Science, Cities, and the Modern World (New York, NY: Riverhead Books, 2006). Kane, E., Russian Hajj: Empire and the Pilgrimage to Mecca (Ithaca, NY: Cornell University Press, 2015). Kedrova, O. V., ‘Dinamika i osobennosti epidemicheskikh proiavlenii kholery v nizhenem novolzh’e period s 1892 po 1996 god’. (Dissertatsiia na soiskanie uchenoi stepenii kandidata meditsinskikh nauk. Ministerstvo zdravookhraneniia Rossiiskoi Federatsii, Rossiiskii nauchno- issledovatel’skii protivchumnyi institute ‘Mikrob’, Saratov, 1999). Klodnitskaia, S. N., N. N. Klodnitskii, 1868–1935: Bydaiushchiesia deiateli otechestvennoi Meditsiny (Moscow: Gosudarstvennoe izdatel’stvo meditsinskoi literatury, 1956). Kotkin, S., Stalin: Paradoxes of Power, Volume I 1878– 1928 (New York, NY: Pengin Books, 2014). Krug, P., ‘Russian Public Physicians and Revolution: The Pirogov Society, 1917– 1920’ (Ph.D. diss: University of Wisconsin, 1979). Kudlick, C. J., Cholera in Post-Revolutionary Paris: A Cultural History (Berkeley, CA: University of California Press, 1996). Kuhn, T. S., The Structure of Scientific Revolutions (Chicago, IL: University of Chicago Press, 1996). Landes, D. S., The Wealth and Poverty of Nations Why Some are So Rich and Some So Poor (New York, NY: W.W. Norton & Company, 1999). Latour, B., The Pasteurization of France (Cambridge, MA: Harvard University Press, 1988). Leavitt, J. W., and Numbers, R. L., Sickness and Health in America: Readings in the History of Medicine and Public Health, 3rd edition (Madison, WI: University of Wisconsin Press, 1997).

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Lecourt, D., Proletarian Science? The case of Lysenko (London: Schoken Books, 1978). LeDonne, J. P., The Russian Empire and the World, 1700– 1917: The Geopolitics of Expansion and Containment (Oxford: Oxford University Press, 1997). Lih, L. T., Bread and Authority in Russia, 1914 – 1921 (Berkeley, CA: University of California Press, 1990). Lincoln, W. B., Sunlight at Moonlight: St Petersburg and the Rise of Modern Russia (New York, NY: Basic Books, 2002). Long, E. R., Selected Readings in Pathology from Hippocrates to Virchow (Springfield, IL: C.C. Thomas, 1929). Lotova, E. I. and Kh. I. Idel’chik, Bor’ba s infektsionnimi bolezniami v SSSR, 1917– 1967 (Moscow: Medgiz, 1967). Majd, M. G., The Great Famine and Genocide in Persia, 1917 – 1919 (Lanham, MD, 2003). Malia, M., Russia under Western Eyes: From the Bronze Horseman to the Lenin Mausoleum (Cambridge, MA: The Belknap Press of Harvard University Press, 1999). Markel, H., Quarantine! East European Jewish Immigrants and the New York City Epidemics of 1892. (Baltimore, MD: Johns Hopkins University Press, 1997). Mawdsley, E., The Russian Civil War (Boston, MA: Unwin Hyman Inc., 1987). Mayer, E., Rudolph Virchow (Wiesbaden: Limes, 1956). Mazing, Iu. A., Andriushkevich, T. V., and Iu. P. Golikov, Rasskazy o velikom bakteriologove S.N. Vinogradskom (Saint Petersburg: Rostok, 2002). McGrew, R., Russia and the Cholera (Madison, WI: University of Wisconsin Press, 1965). McMeekin, S., The Berlin-Baghdad Express (London: Belknap Press, 2010). McNeill, J. R., Something New Under the Sun: An Environmental History of the Twentieth-Century World (New York, NY: W. W. Norton & Company, 2001). McNeill, W. H., Plagues and Peoples (New York, NY: Bantam Doubleday Bell, 1998). Michaels, P., Curative Powers: Medicine and Empire in Stalin’s Central Asia (Pittsburg, CA: University of Pittsburg Press, 2003). Morris, R. J., Cholera, 1832, the Social Response to an Epidemic (New York, NY: Holmes and Meier, 1976). Nesterenko, A. I., Kak byl obrazovan Narodnyi Komissariat Zdravookhraneniia RSFSR (Moscow: Meditsina, 1965). Nove, A., An Economic History of the USSR: 1917 – 1990 (New York, NY: Penguin Books, 1993). Pelling, M., Cholera, Fever, and English Medicine (Oxford: Oxford University Press, 1978). Porter, D., The History of Public Health and the Modern State (Atlanta, GA: Rodopoi Editions, 1994). Raleigh, D. J., Experiencing Russia’s Civil War: Politics, Society, and Revolutionary Culture in Saratov, 1917– 1922 (Princeton, NJ: Princeton University Press, 2002). Robbins, R. G., Famine in Russia, 1891– 1892 (New York, NY: Columbia University Press, 1975). Rogger, H., Russia in the Age of Modernisation and Revolution, 1881– 1917 (New York, NY: Longman Publishing Group,1983). Rosenberg, C., The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago, IL: The University of Chicago Press, 1987).

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Sahadeo, J., Russian Colonial Society in Tashkent, 1865– 1923 (Bloomington, IN: Indiana University Press, 2007). Said, E., Orientalism (New York, NY: Vintage Books, 1979). Smallmann-Raynor, M. R. and A. D. Cliff, War Epidemics: An Historical Geography of Infectious Diseases in Military Conflict and Civil Strife, 1850– 2000 (Oxford: Oxford University Press, 2004). Rogan, E., The Fall of the Ottomans: The Great War in the Middle East (New York, NY: Basic Books, 2015). Snowden, F., Naples in the Time of Cholera, 1884 – 1911 (Cambridge: Cambridge University Press, 2001). Solomon, S. G. (ed.), Doing Medicine Together: Germany and Russia between the Wars (Toronto: University of Toronto Press, 2006). Steinberg, M., Voices of Revolution, 1917 (New Haven, CT: Yale University Press, 2001). Todes, D., Darwin Without Malthus: The Struggle For Existence in Russian Evolutionary Thought (Oxford: Oxford University Press, 1989). ——— Pavlov’s Physiology Factory: Laboratory Interpretation, Laboratory Enterprise (Baltimore, WI: John’s Hopkins University Press, 2002). Vardugin, V. I., Vo vlago narodnogo zdravia (Saratov: OAO ‘privolzhskoe knizhnoe izdatel’stvo’, 2005). Vucinich, A., Science in Russian Culture: A History to 1860 (Stanford, CA: Stanford University Press, 1963). ——— Science in Russian Culture: 1861 – 1917 (Stanford, CA: Stanford University Press1970). Waldron, P., End of Imperial Russia, 1855– 1917 (New York, NY: St. Martin’s Press, 1997). Walker, L. K., ‘Public Health, Hygiene and the Rise of Preventative Medicine in Late Imperial Russia, 1874– 1912’ (Ph.D. diss., University of California, Berkeley, 2003). Weindling, P. J., Epidemics and Genocide in Eastern Europe 1890– 1945 (Oxford: Oxford University Press, 2000). Wertheimer, J., Unwelcome Strangers: East European Jews in Imperial in Imperial Germany (Oxford: Oxford University Press, 1987). Westwood, J. N., A History of Russian Railways (London: George Allen and Unwin, 1964). Winslow, C. E.- A., The Conquest of Epidemic Disease: A Chapter in the History of Ideas (Madison, WI: University of Wisconsin Press, 1980). Winter, K., Rudolph Virchow (Leipzig: Urani-Verlag, 1956). Zalkind, S., Ilya Mechnikov: His Life and Work (Honolulu: University Press of the Pacific, 2001).

Articles & Chapters

Ames, E., ‘A Century of Russian Railroad Construction: 1837 – 1936’, American Slavic and East European Review 6, No. 3/4 (December 1947), pp. 57 – 74. Argenbright, R., ‘Lethal Mobilities: Bodies and Lice on Soviet Railroads, 1918 – 1920’, Journal of Transport History 29 (September 2008), pp. 259 – 76.

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INDEX

aerobic, anaerobic, 18, 24, 111 aetiology, 4, 10 – 12, 15, 25 – 6, 59– 63, 65, 68, 74, 88, 97, 100, 106 – 7, 116, 121, 200, 235, 253 Almazov, V. I., 159 anti-contagion, anti-contagionist theory, 10 – 11, 44 assenizatsiia (in French, assainissement), 217 Astrakhan’, 13, 18 – 22, 38– 9, 43 –5, 50, 54– 7, 61, 71, 78, 84 – 6, 95, 103, 105– 6, 108, 110– 11, 166, 188, 208– 9, 245, 247 autochthonist theory, 61, 253 bacillus, 64 Bacillentra¨ger (en), 105 bacteria, 1, 6, 10, 17, 19, 25, 27, 30–2, 63– 5, 74, 85, 87, 96, 101, 103, 108, 113, 116 – 17, 169, 192, 195, 226, 229, 254 Baku, 38, 44, 55, 69, 84– 8, 117, 142, 218 Barykin, V. A., 235 Beketov, A. N., 28 Belousova, A. I., 182 Bengal, Bay of, 17 – 18, 20, 36 – 7, 59, 61 Bezredka, A. M., 32, 236– 7

Black Sea, 20 – 21, 39, 44 – 5, 48 – 9, 52, 54, 57, 69, 71, 85, 102, 120, 123, 150, 156, 207, 209, 224– 5, 242, 246 –7 Blumenthal, F. M., 138, 166, 169 – 70 Bordet, Jules, 237 Braudel, Fernand, 1 Caspian Sea, 1, 18 –21, 38, 43 –4, 54, 69, 102, 104– 5, 243 Central Asia, 5, 36, 38, 43, 57, 69, 113, 241–3, 245– 7 China, 37, 48, 50– 1, 54, 90, 245 contagion (contagionist theory), 2, 7, 10–12, 25– 7, 33, 40, 44, 49, 56–7, 59, 62, 66, 75 – 6, 87, 90, 94, 97, 104– 5, 108, 121, 155, 194, 210, 233, 251, 253 copepods, 18, 66, 116 Crimea, 14, 45, 50, 56, 224 Crimean War, 12, 45– 6, 50, 67 Darwin, Charles, 4, 7, 8, 28 – 30, 74, 90, 222–3 Diatropov, P. N., 29, 58, 131, 133, 158–60, 166, 174, 202, 236 Dobrietser, I. A., 186 Dobroslavin, A. P., 200, 254

INDEX Ekaterinoslav, 44, 55 – 6, 69, 102 – 3, 109, 138, 242, 247 El Nin˜o Southern Oscillation (ENSO events), 1, 13, 17, 20, 36 – 7, 48, 50– 1, 66, 69– 70, 100, 124, 150, 152, 154– 5, 163 – 4, 166, 173, 216, 252 environment, 1 –2, 4 – 8, 10 – 12, 14, 16– 18, 20– 1, 24 – 8, 32 –3, 43, 50, 56, 58– 63, 67, 69, 72, 79, 84– 5, 87, 94, 97, 99 – 100, 102– 11, 115– 17, 121– 2, 128, 158 – 9, 163– 4, 169, 173, 183, 195, 200– 1, 209, 223, 225, 243, 247, 249, 251, 253–4 Erismann, F. F., 28, 52, 58 – 62, 64– 5, 67, 70, 75, 199– 202, 236, 253– 4 Ermolov, A. P., 38 – 9 eugenics, 68– 9, 84, 88, 97, 199, 202 famine, 1 – 2, 6, 8, 12 – 15, 17 – 20, 34– 9, 41– 8, 51 – 4, 57, 60, 66– 7, 69 – 71, 78, 91, 93 – 4, 97, 100, 122– 3, 127, 129, 141, 150, 152– 3, 158 – 9, 163– 5, 167 – 8, 173– 4, 178 – 9, 181, 188– 9, 194– 5, 197– 9, 203– 4, 207– 8, 210, 214, 216– 17, 219, 221–2, 224, 233– 6, 239– 40, 249, 251– 2, 254– 5 Great Famine (India, 1897– 99), 19 Great Famine (Persia, 1917– 19), 150, 208 Hungry Forties (1840s, Europe), 39 feldsher, 47, 78, 146, 162, 164–5, 186, 188 fermentation, 24– 6, 63, 83, 111 Ferran, Jaime, 32, 135 Flu (Spanish, Pandemic of 1918), 154– 5, 163, 171, 190 Flu¨gge, Carl, 31, 95 France, 35, 45, 50, 53, 61 –2, 124, 135 Frenkel’, Z. G., 227, 229– 30 Friedan, Nancy, 10 – 11

311

Gamaleia, N. F., 11, 28, 32, 58, 64, 68, 81, 84 – 7, 99 – 100, 102 –3, 108– 9, 115 – 18, 120– 2, 126, 151, 158, 191, 207, 236, 245, 247, 253 Ganges River, 18 – 19, 36, 243, 247 Germany, 4, 6, 12, 15, 25, 44, 50, 117, 123, 128– 9, 219 GINZ (Bacteriological Laboratory, Moscow), 243 Glotova, E. V., 137, 141, 152 Great Britain, 4, 12, 34 – 6, 42, 45, 49, 124, 142 gubzdravotdel, 210 gubzdravotdely, 164, 211 Hastings, Lord Francis Edward Rawdon, 37, 123 Henle, Jacob, 26 –7 Henze, Charlotte, 11, 57, 99 Himalayas, 17 – 18 Hutchinson, John F., 11, 64 hygiene, 6, 13, 24 – 5, 28 – 9, 31, 58 – 9, 69, 78, 84, 91 – 2, 110, 116, 130, 143, 151, 164 – 5, 174, 188, 199 – 203, 219 – 20, 226 – 7, 229, 237, 240, 243, 245, 249, 254 general hygiene, 199, 202, 220 social hygiene, 69, 84, 143, 174, 188, 199– 202, 219 – 20, 227 Iakovenko, V. A., 226 – 7 Iaroslavl’, 13, 55 – 6, 125, 129– 31, 166, 182, 187, 189, 209, 253 immunity, 7, 14, 16, 19 – 20, 29, 31, 60, 65 – 6, 136, 138, 158, 191 – 3, 196, 199, 223, 234– 5, 237, 239–40, 244, 255 cellular (phagocytic), 28, 30– 2, 192, 223 humoral, 30 – 2, 95 Isaev, V. I., 31, 58, 64, 237

312

RUSSIA

IN THE

Kazan’, 13, 45, 52, 56, 69 – 70, 112, 122, 130, 143, 148, 166, 171– 2, 185, 213 Kharkov, 55 – 6, 113, 131– 4, 138, 145, 151, 237, 239 Khavkin, P. V., 77, 127, 162, 165, 170, 173, 178– 9 Khlopin, G. V., 19, 21, 100, 102– 3, 110– 11, 151, 199– 200, 202, 226, 229, 253– 4 Kiev, 55 – 6, 125, 137 – 8, 188, 239 Klodnitskii, N. N., 18, 103– 6, 108–9, 111, 121– 2, 253 Koch, Robert, 2, 6, 10, 12, 15– 16, 24– 7, 30 – 3, 45, 51, 57 – 60, 62– 6, 85, 87, 94– 7, 100, 104 –6, 108 – 9, 115– 17, 122, 162, 191– 2, 251, 253– 4 Koch’s vibrio, 6, 15– 16, 27, 62, 64, 83, 169, 192 Kolesnikova, E., 169, 182 Krasnodar, 236– 7, 245 Krementsov, Nikolai, 11 Lastochkin, I. N., 229– 2 League of Nations, 3, 222, 244, 246, 248 Lenin, V. I., 14, 89, 155– 6, 160, 162– 6, 171, 174, 195, 197– 8, 202, 204, 207, 208, 210, 215 – 16, 219– 20, 234, 250, 253 Levetskii, V. A., 235 Liebig, Justus, 24, 27, 31, 44, 63, 116 Little Ice Age (1300 – 1850), 35 Liubarskii, V. A., 235– 7, 255 Mariinskaia System, 13, 21, 23, 55, 129, 187, 189, 253 Mechnikov, I. I., 25, 28 – 32, 58, 63–6, 81, 95, 101, 115, 122, 135, 158, 191– 2, 223, 236, 254 Meziatsev, P. Ia., 72 microbe, 1, 7 – 8, 14 – 16, 18– 19, 25, 27, 29–30, 32, 37– 8, 41, 44, 48,

TIME OF CHOLERA 57, 61, 63– 6, 72, 78, 87, 105, 111, 144, 155, 165, 169, 179, 182, 191– 2, 195, 200, 224, 235, 237, 249 monsoon, 17, 36, 48, 66 Morsannadzora (the Soviet Sanitary Department of the Seas), 225 Moscow, 13, 28, 45, 52, 55, 59, 69, 71, 77, 90–1, 99, 101, 110, 124 – 5, 128, 130, 137– 42, 151, 157, 159–61, 166 –8, 170, 172 –4, 185–6, 188– 9, 198– 9, 201, 207, 219, 231, 233– 4, 240, 242, 250 Napoleon Bonaparte, 35, 123, 155 Narkomzdrav RSFSR, 163, 165, 168, 170, 172, 174, 178, 181, 188 – 90, 193–4, 203– 4, 206– 10, 213, 220 –1, 223 – 4, 243 Nevskii Prospekt, 153, 181 obshchestvennost’, 9, 51, 124 OChVSU, 225 Odessa (bacteriological laboratory), 21, 26, 29–30, 32, 48 –9, 58, 65, 69– 70, 81, 84, 87, 93, 103, 109, 113, 116– 17, 131, 135, 138, 158, 225, 236, 254 Ol’denburgskii, Alexander (Prince), 159–60 Orient, 5, 21, 30, 77 Osipov, E. A., 201, 236, 254 Ottoman Empire, 4, 35, 44 Pale of Settlement, 92 – 3 Pasteur, Louis, 6, 18, 24 – 6, 29 – 33, 51, 62– 5, 67, 83, 104, 108, 111, 115 –16, 159, 191 – 2, 254 pasteurisation, 62 Pavlov, I. P., 11, 81, 156, 169, 238, 254 Pettenkofer, Max von, 6, 25– 8, 33, 54, 61– 3, 65 – 6, 83, 96, 107 – 8, 110, 116, 159, 200, 217, 220, 253– 4 Pfeiffer, Richard, 31, 64 – 5, 237

INDEX phagocytes, phagocytic theory of immunity, 30 – 2, 65, 223 putrefaction, 24, 63, 116 Ring of Fire, 17 See also Sunda Arc, Indonesia Rostov-on-Don, 56, 69, 208, 238 Rozanov, N. N., 217– 18 Russian Civil War, 9, 12, 19, 154– 5, 165, 193, 197, 204, 208, 210, 219, 229 Russian Revolution February Revolution, 150, 154–6, 159 October Revolution, 162, 167, 213 Rybinsk, 13, 21, 129– 30, 172, 182, 186– 7, 209, 253 Samara, 56, 70, 85, 100– 13, 115, 121, 140, 148, 191, 208–9, 217– 18, 221, 247 Sandezstantsiia (under the Soviets, a Sanitary Disinfection Station), 226 Sanitary Executive Commissions, 68, 73– 6, 78, 81– 3, 87, 90, 94, 112, 119– 21, 122, 125, 142, 149, 161, 165, 211 Saratov, 13, 24, 55 – 6, 62, 69– 70, 78 – 86, 88, 100, 103, 105, 110, 112– 13, 115– 17, 119, 124, 142– 9, 151, 166, 171, 183, 186– 8, 194, 197– 8, 203, 205, 208 – 10, 212– 13, 216– 19, 224, 233, 238, 247– 8 Savchenko, I. G., 235– 8 Semashko, N. A., 162– 3, 174, 199– 200, 202– 3, 207, 210, 219, 234, 254 Serdobov, L. P., 146– 7, 149, 151 smallpox, 78, 102, 135–6, 147, 178, 191– 2, 237 Solomon, Susan, 11 St Petersburg, 13, 21, 24, 28, 39, 41, 45, 48, 55– 6, 58, 64, 69, 74, 81,

313

89, 99, 102– 3, 106, 108, 110, 114–18, 120, 122, 125, 127, 157, 173, 175– 6, 179 –81, 187, 200, 219, 253 Leningrad (1924 –91), 13, 235, 250 Petrograd (1914– 24), 13, 93, 125, 127–30, 138, 141, 151–3, 155–6, 159–61, 166–8, 170–81, 184–9, 198, 204, 206, 211, 216–17, 219, 226–34, 247, 253 Stalin, Joseph, 200– 2, 255 Straits, 36, 45, 49 Sunda Arc, Indonesia, 17, 35, 51 Taranukhin, V. A., 77, 99 – 100, 102–3, 105– 11, 114– 15, 117, 120–2, 151, 157, 191, 217 Tarasevich, L. A., 16, 29, 32, 58, 77, 101, 135– 7, 141, 151, 154, 158–60, 163, 174, 193, 199, 207, 213, 221– 2, 231, 233– 4, 237, 239, 245– 6, 252, 254 teleconnections, 17 Teziakov, N. I., 114, 121, 142–3, 147, 149, 151, 186, 204, 210, 220, 250 Time of Troubles, 34, 194 trustees, 78, 82, 112, 124, 132– 3, 144 –5, 164, 186, 212 Tsar (Russian) Alexander I, 38 Alexander II, 50 – 1, 124, 142 Alexander III, 50, 52, 94, 138 Boris Godunov, 34 Nicholas I, 42 – 3 Nicholas II, 52, 94, 103, 124, 137, 142, 208 Peter I ‘the Great’, 21 tuberculosis, 140, 169, 202, 235 typhoid, 52, 63, 65, 78–9, 102, 116–17, 128, 130, 133, 135–8, 143, 147, 178, 193, 208, 217, 230–3, 235, 237

314

RUSSIA

IN THE

uchastok(u), 201 Union of Towns, 123, 125, 133– 4, 137, 141– 2, 151, 158– 9 Union of Zemstvos, 14, 128, 132– 4, 137– 8, 141– 2, 145, 151, 158– 9 vaccination, 7 –8, 32, 65–6, 77, 101– 2, 124, 129, 135– 8, 140 –1, 143, 151– 2, 157 – 60, 163 – 5, 169, 173, 182, 184–7, 190– 4, 196, 199, 203– 5, 207, 213– 14, 220, 222– 5, 233, 236– 40, 242– 5, 249– 20, 253, 255 vibrio, 1 –2, 5– 6, 8, 11 – 12, 15– 21, 26– 7, 37 – 40, 43 – 5, 48, 54 – 7, 59– 62, 64– 6, 69 –72, 74, 83, 85, 87– 8, 95 – 6, 101, 103 – 6, 108– 9, 112, 118, 129, 142– 3, 148– 9, 155, 166, 169– 70, 178, 182, 188– 90, 192, 195, 199, 202, 204, 208– 9, 214, 222, 224, 227, 233– 4, 237, 239– 40, 246– 7, 249, 251– 3 Virchow, Rudolph, 29– 30, 44 virus, 1, 26, 63 volcano(s) Krakatoa, 51, 53, 55 Mayon (Philippines), 35 Soufriere (Saint Vincent Island, Caribbean), 35 Tambora, 35–7, 51, 55 1809 unknown, 35

TIME OF CHOLERA Volga River, 13, 18 – 22, 37, 45, 48, 50– 1, 54 – 7, 69, 78– 9, 85 – 7, 100, 102– 5, 107 –12, 129 –30, 140, 144, 148, 166– 72, 182– 3, 185, 187– 9, 194, 197 – 9, 202 – 3, 205–10, 214, 216 – 17, 219, 233, 240, 245– 7, 250, 252 Voronin, E. V., 237 World War I, 9, 12– 14, 29, 47, 77, 122, 125, 130, 134, 136, 138, 151 –2, 155, 168, 174, 179, 186, 192, 195, 204, 212, 217, 219, 227, 247 Zabolotnyi, D. K., 11, 29, 32, 100–1, 111, 122, 126, 158, 169, 182– 3, 195, 235– 6, 238, 250, 254 Zemgor, 14, 151, 160, 163, 164, 168, 212 zemstvo, 6, 9, 11, 13– 14, 16, 46 – 7, 52– 3, 58, 68, 70, 73 – 4, 76– 7, 80– 1, 87, 90, 92, 94, 97 – 8, 102–4, 109, 112, 114– 15, 118 –34, 137 –8, 141 – 2, 144 – 5, 147 –9, 151, 157 –62, 164–5, 173, 182, 189, 192, 194, 196, 201–2, 211, 213, 220, 239– 40, 250 zemstvo medicine, 14, 28, 48, 58, 183, 200–1