Matthew Smallman-Raynor and Andrew Cliff, Atlas of Epidemic Britain: A Twentieth Century Picture, Oxford University Press, Oxford, 2012, 224 pages, £ 125.00 cloth. ISBN 9780199572922.

The Atlas of Epidemic Britain is a carefully researched, beautifully illustrated, encyclopedic treatment of the incidence of endemic and epidemic diseases in Great Britain in the twentieth century. The result is one of those very occasionally invaluable references that sit on the shelf until needed. It has taken months of reading and rereading to figure out why I admire and dislike this atlas in equal measure. Struggling with that, the deeper question became, what purpose do such atlases serve?

The Atlas

The atlas is a peculiar kind of essay that builds upon individual plates and illustrations to develop a central theme (Wood, 1987). In the medical literature atlases refer to illustrated texts in anatomy and pathology. Andreas Vesalius’s De Humani Corporis Fabrica (1543),  the grandfather of all future anatomical atlases, was created not merely to catalogue the individual parts of the human body, but to argue that medical knowledge is something to be tested rather than passively received in lectures. His text-cum-atlas therefore was not only the first illustrated atlas of the human body, but also the first systematic description of anatomical dissection, a how-to manual. Its modern inheritor, Netter’s Atlas of the Human Body (2006), is one of my constant references.

The first printed world atlas, Ortelius’s Theatrum Orbis Terrarum (1570), similarly trumpeted knowledge as a changing and experiential thing.  It collected the individual maps and reports of sixteenth-century explorers and commercial travelers to present the mercantile world and its trade potential. Its focus was evident in maps and the text that, for example, promoted Europe’s bountiful resources and its Christian nature as evidence of its potential (Koch, 2011). The Theatrum was a thoroughly commercial enterprise (costing 7 guilders with maps in black and white, 16 guilders for the color edition) targeted mainly at a growing mercantile community. Its power came from the breadth of its map collection, “all of which together asserted a reality experienced piecemeal by individuals who had described this or that country, or visited this or that city” (Koch, 2011: 39). 

Fig. 1. The first anatomical atlas insisted upon dissection, rather than lectures, as the primary means for learning human anatomy (source: Saunders 1973).

Explicitly or implicitly, every good Atlas has a point to make, a story developed through illustrations, maps, and text. And so we have economic, medical, and social atlases (Smith, 2012), all describing the geographies of a state or region or the world from a particular point of view. The plates of any good atlas “focus upon relations between phenomena, and a careful consideration of how to map the mutability and dynamism of the built and natural environment in which this or that phenomenon resides” (Cattoor and Perkins 2014).

Epidemic Britain: A Twentieth Century Picture

The Atlas of Epidemic Britain, its authors write in their forward, “maps and interprets the complex time-space tapestry woven by the uneven retreat of some infectious diseases, the emergence of new infections, and the re-emergence of certain historical plagues in twentieth-century Britain” (page 9). In doing so, it changes the scale of investigation from the  World Atlas of Epidemic Diseases (Cliff and Haggett 2004) to that of Britain alone. This, the authors say in the forward, permits them to build upon Charles Creighton’s landmark two-volume work A History of Epidemics in Britain (1891).

A milestone in epidemiology and public health, Creighton’s Epidemics was an encyclopedic review of disease incidence in Great Britain, from plague to cholera and beyond. Like Creighton’s Epidemics, this Atlas gives no particular emphasis on any single disease. For the twenty-first-century medical historian, it is cholera that defined that century and John Snow’s London research that dominated research on the disease. But in Creighton’s nineteenth-century telling, cholera was simply one of the many diseases to be catalogued.  John Snow’s name is not mentioned at all. This is jarring but should not be surprising. Snow’s fame was, after all, an invention of twentieth century sanitarians like MIT’s Charles Sedgwick (1911), and later, of public health specialists (Koch, 2004).

Fig. 2. In De Humani Corporis Fabrica Vesalius includes plates like this to remind fellow physicians and students that humans—in health and disease—exist within the environment (source: Saunders 1973).

Similarly, the Smallman-Raynor and Cliff Atlas does not focus on any particular outbreak, epidemic or pandemic. There is little attempt to order the last century’s epidemics in relation to their effect on society or medical knowledge. It pays no particular attention to the 1918 influenza epidemic, for example, nor to the recurrent and progressively serious poliomyelitis outbreaks in the first half of the century, or HIV in the second. They are covered but not as critical or watershed events in epidemiology and public health. While the Atlas catalogues a startling range of disease occurrences, there is no overriding point of view, no methodological argument that ties the atlas together.

This is in sharp contrast with the first Atlas in the Oxford/Blackwell series. The 1988 Atlas of Disease Distributions was a critical, game-changing work produced by one of this text’s authors and geographer Peter Haggett. In their forward the current coauthors generously acknowledge their debt to Haggett and that first Atlas in this series. Like Vesalius’ De Humani Corporis Fabrica, the 1988 Atlas was first and foremost a textbook whose narrative was methodological rather than referential. Each chapter introduced not only a description of this or that epidemic, beginning with cholera in London, but also the means by which its occurrence and progress could be analyzed.

Other disease atlases—for example Rodenwalt and Jusatz’s Welt Suchen Atlas (1952-1961)— had used arrows and circles to demonstrate the progress of dynamic diseases like cholera in a country, or the world. The Atlas of Disease Distributions showed us how to map such dynamics in a rigorous manner. For practitioners there were algorithms and explanations as well as illustrations, and of course, maps.

Similarly, a series of twentieth century cancer atlases mapping the statistical incidence of cancer were at once investigative and instructional tools. Howe’s Atlas of Disease Mortality in Great Britain (1963) was at pains to explain the statistics which underlay its individual map plates. Likewise, the Atlas of Cancer Mortality for U.S. Counties (1975) was a narrative of the “war on cancer” that promoted a research agenda. As such, it was created “to examine the geographic patterns of disease in the hopes of sparking testable ideas about their cause” (Pickle, 2009). The theme was research-directed amidst the variation in specific cancer rates nationally. “Hot spots” of unusual incidence became targets for intense investigation (Anderson, 1987).

Atlas of Epidemic Disease in Britain

When Creighton’s survey of British epidemics was published in the 1890s, bacteriology was in its infancy and virology unknown. Epidemiology was as yet unborn and public health, “sanitary science”, a matter of simple, statistical incidences of mortality and morbidity in geographically specified populations. As importantly, pandemic disease seemed to have disappeared, at least temporarily. Except for isolated outbreaks, cholera had largely disappeared from Britain. The last pandemic of plague to gird the world occurred in the 1890s, but the resulting mortality in Britain was negligible.

There was thus no urgency in Creighton’s encyclopedic review and, more importantly, no context that would order an understanding of the endemic and pandemic diseases that had affected the nation’s population. Nor was there much sense of the global dynamics of disease (except cholera) that might question the very idea of a national review. Thus in Creighton, Britain exists without reference to other nations. 

Figs. 3a and 3b. The Atlas provides a profusion of graphs and maps at varying scales of incidence (source: Smallman-Raynor and Cliff 2012, pages 124-25).

The twentieth century, however, has been filled with pandemics that traveled from nation to nation and from people to people. It began with the increasing incidence of poliomyelitis in 1909-12, returning every decade or so with ever increasing virulence into the 1950s. The 1918 influenza pandemic was an international trauma imported from the United States and spread through World War I troop movements. Influenza epidemics, some more virulent than others, periodically traveled the globe. And, of course, the retrovirus HIV created a new pandemic whose very nature was unclear and, once the natural of retroviral infection was understood, remained for a time untreatable.

In the face of the dynamics of these and other disease events, a national disease atlas seems somehow not merely quaint. but terminally limited. It is not that this atlas does not treat poliomyelitis carefully. It reports on its early incidence (up to 1926) in one section, and in another, the later outbreaks culminating in the 1950’s pandemic. And its maps of incidence at varying scales are exemplary. On some pages it pictures newspaper stories, an iron lung and other cultural traces of the last pandemic. But the whole serves in the Atlas neither as a lesson in disease diffusion, perhaps the most important lesson of twentieth-century pandemic disease,  nor as a cautionary tale emphasizing the importance of national vaccination. 

Fig. 4. Many of the disease entries include social traces of the disease events (newspaper photos and stories) as well as charts, graphs, and maps (source: Smallman-Raynor and Cliff, 2012, page 118).

Nor does this atlas pay much attention to the environmental and social realities that promote the incidence of specific diseases. Since the early nineteenth century, British researchers have been leaders in arguing disease in the context of “the totality of social and economic conditions in which the industrial revolution had left many poor people” (Hamlin, 1998: 13). This has become an ever more important and more generally accepted theme in recent decades (Wilkinson, 1996). And yet across all the Atlas’ maps I see little that correlates income inequality, industrial air pollution, soil contaminants or population travel patterns (international or national) and disease incidence.

So despite the superb graphics, cartographic and statistical, we have, a curiously nineteenth-century perspective here. The rich dynamics of disease as a complex dynamic seems, somehow, muted. The atlas doesn’t say … much at all. This may be an unfair imposition of a reviewer’s prejudice upon the work of two very knowledgeable, extremely capable authors. But a twenty-first century atlas should, I would think, emphasize  two crucial themes of twenty-first century epidemiology and public health. The first is the truly global nature of disease incidence among constantly mobile, traveling populations. The second is the degree to which disease burden is influenced by ecological, and separately, socioeconomic factors. At least since the Black Report (Davey-Smith, 1990) the inverse relation between mortality and socioeconomic status has been a constant in the public health literature (Pappas, 1993).

The nature of the atlas is the story it tells. From Vesalius and Ortelius to their modern inheritors, a great atlas requires a theme, commercial, investigative, methodological or social. I’m just not sure what this atlas says. The diseases it covers are encyclopedic; the maps are better than good; the science accurate and up-to-date. As a quick reference to anything from anthrax to whooping cough, the result is more than useful. But an encyclopedia is not an atlas. The former is a catalogue, while the latter tries to say something about a catalogue of events. 

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