Visualising data on health and mortality has a most up-to-date ring to it, as if it had required the rise of big data and computational tools for something as intricate as visual health statistics to develop. Surprisingly, however, already the mid-19th century saw a huge upsurge in the use of statistical graphics relating to diseases and epidemics.
A famous example was this graphic, which the British social reformer Florence Nightingale developed after the British troops experienced a largely self-inflicted debacle in the Crimean War. Since its publication in 1858, this piece has made the “big tour” and is recognized today as one of the prime examples of historical data visualisation.
In a somewhat curious layout – to be read clockwise, beginning with the right hand circle – the diagram shows the causes from which British soldiers died during the Crimean war, from April 1854 (when British troops arrived in Bulgaria) to March 1856 (when the war was over). Each of the wedges refers to one month. The colouring indicates three different death causes: red are deaths from wounds received in battle, blue are deaths from infectious (“mitigable zymotic”) diseases, black are deaths from other causes. Nightingale constructed the areas of the segments proportional to the annual rate of mortality per 1.000 soldiers in each month. What immediately strikes the eye is the overwhelming proportion of deaths resulting from infectious diseases.
Interestingly, the Crimean War has almost completely vanished from common European memory. At the time, the British public perceived it as an unnecessary conflict which involved heavy losses and revealed desastrous conditions regarding the medical provision for the soldiers. For the first time in history, the new technology of the telegraph allowed reports from the front to be sent back to London’s newspapers in a matter of hours, providing the general public with timely reports of acute and miserable conditions near the battle grounds.
With much of the conflict happening around the Black Sea, the Ottoman government provided the Barracks of Scutari (today the Selimiye Barracks) as the main hospital for the allied British troops. The large stone building, located on what is now the Asian shore of Istanbul, was unsuited to this use from the very beginning, not the least because its premises were filthy and lacked supply in clean water. Furthermore, the British troops were surprisingly unprepared: neither transport carriages for the wounded nor basic medical supply (such as clean linen and shirts or clean water) were available.
Florence Nightingale at the time was a young woman from an upper class family, well educated, very well connected and determined to carve out a professional role for herself in nurse education. When William Russell (considered one of the first modern war correspondents) reported to the London Times about the devastating conditions at Scutari in 1855, mentioning that there were no nurses to look after the British patients, she convinced the Secretary of War to send a group of nurses and managed to set herself at the top of this privately funded, small expedition to Scutari. Upon her arrival there, she found unbearable conditions, with infectional diseases rampaging among the hospitalised soldiers. She soon was able to mobilise acute help to bolster up the basic supply of equipment and have the hospital premises amended.
Back in London after the war, she embarked on a political campaign to bring about a sanitary reform in the army. In an extensive internal report (Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army), she gathered an overwhelming body of evidence for her cause, combining rigourous statistics, extensive quotes from reports, internal communication and letters of the medical staff with just a few personal accounts of her own experiences. This, in combination with her relentless lobbying, helped to bring about some of the much needed changes in hospital administration.
The report contains two black and white diagrams which might have been preliminary versions (one is shown here above). It is interesting to see how – while the construction principle remained the same through all three diagrams – the emphasis shifted a little in each piece. Here, for instance, Nightingale compared the mortality in the army with the average mortality experienced in Manchester (at the time one of the most unhealthy environments in Great Britain), marked as a dotted line around the center.
Considering the 1000+ pages of the report, the diagrams form but a little mosaic piece in the whole of her argument. They do, however, develop a strong visual rhetoric, corroborating her claim that the unbelievable losses of soldiers due to infectious diseases is inhumane and avoidable.