Healthcare Reform

“I was three chapters in,” Johnson says, “and the story was really an engine, propelling me along in writing it. And I had this embarrassing moment where I realized, you know what? I think people really like books with stories! I felt like, as a writer, I had this huge weapon at my disposal for the first time. I’ve written five books. I can’t believe I’ve been doing it without this!”

The story’s a page-turner, but it’s in service of two larger arguments: one about the rise of the city as the central organizing structure of modern life, and the other about the human mind’s capacity for identifying patterns and applying those insights to clear the fog of conventional wisdom and improve the species’ lot.

London in the mid-19th century was literally choking on its own excretions. The first efforts to relieve the problem — building sewers that dumped waste directly into the water supply — intensified it instead. The scientific establishment, in thrall to the dominant “miasma theory,” believed that disease was transmitted via air, not water.

“The Ghost Map’s” protagonists, John Snow and Henry Whitehead, gifted amateurs both, analyzed the 1854 cholera outbreak in Soho and used their information, eventually, to overturn the expert consensus. They succeeded not only because they were smart and painstaking and open-minded, Johnson argues, but also because they were locals. Their shoe-leather knowledge of the neighborhood helped them make sense of data that the experts at London’s new Board of Public Health had missed.

I talked with Johnson in San Francisco recently, on the eve of the launch of a new Web project he has conceived in tandem with “The Ghost Map”: outside.in, a site that pulls together blog postings, news, reviews and events from across the Internet and organizes them by zip code. It’s a venture that, in the spirit of “The Ghost Map,” aims to harvest the local knowledge of amateurs in densely populated areas and harness it for wider use.

How did you end up writing “The Ghost Map”?

I wanted to write an idea book that could be wrapped around a narrative. So I needed to find some story that connected to all the themes I had in mind. I said to my wife over dinner one night, there’s got to be something out there that I know, that I could take and adapt. We went to see “Seabiscuit,” and we were in the theater watching it, and I remembered the Snow story, which I’d known about forever. I thought, “That’s perfect!” So I literally got up and left the theater and called my agent and said, “I know what the next book is!”

One of the first ideas was that I would tell the story with three protagonists: the bacterium, Snow and the city. And I would try to tell a story that would live on those different scales at the same time. As I researched it, I realized that Whitehead was just as important. That changed it in a lot of interesting ways for me.

But I wasn’t totally sure what it meant to tell the story that way. I ended up saying, OK, let’s take a very short amount of time in a very finite amount of space — these 10 days or so in this neighborhood — and say, what is really going on here, on the level of people, on the level of ideas? But there’s also this analysis of what was probably happening in terms of the population of bacteria in the bottom of the well. And then there’s this broad story about the evolution of London as a city.

I’ve tried not to grant too much importance to any of the levels. If you emphasize one at the expense of the others, the story just becomes less true, or less fully realized. Someone described the approach by saying it had a fractal feel — you just keep zooming in and out, and at each level there’s something new.

I read your recent New York Times Magazine piece on “The Long Zoom,” in which you talked about “Spore,” Will Wright’s new “God game,” and then defined our age in terms of our ability to zoom from the microscopic level to the macrocosmic and back. And I thought, “He’s basically just described the method of his book.”

Well, I’ve been going around the country for the last year talking about video games, because of “Everything Bad Is Good for You.” And people would ask, what are you doing next? And I’d joke with them, I’d say, well, the logical next thing — cholera! You do “Grand Theft Auto,” and then you do 19th-century cholera. “The Long Zoom” was the connection.

And there is a gaming connection — the old Game of Life.

Yeah. Or “SimCity.”

“The Ghost Map” read to me like history as written by a “SimCity” freak. Is it fair to assume you’ve spent many, many hours of your life playing it?

It’s definitely my favorite game of all time. And it’s the only game that I really have lost a lot of time to — every time a new version comes out. It’s my great love.

Your love for cities is clear in “The Ghost Map.” You talk about how cities actually make a lot of environmental sense, and use New York, with its carbon-conserving mass transit, as an example. But outside of New York and a handful of other places, American cities, with their suburban and exurban sprawl, don’t really live up to that ideal, do they?

Partially that’s there because there is a history of the environmental movement being back to nature, anti-urban in general. And a lot of that is the stuff that Stewart Brand’s been writing and talking about for the last couple of years. So it’s there to say there is a model — you don’t have to return to nature and give up on a modern urbanized lifestyle to be green; you just need to build a certain kind of city. It’s worth saying again that this certain kind of city has a certain level of density. It can’t be just an automobile satellite city, that’s probably the worst.

We know that centralized urban planning doesn’t work in all kinds of ways. But the no-planning-at-all model has big problems, too.

My dad used to say that when “Emergence” came out. I grew up in D.C., and he’d drive around Rockville, Maryland, which is all strip malls and things like that, and he’d say, “This is totally unplanned, and it’s the most hideous thing you’ve ever seen. How do you reconcile that with your celebration of bottom-up?”

One of the lessons of the book is the importance of moving across scales — being able to think, OK, I have all this local activity in my life, I make these decisions as a native of the city or suburb or wherever I am, but I’m part of a larger system and pattern and that system has a life of its own, and it has huge consequences, and if you help contribute to or build the wrong kind of system it’s a 100-year mistake, or a 200-year mistake. Like the Big Dig. And that’s a difficult way to think. People aren’t naturally land-use planners or urban planners. But being able to think that way as a citizen, I think, is increasingly important.

“The Ghost Map’s” description of the short-term failure of London’s public institutions to deal with sanitation and cholera made me think of the contemporary debate between the libertarian, small-government crowd and the old liberal ideal of government solving our problems. You seem to be saying, OK, public institutions are going to act, and they will probably get it wrong the first time, but that doesn’t mean we should give up on them — because then you can’t have a city.

This story’s been told before — it’s a public health classic, an epidemiology classic. One of the things I was trying to do was also turn it into a story of a certain kind of urbanism. Snow and Whitehead were both locals, and they had on-the-ground knowledge of this thing that had attacked their neighborhood, and they were able to understand it better than the authorities. Some of it came from Snow’s scientific background and his training and his brilliance, but some of it came from the fact that they were connected to this neighborhood and they were able to see the patterns and get the information they needed.

And so I think we ought to have great respect for top-down public health institutions and other institutions outside the market. But we also need better systems for that on-the-ground local knowledge to trickle up. That’s why at the end of the book I talk about 311, the New York system that’s now showing up in a lot of different places. 311 says, listen, we’re going to deputize the entire city to be our eyes and ears on the street. And if there’s a pothole here, if there’s a homeless person here, you can dial three numbers and you’ll get it into our database. So civic top-down institutions are intervening in this open marketplace of a city, but they’re feeding on information that comes from below. That’s the balance you want to have.

There’s a great passage in “The Ghost Map” where you describe the many different “tributaries” that flowed together in order to break the dam of received opinion and overturn the miasma theory. Isn’t that similar to Thomas Kuhn’s idea in “The Structure of Scientific Revolutions” about paradigm shifts?

One of my intellectual interests since I was in college is what happens at the transition points between those paradigms. When I was in grad school, my training was in the 19th-century novel. This is the one book I’ve written for which I actually have credentials! One reason I was interested in this period was to look at those transition points. We understand paradigms of research; what we don’t have is the moment where you’re segueing from one to the other.

So this is just a great case study in that, where you’re right in the middle of a great historical transformation, the birth of a whole new way of living. No one had ever built a city like metropolitan London before. And in the middle of that you have this scientific paradigm that’s been dominant, the miasma theory, that’s about to crack. And you’re there right at the fault line.

And of course what happens is that it’s very messy. It does involve a genius: Snow clearly was just an incredibly gifted, brilliant guy. But that wouldn’t have been enough. It needed to be the genius at the right time, with the right set of skills, with a whole host of other things flowing into his life. And he needed help — he needed his Whitehead.

Something wonderful happens in “The Ghost Map” when you shift to the perspective of the cholera bacteria. I got the same feeling I had as a kid reading Olaf Stapledon’s “Last and First Men,” in which human history gets reduced to a tiny dot on an inconceivably vast timeline.

It’s hard to talk about bacteria and viruses, things that we can’t perceive. One way is to just weigh them — to say, the biomass of bacteria is huge, some insane number. And the response is, my god, that’s incredible. But what’s more intense, and gives you that sublime moment where you’re a little bit overwhelmed by it, is to think about it in a kind of systems way. That’s when you say — this is an old Lynn Margulis line — if you eliminated all humans on the planet, in a day, basically, life on earth would continue uninterrupted, nobody would notice, the whole system would continue to work. But if you eliminated the bacteria, everything would die. The bacteria are really doing the essential work of recycling everything. So on some level you have to say, whose planet is this?

To make a planet work with life, you have to have recycling. And to make a city work, you have to have recycling. What was happening in London was this amazing unplanned project of recycling with the scavenger class who start the book — just wading through the muck and gathering all this stuff.

It’s a pungent opening to the book, with the “mud-larks” and the “pure-finders” and the “night soil men.” It definitely feels like something written by someone with small children in the house. You never stop thinking about waste disposal.

I have three boys, five years and younger. I told them about the book, and the older one said, “Daddy’s writing a book about poop!” They were delighted to hear that.

There were these great epic problems that everybody was wrestling with in 19th-century London — you know, what is the role of class stratification? and, should unions organize? and so on. But they were also wrestling with the question of what are we going to do with all this shit? In many ways it was absolutely as vital and important as all these other questions. They had to solve it. But it doesn’t lead the history books.

Somebody said to me about the opening sections, “They didn’t include that in ‘Masterpiece Theater’!” But of course it’s all there in Dickens, and in Mayhew, and in Engels, all those classic books.

In “The Ghost Map’s” epilogue, looking at the long-term prospects for the big-city way of life, you conclude that our cities probably have a lot more to fear from nuclear explosion than from deliberate biological assault. How did you get there?

I tried to hit as much of a balance as I could. My tone is naturally optimistic. When the subject turns to things like global pandemics, there’s almost never any reporting about what the potentially positive scenario would be. Is there a way where you can imagine the next 50 or 100 years without one of these things coming along and wiping out 100 million people? And if that happens, why? I do feel it’s a major fault right now in the media: We’ve gone from “If it bleeds it leads” to “If there’s a small possibility it might bleed in the next 30 years, it leads.”

Avian flu is terrifying, and it very well might erupt in coming years, and millions of people could die. But it’s worth pointing out that all of this work preparing for it is preparing for an organism that, as far as we know, does not exist yet. So we’re ahead on some level. We keep getting better. And there is at least an argument to be made for the fact that over the long run, the viruses and the bacteria won’t be able to keep up with our technological advances.

But, you know, in the long run we’re all dead! So that doesn’t mean in the short run we shouldn’t be concerned about it, we shouldn’t continue to do the work that’s making that long run possible.

The point where the final chapter is decidedly not optimistic is with the other threat to large-scale, dense metropolitan living, which is nuclear terrorism. Because no one is working on a vaccine for a bomb. Maybe they’re working on dealing with radiation sickness. But you can’t stop things that blow up from killing people. Obviously, it was a little timely; the book came out just in time for another player, North Korea, to join the nuclear stage.

When you were writing that epilogue, Iran was the bubbling crisis you mentioned.

I know — it’s like, you can’t keep up! That’s clearly to me the nightmare scenario. If you did have a few detonations in large metropolitan areas, it would radically change the cost-benefit analysis of people living in cities all over the world. My wife and I are incredibly committed to raising our kids in a dense multicultural urban environment, and 9/11 hit pretty close to home for us. We thought about leaving, just with 3,000 dead. So if a million die, I think we move. And if I’m moving, a lot of other people are moving — because part of my whole professional career has been about celebrating that kind of lifestyle.

Your optimism in “Ghost Map” is based on our species’ ability to interpret patterns of evidence intelligently. That made me think of 9/11 — where we had a lot of evidence, but it was obscured, in pieces, or ignored. So maybe we’re still not doing a very good job of reading evidence in lots of areas — social structures, political organizations.

I would completely agree with that. In the case of 9/11, issue one is, large distributed organizations, particularly ones with antiquated computers and bureaucracies, traditionally have a hard time detecting patterns. And the other thing is that the data is all closed.

Another crucial element in “The Ghost Map” is that William Farr started publishing weekly bills of mortality organized by disease. And made them publicly available. If that had been closed knowledge, if only public health authorities were allowed to see these charts, they’d have lost the key data on who was dying and why, because they were stuck on the wrong idea. But there was a “Given enough eyeballs, all bugs are shallow” kind of philosophy — a notion of “Let’s get it out there, and maybe it’ll be useful to somebody.” Every week the report would come out. Snow would say, ah, yes, numbers, data! And an amateur was looking at it, and had this insight, and was able to do something with it.

Obviously there is a reason why the FBI doesn’t post online every single tip it gets. But pattern detection just works better the more folks who have access to the data and who have new ways of representing the data. So on the one hand there’s a great explosion in that, in the online world and the Web. Think of the multiple ways we have of mapping the blogosphere — it’s just incredible. Things that you and I were dreaming of 10 years ago, and now 35 companies are working on new ways to map all these conversations.

But as far as we know, that’s not going on inside these intelligence organizations. I know it’s what they want to be doing. That’s what Poindexter was trying to do — people got all over him, but it was not a preposterous idea, the open futures market. It was an attempt to figure out a way to use the wisdom of crowds.

So are there miasma theories out there today? Or is that impossible to answer, because we just can’t see them?

Every age has these blind spots. Normally they have multiple ones. So you have to assume that your age does too. Part of what you’re supposed to do as an educated intelligent person is try and figure out the giant weird invisible elephant in the room that nobody’s talking about — the thing that everybody’s missing. But it’s hard. They’re blind spots for a reason.

Tell me about your new Web project, outside.in.

It’s a really fun thing for me, which has happened a couple of times in the past, where the ideas I’ve been working on intellectually in a book have trickled over into a software or Web project. The idea animating it is, there’s this amazing, beautiful wave of local amateurs — Henry Whiteheads, John Snows — out there today. They’re writing about their neighborhoods, sharing all this information, writing about all that passionately important stuff that makes up the day-to-day existence of people’s lives right outside the zone of the family: the school down the street they’re worried about, the park that maybe’s going to open or not, the new restaurant that may be there.

These things haven’t traditionally had a form of media for them. And suddenly, thanks to the blogs, and sites like Yelp and Backfence or Judy’s Book, they have this amplification. Then of course traditional media is writing about local issues, too. Your restaurant down the street’s being reviewed by your local paper. But the problem is, it all exists off in these different compartments.

We decided to take all those pieces of information and set up a very easy system for tagging them geographically. Often when people are thinking about local information they don’t want to know exactly where this is on a map. They’re thinking, I just want to know what’s around me at this particular point in space. The cool thing is that it gives you this “what’s happening now at this point in space” dashboard and you can zoom in and zoom out. But it also leaves behind a trail of information that continues to be relevant.

It took shockingly little money to get it started. And we’re gonna see what happens. It’s in that nice zone where you can see a real business there — local advertising and zip-code-based national advertising is huge. On the other hand, it’s one of the great passions of my life to figure out ways to get city neighborhoods to work better and to communicate better.

It reminds me of when I was writing “Emergence” and I was doing Plastic. And the two were so tied up in each other. In some ways “Interface Culture” and Feed were like that in the same way. So this is the third time I’ve had a book and a software project that have been aligned with each other. It’s been fun.