Tuesday, May 6, 2014

The London Cholera Epidemic as Compared to Present Day Fracking

When science and technology catch up to the determination of researchers, when knowledge is applied and leads to the discovery of a diagnosis, when puzzling biological mysteries of disease are finally pinpointed, our society as a whole will begin the eradication of the determinant of death. The paradox seems to be, that whenever we finally figure out what it is that Mother Nature is doing, and how she’s doing it, right when we think we’ve figured out a natural killers’ kryptonite, a new health problem sweeps the face of the Earth and new problems persist to make the jobs of public health soldiers harder.  

John Snow’s Hypothesis

            Around 400 B.C. is when it all really began. Hippocrates struggled to explain the cause of diseases within in his book On Airs, Waters, and Places, when he suggested something no one else of his time had, “Environmental and host factors such as behaviors might influence the development of disease” (CDC 2012). Then around 1662, John Graunt published information, such as displays of birth, death, and disease occurrences, with noted disparities between males and females, high infant mortality, urban/rural differences, and seasonal variations. Then William Farr, who looked up to Graunt, used his work as an example to become what many consider ‘the father of modern vital statistics and surveillance’ (Winterton 1980), and also ‘developed many of the basic practices still used today in vital statistics and disease classification’ (CDC 2012). Each of these men’s contributions to society were very important because collecting essential data and then assembling and evaluating it before sending it off to responsible health authorities and the general public, ensures a high quality research.
            John Snow, an anesthesiologist that was apprenticed in Newcastle-upon-Tyne to be a surgeon at the age of fourteen, seriously bettered London of it’s cholera outbreak in 1854, and also contributed greatly to the field of public health. When Snow essentially proved the many in the mid 1800s, that believed diseases was spread strictly through pockets of air (Winterton 1980), that they were wrong, he made a huge impact on the future. When the cholera outbreak erupted in the Golden Square of his city, John Snow who nobly quit his job as a doctor in 1848 (Winterton 1980), decided to pursue the mystery of death that was storming over London. John Snow decided to conduct an experiment unlike one no other persons of his time had, and his experiment was unique because he incorporated science, politics, social aspects, and intuition into a perfect new discipline that would in the future be known as ‘epidemiology’.
            John Snow’s hypothesis was that the source of water in London drank was the cause of people in the city getting sick and dying rapidly. John Snow arrived at this hypothesis by traveling around London, interviewing strangers, along with the engineers that understood the materials septic pools were made of, and collecting data. This procedure alone was not unlike any of the previous public health tactics mentioned, but what was different was Snow’s idea to draw a map of London and plot the data he collected directly based upon geography. Snow was smart enough to also plot the location of serviceable water wells. Using the map to spot patterns, Snow noticed the people that were getting sick all lived by the same well.
            When John Snow found organic content in the Broad Street pump, he begged the officials to remove the handle of the pump, despite it’s reputations for ‘good water’ (Winterton 1980). Snow went against the grain and proved a lot of people wrong. For example, The Presbyterian Coventor felt that the cholera outbreak upon England was a visitation of God due to the Catholic Emancipation in 1829. (Winterton 1980), and due to high overcrowding in the poor parts of land, poor people experienced a greater incidence of infection, and this lead to the assumption that the rich were consciously exterminating the lower classes. No one understood, during the 1850s, that diarrhea and cholera were referred to as separate diagnoses, with the former sometimes progressing to the latter. Snow acted like an investigator and by doing so, proved his hypothesis to be correct.

Cholera Epidemic in London

            The cholera epidemics of London took place during 1831 – 1833; 1848 – 1849; 1853 – 1854 and 1866. The first detected case of cholera was in Sunderland in February 1831 (Winterton 1980). According to the History of Medicine, “The epidemic originated from Bengal which had spread overland through Russia to West Europe and was brought to England by seamen from Hamburg.” The outbreaks were horrible, killed many people, and made fluctuations that were hard to predict, up until 1854. During the summer the death rate rose until September began; then the numbers reached a dramatic peak. The death rate was 11,000 or 4.5 per 1,000 (Winterton 1980).
            The Journal of History of Medicine gives a wonderful set of statistics that helps the reader better comprehend the demographics of the 1854 London Cholera Epidemic:

            The Golden Square and Berwick Street Subdistricts of St. James’ Westminster  had been fashionable in the early 18th century but had become much decayed by the mid 19th century. The houses were still considered ofa good standard and were   highly rated, but the overcrowding was great. In Broad Street the average number of inhabitants per house was 18. The St. James’ district covered 164 acres with a population of 36,000. This was divided into three subdistricts, St. James’ Square,       Berwick Street and Golden Square. The two last covered an area of 80 acres with a population of 25,000, a rate of 300 persons to the acre, one of the highest in London at the time. (Winterton 1980).

            The bacteria Vibrio cholera is seldom seen in the United States, and according to the World Health Organization (WHO), “A total of 58 countries reported a cumulative total of 589,854 cases including 7,816 deaths,” (case fatality rate of 1.3%) in 2011.  No one even today is completely immune to cholera; however; one specific group that was not affected by the cholera outbreak were the regulars at the London pub. John Snow was very thorough in his research and detailed, and made sure to inspect every aspect of the town, so Snow did not forget about the bar. What he found was that the brewery had their own deep well, and did not use other sources of water, which Snow found to be contaminated.

Type of Data Used or Other Data Wanted

            John Snow collected two different types of data during the cholera outbreak in London, and these two sets of data influenced the field of public health because people had not approached social problems in the same investigative nature as Snow did. Snow collected qualitative data; data that had nothing to do with numbers, but rather with drawings and linguistic descriptions, and quantitative data; data that focuses purely on mathematical equations and numbers. By using both types of data Snow was able to better play the role of an investigator and discovered the source of disease in his city.     Knowing what I now know, I would want to collect an additional set of data, one that John Snow did not collect, in order to better help explain the presence of a health disparity in terms of cholera. By conducting a survey to all the people of London, or more realistically some percentage of the total population, Snow might be able to prove that people are very misguided when it comes to the facts and importance of hygiene. By asking all the towns people what they think the source of disease in their town is, and documenting the answers, one could eventually put together a presentation of the results. It would be interesting to see how educated the majority is on problems, and to better understand where the misunderstanding lye. If people really knew the benefits of washing their hands, perhaps they would do it more.

The Role that Maps Played in the Cholera Epidemic

            Maps can be used as tools in the public health field. They are incredibly useful when trying to identify sources of disease because they can easily be manipulated in order to alter the focus and hypothesis of a research plan. In order to come to precise research conclusions maps should be carefully studied. By adding or changing the social public health variables labeled on a map, scientists are remarkably better able to identifying patterns and inurn creating helpful predictions about causation. For example when John Snow located the wells on his map of London he noticed a patter that would have been difficult to see without a map. They also help us better explain the presence of health disparities. Public health advocates can start creating a plan to begin the elimination phase of health disparities, the way John Snow finally convinced his townspeople to eradicate the pump of the infected water well. Without the maps John Snow produced, he may not have been able to convince his local townsmen that his hypothesis was correct. The smaller model of the town, and the physical ability to hold the evidence seems to help people of convincing other people. The maps that John Snow used impacted the identification and elimination of health disparities because John Snow did something that no one else, in really the history of time had.
Comparison of Current Fracking to the Historic Cholera Epidemic

No one in the movie PROMISE LAND served the role as a “John Snow” in regards to fracking. A “John Snow” in todays public health problems of fracking would play the role of a true leader, one that does not switch teams, or not know who they are working for.
            Fracking’s impacted population are the many that live hundred sometimes even thousands of miles away from a fracking well. Cholera’s impacted population are the people drinking from a specific water source, which leads one to assume they live near the source of the problem.
            The collection of data for fracking is found mostly by biases researchers that claim to be environmentalist; as seen in the movie Promise Land.  If not from a bias research, the data collected is still very limited because the consequences of fracking take time to surface, and are very unknown to the new field of science. The collection of data for cholera is found everywhere globally by both government and NGOs, due to it’s popularity and familiarity in today’s public health field.  
            The role that water plays in fracking is very important. In order to frack, you must use water and this is an issue because heating water and using it not to aid the millions across the globe that are dying due to dehydration, brings up ethical questions, especially in the public health field.

The Role of Data in Informing Public Health Stakeholders

            The EPA explains fracking in a very simple way, “Fluids, commonly made up of water and chemical additives, are pumped into a geologic formation at high pressure during hydraulic fracturing. When the pressure exceeds the rock strength, the fluids open or enlarge fractures that can extend several hundred feet away from the well. After the fractures are created, a propping agent is pumped into the fractures to keep them from closing when the pumping pressure is released. After fracturing is completed, the internal pressure of the geologic formation cause the injected fracturing fluids to rise to the surface where it may be stored in tanks or pits prior to disposal or recycling. Recovered fracturing fluids are referred to as flowback. Disposal options for flow back include discharge into surface water or underground injection.” I would use current day data to inform or influence the public health field (workers, policy makers, etc.). This would help in developing a program such as more research.

In conclusion, we need someone today to protect us from fracking, drilling wells and septic pools, we need someone to protect the community the way John Snow protected his community in London; however, we cannot depend on a ‘John Snow’ we all need to come together, crave and work towards a group wisdom.


Centers for Disease Control and Prevention. (2012). Principles of Epidemiology in Public HealhPractice, 3rd Edition. Lesson 1: Introduction to Epidemiology, section 2. Retrieved from          http://www.cdc.gov/osels/scientific_edu/SS1978/Lesson1/Section2.html.

Promise Land. Dir. Gus Van Sant. Perf. Matt Damon, John Krasinski, Frances McDormand, and Hal Snow J. Snow on cholera. London: Humphrey Milford: Oxford University Press; 1936.

Thacker SB. Historical development. In: Teutsch SM, Churchill RE, editors. Principles and practice of public health surveillance, 2nd ed. New York: Oxford University Press; 2002. p. 4–16.

Winterton, W.R. (1980). The Soho Cholera Epidemic 1854. History of Medicine, pg. 11-  17. Retrieved from http://courses.washington.edu/envh311/Readings/Reading_03.pdf.

WHO. Cholera 2011. Weekly Epidemiology Rec. 2012; 87; 289-304.