John snow and cholera dr paul bingham - isle of wight cafe scientifique - nov 2013

Café Scientifique: 11 November 2013 ‘John Snow Bicentenary,

Cholera Epidemiology,

the Isle of Wight and Haiti’.

My talk - not just a narrative account of medical history!

Modest aim of presentation : to give insight into how science advances & to provoke discussion

Greatest Doctor of all time?

Type question into

Greatest Doctor of all time?

Greatest Doctor of all time?

Hospital Doctor Asked its readership in March 2003

Greatest Doctor ever?

Greatest Doctor ever:

1. John Snow (1813-1858)

2. Hippocrates (460-370 BC)

3. Dame Cicely Saunders (1918-2005)

John Snow – London’s number 1 Anaesthetist

End 1846 ‘Ether’ arrives from Boston

1847 Book ‘On the Inhalation of the Vapour of Ether in Surgical Operations’

Anaesthetist to royalty 1853 Provided anaesthetic for the birth of Prince Leopold (no. 8) ‘Dr Snow gave that blessed chloroform and the effect was soothing, quieting, and delightful beyond measure’ 1857 Birth of Princess Beatrice (no. 9) (1858 Posthumous book ‘On Chloroform and Other Anaesthetics’ Snow is said to have given 11,000 anaesthetics without a death)

Anaesthetics – not enough to account for increasing veneration of Snow during last century

Reputation:

Anaesthetics – not enough to account for increasing veneration of Snow during last century

Reputation:

Cholera - But why did Snow bother?

John Snow Pub

But he was teetotal

London School of Hygiene & Tropical Medicine

John Snow Lecture Theatre

College of the University of Durham Founded 2001

Waves of cholera/deaths E & W IOW (Snow)

1832 22k 2 Apprentice in Sunderland

1848/9 53k 188 Used IOW data

1854 20k 35 Broad Street

South London water supply

1866 14k 125 Dead

Snow • Had a strong conviction

that cholera was transmissible by water, food and person-to-person

• Applied the science then available

• But his findings not endorsed by the medical or political establishment

Transmission via water

1850: JS founding member of the Epidemiological Society of London

Snow called in Hassall

Hassall’s 1854 illustration of rice-water evacuations

Great missed opportunity

Filippo Pacini

Pacini now acknowledged as discoverer of cholera organism Work of Louis Pasteur and Robert Koch was to follow

Broad Street Pump

Rev Henry Whitehead

Context provided by modern historians

Paper 1990:

‘Who made

John Snow

a hero’

Charles Creighton

1894 ‘History of epidemics in Great Britain’

Two volumes

16 000 pages

One sentence on Snow

Major Greenwood

1934 ‘Epidemics

and Crowd Diseases’

Chapter on Cholera

But no mention of Snow

Historians point out:

• in the 1840s and 50s there was much confusion over cholera

• Many ‘pet theories’ were published

• Snow’s work did not lead to a scientific revolution

Snow was made famous by Hampton Frost

• 1936 republished second edition of ‘Snow on Cholera’

• Used Snow’s outbreak maps

as a John Hopkins class exercise

• Hampton’s pupils wrote the textbooks of the second half

of the 20th century

Good story:

• Poor boy made good

• Solitary medical genius

• Public Health hero

Good scientist?

Tom Koch: John Snow –

• Rushed to print

• Misused data

(Snow did not endear himself

to Thomas Wakley)

But he was right!

First 1848/49 IOW death from cholera 20th Dec 1848: The surgeon of the Cowes

District reported to the Guardians of the Poor that a case of malignant Cholera he had under his care had terminated fatally. The name of the Individual was Charles Nutkins, a sailor, 27 years of age who returned on the evening of the 15th December from Rotterdam via London and Southampton and died in the night of the 16th.

National enquiry conducted in 1849 of previous year’s outbreak by Provincial Medical and Surgical Association

Published a questionnaire in its Journal

Few responded but

Mr Bloxam of

Newport did

Read by Snow who contacted Mr Bloxam for more detail

Snow published the Carisbrooke cluster in the second edition of his ‘On the Mode’ as an example of the transmission of Cholera via food

12 January 2010: Haitian Earthquake

Moment magnitude scale 7.0 Depth 8 to 10 Km 15 Km southwest of Port-au-Prince 220,000 killed

Haitian Earthquake

2010 Haitian outbreak of Cholera No evidence of cholera in Haiti before 2010

Since Oct 2010, has killed 8,361 (17 Oct 2013)

Haitian outbreak of Cholera: Sudden, and initially localised

Artibonite District

UN: ‘the main task is to control the outbreak not look for the source’

Jan 2011 New England Journal of Medicine

‘Haitian outbreak

strain shares

ancestry with

recent South Asian

strains and not

those circulating

in Latin America

and East Africa’

UN independent panel report

‘The sanitation conditions at the (Nepalese) camp were not sufficient to prevent faecal contamination’

UN independent panel report

The outbreak could not have occurred ‘without simultaneous water, sanitation and health care system deficiencies’

‘Outbreak caused by the confluence of circumstances - not the fault of or deliberate action of a group or individual’

(Oct 2013: Haitian strain found in Mexico)

Tom Koch

‘Science is not about being right but convincing others you are right’

Tom Koch

‘When in the thick of another epidemic, raise a

glass of lemonade to John Snow,

but follow it with

a chaser for all the

other alcoholics

who laboured in

the field’

Questions/Conclusion • John Snow is venerated by the specialty of public

health – but should he be? Should science have heroes?

• As a scientist, is it enough just to be right? • The Isle of Wight’s connection with cholera and

Snow’s bicentenary (Carisbrooke cluster/Hassall at Ventnor/Queen Victoria) have been commemorated - just in time.

• Organism genetics (bacteria ‘fingerprinting’) is revolutionising outbreak investigation.

"You and I", he (Snow) would say to me, "may not live to see the day, and my name may be forgotten when it comes, but the time will arrive when great outbreaks of cholera will be things of the past; and it is the knowledge of the way in which the disease is propagated which will cause them to disappear.“ Rev Henry Whitehead at his farewell dinner