Presented by Dr Paul Bingham, who used to be the NHS Director of Public Health on the Isle of Wight, on Monday 11th November. 'John Snow Bicentenary, Cholera Epidemiology, and the Isle of Wight' John Snow discovered the source of cholera in the 19th century and Paul will also bring the subject up to date by looking at the ongoing problem of Cholera in Haiti.

1. Café Scientifique: 11 November 2013
‘John Snow Bicentenary,
Cholera Epidemiology,
the Isle of Wight and Haiti’.

2. My talk - not just a narrative
account of medical history!
Modest aim of presentation :
to give insight into how science advances
& to provoke discussion

3. Greatest Doctor of all time?
Type question into

4. Greatest Doctor of all time?

5. Greatest Doctor of all time?

6. Hospital Doctor
Asked its readership in March 2003
Greatest Doctor ever?

7. Greatest Doctor ever:
1. John Snow (1813-1858)
2. Hippocrates (460-370 BC)
3. Dame Cicely Saunders (1918-2005)

8. 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’

9. 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)

10. Reputation:
Anaesthetics –
not enough to
account for increasing
veneration of Snow
during last century

11. Reputation:
Anaesthetics –
not enough to
account for increasing
veneration of Snow
during last century
Cholera - But why did Snow bother?

12. John Snow Pub
But he was teetotal

14. London School of Hygiene & Tropical Medicine
John Snow Lecture Theatre

15. College of the University of Durham
Founded 2001

17. Waves of cholera/deaths
E & W IOW
1832
22k
2
1848/9 53k 188
1854
20k
35
1866
14k 125
(Snow)
Apprentice in Sunderland
Used IOW data
Broad Street
South London water supply
Dead

18. 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

19. Transmission via water

23. 1850: JS founding
member of the
Epidemiological
Society of London

24. Snow called in Hassall

25. Hassall’s 1854 illustration of
rice-water evacuations
Great missed opportunity

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

27. Broad Street Pump
Rev Henry Whitehead

28. Context provided by modern historians
Paper 1990:
‘Who made
John Snow
a hero’

29. Charles Creighton
1894 ‘History of epidemics
in Great Britain’
Two volumes
16 000 pages
One sentence on Snow

30. Major Greenwood
1934 ‘Epidemics
and Crowd Diseases’
Chapter on Cholera
But no mention of Snow

31. 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

32. 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

33. Good story:
• Poor boy made good
• Solitary medical genius
• Public Health hero

34. Good scientist?
Tom Koch: John Snow –
• Rushed to print
• Misused data
(Snow did not endear himself
to Thomas Wakley)
But he was right!

35. 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.

36. 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

37. Read by Snow who contacted Mr Bloxam for more detail

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

39. 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

40. Haitian Earthquake

42. 2010 Haitian outbreak of Cholera
No evidence of cholera in Haiti before 2010
Since Oct 2010, has killed 8,361 (17 Oct 2013)

43. Haitian outbreak of Cholera:
Sudden, and initially localised
Artibonite
District

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

45. 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’

46. UN independent panel report
‘The sanitation conditions at the (Nepalese)
camp were not sufficient to prevent faecal
contamination’

47. 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)

48. Tom Koch
‘Science is not about
being right but
convincing others you
are right’

49. 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’

50. 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.

51. "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