John Snow Research Articles

Curiosity, Discipline, and Joy; and the Greatest of These Is Joy

Curiosity, Discipline, and Joy; and the Greatest of These Is Joy

The practising public health researcher

Progress in public health practice has often been reached by professionals who worked in routine practice and solved the problems they met with scientific methods. A classic example is John Snow's intervention in the London cholera epidemic, closing a water pump after analysing the spread of cholera cases.1 However, the expansion of the knowledge base of public health leaves to be answered whether this combination of work in practice and scientific research is still possible, in particular for public health professionals. With this editorial, I hope to convince the reader of a well-considered ‘yes’. The advantages of a close link between practice and scientific research tend to be acknowledged mostly, even if not combined in one person. Good examples are the generating of new ideas on the aetiology of health and disease, and the accrual of evidence on the effectiveness of interventions. In fact, John … Correspondence: Sijmen A. Reijneveld, Professor of Public health, University Medical Center Groningen, The Netherlands, e-mail: s.a.reijneveld{at}med.umcg.nl

The 2008 US Election and the Economy

Economic issues took centre stage during the 2008 presidential campaign. The deterioration ofthe economy and the deepening financial crisis pushed voters' concerns for their jobs and personal finances to the forefront ofthe election campaign. Barack Obama benefited from the economic downturn to win the White House by criticizing George W. Bush's record and economic policies, by emphasizing the need for a decisive plan to kick- start the economy, and by adopting a moderate and confident attitude in these difficult times. To understand why the economy was so central to this campaign, we have to answer the following questions. How can we assess the Bush administration's economic record? Was it as bad as the voters' reaction seems to indicate? And what is Obama's plan for the economy? Will he be able to turn things around?THE BUSH ADMINISTRATION'S ECONOMIC RECORDOn 20 January 2001, George W. Bush was sworn in as the 43rd president of the United States of America. According to the National Bureau of Economic Research, the country slipped into a recession just a few weeks later, in March. Responsibility for that economic downturn cannot be attributed to the then-incoming administration, however, since the underpinnings of a recession were in place before the November 2000 election. The burst of the high-tech bubble that started during the winter of 2000, the overinvestment linked to that bubble, rising energy prices in the summer of 2000, rising key interest rates, and a 10-year economic run that had just run out of steam all contributed to the 2001 recession.The government's response to this contraction in the economy was delivered through an initial salvo: tax cuts (an election campaign promise) along with retroactive tax rebate cheques that were sent to taxpayers (a compromise granted to Democrats who wished to maximize this short-term economic stimulus).The economy suffered another setback with the terrorist attacks of 11 September 2001, but the recession was over by the end of November. The recovery was slow and a steady stream of job losses occurred until 2003. Financial scandals involving Enron, Worldcom, and others; the wars in Afghanistan and Iraq; and the many terrorist warnings (the infamous orange alerts) undermined the confidence of consumers and investors alike over an extended period. To provide stronger support for the rebound, congress and the White House agreed to another tax cut in 2003. Much like the plan hammered out in 2001, these tax cuts were tailored to sunset in 10 years' time.The remainder of the Bush years saw China rise as an economic powerhouse, the US dollar drop, the real estate market's impressive growth (and meltdown), and hurricane-related shocks in 2005. Bush also had to make several changes to his team of economic experts, with three men holding the position of secretary of the treasury during his two terms as president: Paul O' Neil was appointed in 2001, John Snow in 2003, and Henry Paulson in 2006. Bush inherited Alan Greenspan, who had been president of the Federal Reserve since the end of Ronald Reagan's presidency. Greenspan's mandate was renewed once; he subsequently stepped down to be replaced by Ben Bernanke.Shifts in economic indicatorsBush's first term began in the first quarter of 2001. What exactly transpired during the 31 quarters between then and the third quarter of 2008? Can any comparison with previous presidencies end up with a thumb's up to the current Republican administration?Real GDP has seen average annual growth of 2.3 percent since the start of 2001. This advance is somewhat weaker than the 3.3 percent average recorded since 1953. In fact, this is the weakest performance if we exclude the real GDP performance under George Bush Sr., who was president from 1989 to 1993. It is also 1.4 percentage points below the average annual gain in GDP during Bill Clinton's presidency. George W. Bush's presidency also turned in a below-average performance in terms of most of the main economic indicators, in real terms or volumes, namely consumer spending, non-residential business investment, housing starts, and industrial production. …

Water recycling — forwards or backwards for public health?

Water recycling — forwards or backwards for public health?

The hands of John Snow: clue to his untimely death?

The accomplishments of John Snow (1813–1858), physician-epidemiologist, inventor and anaesthetist to Queen Victoria, are well documented, but the causes of his untimely death at age 45 remain conjectural. Snow suffered...

Vibrio cholerae: Genomics and Molecular Biology

Waterborne infections and epidemics are recurring events in human history, as highlighted by the seven pandemics caused by the bacterium Vibrio cholerae. An exhibit at the New York Historical Society (4 April—2 November 2008) covered the three waves of cholerae epidemics that hit Gotham in 1832, 1849, and 1866. The exhibit provided a human interest backdrop for the 13 scientific chapters in this book (written by leading experts). Death from dehydration was typical following the gastroenteric infection during those years, as is the case today in many parts of the developing world. As laid out in the first chapter, Filippo Pacini (1854) first discovered and Robert Koch (1883) described the organism. The physician John Snow first pinpointed contaminated water as the source of cholerae during an outbreak in London. The fact that cholerae outbreaks have been reported as recently as 2008 (Vietnam), illustrates that the battle against this pathogen is far from over.

Liquor made quicker: alcohol as a synthetic reagent for molecules in anesthesia

Ethanol was an early anesthetic, and chemists transformed it into better ones. Hypnotic/anesthetic/analgesic molecules prepared from ethanol include barbiturates, benzocaine, chloral hydrate, chloroform, diethyl ether, ethyl chloride, ethylene, etomidate, meperidine, paraldehyde, phenacetin, procaine, tribromoethanol, and urethane. Ethanol was sometimes mixed deliberately with the other anesthetics, and John Snow's inhaled amylene came from the “fusel oil” fraction of rotgut whisky.

Clean Water, Sanitation, and the Millennium Development Goals

In nineteenth century London, four large cholera outbreaks killed some 37,000 people. Completion of the capital’s sewer system contributed significantly to later reductions in gastrointestinal infections and increased life expectancy. This achievement was a team effort, but one driving force was the physician John Snow, the 150th anniversary of whose death was marked by a small ceremony on June 16, 2008, in a London public house close to the site of Dr. Snow’s main study of cholera transmission. Despite the venue, the celebratory libation was with water, not just out of respect for Snow’s abhorrence of alcohol but also because one of the occasion’s cosponsors was the international charity WaterAid. Water remains a key factor in disease worldwide. In the last year of his life, Snow wrote: “If the general use of water-closets is to continue and increase, it will be desirable to have two supplies of water in large towns, one for the water-closets and another, of soft spring or well water from a distance.”1 This simple principle of separation is today taken for granted in the developed world, where cholera is largely of historical interest only while globally we still need a World Health Organization task force on Vibrio cholerae infection as the disease refuses to go away.2 Cholera is not the only waterborne infection, of course, and not all illnesses from unclean water are microbial in origin (e.g., contamination with arsenic or man-made chemicals). In the UK, 99.96% of routine water tests now meet national and European standards.3 Any sustained falling off in water quality would be met with public outrage, and a spot check revealing cryptosporidium in a reservoir is headline news. Recognizing the continuing problems for less fortunate parts of the world the World Health Organization now has pragmatic “guidelines” (rather than “standards”) for water quality. Poor sanitation and lack of access to safe drinking water are still contributing to significant and avoidable morbidity and mortality, especially in children. One billion people do not have clean water, and 2.6 billion lack basic sanitation.4,5 United Nations (UN) agencies (and other parties) have long been aware of this situation. Remember the International Decade for Clean Drinking Water? That was 1981–1990 and had the absurdly ambitious target of “safe water and sanitation for everybody by 1990.” That failed. Former UN Secretary-General Kofi Annan then tried the human rights argument: “access to safe water is a fundamental need and therefore a basic human right,” he declared. Now, in 2008, we are roughly halfway through yet another ambitious project, the International Water Decade (2005–2015). This is linked to the 2008 International Year of Sanitation, mischievously referred to by some as the “year of the toilet.” The aim of the latest water decade is more modest than the one for 1981–1990—namely, “to halve, by 2015, the proportion of the world’s population without sustainable access to basic sanitation.” This roughly translates into a reduction from 40% to 20%, and the target is associated with the UN’s millennium development goals (MDGs). It is not, however, one of the primary eight goals. Perhaps, it ought to have been. It is difficult to see how the UN’s ambition of reducing mortality in the under-fives by two-thirds and halving and starting to reverse the incidence of malaria and other major diseases can be achieved without dramatic improvements in the two linked water-related factors of access to safe drinking water and the disposal of human excrement. So, at half-time in the decade, how are we doing? Not brilliantly. Only one of the UN’s regions is on track to achieve all eight MDGs,6 and the latest monitoring exercise records results as “mixed” and “uneven” and notes a “lack of progress in child survival.” Failure in the earlier International Decade for Clean Drinking Water was in part ascribed to an inability to keep up with the rapid pace of urbanization. Unfortunately, two decades on the same argument is being used. Urbanization, together with a rural backlog, means that targets are going to be missed.7 Drinking water and sanitation have not been neglected by UN agencies, but those agencies must be frustrated by the slow progress, especially since the know-how has been around for more than 150 years and cheaper, low-technology solutions are also available.

Correction

In the Salon article about John Snow, an error was made about the date of his death.[1][1] Snow died in 1858, thus making it 150 years since his death. CMAJ regrets the error and apologizes for any inconvenience it may have caused. 1. 1.[↵][2] Koch T. John Snow, hero of cholera: RIP. CMAJ 2008;

Book Reviews

Book Reviews

Ins and Outs of Vibrio cholerae

The gram-negative, motile, curved-rod bacterium Vibrio cholerae can cause cholera —an acute, explosive diarrheal disease. Epidemic cholera was described in the 1500s, but reports of cholera-like symptoms date back much earlier, to the times of Hippocrates and the Buddha. In 1849 John Snow, a London physician, determined that cholera is transmitted by water, and in 1883 Robert Koch successfully isolated the cholera vibrio. Facilitated by the expansion of global trade routes, cholera spread worldwide in 1817 and remains a global health challenge.

The Strange Case of the Broad Street Pump: John Snow and the Mystery of Cholera. By Sandra Hempel (Berkeley, University of California Press, 2007) 321 pp. $24.95

<i>The Strange Case of the Broad Street Pump: John Snow and the Mystery of Cholera</i>. By Sandra Hempel (Berkeley, University of California Press, 2007) 321 pp. $24.95

Remembering Dr. John Snow on the sesquicentennial of his death

On June 16, 1858, the world lost a legendary medical pioneer. John Snow MD, suffered a fatal stroke while nearing completion of his book Chloroform and Other Anesthetics , which was edited and published later that year by his friend and biographer Dr. Benjamin Richardson.[1][1] At the time of his

John Snow, hero of cholera: RIP

Dr. John Snow is not the first man to be honoured for valorous acts he never accomplished, nor is he the first to have honest, partially successful work transformed into a miraculous success. On the 200th anniversary of Snow's death it is time to acknowledge the glorious failure to accept that Snow'

Virginia Smith, Clean: a history of personal hygiene and purity, Oxford University Press, 2007, pp. xi, 457, illus., £16.99 (hardback 978-0-19-929779-5).

Cleanliness is next to godliness, table manners, monetary exchange and a host of other human behaviours; how has it escaped the notice of anthropologists, ethnologists and historians for so long? One of Virginia Smith's many accomplishments in this excellent study is integrating the philosophies and practices central to the subject. Cleanliness is part of medical routines essential for the prevention of disease; it has an aesthetic foundation in the human love of order and beauty and the exercise of such on the body; and it has a moral dimension in perceptions of purity, that of the body in harmony with the soul. By explaining the contradictions inherent in these concepts, the author identifies why the very few previous publications on cleanliness have dealt with either theories of hygiene or related inventions, but not both. Practices enhancing beauty can endanger health; they encourage vanity and self-obsession, behaviours in conflict with moral purity, and scientific discoveries connecting health with hygiene are sometimes incompatible with religious beliefs. Because of these tensions, the history of cleanliness has not been a “positivist” progression of improvement, as Smith demonstrates, but characterized by periods of “regression”, when moral concerns take precedent over the aesthetic or the latter over the scientific. This crucial theoretical basis is clearly laid out in the introduction, after which the author presents a very comprehensive narrative from animal grooming behaviour through to twenty-first-century environmental concerns. Cleanliness begins with biological processes at a cellular level and the instinctive revulsion of all primates for the rotten and excremental. In human society, technology comes to the aid of cleaning activities and influences a wide range of behaviours and artefacts; bathing, shaving, perfuming, hairdressing, laundering, housekeeping, food preparation, to list a few, all of which have a huge impact on domestic material culture, architecture and urban planning. Hygiene is closely linked to religious beliefs and practices: dietary restrictions, the sacred properties of water, beliefs and rituals relating to pollution and purity. The Greeks first made the conscious connection of cleanliness with health and absence of disease, placing the care of the body with diet, sleep and exercise in the regime of enhanced well-being. Such ideas and practices were inherited by the Romans and embraced by Galen as principles of western medicine in its attempts to understand and thereby control the inner workings of the body. However, the standards of hygiene achieved in the classical world did not last; with the fall of Rome went much of the technology necessary to maintain urban communal baths, Christian asceticism rejected the care of the body as detrimental to the soul, and medicine required several more centuries of scientific discoveries to make the microbiological link between dirt and disease. Politics is the fourth factor in the history of cleanliness; as Smith explains, for centuries the means to be clean were available only to the wealthy. The concentration of dirt and frequency of epidemics in urban environments made the importance of public hygiene evident in antiquity, although, until the nineteenth century, this often involved nothing more technical than keeping the unwashed poor well out of sight and smell of the rich. Following John Snow's discovery of the cause of a cholera outbreak in London in the 1850s, the provision of clean water supplies and sewerage were established as modern public health essentials, reinforced by Louis Pasteur's concurrent discoveries in germ theory. Yet as Smith discusses, such “progress” has its detrimental side-effects, environmental and immunological. Clean serves as an excellent introduction to the history of hygiene, body and soul, public and personal. Smith has expertly marshalled a vast amount of research on a wide variety of subjects from an equally impressive range of primary and secondary sources. Her findings are presented in a lucid and engaging style, with remarkable discipline given the breadth of the subject and the limits of the book's size. It is a shame that Oxford did not offer a more generous format; the topic really deserves the large, three-volume presentation of L'Univers Historique's new series, Histoire du corps. Nevertheless, Clean establishes a new domain in the study of human behaviour, providing an essential text for historians of medicine, architecture, and material culture; scholars and students of social history, anthropology, ethnology and cultural studies.

From research to national expansion: 20 years' experience of community-based management of childhood pneumonia in Nepal

Pneumonia is a leading cause of mortality of children aged under five in Nepal. Research conducted by John Snow Inc. in the 1980s determined that pneumonia case management by community-based workers decreased under-five mortality by 28%. Female community health volunteers were selected as the national cadre to manage childhood pneumonia at community level using oral antibiotics. A technical working group composed of government officials, local experts and donor partners embarked on a process to develop a strategy to pilot the approach and expand it nationally. High under-five mortality rates, low access to peripheral health facilities and severe constraints in human resources led Nepal's Ministry of Health to test this innovative approach. Community-based management of pneumonia doubled the total number of cases treated compared with districts with facility-based treatment only. Over half of the cases were treated by the female community health volunteers. The programme was phased in over 14 years and now 69% of Nepal's under-five population has access to pneumonia treatment. Community-based management of pneumonia provides a medium-term solution to address a leading cause of child mortality while the efforts continue to strengthen and extend the reach of facility-based care. Trained community health workers can significantly increase the number of pneumonia cases receiving correct case management in resource-constrained settings, with appropriate health systems' support for logistics, supervision and monitoring. Community-based management of pneumonia can be scaled up and provides an effective approach to reducing child deaths in countries faced with insufficient human resources for health.

Twelve diseases that changed our world

Twelve Diseases That Changed Our World offers engaging observations on a dozen diseases to serve 2 goals. The opening chapters meet the title’s promise by tracing the impact of hereditary blood disorders porphyria and hemophilia on the succession of European monarchs in the 16th through 18th centuries. Also presented is a riveting account of the consequences of a potato blight in 1840s Ireland, which forced migration of millions to England and North America. Thereafter, the book turns to the topic of infectious diseases and the lessons learned from earlier responses to “unanticipated outbreaks of disease” to inform preparedness for future outbreaks. Specifically, the chapters are devoted to the study of cholera, smallpox, bubonic plaque, syphilis, tuberculosis, malaria, fever, influenza, and AIDS. These topics are familiar territory for Dr. Sherman, who recently authored The Power of Plagues, in which he also examines 7 of these infections; his command of the subject matter is evident. Each chapter is packed with information ranging from pathogenesis and clinical manifestations to epidemiologic calculations and antimicrobial drug resistance. A limited number of references are provided in the concluding book notes, grouped by chapter and page number, which offer additional resources for readers seeking more information. Of particular interest is the book’s accounting of 19th-century pioneers in epidemiology and infectious diseases. John Snow’s use of early epidemiologic tools to associate cholera deaths with water from the Broad Street pump, Louis Pasteur’s development of vaccines, and Robert Koch’s discovery of tubercle bacillus and the cholera vibro all get their deserved attention; Florence Nightingale’s use of numerical data to demonstrate improvements in patient hygiene comes as a pleasant surprise. A concise volume written for the general reader, Twelve Diseases That Changed Our World provides an excellent foundation for the study of public health and infection control.

The Strange Case of the Broad Street Pump: John Snow and the Mystery of Cholera. Sandra Hempel.

The Strange Case of the Broad Street Pump: John Snow and the Mystery of Cholera. Sandra Hempel.

The Strange Case of the Broad Street Pump: John Snow and the Mystery of Cholera

The Strange Case of the Broad Street Pump: John Snow and the Mystery of Cholera

John Snow: early anaesthetist and pioneer of public health

This year marks the 150th anniversary of the death of an English physician who achieved lasting fame in two entirely unrelated fields. He was the first professional anaesthetist in England, making important contributions to the newborn specialty, and he was also one of the founding fathers of modern epidemiology and public health.