Causes of Cholera

1. Causes of Cholera Two Camps Miasmatists (M)—Foul Air (FA) Robert Seymour, October 1, 1831

2. Causes of Cholera Chadwick: “all smell is disease” Two Camps Miasmatists (M)—(Often smelly) Foul Air (FA) Robert Seymour, March 1, 1832

3. Causes of Cholera Thames Two Camps 2. Contagionists (C)—Contaminated Water (CW) Give us clean water We shall all have the Cholera It makes me sick George Cruickshank, 1832

4. “In 1830, the Southwark Water Company was located on the South bank of the River Thames between the Southwark and London Bridges. The water intake pipe went from the company to the middle of the river, a short distance to the West of the new London Bridge, which officially opened in 1831.  Later in 1845 the Southwark Water Company merged with the Vauxhall Water Company to become the Southwark and Vauxhall Water Company.  At about the same time, the new company closed the former Southwark Water Company (shown below), and moved up-river to Battersea.”

5. Data on 1848-1849 Cholera Outbreak The Office of the Registrar-General, created in 1838, hired William Farr to compile statistics from birth and death certificates. One of his important contributions was to set up a system for recording the causes of death. William Farr Allowed him to create, Cholera Deaths per 10,000 people!

6. SOURCE: Bingham P, NQ Verlander, and MJ Cheal, “John Snow, William Farr and the 1849 Outbreak of Cholera that Affected London,” Public Health. 2004; 118(6):387-94

7. George Cruickshank, 1832

8. Waterloo Bridge Hammersmith Bridge Southwark Bridge London Bridge ≈1845 Vauxhall Bridge Kew Bridge Battersea Bridge N The Thames runs from West to East

9. Figure 1. Cholera Deaths and the Elevation of London’s Reg. Districts, 1849

10. Table 1. What Explains Cholera Deaths in London in 1849?

11. OLS Fitted Line ^ Interpretation of the slope: each additional foot of elevation is associated, on average, with 1.3 fewer cholera deaths per 10,000 people.

12. Figure 1. Cholera Deaths and the Elevation of London’s Reg. Districts, 1849

13. Figure 2. Cholera Deaths, Elevation and Water Supply of London’s Reg. Districts, 1849 Water from Central London Water from upriver

14. OLS Fitted Line ^ ^ Water from Central London Water from upriver

15. OLS Fitted Line ^ ^ 52.136 Water from Central London Water from upriver

16. Two Camps Miasmatists (M)—Foul Air (FA) 2. Contagionists (C)—Contaminated Water (CW) The data available after the 1948-1949 Cholera epidemic was incapable of resolving the debate. “To measure the effects of good or bad water supply, it is requisite to find two classes of inhabitants living at the same level [Elevation]… but differing in [the water one drinks]… But of such experimentacrucis [sic] the circumstances of London do not admit.” –William Farr (Ghost Map, p. 102)

17. Tuesday, September 5 ————— ALL SMELL IS DISEASE EDWIN CHADWICK The first solid cause for home began to filter through the neighborhood Tuesday morning. For the first time in four days, Henry Whitehead let himself believe that this terrible visitation might finally be passing. The wife of Mr. G, the tailor, had died that morning, but for every new death, Whitehead could point to another dramatic recovery. The servant woman he had been tending to since Friday had risen from what she had assumed would be her deathbed, her pallor much improved. Two adolescents—a boy and girl—had also turned the corner, much to the delight of their remaining family. All three of them attributed their recovery to one thing: they had consumed large quantities of water from the Broad Street pump since falling ill. The speed and intensity of their recovery made an impression on Whitehead that would linger in his mind through the coming weeks.

18. Evidence that Cholera was waterborne from the 1854 Cholera Epidemic 2. Broad Street Pump b) The Exemption Proves the Rule “Snow knew that the case would be made in the exceptions to the rule.” (The Ghost Map, p. 140) Cholera Cases per 10,000 residents …pockets of death where you would expect life.” “Pockets of life where you would expect death… Distance from the Broad Street Pump

19. Cholera Cases per 10,000 residents …pockets of death where you would expect life.” “Pockets of life where you would expect death… Distance from the Broad Street Pump

20. Cholera Cases per 10,000 residents Eley Factory …pockets of death where you would expect life.” “Pockets of life where you would expect death… Work House Distance from Broad Street Pump (miles) Brewery 1 2 5 deaths Susannah lived in Hempstead no deaths Eley Brothers Factory—18 deaths

21. Evidence that Cholera was waterborne from the 1854 Cholera Epidemic 1. John Snow’s Grand Experiment Was it a natural experiment or a difference-in-difference analysis? “London was without cholera from the latter part of 1849 to August 1853. During this interval an important change had taken place in the water supply of several of the south districts of London. The Lambeth Company removed their water works, in 1852, from [the heart of London] to [upriver]; thus obtaining a supply of water quite free from the sewage of London” (Snow, On the Mode of Communication of Cholera, 1855, p. 68). John Snow

22. Southwark Bridge Battersea Bridge London Bridge moved≈1845 Southwark & Vauxhall Water Company (S&V) Seething Wells Intake Moved in 1852 Lambeth Waterworks Seething Wells was beyond the tidal reach of the Thames N The Thames runs from West to East

23. “The experiment ...was on the grandest scale. No fewer than three hundred thousand people of both sexes, of every age and occupation, and of every rank and station, from gentle folks down to the very poor, were divided into two groups without their choice, and, in most cases, without their knowledge; one group being supplied with water containing the sewage of London [S&V], and the other group having water quite free from such impurity [Lambeth Company]” 31 subdistricts Not random 3 served by Lambethonly 16 served by both companies 12 served by S&V only 100 cholera cases per 10,000 residents ≈ 0 cases ≈ random via natural experiment pipes—promiscuously interlinked households—assigned w/o knowledge “smog-bound industrial zones” “relatively well-to-do suburbs” Lambeth households S&V households Same income & elevation 315 cases per 10,000 residents 37 cases per 10,000 residents

24. “In 1849 when cholera was last present in London, mortality due to cholera was similar among persons supplied by the Lambeth Company and the Southwark and Vauxhall Company.” Epidemiologist Ralph Frerichs

25. If the subdistricts that Lambeth served exclusively were “relatively well-to-do suburbs” then it seems plausible that it might have served relatively well-off households in the areas served by both companies (i.e., the households on the border)… Lambeth moved its intake pipe from downriver to upriver. Deaths per 10,000 households C D 1849 epidemic was more severe Increased risk due to foul water: A B Natural experiment 315 A – B Difference-in-difference 37 (A – B) – (C – D) 1849 1852 1854 Controls for the potential non-randomness Validity rests on assignment within the natural experiment being truly random

26. “The DD idea was probably pioneered by physician John Snow (1855), who studied cholera epidemics in London in the mid-nineteenth century.”

27. Friday, September 8 ————— THE PUMP HANDLE “DEATH’S DISPENSARY” On Thursday night, the Board of Governors of St. James Parish had held an emergency meeting to discuss the ongoing outbreak and the neighborhood’s response. Halfway into the meeting, they received notice that a gentleman wished to address them. It was John Snow, armed with his survey of the past week’s devastation. He stood before them, and in his odd, husky voice told them that he knew the cause of the outbreak, and could prove convincingly that the great majority of cases in the neighborhood could be traced to its original source. It is unlikely that Snow went into the intricacies of his broader case against the miasma theory—better to go straight to the telling patterns of death and life, leave the philosophizing for another day. He explained the dismal ratios of survival among the people living near the pump, and the unusual exemptions granted to people who had not drunk the water.

28. He told the Board of Governors of deaths that had transpired far from Golden Square, connected to the area only by the consumption of Broad Street water. He may have told them of the brewery or the workhouse on Poland Street. Death after death after death had been linked to the water at the base of the Broad Street well. And yet the pump remained in active use. They knew as well as any other locals how highly regarded the Broad Street water was—particularly as compared to the other nearby pumps. The members of the Board were skeptical. But they also knew firsthand the smells and noxious fumes that were rampant in the neighborhood; surely these were more responsible for the outbreak than the reliable Broad Street water. Yet Snow’s argument was persuasive—and,, besides, they had few other options. If Snow was wrong, the neighborhood might go thirsty for a few weeks. If he was right, who knew how many lives they might save? And so, after a quick internal consultation, the Board voted that the Broad Street well should be closed down.

29. Evidence that Cholera was waterborne from the 1854 Cholera Epidemic 2. Broad Street Pump

30. a) Spatial Pattern of Deaths

31. 4¼ inches

32. a) Spatial Pattern of Deaths

33. Natural Experiment—random whether people choose to live on the corner of Husband St. & New Street versus at the end of William and Mary Court. One is randomly assigned to live further from the Broad Street Pump. a) Spatial Pattern of Deaths

34. Evidence that Cholera was waterborne from the 1854 Cholera Epidemic 2. Broad Street Pump c) 2nd Examination of the Broad Street Pump. After discovering the “baby Lewis” case, Rev. Whitehead hired (engineer) York who uncovered leaks from the Lewis cesspool into the Broad Street pump’s well. Rev. Whitehead