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


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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.

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

  1. 1. Café Scientifique: 11 November 2013 ‘John Snow Bicentenary, Cholera Epidemiology, the Isle of Wight and Haiti’.
  2. 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. 3. Greatest Doctor of all time? Type question into
  4. 4. Greatest Doctor of all time?
  5. 5. Greatest Doctor of all time?
  6. 6. Hospital Doctor Asked its readership in March 2003 Greatest Doctor ever?
  7. 7. Greatest Doctor ever: 1. John Snow (1813-1858) 2. Hippocrates (460-370 BC) 3. Dame Cicely Saunders (1918-2005)
  8. 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. 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. 10. Reputation: Anaesthetics – not enough to account for increasing veneration of Snow during last century
  11. 11. Reputation: Anaesthetics – not enough to account for increasing veneration of Snow during last century Cholera - But why did Snow bother?
  12. 12. John Snow Pub But he was teetotal
  13. 13. London School of Hygiene & Tropical Medicine John Snow Lecture Theatre
  14. 14. College of the University of Durham Founded 2001
  15. 15. 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
  16. 16. 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
  17. 17. Transmission via water
  18. 18. 1850: JS founding member of the Epidemiological Society of London
  19. 19. Snow called in Hassall
  20. 20. Hassall’s 1854 illustration of rice-water evacuations Great missed opportunity
  21. 21. Filippo Pacini Pacini now acknowledged as discoverer of cholera organism Work of Louis Pasteur and Robert Koch was to follow
  22. 22. Broad Street Pump Rev Henry Whitehead
  23. 23. Context provided by modern historians Paper 1990: ‘Who made John Snow a hero’
  24. 24. Charles Creighton 1894 ‘History of epidemics in Great Britain’ Two volumes 16 000 pages One sentence on Snow
  25. 25. Major Greenwood 1934 ‘Epidemics and Crowd Diseases’ Chapter on Cholera But no mention of Snow
  26. 26. 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
  27. 27. 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
  28. 28. Good story: • Poor boy made good • Solitary medical genius • Public Health hero
  29. 29. Good scientist? Tom Koch: John Snow – • Rushed to print • Misused data (Snow did not endear himself to Thomas Wakley) But he was right!
  30. 30. 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.
  31. 31. 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
  32. 32. Read by Snow who contacted Mr Bloxam for more detail
  33. 33. Snow published the Carisbrooke cluster in the second edition of his ‘On the Mode’ as an example of the transmission of Cholera via food
  34. 34. 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
  35. 35. Haitian Earthquake
  36. 36. 2010 Haitian outbreak of Cholera No evidence of cholera in Haiti before 2010 Since Oct 2010, has killed 8,361 (17 Oct 2013)
  37. 37. Haitian outbreak of Cholera: Sudden, and initially localised Artibonite District
  38. 38. UN: ‘the main task is to control the outbreak not look for the source’
  39. 39. 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’
  40. 40. UN independent panel report ‘The sanitation conditions at the (Nepalese) camp were not sufficient to prevent faecal contamination’
  41. 41. 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)
  42. 42. Tom Koch ‘Science is not about being right but convincing others you are right’
  43. 43. 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’
  44. 44. 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.
  45. 45. "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