ROSALIND STANWELL-SMITH:

Well, my background,

I'm a medical epidemiologist.

I started off in surgery.

But I felt the call of epidemiology.

And during the '90s, I had to run a

course teaching people epidemiology.

And we went down to the John

Snow pub, just to give them

a kind of interesting thing.

And we found that the

pub was really run-down

and no one was bothering about it.

And we knew there was this

big heritage in the states

so we were really
embarrassed, especially

because we had two guys from the CDC

who were lecturing on our course.

As so we said, well, we must

have a John Snow society.

And that's how it started.

DON GOLDMANN: The Institute for

Healthcare Improvement, or IHI,

was founded by Don Berwick, who

you may remember ran for governor.

He's kind of the guru of improvement.

And our mission is to improve health

and healthcare around the world.

And to make care safer and better for

patients and for just general people

who happen to live in a community.

And we do this with a bedrock of

scientific, quality improvement.

And most people think

quality improvement--
you just go out and kind of do it.

But as we've been discussing, it

all involves the scientific method,

you know, prediction, testing,

confirming, adjusting, constantly

running cycles, to prove or disprove

that your theory of causation, how

you get from a change to

a better outcome, is true.

ROSALIND: In a way, the

Miasma Theory was right,

in that there are lots of factors,

your general health, your wellbeing.

They even brought in your morality.

I'm afraid, you know, if you were

immoral, you were going to get cholera.

But that whole idea, the holistic

approach, isn't wrong as such.

But they missed out the single cause.

And people have often said, well, how

was Snow absolutely strong on this?

Well even William Budd,

who was a contemporary,

he came up with the Theory

of Water-borne Typhoid.

He also hedged his bets.

But Snow didn't.

And I think it's very much

because he was a very logical man.

But also, you look at his life.

He starts off as a young doctor in the

minefields of the north of England.

And the mines, in those

days, were disgusting.

You'd go down underground,

there was no sanitation.
If it rained, they'd flood.

They had no way to wash their hands.

They had no toilets.

And he observed this,

and commented on it.

And in 1849 he said, there

must be something going on.

So he was very close to the Germ Theory.

Although he never-- he was years

ahead before people like Robert Koch

came up with the Germ Theory.

But he was close.

And so he was saying, it's

something, it's something

to do with them not washing the hands

and ingesting it from the water.

DON: Well, first I think it's only fair

to say there's no William Farr society.

And you may wonder why

I would bring that up.

Well, it's because

William Farr was wrong.

But he did use statistics, and

one might say epidemiology,

to come to the wrong conclusion.

What he did, as you may know, is to

calculate the occurrence of cholera

around London, and

especially around the Thames,

by the elevation of the

land above the Thames.

And he showed a really strong

correlation between elevation

and lower risk of getting cholera.

Because he believed that

miasmas, these noxious gases that
come from human feces and animal
waste and all that kind of stuff,

all these bad gases

were causing cholera.

And, unfortunately, his

analysis didn't account

for all the other factors that

might have been important,

income level, what kind of house you

lived, what kind of water you got.

All he did was have this theory

about miasmas from the Thames.

And it looks really good.

If you look at that graph, and his data,

it's pretty compelling, but it's wrong.

ROSALIND: There's been

a lot of criticism,

in a way, of the way John Snow

and some of the others of his time

have become an icon of epidemiology.

And people have said, well, why him?

I mean he wasn't the

only one doing maps,

he wasn't the only one who was

beginning to look at statistics.

But what was very interesting about John

Snow, I think, the deductive reasoning.

The fact that he was, yes

he was a qualified doctor,

but he was very much a

scientist of a doctor.

And he believed in measurement.

And he was against

the flow of the times.

There were other people who thought

that cholera might be waterborne.

But it was only as part

of a general theory.

People sometimes want to know

when did epidemiology start.

I mean, we didn't really

call it epidemiology

until well later in the century.

It's really a 20th century

phenomenon, as such.

They wouldn't have thought

of it like that at all.

They understood epidemics because

they had the word in French.

Épidémie.

But it could be just one or

two cases, maybe even one case

if it was a nasty disease.

But the idea of researching

those epidemics,

they would of called like a study.

Or Snow often referred

to the great experiment

that needed to be done to

show that water was the cause.

DON: So when this vast outbreak of

hundreds of cases you said occurred,

he used basic epidemiology, and we use

the term, "shoe-leather epidemiology"

to describe what he did.

He got on his feet and walked around.

And started asking, where are

these illnesses occurring?

And he began to plot

them out on a map, which

is sometimes called the ghost

map, or John Snow's map,

so he could see patterns.

Epidemiologist essentially
look for patterns of disease,

and then make a prediction, or find an

association between hypothetical causes

or origins of the outbreak.

ALYSSA: When you read very

short accounts of this map,

or when you see it presented in

other documentaries, or whatever,

you often get the impression that

John Snow is walking around Soho

with a clipboard and this

map, and putting dots

and making this histogram as he

walks around, which is not true.

And in fact, the more

scholarly accounts that I've

read make it sound like he made the

whole map after, like well after,

this was over.

ROSALIND: Yes, that's right.

ALYSSA: So, did he have a map

he was making in his head?

Did he have a sketch?

Did he just use tables and have a

picture in his head, or what did he do?

ROSALIND: He was very

good at drawing up tables.

And there was something-- because

of his work with anesthesia,

he was very good at

working with compounds

and drawing out effects and things.

So he would have been

making lists of the deaths.

And he would have some people like

the local doctors and Henry Whitehead,

the curator, collecting the death data.

What's very interesting
is his notebooks,

which he kept almost

every day of his life,

for the period that

he's investigating this,

is the time that he doesn't make--

he doesn't keep his notebook--

ALYSSA: He's too busy to write it down.

He's too busy.

And what I think he was

doing was not using a map,

but he was collecting

addresses, and so on.

And when he was presenting the

information to the board of inquiry--

They set up an inquiry, immediately.

So this was a very nasty outbreak with

some important people who had died,

in addition to the poor.

And so he was presenting

the information,

and that's when he drew

the map to convince them.

ALYSSA: The map that's on this

lovely John Snow Society mug.

ROSALIND: Yes.

So he had, if you like,

he'd got the data.

And this was just another

way of demonstrating it.

It wasn't how he solved the outbreak.

DON: When I talk to my students

about this, I always ask them,

so did John Snow perform

a case control study,

which is fundamental in epidemiology.

It's the greatest tool for
working up outbreaks that we have.

In a case control study, you

study the exposure of the cases,

in this case, water

pumps, and the exposure

of the controls, the people who

were not cases, who were not sick,

and their exposure to water pumps.

And there should be a difference.

John Snow did not look at controls.

He only looked at cases.

People were sick, and

arrayed them on a map,

and said these are closer to

the Broad Street water pump,

and here are some exceptions

to prove the rule.

So as the Father of Epidemiology,

the fundamental tool

for working up outbreaks was

not what he actually utilized.

ALYSSA: And the rest of

London not getting sick

is not considered a control?

DON: Well, he didn't really

talk about it that way.

And if you read his stuff, it

wasn't-- he wasn't looking--

he had a vague idea that there

were these people who weren't sick,

but it wasn't in a disciplined way.

Reverend Whitehead, who's not known

as the Father of Epidemiology,

he was a local guy and

he knew everybody and so

he was able to go around

and ask questions.
First he found more cases.

But he also interviewed non-cases.

And that was more like

a case control study.

So maybe Reverend Whitehead ought

to be the Father of Epidemiology.

I mean, but John Snow, what he

did was really quite remarkable.

ALYSSA: So it's at a
particular moment in time

before microscopy is fully

evolving as a proper science,

before the hygiene methods

have really got going.

And yet Snow is 40

years ahead of his time.

In a way, it's tragic he

didn't live to see that.

And what would he have contributed?

Masses, I think.

DON: Isn't it interesting

that you're talking

about how theories, some based

on empiric observation, some

of them remarkably astute, coexisted

side-by-side with nonsense.

ALYSSA: Yes.

DON: And it's no different--

ALYSSA: It's still true

DON: --today.

ALYSSA: Yes.

DON: Right?

I mean, theories-- and I'm not going

to take sides-- but creationism,
homeopathic remedies,
I mean, these are wild,

to me, wild theories that exist

right alongside of modern medicine

with synthetic drugs that are

targeted to conformations of proteins,

and all this data we have about

evolution, and climate change,

and so forth.

So I think it's a natural-- we

hold on to the kind of mysterious,

the not easily explained,

phenomenon and theories.

And at the same time, people

will say, well, you know,

there's this thing called science,

and we can actually use it to predict.