Ministry of Higher Education and Scientific Research

Hawler Medical University

College of Medicine
Community Medicine Department

John Snow and Cholera

A Seminar Submitted to
The Council of College of Medicine/ Community Medicine Department in
Partial Fulfillment of the Requirements for the Degree of Doctorate in Community Health

By
Mohammed Saad Abdullah
Supervised by:
Prof. Dr. Namir G. Al-Tawil
"If you want to learn about the health of a population, look at the air they breath, the
water they drink, and the places where they live.“

– Hippocrates, the Father of Medicine, in the Fifth Century B.C.

John Snow(1813–1858)

o A London physician.

o Anesthesiologist.

o Administered chloroform to Queen Victoria during

childbirth.

o Interested in the cause and spread of cholera.

o Published On Pathology And Mode Of

Communication Of Cholera(1849).

o Father of modern epidemiology.

London in mid 1800 and Thames River

• The 18th–19th centuries :

o Industrialization.
o Migration.
• Demographic shift:
o Overcrowding in poor housing.
o Inadequate or public water supplies.
o Waste-disposal systems.
• “The Great Stink” .
• The Lambeth Company, for technical, non–health-
related reasons, shifted its water intake upstream in the
Thames to a less polluted part of the river.
• Southwark and Vauxhall company did not move the
locations of their water intakes.
A drop of water of Thames River
Miasma theory vs. Germ theory
• Miasma Theory (bad air) : cholera was caused by airborne transmission
of poisonous vapors from foul smells due to poor sanitation.
• Germ theory held microorganisms known as pathogens or "germs" can
cause disease
• the Registrar General William Farr vs John snow.
• At the time, the germ theory was not accepted.
• Louis Pasteur 1861.
• Robert Koch in 1883.
• Filipo Pucini 1984.
William Farr findings
Critique William Farr findings

• Individuals living at lower altitudes much more likely to be drinking water

containing the sewage of those at higher elevations.

• Inhalation of bad air would make more sense if the cholera patient developed a
respiratory disease, but he saw that clinically the disease begins as a
gastrointestinal affliction.
Snow’s work and hypothesis

• Epidemic: Broad Street, Golden Square, in Soho, a poor district of central London
with unhygienic industries and housing.

• “shoe-leather epidemiology”

• Hypothesis: the mortality rate from cholera would be lower in people getting
their water from the Lambeth Company than in those obtaining their water from
the other companies.
( The Grand Experiment 1853-1854)
Number of Deaths
Cholera deaths
Original map (Ghost map)

o Regulation: Any governmental intervention, direct or indirect, designed to alter

human behaviour.
o E.g use of compulsory seat belts.
o Laws may be useful in times of emergency or in limited situations such as control
of an epidemic disease (COVID-19).
o Failure of the coercive approach:
1) The cause of disease (medical or social) cannot be eradicated by legislation.
2) In areas involving personal choice (e.g., diet, exercise, smoking) no government
can pass legislation to force people to eat a balanced diet or not to smoke.
Observation and evidence

• That the cases either lived close to or were using the Broad Street pump for
drinking water.

• brewery workers and poorhouse residents.

• Susannah Eley (Hampstead subdistrict)

• Patient Zero (Baby Frances Lewis)

The story of Workhouse and lion Brewery
Water Pump
Distribution of Cases
The Broad Street Pump

 It all starts with a pump.

 surveyed deaths reported in the homes mostly

near the pump and used it for their drinking

water.

 removal of the handle, and the already declining

epidemic.
JOHN SNOW
Lessons learned

• It is not always necessary to know every detail of the possible pathogenic

mechanisms to prevent disease.

• Dr. Snow recognized that part of treating disease requires viewing patients not as

individual, isolated cases, but within the larger environment in which they live.
References
• Aschengrau, Ann_ Seage, George R - Essentials of epidemiology in
public health-Jones & Bartlett Learning (2020).
• Celentano, D. (2018) Gordis Epidemiology. 6th Edition, Elsevier,
Amsterdam..
• Tulchinsky TH. John Snow, Cholera, the Broad Street Pump;
Waterborne Diseases Then and Now. Case Studies in Public Health.
2018:77–99. doi: 10.1016/B978-0-12-804571-8.00017-2. Epub 2018
Mar 30. PMCID: PMC7150208.