Looking Beyond the Pump Handle

What a Cholera Outbreak can Teach us about Homeland Security.

Soho, London. 1854. The neighborhood is bustling much like it is today. However, due to growth, there is overcrowding in the neighborhood apartments resulting in individuals living in close quarters. At the intersection of Broad Street and Cambridge Street stands a water pump. Indoor plumbing is non-existent, so fetching water requires more effort than turning on a faucet. Potable water isn’t piped straight into homes, so families need to collect water from the communal pump to drink, clean, wash, etc. Removing human waste isn’t as simple as flushing the toilet. Soho is different from other parts of London, there is no sewage system in the neighborhood to remove waste. Instead, families discard their waste by throwing it into cesspits found underneath their homes. “Nightsoil collectors” collect the waste at night and deposit the cumulative waste in the River Thames.

Soho Square, Soho, London. Public Domain.

The Miasma Theory

Cholera was not new to the citizens of London. Cholera was commonly referred to as “The Blue Death” because the victims would literally turn blue due to ruptured capillaries that resulted from extreme dehydration. Unfortunately, cholera deaths were not uncommon and causing public outcry and fear. Doctors were perplexed, no theory could explain the etiology of this disease.

This unknown etiology gave rise in the belief of the Miasma Theory that became the predominant theory of what caused the spread of cholera and other diseases (e.g. plague and chlamydia). This theory suggested that disease was caused by miasma (μίασμα, ancient Greek for “pollution”), “bad air”, also known as night air. The theory held that the origin of epidemics was due to a miasma, emanating from rotting organic matter. Essentially, individuals would become ill after being in contact with the bad air. Florence Nightingale, a prominent figure in wartime nursing, was a proponent of this theory, providing more credence to this belief. Under the miasma theory, disease was due to exposure in the environment and not through exposure to other infected individuals — person-to-person transmission was simply impossible.

Source: John Snow, Inc.

Dr. John Snow

When the name “John Snow” is mentioned in conversation today, many think of the character from the popular HBO show, Game of Thrones. However, another John Snow — that was actually real — is a prominent figure in the history of public health. Dr. John Snow (1813–1858), was an accomplished physician, finishing medical school by the age of 18, who lived in the Broad Street area. Dr. Snow, was a leading figure in the newly developing field of anesthesiology; he found more effective and less risky methods to administer anesthetic. In the past, Snow had expressed doubt in the miasma theory. He also had suggested that cholera was a digestive disease and published his theory in 1849.

The Creation of Modern Epidemiology

During the summer of 1854, an intense outbreak of Cholera was quickly spreading throughout the neighborhood of Soho in London, England. In just four days alone, 127 individuals died due to dehydration and other complications related to cholera. Within a week, the number grew to more than 500. The unknown etiology only motivated Snow to study the transmission and find the source of the disease. He also had a personal motivation — he lived in Soho. Snow scoured the neighborhood and interviewed nearly every occupant of the homes where a cholera case occurred. Using this information, Dr. Snow initiated the art of medical cartography by drawing his own map of Broad Street.

Source: University of California — Los Angeles. For an interactive look, click here.

The Cholera outbreak of 1854 devastated the Soho neighborhood. In total, 616 individuals died and no one could determine the causal factor and, subsequently, how to stop the spread of the disease.

When Snow completed the map, he could see that the distribution of cholera cases centered around the Broad Street area, but there were some outliers. Workers at a nearby brewery did not have any cases of cholera and cases also occurred in areas that had their own water pump, suggesting that there was no correlation between locale and cases.

Until Snow conducted further investigations.

The Peril of Cool Water

The Broad Street pump was was said to have colder water than any of the other pumps nearby, meaning that individuals from surrounding neighborhoods would come to the Broad Street pump to have a drink along the way or they would even travel to the Broad Street pump for their sole source of water. A lady by the name of Susannah Eley moved from Broad Street, but still preferred the water from the Broad Street pump, so she had the water delivered daily. However, how does this explain the workers at the local brewery? Well, while we know that water is healthy, it is not always the preferred beverage, both in 1854 and today. The brewery allowed their workers to drink while on the job as part of their salaries, so these employees tended to drink alcohol rather than water.

Using this evidence, Snow was able to convince city leadership to remove the pump handle from the Broad Street pump and the cholera case count growth decreased substantially. Further investigations eventually found that the Broad Street pump well was dangerously close to underground cesspools that leaked into the well, acting as the catalyst for the Soho outbreak. Despite the evidence and support from city leaders, not everyone agreed with Snow.

Source: Giphy.

Despite Snow’s evidence suggesting that cholera was transmitted via the fecal-oral route, many in the medical community did not want to renounce the miasma theory. Local leaders chose to not release Snow’s detective work to the public, thinking it was too much for the public to stomach (all pun intended). It wasn’t until 1885, when Robert Koch identified Vibrio cholerae as the bacillus causing the disease that he had proof of his theory. Snow was right, but wasn’t around to see this discovery himself.

Source: The Guardian.

Looking Beyond the Pump Handle

In the case of the 1854 cholera outbreak, many would say, at the time, that it was the pump handle that caused the outbreak. It wasn’t immediately known that the actual cause was the cesspits leaking into the broad street pump well. To discover the true cause of the outbreak, authorities had to look beyond the pump handle — providing some symbolism that we can apply to the field of homeland security. In many cases, individuals take the information for face value without utilizing the art of critical thinking. The 2016 election and the troublesome topic of “Fake News” (e.g. pizzagate) serves as a prime example.

The title of this article is a directive for members of the homeland security enterprise.

As members of the homeland security enterprise, we cannot allow the cesspits of the world to leak into our wells of knowledge and pollute our judgement. We must always use extreme care when accepting information at face value, especially if there is an unknown etiology at play. We must try our best to remain non-partisan and to protect the homeland to the best of our abilities.

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More information on Snow:

Now considered the father of modern epidemiology, John Snow died on June 16, 1858, at the age of 45, but his legacy lives on; so much so that John Snow, Inc. named their company after the great doctor. If you are interested in Dr. Snow and his work, I’d suggest reading The Ghost Map by Steven Johnson or watching his Ted Talk. Today, a monument stands across the street from the John Snow Pub (pictured at the top of this article), while a section of the sidewalk along the pub marks the spot where the original pump once stood in 1854. For more information on the pub or the monument, click here.