OPINION: John Snow’s Birthday A Reminder Cholera Is Killing People In 47 Countries

Yemen remains in the headlines as it continues to suffer from the worst outbreak of cholera in modern history. Most Americans would be quite surprised to learn that cholera also occurs in the U.S., though clearly it no longer poses a public health threat here. To understand why involves a medical detective story and an artifact in a chic London neighborhood that remains a stark reminder of deadly lessons not fully learned.

Back in 1831, experts thought polluted air, termed “miasma,” was to blame for two decades of cholera outbreaks that plagued England’s cities, killing tens of thousands of people. Except for one physician named John Snow. He believed he had traced an earlier London outbreak to a contaminated water supply. Not surprising, neither the local authorities nor the water company liked that theory. Four deadly cholera outbreaks did nothing to change minds, or the water and sanitation situation.

Then on August 31, 1854, the Soho neighborhood of London was hit by a devastating cholera outbreak: 127 people living in or near Broad Street died in the first three days, and within 10 days fatalities had skyrocketed to 500. This infectious disease is indiscriminate, attacking rich and poor. Its rapid onset of severe cramps and diarrhea can lead to a gruesome death within hours. Dr. Snow remained isolated in his belief that cholera spread through sewage-tainted water, but this new outbreak offered him another grim opportunity to prove his theory correct.

Interviewing victims’ families led him to what he believed to be the source of the epidemic. Nearly every death was clustered around a water pump at the corner of Broad and Cambridge streets. Snow collected a water sample from the pump and observed “white, flocculent particles,” further convincing him that the water was the culprit.

Local authorities remained skeptical, but they did agree to remove the handle from the Broad Street pump as an experiment. With access to water from this pump blocked, the outbreak, which had already started to slow down as the colder months approached, abruptly ended.

A month after the epidemic began, 616 Soho residents were dead. Yet some circumstances initially defied explanation. There were the 530 inmates of the Poland Street workhouse, just around the corner from the pump. Only five had contracted cholera. And none of the seventy men who worked at the Broad Street brewery got sick. Snow continued his investigation and learned that the workhouse had its own well and the brewery workers were provided a daily allowance for free beer — they weren’t drinking the water.

A widow and her niece had also died of cholera during this timeframe, though neither had been near Soho. Interviewing the wealthy widow’s son, Snow learned that she had once lived in the Broad Street area and liked the taste of the well water enough that relatives sent barrels of it to her. Her last delivery was August 31. The widow shared that water with her niece. It would be their last taste of Broad Street water.

Several months later, the Board of Health would still dismiss Snow’s theory. Others would pursue their own theories, including the Reverend Henry Whitehead who was convinced the cause was divine intervention. But as he worked to prove his theory, he came to affirm Dr. Snow’s, and helped Snow identify the likely cause of the Soho outbreak: the diapers of an infant who had died of diarrhea had been soaked in water dumped into a leaking cesspool — three feet from the Broad Street well.

We now look back on this mid-nineteenth century tragedy with curiosity and perhaps arrogance. After all, despite hundreds of clustered deaths, Dr. Snow’s persistence, his evidence, the open cesspools, and overcrowding in Soho, authorities did little to stop the very real threat of additional catastrophic cholera outbreaks.

What we have since learned is that cholera, a naturally-occurring bacteria native to the aquatic environment across the globe, should no longer be a public health threat anywhere. How then to explain that today, 47 countries across Africa, Asia, Latin America, and the Middle East continue to contain hundreds of cholera hotspots, with an estimated three million cholera cases every year, worldwide, and 100,000 deaths?

Cholera’s cause is simple, but the explanation of why it is allowed to persist is not: Globally, 2.1 billion people still lack access to safe drinking water and 4.5 billion are without safely managed sanitation. In Yemen, where over one million people have contracted cholera and some 2,500 have died, the United Nations estimates 16 million people lack access to safe water and basic sanitation.

The real question is, what will it take to convince today’s authorities to treat the absence of WASH — safe water, effective sanitation, and appropriate hygiene — as the global health emergency it represents? Coordinated efforts to prevent cholera, as well as at least a dozen other waterborne diseases, must be accelerated.

Cholera-endemic country governments are taking the lead and developing national plans to tackle cholera. There is a clear role for outside support to complement those governments. Because the vast majority of the efforts to eliminate cholera as a public health threat will heavily depend on a sustained commitment to safe drinking water and sanitation improvements, the U.S. government and others can be catalytic donors and technical partners.

Dr. John Snow, born 206 years ago today, is now admired as the father of modern epidemiology. The Broad Street pump saga and his story remain important, in large part for lessons we have yet to fully learn.

John Oldfield (@JohnForWater) is a principal at Global Water 2020, an advocacy initiative in Washington, D.C. dedicated to accelerating progress toward global water security. He previously led Water 2017 and WASH Advocates.