Syndemic Prevention Network: Monograph -- Revisiting Broad Street: A Cautionary Tale

Although the notion of assuring healthful conditions was only recently articulated as the driving purpose of public health action, it is fair to ask, what have we learned about this sort of work since it was formalized in the mid-1800s? One recent commemoration of that history marked the 150-year anniversary of John Snow’s famous removal of the Broad Street pump handle (Centers for Disease Control and Prevention, 2004a).

In 1854, the residents of London were contending with the third in a series of cholera epidemics, following previous outbreaks in 1831 and 1848. Each of the two earlier epidemics had killed tens of thousands in a frightening and horrific way. As Sharon Guynup described it, “one could be healthy at dawn and buried by dusk” after a rapid and lethal progression of diarrhea, vomiting, and spasms (Guynup, 2004).

Mid-19^th century London was also the center of the industrial revolution. Drawn by the promise of higher-paying work, rural families moved en masse to working class neighborhoods like the one surrounding Broad Street. Hedging their bets, many brought with them the animals that had sustained them on small farms, creating a crowded neighborhood that interspersed cowsheds and slaughterhouses with eight-to-a-room urban slums. London was experiencing rapid modernization, but much of this left the residents of Broad Street behind.

Their aging and overcrowded structures were situated over fetid cesspits. The sewers underneath and the structures above were pressed to the breaking point, and the break occurred in 1854 when the infectious agent of cholera was introduced into these adverse conditions (Frerichs, 2004; Summers, 1989).

Discovery of the cholera vibrio was still two decades away. In the absence of definitive scientific evidence of cholera’s cause, a fearful populace experienced the literal meaning of an epidemic: an unknown and mysterious affliction put upon (epi) the people (demos). Self-styled experts weighed in with different theories about whether bad air, bad water, or divine intervention was the real culprit. Snow believed that something in the water was to blame, mainly because he thought an airborne cause would manifest itself in people’s lungs (which cholera did not). Still, he had trouble persuading anyone else since the “poison” in the water could not be seen. Moreover, the stench from raw sewage was extreme, literally blurring the boundary between water and air.

Today, Snow is rightly hailed as a hero of modern epidemiology for his pioneering collection and analysis of death records, household interviews, and geographic maps, noting from these data that cholera cases were highly concentrated among households drawing water from the Broad Street pump. He further demonstrated that the pump was supplied by the water of two companies, one drawing water upstream from the Thames River, and the other downstream where contamination with raw sewage had occurred. With this evidence in hand, he persuaded the Board of Guardians (a city council-like body responsible for public health, welfare, and sanitation) to remove the pump handle. The incidence of new cases dropped immediately, and a public health legend was born.

Snow’s action prevented many thousands of deaths in the short term. Yet this version of the story, while powerful, is incomplete. The dramatic decline in cholera deaths was, in fact, a fragile gain. Closing the pump temporarily never addressed the adverse conditions that feature so prominently in a fuller portrait of the Broad Street neighborhood and so many other similarly stressed areas of the city. The people in those neighborhoods were still vulnerable—both to cholera and to an array of other afflictions. Investigators writing for a magazine called The Builder returned to the Soho neighborhood around Broad Street one year later, in 1855, to examine how conditions had changed: they found that no improvements at all had been made.

The epidemic had ended, but inaction in the face of these adverse conditions continued. Four years after Snow’s intervention, the stench from the Thames had grown so overwhelming that the British Parliament was closed for one of the few times in its history, after unsuccessful attempts to deal with the odor by draping curtains soaked in chloride of lime across the windows. It was not until the 1870s, after a fourth cholera outbreak in 1866—which killed nearly 4,500 people—that an innovative sewage system designed by engineer Joseph Bazalgette matched the above-ground modernization with improvements down below (Guynup, 2004).

Why isn’t Joseph Bazalgette’s contribution commemorated by the CDC, along with those of John Snow and the other actors who played a role in this larger civic venture? The story of the pump handle and its veneration today reveals many of the attributes traditionally emphasized by health professionals: a sharp focus on a specific, technical intervention; a concentration on immediate reductions in morbidity and mortality from just one cause; and a declaration of victory based on those criteria.

Highlighting these particular plot points both distorts and discounts the populist nature of public health work. It portrays health action as decisive, scientific, and heroic in the sense of having a single actor at the center, while obscuring a broader view of this work as a kind of public craft, one that is open to the contributions of many while being iterative, improvisational, cumulative, inspired, and technical all at once (Boyte, 2000, 2004b; Fortun and Bernstein, 1998; Lindblom, 1959; Scott, 1999).

SOLVING FOR PATTERN
A bad solution is bad because it acts destructively upon the larger patterns in which it is contained...because it is formed in ignorance or disregard of them. A bad solution solves for a single purpose or goal, such as increased production. And it is typical of such solutions that they achieve stupendous increase in production at exorbitant biological and social costs…Good solutions recognize that they are part of a larger whole. They solve more than one problem and don't create new problems. A good solution should not enrich one person by the distress or impoverishment of another.

-- Wendell Berry

To see the actions of Snow, Bazalgette, and others as part of a larger public craft acknowledges the reality that efforts to protect people’s health evolve over time, involving more issues than health alone and a more varied cast of characters than experts in medicine, statistics, or human biology. Storylines that portray public health work as a craft are therefore not strictly about solving singular problems, but rather about solving for pattern (Berry, 1981).

When crafting healthful conditions—and seeing those conditions as affecting peoples’ freedoms—the pump handle story presses toward a different ending. It may, in fact, have no end at all. For we can readily observe how the actions of Londoners in the 19^th century are still unfolding today, triggering further actions as we confront different versions of the same essential challenge to design living conditions that support our prosperity and well-being (Jackson, 2003).¹⁵ Joseph Riley, former Mayor of Charleston, South Carolina and founder of the Mayors’ Institute on City Design identifies this long arc connecting past, present, and future as the most important dimension of public leadership.

Looking back at how our predecessors tried to address the 1854 cholera epidemic, one is struck by the portfolio of the Board of Guardians: public health, welfare, and sanitation. In modern society, these functions have become separated from one another by elaborate administrative and professional boundaries (Weber, 1946). The fine-grained specialization of these and other health-related functions has created a sizable gulf between different groups of professionals, each with different institutional affiliations and a different slice of technical knowledge. It also separates professionals of all stripes from the citizens they profess to protect and serve (Benveniste, 1977; Boyte and Kari, 1996b; Illich, 1977; Jennings and Hanson, 1995a).

If the modern-day guardians of population health see their work as a craft-like endeavor to assure healthful conditions, then that work becomes something different than an endeavor to make people healthier, although that is a main motivation.¹⁶ Neither is the primary purpose to control disease, prevent premature death, nor enhance quality of life, all of which are also valued outcomes. On its surface, the emphasis on assuring conditions does not match any of the familiar ways that health professionals routinely use to justify their actions and careers. It expands the circle of those responsible for the public’s health far beyond a cadre of trained professionals, resting control within a dynamically complex system that is animated by the actions (and inactions) of every citizen, institution, and the public as a whole (Sigerist, 1996). Most intriguing of all, this idea of assuring healthful conditions steps beyond the confines of over 150 years of formal public health science.

Actions to intervene in people’s lives can be guided by a science that thinks about individuals—as does medicine—or even collections of individuals—as does epidemiology (Pearce, 1999). But it is an entirely different proposition to use either of those sciences as a principal guide for assuring the healthfulness of constantly changing and politically contested conditions. That prospect warps many people’s idea about what public health scientists can do. It even challenges strongly-held values about what science itself is meant to do (Chalmers, 1999). Still, if public health work aspires to assure certain conditions that are publically crafted and constantly in flux, then the concepts and methods that shape health policy must themselves resemble the features of dynamic, democratic systems.

A strong consensus has formed among health scholars around the need to render public health science and policy at an ecological level, consistent with the craft of assuring healthful conditions (Green, 2006; Green and Kreuter, 2004; Susser and Susser, 1996). But few of the frameworks put forward to date have transcended the conceptual problems that arise by seeing improvements in people’s lives as the mostly highly valued end (Buchanan, 2000). What it means to organize science and society around the goal of continually and equitably assuring conditions for health is still a puzzle.

One clue is to think differently about the role of science in guiding health action. In the Broad Street story, actions designed to prove or disprove the competing theories of cholera’s causes (even the one that turned out to be correct) could not safeguard the health of area residents as thoroughly as the pragmatic combination of separate innovations made by doctors, engineers, public officials and others that, together, rendered cholera less mysterious and permanently reworked the flow of sewage in the changing London landscape.

Likewise, the tendency in hindsight to represent the John Snow story as an unqualified victory reveals a narrow parsing of health itself. It distorts the full scope of the challenge that we face as a people to limit our collective vulnerability to many health threats at once and over time. In the midst of the London cholera epidemic, removing the pump handle reduced the accelerating incidence of cholera quickly and effectively, but it did not alter people’s vulnerability to other infectious threats of the day (e.g., syphilis, tuberculosis, smallpox), nor to those environmental and occupational threats that remained—and accumulated—in their homes and workplaces. Furthermore, Snow’s conviction that polluted water was to blame for all infectious diseases also led, ironically, to his defense of industrial manufacturing processes that we now know to have been extremely dangerous to the public’s health (Lilienfeld, 2000). These facts are difficult to reconcile with the heroic, scientific storyline, so they tend to be overlooked.

It is not surprising that Snow and the people whose lives he saved viewed his intervention as a success. However it is surprising that today, more than a century and half later, we still commemorate it as a flatly successful event, knowing full well that it did relatively little to assure safer, healthier conditions over the long-term for Broad Street residents.¹⁷ If modern public health workers had truly taken to heart our present mandate to assure healthful conditions for all, we would draw different lessons. We would do better to recognize the tremendous value—as well as the painful insufficiency—of halting the spread of cholera temporarily, while leaving people vulnerable to the same problem later.¹⁸ And we would notice more readily that the received storyline overlooks the contributions made by so many other actors whose work before and after Snow also helped to free us from the scourge of cholera.

15. The current obesity epidemic in the US, for example, is widely thought to stem from a similar dysfunctional interaction between the built environment and human health (Frumkin, Frank, Jackson, 2004).

16. Hannah Arendt offers a detailed exegesis on the dangerous categorical error underlying all endeavors to “make people” into a particular form (Arendt, 1958). As Margaret Canovan explains in the introduction to Arendt’s writing, “to understand political action as making something is in Arendt’s view a dangerous mistake. Making–the activity she calls work–is something a craftsman does by forcing raw material to conform to his model. The raw material has no say in the process, and neither do human beings cast as raw material for an attempt to create a new society or make history. Talk of ‘Man’ making his own history is misleading, for (as Arendt continually reminds us) there is no such person: ‘men, not Man, live on the earth and inhabit this world.’ To conceive of politics as making is to ignore human plurality in theory and to coerce individuals in practice” (Canovan, 1998:xvii).

17. There have been several attempts to critique the valorized rendition of John Snow’s work. For the most part, however, these commentaries challenge the myth of Snow as a neutral scientific observer by emphasizing the political values that he exhibited and the particular philosophy of science that he employed. For example see the following exchange from the American Journal of Epidemiology: (Brunskill, 1992; Dunn, 1992; Krieger, 1992; Vandenbroucke, Eelkman Rooda, Beukers, 1991).

18. For an example of the opposite strategy, wherein the solution to an immediate problem is crafted in such a way as to assure that it would not recur again, consider Nainoa Thompson’s approach to the problem of natural resource depletion in Hawaii. In 1990, the Polynesian Voyaging Society embarked on a project to build a traditional Hawaiian canoe using only native materials, as their ancestors had done. An instant problem arose when no one could locate a tree of sufficient size and strength out of which to fashion the hull. Their venture was thwarted by the almost total deforestation of Hawaii’s koa forests. Whereas historical records indicate that early Hawaiians built several thousand canoes per year, it was impossible for modern Hawaiians to build even one. The project eventually continued by accepting the gift of a Sitka spruce from Native Alaskans, but not before Thompson and his colleagues initiated a massive reforestation of their own koa stand (Evenari and Thompson, 1992; Thompson, 1995)

Crafting Conditions

Revisiting Broad Street: A Cautionary Tale