Where do you find the conjunction of epidemiology, mathematics, anthropology, and Victorian history? You do in this enlightening book, The Ghost Map, subtitled "The Story of London's Most Terrifying Epidemic - and How It Changed Science, Cities, and the Modern World. The subtitle is not an overstatement for this is one of the best books about the history of science that I have read. Steven Johnson provides the details of an episode in the improvement of scientific understanding that makes you wonder that such improvement ever occurs. Just as important as the scientific story are the connections the author makes between it and the history of the growth of cities with the impact of disease and its control on the possibilities for further growth. The background of certain key contributors, both medical and political, along with such contextual information as the history and literature of the times, 1850's London, adds to the wealth of information that makes the story of this Cholera epidemic worth reading. I enjoyed each chapter as I learned about an important chapter in the history of science. ( )

Reviewed by Mr. Kome ( )

An extremely well written, accessible account of the birth of the domain of public health. Johnson looks at every level of the cholera epidemic, from the microbial level to the politics of miasma theory. This depth makes in much easier to understand the importance of the containment of the Broad St. outbreak from a history of public health standpoint than if the book was presented without the microbial or political motivators behind the containment. Finally, "Ghost Map" is a concise read that avoids getting caught up in the minutiae of the epidemic which also adds to its accessibility.

The one major strike against "Ghost Map" is that its conclusion and especially its epilogue lacks the focus that makes the body of the book so successful. Johnson strays into the growth of super-cities and the impact of terrorism as a limiting factor of urban development, neither of which has anything to do with cholera or public health (except for a few words on bio-terrorism). Discussions of urban development are crucial when discussing public health, but Johnson fails to make this connection explicit. Clearly, Johnson was moved by the fear that gripped New York City after September 11th and felt a connection with the fear that gripped London during the Broad St. cholera outbreak. Regardless, this is still an excellent book whose ending begins to drift away from its thesis. Well worth reading. ( )

The basic narrative is about the investigation of the cholera epidemic in London that began to bring about the end of the miasma theory of infectious diseases.There reached a point in the book where it felt like the story had been told but author was just trying to increase the overall page count for the book.The epilogue is a drawn-out pontification of the author's assertion of the superiority of the urban lifestyle over the rural lifestyle and seems to be a completely unnecessary addition to the book. ( )

“The probability of an outburst or increase during [calm, mild] weather, I believed to be heightened on holidays, Saturdays, Sundays, and any other occasions where opportunities were afforded the lower classes for dissipation and debauchery” – unattributed quote by ‘expert’ regarding how cholera disproportionally attacks the poor and other social underclasses, in Victorian London.

As strange as this seems to modern eyes, this statement was backed up by scientific evidence, or at least what passed for such in England of the mid-19th century. During this time, the predominant theory for the spread of contagion and sickness was miasma (Greek for “pollution”), that is bad smells and foul air were the causes of disease.

The Ghost Map: the Story of London’s Most Terrifying Epidemic – and How it Changed Science, Cities, and the Modern World, by Steven Johnson (Riverhead Books) is the story of Dr. John Snow and Rev. Henry Whitehead’s discovery of the water-born transmission of cholera, a disease which struck with terrifying regularity in London and other large cities. The popular folklore is that Dr. Snow plotted cases of cholera deaths on a map, and deduced that the outbreak’s source was a particular well in a poor section of London, and removed the handle to the pump, thereby halting the epidemic, and was hailed as a hero.

The true story is not nearly so neatly packaged. Dr. Snow noticed, in earlier epidemics, a pattern of isolated groups either contracting cholera in isolation, or seeing groups that were spared contagion in the middle of a raging epidemic. Using his skills and experience, he correctly deduced that water somehow carried the source of the disease (although he had no idea about germ theory), and managed to track the common source to the water well located on Broad Street, in the area now known as Soho. Although he was unable to find anything in the water that could be the source of the disease (in fact, other wells had cloudy or smelly water, but no pattern of contagion). Over a period of months, however, he was unable to convince the health boards and community groups of his findings, because it was commonly known that bad smells were the source of disease, and indeed this had been known for centuries. This belief was continually reinforced because the most stricken areas, such as Broad Street, also happened to be the dirtiest and most fetid location in London. The scientists of the day could confirm their views by taking an (admittedly short) stroll through the impacted areas.

London grew from a city of a few hundred thousand to over 2 million in a matter of decades. Before the growth, most human waste was collected and carried to the surrounding farmland for fertilizer. However, with the rapid grow and expansion of the city limits, the feasibility and cost to remove ‘night soil’ became too expensive for the poor, and so the waste collected in the cesspools under the houses and in open pits in the alleys and yards. What few sewage systems existed dumped the untreated water directly into the Thames. The invention of the water closet increased the problem, since the additional water used for flushing ended up in the same overflowing pits. London was drowning in human waste, and it was commonly believed that the city would eventually perish under its mountain of refuse. And, common ‘scientific’ belief was that since the worst situation, and the worst smells, existed in the poorest neighborhoods, as did the greatest incidences of disease, crime, and death, the poor somehow brought it upon themselves, hence the quotation at the beginning of this article.

Dr. Snow eventually persuaded the local council to remove the pump handle, but by this time, new cases of cholera (and the original index source of the outbreak) had moved on. The councils were not, however, persuaded of the validity of their belief in miasma. In fact, Dr. Snow’s views were openly mocked on the pages of The Lancet and the newspapers of the day. How did they explain that in some cases, some members of a family died while other survived, while supposedly breathing the same foul air? Or that one household might entirely succumb while their immediate neighbors, who shared a yard, might all survive? The Victorians concluded, based on their understanding of the evidence, was that a person’s inherent constitution and moral character could be protective. Reverend Whitehead, who served as the local vicar and knew nearly all of the people of the Broad Street area on a first-name basis, initially scoffed at Dr. Snow’s hypothesis, as well, but became intrigued and finally assisted Dr. Snow’s data collection efforts when he realized that the ‘constitution and moral character’ of the individuals succumbing to cholera did not necessarily jive with the mortality cases. He also helped Dr. Snow track down and tabulated cases of cholera among ‘the better sort’ of people who no longer lived in the Broad Street area but may have partaken of the well’s water during a visit. He was also impressed that the entire population of a workhouse (the Victorians’ favorite scapegoat) survived the outbreak, as did all of the workers at a particular brewery, who were paid in product and never drank water.

In the end, it was not an epiphany that led Dr. Snow to his breakthrough, but years of plodding, shoe leather, tedious tabulation of victims, and his now-famous map, that convinced the skeptics of his claim. It was nearly 10 years after the outbreak before Dr. Snow’s discovery was finally accepted by mainstream scientists and politicians, and it was shortly after that that London finally embarked on the ambitious plan to install both sewer collection systems and to supply filtered water to the population of London. The last cholera outbreak was in 1866, shortly before the completion of the system. London’s example served as a model for the other great cities of the world.

Dr. Snow and Rev. Whitehead’s true legacies are not that they stopped cholera epidemics, but that they introduced a multidisciplinary approach in thinking about medical and scientific problems, and moderized the methods of scientific inquiry. ( )