Elsevier

The Lancet

Volume 381, Issue 9874, 13–19 April 2013, Pages 1302-1311
The Lancet

Review
John Snow's legacy: epidemiology without borders

https://doi.org/10.1016/S0140-6736(13)60771-0Get rights and content

Summary

This Review provides abstracts from a meeting held at the London School of Hygiene and Tropical Medicine, on April 11–12, 2013, to celebrate the legacy of John Snow. They describe conventional and unconventional applications of epidemiological methods to problems ranging from diarrhoeal disease, mental health, cancer, and accident care, to education, poverty, financial networks, crime, and violence. Common themes appear throughout, including recognition of the importance of Snow's example, the philosophical and practical implications of assessment of causality, and an emphasis on the evaluation of preventive, ameliorative, and curative interventions, in a wide variety of medical and societal examples. Almost all self-described epidemiologists nowadays work within the health arena, and this is the focus of most of the societies, journals, and courses that carry the name epidemiology. The range of applications evident in these contributions might encourage some of these institutions to consider broadening their remits. In so doing, they may contribute more directly to, and learn from, non-health-related areas that use the language and methods of epidemiology to address many important problems now facing the world.

Section snippets

Cesar G Victora

Whether or not John Snow should be regarded as the father of epidemiology is open to debate, because some of his predecessors such as William Farr might also be credited with such a distinction. However, Snow was unquestionably an essential link in the causal chain that led epidemiology to what it is now. His ingenuity in placing cholera cases on a geographical grid, and in comparing cholera incidence according to sources of household water supply, constituted groundbreaking innovations in the

Kenneth J Rothman

In his writings on cholera, Snow revealed his thinking about how causal inference works. His articulate arguments were laid out meticulously in great confidence, such as when he concluded “Whilst the presumed contamination of the water of the Broad Street pump with the evacuations of cholera patients affords an exact explanation of the fearful outbreak of cholera in St James's parish, there is no other circumstance which offers any explanation at all, whatever hypothesis of the nature and cause

Patrick S Moore, Yuan Chang

Up to one in five cancer cases worldwide are now known to be caused by infection, and mainly by only seven human viruses. However, new genomic technologies are revealing hundreds of previously unknown agents. How well does epidemiology do in terms of telling us whether any of these new agents actually cause cancer?

Two very distinct stories emerge from the two most recently discovered human cancer viruses: Kaposi's sarcoma herpesvirus and Merkel cell polyomavirus. Kaposi's sarcoma became

Val Curtis

John Snow recommended handwashing and personal hygiene for the prevention of cholera almost 160 years ago.15 At about the same time, Ignaz Semmelweis showed that childbed fever could be prevented by hand disinfection.16 Generations of parents have since attempted to instil handwashing habits into their children. 10 years ago, we reviewed the evidence and concluded that handwashing with soap could reduce the risk of diarrhoea by 47% and potentially save 1 million lives in developing countries.17

David L Heymann

When a cholera outbreak led to a civil disturbance in Haiti 9 months after the 2010 Haitian earthquake, cholera once again took a place at the interface of health, water, and sanitation; international travel; and global politics. The first known cases of the outbreak were reported downriver from a UN Stabilization Mission base, and suspicion fell on the UN Stabilization Forces as the source of the infection.26 When third-generation real-time DNA sequencing linked the strains of Vibrio cholerae

Gary Slutkin

Throughout history, only infectious diseases and violence have killed up to tens of millions of people in epidemic form. However, in the past 200 years, we have made substantial progress in more successful management of infectious diseases, as a result of scientifically understanding the epidemiology, microbiology, and invisible forces of transmission. Yet, our understanding of violence remains stuck in thoughts of bad people and morality that we replaced a long time ago for infectious diseases

Robert M May

Explicitly mathematical approaches to epidemiology date from Daniel Bernoulli's evaluation, in 1760, of the efficacy of variolation against smallpox. However, most people acknowledge John Snow's spot map analysis (itself effectively mathematical) of the cholera epidemic in 1854 as the birth of modern epidemiology.

Mathematical modellers (myself included) have, however, been rather slow to recognise the mathematically inconvenient fact that one cannot usually treat a population as homogeneous,

Vikram Patel

The profile of the global burden of disease has changed profoundly since John Snow's time. We now know that non-communicable diseases are the leading causes of death and disability, and that their proportionate contribution to this burden is rising inexorably in tandem with the epidemiological and demographical transitions in most countries. These very diverse health conditions include mental disorders, which are arguably the most neglected of all global health challenges. Depression is the

Ian Roberts

John Snow got the handle taken off the pump. He did not estimate the burden of disease due to cholera, insist that cholera was made a public health priority, or lobby for more funding for cholera research. Rather, he “respectfully requested an interview” with the Board of Governors of St James Parish, who, on hearing his appraisal of the aetiological factors, ordered that the handle be removed from the Broad Street pump.

For maximisation of health with the resources available, the important

Richard Wortley

A fundamental distinction can be drawn between explanations of crime and explanations of criminality. Most criminological research and theory—including that from an epidemiological perspective—have focused on the second of these issues. Researchers have sought to identify historical factors—perinatal trauma, parenting and disciplinary style, child abuse and neglect, economic deprivation, adverse schooling experiences, association with antisocial peers, and so on—that affect why some individuals

Carole Torgerson

The most robust research design to establish effectiveness is widely accepted to be the randomised controlled trial.60 Although the randomised controlled trial is widely used in health-care research, its first use in the last century was in the area of education. In 1931, Walters61 randomly allocated students in a university setting to a mentoring programme or a control situation and then measured academic outcomes. Later, in 1940, Lindquist62 described how the natural unit of allocation in

Angus Deaton

Epidemiological methods are having a large and largely unhelpful effect on statistical practice in economics.

In the early 1990s, several important natural experiment studies were done in economics. Snow's work, especially as described by David Freedman,64 was often explicitly acknowledged, and admired. In one study, investigators looked at the effects of increasing the minimum wage on employment by comparing fast food restaurants in New Jersey and Pennsylvania, USA.65 Another study used the

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