In most of medicine, and in Health Protection in particular, one occasionally comes across people who have made questionable decisions which have had severe consequences. When people decline routine vaccinations or fail to use a condom for specious reasons, it can be both depressing and frustrating to be picking up the pieces.

It’s easy to rationalise that health is not at the top of everyone’s personal agenda and that sources of misinformation are common and commonly believed. At these times, it feels like the most productive outcome is to channel the frustration into improving the information on offer and trying to reach the people who have missed it.

A friend once told me to think of ‘health’, a topic which most of my life is dedicated to, in terms of ‘transport’, a topic with which I’m intimately engaged as a ‘user’ but in which I’m completely non-expert:

I might get frustrated that people don’t take obvious preventative health measures, but when was the last time I checked my tyre pressure, an obvious ‘preventative measure’ in the ‘transport’ world? (I’ve done it once in the nine years I’ve owned my car.)

I might get annoyed that people don’t have any idea of the true cost of their healthcare, but what’s the true cost of the public transport I take to work each day? (I’ve no idea.)

I might think that’s it’s patently obvious that homeopathic remedies contain no active ingredients and are a total waste of money, but what’s the evidence of benefit for the ‘premium’ grades of petrol? (I often buy them, even though there’s probably no benefit.)

And then, just occasionally, I come across something that seems so appalling unappealing that I’m baffled that anyone, medical knowledge or not, could possibly want to engage with it, let alone risk harm by doing so:

One type of apitherapy is live bee acupuncture, which involves applying the stinging bee directly to the relevant sites according to the specific disease.

Live bee acupuncture. Wowzers trousers. This paper by Vazquez-Revuelta and Madrigal-Burgaleta in the Journal of Investigational Allergology and Clinical Immunology, from which the above quote is taken, reports a terribly sad case of a 55-year-old woman who died from live bee acupuncture.

The paper reports that she’d been attending four-weekly for two years for the procedure, with the aim of treating

muscular contractures and stress.

As one might expect,

the risks of undergoing apitherapy may exceed the presumed benefits, leading us to conclude that this practice is both unsafe and unadvisable.

There is little about this paper which isn’t at least mildly astonishing. But then I wonder… I don’t know what the transport equivalent of intentional bee stings might be, but perhaps I engage in that too.

The alarmingly cute picture of a bee at the top of this post was posted on Flickr by Ozzy Delaney. I’m reusing it here under its Creative Commons licence.

A couple of news stories I’ve read lately have made me think about our approach to regulation of advertising.

First, there was this story by Travis M Andrews in The Washington Post about the portrayal of smoking in shows made for streaming services:

Among the vices often embraced by streaming services and avoided by broadcast television is tobacco in all in its forms … A study compared seven popular Netflix shows to seven popular broadcast shows. In this sample, it found Netflix’s shows featured characters smoking almost three times as often as those produced by broadcast networks like NBC, ABC and CBS.

Now, we could spend all day poking holes in this ‘study’, but the thought is still going to fester: it does seem like there might be more smoking in these shows than in those on broadcast TV.

Second, there was this BBC Trending story by Branwen Jeffreys and Edward Main about YouTube stars being paid to encourage kids to cheat on school assignments:

YouTube stars are being paid to sell academic cheating, a BBC investigation has found. The BBC Trending investigation uncovered more than 1,400 videos with a total of more than 700 million views containing EduBirdie adverts selling cheating to students and school pupils. In some of the videos YouTubers say if you cannot be bothered to do the work, EduBirdie has a “super smart nerd” who will do it for you.

This isn’t so obviously related to health but does highlight an issue with inappropriate advertising within online streams which are typically seen by children and young people.

Both of these stories made me reflect on the work that has gone into restricting advertising of harmful products such as cigarettes and energy dense foods, and how the fruit of that work might be lost if legislation doesn’t keep up with changing media consumption habits.

For example, there are no regulations around the portrayal of smokers on streaming shows, whereas broadcast shows must comply with Ofcom’s rules, including Rule 1.10:

Smoking must generally be avoided … unless there is editorial justification.

There seems to be non-stop debate in the media press about whether TV ads or online ads are more ‘impactful’, with the conclusion usually predictable according to who has funded or published the work. But it does seem increasingly clear that many people (including me) are now watching more streamed content than broadcast content, and that this is more common among younger people.

It’s hard not to worry that the slow pace of legislative change might cause us to unintentionally slide back to an era of lesser regulation of what is actually seen despite strong evidence of harm. We really mustn’t let that happen.

The photo at the top was posted on Unsplash by Tina Rataj-Berard and is used here under the Unsplash licence.

A couple of years ago, I wrote a post for the Fuse Open Science Blog about the system failures which lead to patients ‘inappropriately’ presenting at A&E, and how this is often blamed on patients who are expected to self-triage with a high degree of accuracy. I’ve thought of this today because it popped up in my Facebook ‘memories’.

This has prompted a couple of completely disconnected thoughts.

My first thought is that what I wrote then remains true today, and has become even more relevant with ever-increasing pressure on NHS Trusts. Effective triage of patients to the ‘correct’ NHS services is a nut that remains stubbornly uncracked.

More money has been ploughed into putting GPs in A&E departments, despite mixed evidence on cost and patient throughput. Some companies are experimenting with triage chatbots for the NHS which feels to me like an unlikely solution to the problem of sorting acutely unwell patients. The NHS Choose Well campaign keeps steaming ahead at various levels of the NHS as though doing more of the same will result in a completely different outcome.

Anecdotally, clinical colleagues tell me that last winter was ‘better’ than others in recent years, in as much as A&Es were over-filled with patients who should be there rather than patients who shouldn’t be there. Of course, that means departments are more pressured. Perhaps the fear of long waits and ‘chaos’ puts off ‘inappropriate’ attendees. I’m certain that it puts off some ‘appropriate’ attendees and that this will, at least in a very small way, have contributed to excess winter deaths for 2017/18.

My second—unrelated—thought is that I have absolutely no memory of writing or publishing that Fuse article. I mean, I know I wrote it, but I have no memory of constructing it, or of looking up the stuff about Joseph Hodgson and drawing a parallel between misuse of historical charitable hospitals and the modern NHS.

I’m always bad at remembering things I’ve worked on in the past, but to have such a complete absence of any memory for something I wrote (and clearly put thought into) only 24 months ago is remarkable even for me.

I can only assume I was knackered when I wrote it… which would also explain the slightly crap call-back pun in the last line. I can see what I was trying to do, but reading it now, I think it slightly missed the mark.

The picture at the top is a cropped and edited version of a photo published on Flickr by gwire. I’m using it under its Creative Commons licence.

Last week, I read this remarkable story about a new cruise ship by Oli Franklin-Wallis in Wired, and have been thinking about it ever since:

Symphony of the Seas – which, on its maiden voyage from Barcelona in March 2018 became the largest passenger ship ever built – is about five times the size of the Titanic. At 362 metres long, you could balance it on its stern and its bow would tower over all but two of Europe’s tallest skyscrapers. Owned and operated by Miami-based cruise line Royal Caribbean, it can carry nearly 9,000 people and contains more than 40 restaurants and bars; 23 pools, jacuzzis and water slides; two West End-sized theatres; an ice rink; a surf simulator; two climbing walls; a zip line; a fairground carousel; a mini-golf course; a ten-storey fun slide; laser tag; a spa; a gym; a casino; plus dozens more shopping and entertainment opportunities.

Cruise ships mean two things to me.

Earlier this year, I went on a ‘mini-cruise’ from Newcastle to Amsterdam aboard a DFDS ship. The journey was an overnight 15 hour or so thing, so certainly not equivalent in any way to spending weeks at sea on the world’s biggest cruise ship. The rationale for this was that I fancied a last-minute break and couldn’t find a cheap flight from Newcastle, so went on a cheap boat instead, spent a day in Amsterdam, and took a cheap flight from there. This worked remarkably well, and I’d do it again.

This was the first time I’d been on an overnight boat since our annual family camping trips to France when I was a child. Prior to going, I’d sort of thought in the back of my mind that I might be the sort of person who might one day enjoy a proper cruise. This experience put me off.

The ship was lovely, and I was particularly impressed by the cabin. I had expected a pokey bunk-bedded hovel but was actually rewarded with a fairly large space which looked not unlike a Travelodge room, with an en-suite bathroom. The food on board was also much higher quality than I would have expected. But I am somebody who likes to wander—and even with only 15 hours on the ship, I was itching to get off and explore. Exploring the ship felt a bit constrained.

It was silly of me not to realise this in the first place. Wendy and I ruled out going to an idyllic holiday resort last summer for the sole reason that it was located on a main road along which walking was not advised, so we couldn’t ‘go for a wander’ without catching a bus or taxi somewhere first. I hadn’t really clocked that ‘going for a wander’ wasn’t really a go-er on a ship.

While the Symphony of the Seas is ridiculously bigger than the ship I was on (it’s more than twice as long and can take four times as many passengers across twice as many decks), I still think I’d feel ‘cooped up’ pretty quickly. So I don’t think I’ll be going cruising anytime soon.

My other relationship with ships is professional. One of the more esoteric parts of my role as a Consultant in Health Protection is that I am the designated Medical Officer for a number of ports. This gives me certain legal responsibilities relating to ships and the health of their crew—most of which are thankfully delegated to people much more expert than me. But just imagine how complex an outbreak of norovirus or Legionnaire’s disease could get on a ship as huge as Symphony of the Seas. I was fascinated to read in Oli’s article about some of the steps taken to mitigate the risks:

“The level of hygiene is extreme,” Yrjovuori announced, as we passed a hand-washing station. Though ship-wide outbreaks of sickness make the news at least once a year, the total number of passengers who fall ill is a fraction of one per cent. But close quarters enable outbreaks, so sanitation regulations at sea are stringent. Every part of the ship, from lift buttons to the casino’s chips, are sanitised daily; interior materials have to stand up to the high level of chlorination from the constant cleaning. Rubbish is frozen in vast storage containers to slow bacteria growth and is only removed in port.

Fascinating stuff… perhaps we could even try and replicate some of it on land!

The pictures in this post are my own from the above-described ‘mini-cruise’ adventure. The pictures in the Wired article are a great advert for the power of print, looking far more arresting as double-page spreads than as on-screen images.

A few years ago, I did a stint in General Practice. One of the commoner things people would come and see me for was a sore throat, and as a good antimicrobial steward I tended to send them away with self-care advice.

One bit of advice I routinely gave to adult patients was to gargle with salt water: dissolve half a teaspoon of salt in half a cup of boiled water mixed with half a cup of cold water, gargle with it for a minute and spit it out. I think it may even have been written on the little self-care leaflets I used to dish out.

This has a surprising amount of evidence behind it for a home remedy, though largely in the context of postoperative throat pain. It is now the published NHS advice for sore throats—it may have been at the time too, I’ve no idea.

What sticks in my mind about this advice is the number of people who mentioned at unrelated later appointments what excellent advice it had been. I even remember a singer telling me the advice had rescued a performance she thought she may have to cancel. In my experience, patients aren’t especially forthcoming with positive feedback on self-care strategies, but I really seemed to get a lot about this advice. Despite that, and despite a vague awareness of the evidence base, I didn’t really believe it. I mean, it sounds like utter nonsense, like the sort of folk remedies you hear for all kinds of things that aren’t evidence-based (and can even be downright unhelpful).

And yet… over the last week or so, for the first time in as long as I can remember, I’ve been suffering from a really sore throat. I tried gargling salt water. And, blow me down with a feather, it really works. Certainly, I’ve found it far more effective than any throat sweets or sprays I’ve come across.

I think there’s probably a deep message in here somewhere about common sense being remarkably uncommon, or about doctors being the worst patients, or about a disconnect between academic evidence and belief systems. But really, I’m just trying to say if you have a sore throat, try gargling with saltwater. It worked for me.

I came across the advert at the top of the post via the Boston Public Library online. I wonder if there are any medications advertised today as for both “man and beast”? If you’re wondering, you didn’t have to get your “beast” to gargle it:
it could also be applied topically (hence ‘liniment’, which is a word we don’t use nearly enough these days).

I don’t often stick work stuff on here… but here are a couple of videos of me and Michelle Henderson (one of my colleagues) talking about World TB Day, which is today!

Tomorrow is #WorldTBDay. Watch @sjhoward and Michelle Henderson talk about unique challenges of TB in the North East and symptoms to look for. pic.twitter.com/dEN8ejN5DA

— PHE North East (@PHE_NorthEast) March 23, 2018

#WorldTBDay the quicker TB is diagnosed the sooner it can be treated – watch the below to find out why early diagnosis is so important ⬇️ pic.twitter.com/SkzZGi2Tdd

— PHE North East (@PHE_NorthEast) March 23, 2018

When people accuse politicians of lying, I generally roll my eyes. Almost a decade ago, I laid into my local MP for sending me an inaccurate letter. Guido Fawkes picked it up and called the poor guy a moronic liar. The episode was a whiny hurling of personal insults that achieved nothing of value. I still slightly regret it.

And these days, too often people choose to quote politicians out of context, wilfully misunderstand their position, or turn slips of the tongue into conspiracy theories. I have no interest in any of that.

And yet. And yet. And yet, I have noticed a lot of inconsistency in Government statements on the Junior Doctors’ Contract dispute. I’m not accusing anyone of lying. I’m not even accusing anyone of being deliberately misleading. I’m just highlighting statements which, as far as I can see, don’t match one another.

Look through the list yourself. Check out the sources. Draw your own conclusions.

There will be no imposition.

Source: Government statement in response to petition, 21 March 2016

There has been no change whatsoever in the Government’s position since my statement to the House in February … We are imposing a new contract, and we are doing it with the greatest of regret.

Source: Jeremy Hunt, speaking in Commons debate, 18 April 2016

Is it really the Government’s position that “no imposition” and “we are imposing a contract” mean the same thing?

No trainee working within contracted hours will have their pay cut.

Source: Jeremy Hunt, speaking in Commons debate, 11 February 2016

No one will see a fall in their income if they are working the legal hours.

Source: Ben Gummer (Parliamentary Under Secretary of State for Health), speaking in Commons debate, 21 March 2016

Is it the Government’s position that “contracted hours” and “legal hours” mean the same thing? Or did Gummer choose to to undersell the Government’s own guarantee on 21 March?

It will actually cost us more. If you’re going to ask more doctors to work at weekends, you’re going to have to pay more.

Source: Jeremy Hunt, on The Andrew Marr Show, 7 February 2016

[We have agreed] the cost neutrality of the contract

Source: Jeremy Hunt, in letter to Professor Dame Sue Bailey, 5 May 2016

Does the government consider “cost neutrality” and “it will actually cost us more” to have the same meaning?

What we do need to change are the excessive overtime rates that are paid at weekends. They give hospitals a disincentive to roster as many doctors as they need at weekends.

Source: Jeremy Hunt, speaking in Commons debate, 13 October 2015

What we’re actually doing is giving more rewards to people who work the nights and the more frequent weekends.

Source: Jeremy Hunt, on The Andrew Marr Show, 7 February 2016

Was the Secretary of State mis-speaking when he said that the contract reduced excessive overtime rates at weekends, or when he said that the new contract increased them?

Certain features of the new contract will adversely impact on those who work part-time, and a greater proportion of women than men work part-time; women, but not men, take maternity leave and some aspects of the new contract have certain adverse impacts regarding maternity; certain features of the new contract will potentially adversely impact on those who have responsibilities as carers.

Source: Government Equity Analysis of new contract, published 31 March 2016

Shorter hours, fewer consecutive nights and fewer consecutive weekends make this a pro-women contract that will help people who are juggling important home and work responsibilities.

Source: Jeremy Hunt, speaking in Commons debate, 18 April 2016

Is it the Government’s position that it got its own Equality Assessment wrong when it concluded that it discriminated against women?

No doctor will ever be rostered consecutive weekends.

Source: Jeremy Hunt, speaking in Commons debate, 18 April 2016

Good practice guidance will be published in the near future to support employers, including guidance on rotas and scheduling, and will make clear that, where possible, routine rostering of consecutive weekends should be avoided.

Source: NHS Employers, 31 March 2016

Does the Government consider that “ever” and “where possible” mean the same thing?

We will make the NHS more convenient for you. We want England to be the first nation in the world to provide a truly 7 day NHS.

Source: Page 38 of the Conservative Party Manifesto, 2015

There is concern that the government may want to see all NHS services operating 7 days. Let me be clear: our plans are not about elective care.

Source: Jeremy Hunt, speaking in Commons debate, 25 April 2016

Were the Conservatives up front about not including elective care in their plan to make the NHS more convenient with a truly 7 day service?

Source: First line of the first page of the Conservative Party Manifesto, 2015

The first line on the first page of this Government’s manifesto said that if elected we would deliver a seven-day NHS.

Source: Jeremy Hunt, speaking in Commons debate, 25 April 2016

Will Hunt correct the Parliamentary record for misquoting his own Party’s manifesto?

It is now not possible to change or delay the introduction of this contract.

Source: Jeremy Hunt, in letter to Dr Johann Malawana, 19 April 2016

We will pause introduction of the new contract for five days from Monday should the Junior Doctors’ Committee agree to return to talks.

Source: Jeremy Hunt, in letter to Professor Dame Sue Bailey, 5 May 2016

Is Hunt claiming to have achieved the impossible? Or was was his earlier statement erroneous?

Images used under by or by-sa licence as appropriate. Sources (in order of appearance): Ted Eytan, Roger Blackwell, University of Salford Press Office, Garry Knight, Ted Eytan (again), Garry Knight (again), NHS Confederation, Roger Blackwell (again). Thank you all!

There are roughly half a million beds in residential or nursing care homes in the UK.¹ Private providers operate almost all of these beds (90%) though the sector isn’t particularly lucrative: the average operator draws a profit of less than £5 per resident per day. Most beds are funded either in full (40%) or in part (10%) by local authorities. The NHS pays for a few (5%).

Central Government funding to local authorities was cut by 25% per person over the period of the last Government, though these cuts were not uniformly distributed across the country. This came on top of smaller reductions in funding over the previous five years. As a result, local authorities had much less to spend on social care. The number of day care places plummetted by 50% over a decade. About 20% fewer people received local authority funded care in their own home. And, partly as a result of this, the number of older people in residential or nursing care homes rose by more than 20%.

Over the next five years, we will see a perfect storm in social care for elderly people. The number of people aged over 75 is predicted to grow from 5.3 million today to 6.1 million in 2020 (a virtually unprecedented rate of increase, almost double what happened over the last five years). Yet Central Government funding to local authorities is to be cut further. Funding is being reduced while demand is predicted to increase more than ever before.

The burden will fall on the NHS, as it is in NHS beds that people often wait for care home places. The absurdity of this is that the average per-night cost of staying in an NHS hospital is three times greater than the average care home cost.

Yet there is another insidious factor imposed by Government which will push this situation from ‘substantial problem’ to ‘perfect storm’.

Most workers in residential and nursing care homes are paid minimum wage. By 2020, this will rise fromt £6.50 to £9.

Few could argue with giving hard-pressed workers a living wage. But given that average care home profits are less than 21p per patient per hour, care homes cannot maintain their current charges while increasing staff wages by £2.50 per hour. Yet they cannot raise their fees because Government cuts mean that local authorities can’t pay.

So what happens when care costs increase and funding decreases? First, care is cut: HC-One, Britain’s third-largest care home provider, is already training carers to take on highly skilled tasks which were previously done by more experienced and expensive nursing staff. But, since the cost of those carers is also increasing rapidly, this is only a stop gap solution. As Southern Cross, previously the UK’s largest care home provider, showed in 2011: care home providers can and will collapse.

As care home companies collapse, the supply of care home beds collapses with them. More elderly people get ‘stuck’ in NHS beds, at much greater cost to the taxpayer, and much greater risk to their own health.

And, to add extra thunderbolts to the storm, the number of NHS beds is decreasing rapidly: by nearly a quarter over the last ten years, with no sign of slowing. In this context, an increase in elderly people needlessly occupying NHS beds due to a lack of social care will cause the NHS to grind to a halt.

The underlying problem here is that the Government fails to understand that protecting NHS funding does not protect NHS services. Health and social care are two arms of the same beast: cutting one leaves the other with more to do. Yet the long-term solution isn’t obvious: there are limits to the burden of tax people are willing to carry to fund health and social care services.

The forecast is for bigger storms ahead.

Today, Philosophical Transactions of the Royal Society B has published a paper I co-wrote with the Chief Medical Officer and some public health colleagues on antimicrobial resistance policy. The abstract says:

Antibiotics underpin all of modern medicine, from routine major surgery through to caesarean sections and modern cancer therapies. These drugs have revolutionized how we practice medicine, but we are in a constant evolutionary battle to evade microbial resistance and this has become a major global public health problem. We have overused and misused these essential medicines both in the human and animal health sectors and this threatens the effectiveness of antimicrobials for future generations. We can only address the threat of anti-microbial resistance (AMR) through international collaboration across human and animal health sectors integrating social, economic and behavioural factors.Our global organizations are rising to the challenge with the recent World Health Assembly resolution on AMR and development of the Global Action plan but we must act now to avoid a return to a pre-antibiotic era.

The paragraph which has received most attention – perhaps surprisingly in a paper which predicts that more people will be dying of AMR than cancer and diabetes combined within decades – is one on food prices:

Public support for action to tackle AMR is crucial, as many measures to mitigate the effects of resistance will incur substantial financial and societal costs, which will ultimately be borne by the public, both through taxation and,probably, through higher purchase costs of products whose manufacturing methods are altered. For example, a pricing paradox exists in farming whereby antibiotics, an increasingly scarce natural resource, cost less than implementation of more rigorous hygiene practices. Reversal of this paradox may lead to higher food prices. While these costs are undoubtedly lesser than the long-term cost of unmitigated antibiotic resistance, they are also more immediate and, superficially at least, discretionary.

Anyway, it’s all quite interesting stuff (though I guess I’m a bit biased). Read it here.

Today marks the 202nd birthday of John Snow, the anaesthetist whose work on cholera changed the course of modern medical history, kicked off the modern era of public health, and—in 2003—saw him voted the greatest doctor of all time in a UK poll.

Snow is best known for his work on the 1854 cholera outbreak in Soho, London. He used what we would now call epidemiological techniques to map the outbreak and figure out that cases were centred around the Broad Street water pump. It turned out that the pump was dug mere inches from a cesspit which was leaking into the water supply, causing illness in those who drank from it.

The relevance of Snow’s work to modern public health cannot be overstated. Having spent much of his bicentennial year writing speeches with the Chief Medical Officer, I’ve found myriad parallels to draw between modern public health and the 1854 outbreak, and today seems as good a day as any to share some of them.

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In the recent past, public health has been criticised for being too remote and too disconnected from the communities it serves, leading to a considerable gap between what public health teams provide and what people actually need. There are a number of ways of tackling this, but perhaps one of the most important developments in the last few decades has been the cultivation of truly integrated multidisciplinary public health teams. These bring together people with a wide variety of backgrounds and skills to work on some incredibly knotty problems.

And so it was with the 1854 cholera outbreak.

Snow couldn’t have worked on the outbreak alone, as he had no community connections. Without his partnership with Reverend Henry Whitehead, the curate of St Luke’s Church in Soho, Snow would never have been able to find details of the cholera cases he needed to draw up his impressive maps and tackle the outbreak. Only by working with someone with different skills and a different background was Snow really able to connect with his community.

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Following the Health and Social Care Act of 2012, much of the responsibility for public health services passed to Local Authorities. You don’t have to spend too much time around public health teams to hear occasional grumbles about this—while people recognise the potential for influencing the wider determinants of health by working in Local Authorities, there are often frustrations about having to convince non-specialists of the utility and evidence base of certain courses of public health action.

And so it was with the 1854 cholera outbreak.

People often believe that Snow himself removed the handle from the infamous Broad Street pump to prevent the spread of the cholera outbreak. He didn’t; probably because that would have been considered vandalism, and possibly because—as an anaesthetist—plumbing skills weren’t his forte.¹ Instead, he talked his Local Authority into removing the pump handle. He initially found it difficult to get the message across, and his beautiful maps actually stem from his attempts to persuade the Local Authority to take action rather than from his investigation itself. Ultimately, the Local Authority either bought his argument or tired of him banging his drum, and removed the handle, saving the day.

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In modern public health, people often complain that national government interferes in the ability of local teams to act, either through interfering with the supply of funds, or through giving seemingly endless direction on things that should be considered or done at the local level.

And so it was with the 1854 cholera outbreak.

It’s an oft-forgotten footnote to the outbreak story that, having heard of what had happened in Soho, the national government ordered that the Broad Street pump handle be re-attached. There were too reasons for this: electorally, the closure of the Broad Street pump was a bad thing, for it was one of the most popular pumps in London, renowned for the clarity and taste of its water; scientifically, it was thought that the idea of faeco-oral transmission of disease was simply too disgusting to be true.

Yet when the pump handle was reattached, the outbreak didn’t restart. This was probably because the cesspit next to the pump well had been emptied—but it should also remind us that no matter how crazy they may seem, not all ideas from national government are completely mad.

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Effectiveness in modern public health can often involve challenging and overturning the status quo, sometimes in the face of considerable opposition from those with entrenched views.

And so it was with the 1854 cholera outbreak.

At the time of the outbreak, disease was thought to be transmitted by miasma—bad air. Today, it’s easy to underestimate the degree to which this faintly ridiculous theory was accepted: a glance through contemporary medical journals will reveal paper after paper on the design of hospitals and homes to promote the best flow of miasma. Indeed, one of the reasons so many Victorian hospitals had their morgues in the basement was so that miasma from the dead wouldn’t waft across other patients.

Snow—an anaesthetist, let us not forget—overturned the apple-cart of contemporary medicine by suggesting that disease could be water-borne. Virtually nobody believed him, and after 1854, he spent much of the following four years prior to his death trying to compile data to demonstrate his findings. His was a revolution that didn’t come easily. The Lancet, in an editorial on Snow’s theory in 1855, said

In riding his hobby very hard, he has fallen down through a gully-hole and has never since been able to get out again … Has he any facts to show in proof? No!

Yet, of course, germ theory proved Snow right—and The Lancet finally got round to publishing a correction on Snow’s 200th birthday.

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When working in public health in the North of England, it can often feel like breakthroughs made here are not fully appreciated, respected and integrated into practice until they’ve been endorsed by others—and particularly those in London.

And so it was with the 1854 cholera outbreak.

Snow was born in York trained at Newcastle Medical School. The first cholera outbreak he helped to tackle was in Newcastle in 1831, and though he was just 18 at the time, many believe that this is when he first developed the idea that cholera may be transmitted through water. Yet it wasn’t until his London-based work 23 years later that anyone took a blind bit of notice!