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Sleuths on the scent of a superbug STUART KELLY

The Ghost Map by Penguin: Lane, £16.99

AT THE end of a sweltering August 1854 in Broad Street, Soho, London, a baby had

diarrhoea. A fortnight later, nearly 700 people who lived within 250 yards of

the child's home had perished. A tenth of the population of Broad Street died,

and only four of the 45 adjacent houses completely escaped any mortality. It was

perhaps the most virulent outbreak of cholera the city had ever witnessed, and

The Ghost Map tells the story of the two men who, against the prevailing

scientific wisdom, identified the source of the infection and prevented the

further spread of the epidemic.

One of them was Dr Snow, a brilliant anaesthetist, who had risen from

humble origins to treating Queen . He was diffident, teetotal,

vegetarian and was subjected to outraged denunciations in the pages of the newly

formed medical journal The Lancet. The other was a conscientious, open-minded,

sociable young clergyman, the Rev Henry Whitehead, who spent those awful weeks

in September tending to the families decimated by the disease.

It is a rattling scientific mystery: but in the hands of - author

of Everything Bad Is Good For You and, more importantly, Interface Culture and

Emergence - it becomes something much richer. Through the keyhole of Snow and

Whitehead's quest to counter the cholera outbreak, shows the reader a

vast, interconnected picture about urban and bacterial life: how information and

illness spreads, how ideas and sewage flow; in short, the whole ecosystem of

what a city 'means'. The Ghost Map is not just a remarkable story, but a

remarkable study in what we might learn from that story.

Part of its success is in the detailed context that provides. In 1854,

as detailed in Henry Mayhew's classic London Labour And The London Poor a decade

earlier, there existed a substantial underclass of scavengers, bone-pickers,

mud-larks, pure-finders, night-soil-men and crossing-sweepers. In one of the

salient comparisons that enrich 's text and the reader's understanding,

he notes that if they had all been relocated out of London they would have

formed the fifth biggest city in England. Their purpose in the metropolis was

simple, if unsavoury. Someone had to deal with all the filth.

LONDON WAS an industrial-age city with medieval waste-disposal. It wasn't just

open drains and overflowing cesspools: in some properties the cellars were

waist-deep in excrement. Yet, in one of the paradoxical virtuous circles that

specialises in, the transportation of this dung to the countryside had

enhanced the fertility of the soil, and meant that the city's increased food

requirements could be met.

Nonetheless, the sanitary conditions were a problem. There had been cholera

scourges beforehand, and the prevalent orthodoxy had it that the cause was

" miasma " - or, more bluntly, fetid, airborne stench. By a combination of

rationalism and local knowledge, Whitehead and Snow traced the very water-pump

that had been infected, even " Case Zero " - the sickly child whose nappy had

seeped into the drinking water.

Why did the miasma theory, against all evidence, enjoy such support?

doesn't offer a single cause, but a cluster of " overdetermined " factors. There

was the classical precedent of Hippocrates, and the unthinking conservatism that

aligned poverty with pestilence. Perhaps most important, however, was

involuntary instinct. Human noses may not be on a par with dogs', but they are

astonishingly sensitive organs, and they are hardwired into a very old part of

our brains. There is an evolutionary advantage in just gagging at foul smells -

it protects us from ingesting infected or decaying matter. Cholera, ironically,

was historically slow to spread because the idea of swallowing effluent is

unthinkable. Bad smells were obviously bad. A few parts diluted in a million

could go undetected.

Snow's challenge was that the answer was as invisible as the stinks were clear.

On one hand, the bacteria were microscopic. Infected water looked perfectly

transparent. On the other, the city-wide distribution pattern of fatalities was

just as difficult to visualise. Only by painstaking work and door-to-door

enquires did the true picture emerge.

The ghost map of the title refers to the ingenious way Snow represented his data

- a method now referred to as a Voronoi diagram. All cities have shortcuts as

well as cul-de-sacs, and Snow cleverly mapped the walking proximity to the

infected water-pump. You might be close to it as the crow flies, but a good

schlep away by foot. In this, Whitehead's parish experience was invaluable. He

knew how his parishioners went about their business. here sees a link to

the " new localism " of the internet, where amateurs, rather than corporate

planners, can best reflect a particular district's concerns, highlights and

character.

The lessons derives from Whitehead and Snow's successful investigation

are manifold. In the 19th century, the very idea of having more than two million

people living in a space of 90 square miles seemed irrational. Now it's normal.

What was at stake with cholera, to its contemporaries, was not so much staying

alive in the city but whether or not cities were even capable of sustaining

life.

On a pragmatic level, Whitehead and Snow paved the way for practically liveable

cities. They also, according to , revealed a more " emotional " level to

urban living. Two strangers, outwardly very different, one a man of science and

the other of faith, became friends. London, for all its grime and grief, was

still a place where new possibilities could occur. gives a stirring

defence of city life - ecologically, socially, in terms of health, in terms of

opportunity.

It may be one of the more contentious points in the book, but there is a certain

logic behind the idea that if we wish to preserve natural ecosystems, more

people will have to live in cities. The footprint of cities, however, depends on

very old-fashioned mathematics of scale. Disperse the population of Portland

across the state of Oregon, and you'd need 5,000 miles more of pipes, and

100,000 septic tanks. Congregation may be better than a return to nature.

It is not a wholly rose-tinted view. By 2015, the largest cities will be Tokyo,

Mumbai, Dhaka, Sao o and Delhi, and the scientific endeavour required to

turn the 'shadow cities' of squatters and shanties into viable residences will

be equal to Snow and Whitehead's. also addresses the problems of

terrorist threats, avian flu and other biological hazards, but reserves his

chief anxiety for old-fashioned nuclear explosions.

It is difficult to do justice to the exuberance of 's ideas, or to his

uncanny knack of finding connections and parallels between the most diverse and

esoteric disciplines. The Ghost Map is a challenging and exciting work which

removes historical non-fiction from the heritage industry and puts it back into

lively, impassioned debate.

http://scotlandonsunday.scotsman.com/review.cfm?id=1711812006

weaves multiple strands together in 'The Ghost Map'

Reviewed by Judy Goldstein Botello October 22, 2006

BOOK REVIEW

The Ghost Map: The Story of London's Most Terrifying Epidemic – and How It

Changed Science, Cities, and the Modern World

; Riverhead Books, 320 pages, $26.95

When cholera tore through London's Soho in 1854, more than 700 souls perished in

the course of 10 terrifying days. Almost every family lost someone, and many

families disappeared entirely, succumbing together in rooms dim with suffering

and death.

The medical authorities of the day believed that cholera was caused by miasma, a

vaguely defined poisonous vapor thought to be identifiable by its stench. And

stench was plentiful in Soho. It steamed from the mounds of human waste that

overflowed household cesspools. It wafted from the piles of night soil that

accumulated in basements and backyards. And it seeped with that raw sewage into

the water that gushed from the popular Broad Street pump into the pitchers and

jugs of the parish residents who gathered there to collect drinking water for

their homes.

In the end, of course, that contaminated water turned out to be teeming with

Vibrio cholerae, a bacterium that thrives in the human intestine and kills

within hours from massive dehydration. But although a few visionaries – most

notably Dr. Snow – claimed that cholera came from ingesting contaminated

water, the bulk of the medical establishment clung staunchly to the miasma

theory.

's " The Ghost Map " tells the story of Soho's 1854 cholera

outbreak, tracing the complex interplay among personalities and events that

finally led the parish's Board of Governors to remove the Broad Street pump

handle. writes of that decision, " [it] marks a turning point in the

battle between urban man and Vibrio cholerae, because for the first time a

public institution had made an informed intervention into a cholera outbreak

based on a scientifically sound theory of the disease. " In the years that

followed, Snow's so-called ghost map – a carefully constructed graphic

representation of the 1854 fatalities in relation to their water source –

convinced local government that cholera was, indeed, a waterborne infection; the

resultant renovation of London's sewer system put an end forever to cholera in

that city.

The story of Snow and the Broad Street pump has become an icon of medical

history: the quiet man of science initially scorned by his colleagues but

eventually celebrated as a hero of epidemiology and public health.

tells the tale with verve, spicing his narrative with scenes of

Dickensian squalor and the vibrant street life surrounding that squalor. But in

's hands, " Ghost Map " morphs into something more than mere history, and

his readers will recognize a reworking of his favorite themes: the interface of

culture and technology; the phenomenon of emergence (the bottom-up organization

of small interconnected elements into more complex systems); and always, like a

constant bass line in 's extended riff, the theme of urbanism – the

metropolis as a glorious culmination of emergence, technology and culture.

In his earlier books, positioned himself as a kind of Gen-X is de

Tocqueville, brimming with enthusiasm for the new culture he sees evolving on

the frontiers of science, technology and media. But unlike de Tocqueville,

is a product of the very culture he describes: He is a man obsessed by

systems, and by the web-like patterns of interconnected systems.

In " Ghost Map, " he tunes his systems-seeking antennae to the streets of 1854

Soho, celebrating Snow's consilient thinking, his analysis of patterns and

connections across various disciplines. Dr. Snow " was not interested in

individual, isolated phenomena; he was interested in chains and networks, in the

movement from scale to scale. " When the scale expanded exponentially during the

epidemic of 1854, Snow needed an ally, and introduces a second hero into

the story. Henry Whitehead was a gregarious and compassionate young curate

serving one of Soho's poorest areas; he visited the homes of his afflicted

parishioners as a friend as well as a clergyman. Although he initially embraced

the miasma theory, Whitehead underwent a gradual conversion based on detailed

observations of his devastated parish and on probing conversations with a new

acquaintance, Snow.

maintains that Snow's famous map could not have been drawn without

Whitehead's intimate knowledge of the individual families who lived around the

Broad Street pump. The map and its aftermath " should be understood not just as

the triumph of rogue science, but also ... as the triumph of a certain mode of

engaged amateurism, " writes . " ... The triumph of twentieth-century

metropolitan life is ... the dark ritual of deadly epidemics replaced by the

convivial exchanges of strangers from different backgrounds sharing ideas on the

sidewalk. " In other words, 's ubiquitous bass line: urbanism in all its

bottom-up glory.

From " the triumph of twentieth-century metropolitan life, " leaps

undaunted into the 21st century, contemplating, in the book's final chapters,

the long-term prospects for our increasingly urban planet. Notwithstanding a few

sober caveats on the dangers of high population density (the killing efficiency

of terrorist acts and deadly microbes increases directly with urban density), he

remains blithely optimistic. The story of the Broad Street pump, he suggests,

offers a model of hope for the future: Science will prevail over superstition,

and technology over squalor.

Meanwhile, in the burgeoning cities of today's developing world, cholera

continues to claim thousands of lives each year, while malaria, tuberculosis and

AIDS – all, like cholera, preventable diseases – claim millions. In the real

world, lack of political will often trumps technology, and 's dogged

optimism can sound almost brazen, as in his assertion that the poverty-stricken

squatters in Sao o's favelas choose to live there " because cities are where

the action is. " What he means is that cities offer to the rural poor a way out

of poverty – but many never escape those hellish cities-within-cities that make

Dickens' London look like St. Tropez.

While gazing through his half-full glass at the future's far horizon, where, he

believes, science and technology will have wrought their magic, takes a

cavalier attitude toward proximate suffering, observing coolly that during the

century or so before the world gets its act together " there will no doubt be

episodes of large-scale human tragedy, including cholera outbreaks that will

claim far more lives than were lost in Snow's time. " (So far this year, cholera

has claimed more than 2000 lives in Angola alone.) And he ignores completely the

unintended consequences of scientific progress: Drug-resistant microbes, for

example, or the upsurge of diabetes in prosperity's wake.

Like Snow, is a consilient thinker, weaving credible

theories from trends and patterns and complex connections. But like Snow,

needs a Henry Whitehead, someone to infuse those theories with the warm

breath of lived human experience.

http://www.signonsandiego.com/uniontrib/20061022/news_lz1v22map.html

Judy Goldstein Botello is a physician and author living in San Diego County.

A Drink of Death By DAVID QUAMMEN, NY Times

THE GHOST MAP: The Story of London's Most Terrifying Epidemic -- and How It

Changed Science, Cities, and the Modern World. By . 299 pp.

Riverhead Books. $26.95.

Several days ago I picked up a serious magazine and found , among

a panel of experts, discussing literacy in the age of video games. He offered

some mischievously counterintuitive thoughts, similar to those in his 2005 book

about popular culture, ''Everything Bad Is Good for You.'' One of his views,

much simplified, is that Grand Theft Auto makes children smart. And maybe it

does: some players evidently compose their own guidebooks for that vivid, ugly

game, offering hundreds of pages of tactical tips and strategic advice. ''If you

spend time assessing these complex systems and writing about them,''

told his fellow panelists, ''then you should be able to take that skill and

apply it to a real-world ecosystem or a political system or a cultural system.''

himself, having spent much of his childhood playing baseball-simulation

games rich with complexity and data, has now applied his own nimble cognitive

skills to a real-world ecosystem much messier than any imaginary ball diamond or

video-game universe: the city of London in the mid-19th century, with its 2.4

million humans, nightmarish plumbing and burden of dangerous microbes.

''The Ghost Map'' takes , who has also written books on neuroscience and

on the cultural implications of computer interfaces, in some new directions --

into historical narrative and the ecology of infectious disease. This time he

acknowledges that not everything bad for you is good. In fact some of it, like

the bacterium Vibrio cholerae, can be deadly.

There's a great story here, one of the signal episodes in the history of medical

science, and recounts it well. It centers, figuratively and literally,

on the infamous Broad Street pump. That pump, which was public, free and

previously considered a safe source of drinking water, drew from a well beneath

Golden Square, home to some of London's poorest and most overcrowded people. In

the last week of August 1854, many residents of Golden Square suddenly took sick

and began dying. Their symptoms included upset stomach, vomiting, gut cramps,

diarrhea and racking thirst. Whatever the cause, it was fast -- fast to kill

(sometimes within 12 hours of onset) and fast in spreading to new victims.

''Hundreds of residents had been seized by the disease within a few hours of one

another, in many cases entire families, left to tend for themselves in dark,

suffocating rooms,'' writes. Seventy fatalities occurred in a 24-hour

period, most within five square blocks, and hundreds more people were in danger.

''You could see the dead being wheeled down the street by the cartload.''

The medical authorities quickly enough put a name to this affliction. It was

cholera, known and dreaded in Britain since earlier outbreaks in the 1830s and

'40s, one of which had killed 7,466 Londoners within two years. But naming the

disease was far easier than curing it in an individual, or stopping its spread

in a population. None of the authorities understood what cholera was or how it

worked. Conventional wisdom took it for a miasmal disease, traveling by air as

some sort of lethal vapor -- a killer smell. If it preferentially affected the

poor, by this line of thought maybe that was because they lived in fetid

circumstances.

Snow, a private physician who had treated cholera during his apprenticeship

in Newcastle, had a different idea. He believed that the disease was caused by

an unidentified agent that victims ingested, probably in contaminated drinking

water. ''Cholera wasn't something you inhaled,'' explains, describing

Snow's crucial insight. ''It was something you swallowed.''

Snow was a ''consilient'' thinker, according to , using an old word

recently revived by E. O. , meaning that Snow combined insights from

different disciplines and different scales of investigation. He examined water

samples under a microscope. He studied the weekly statistics on cholera death

throughout London, looking for geographical patterns. Eventually he drew a map

-- the ''ghost map'' of the title -- that showed the correlation between cholera

cases and walking distance to the Broad Street pump. One week after the outbreak

began, having heard Snow's arguments, the local Board of Governors ordered the

shutdown of the Broad Street pump. Soon afterward the epidemic sputtered to an

end. And that's the satisfying denouement of the tale in its often-told,

bare-bones form: Snow pioneers the science of epidemiology and, by having a

pump handle removed, saves hundreds of lives. Among the points usually omitted,

however, is that Snow himself never managed to see or identify what it was, in

the water, making people sick. He got the epidemiology, but not the

bacteriology.

The fuller version of the story, as told by , is more complicated. It

includes another key character, an assistant curate named Henry Whitehead, who

ministered to residents of Golden Square and knew the details of their lives

well enough to identify the epidemic's starting point (a sick baby, whose

diapers contaminated the Broad Street well). It also includes an Italian

researcher named Filippo Pacini, who identified the cholera bacterium around the

same time Snow failed to see it, and who published a paper that lay ignored

for 30 years.

Most intriguingly, goes beyond the immediate details of the 1854

epidemic to consider such related matters as the history of toilets, the

upgrading of London's sewer system, the importance of population density for a

disease that travels in human excrement, and the positive as well as negative

aspects of urbanization itself. Never before n London, reminds

us, had 2.4 million primates of any species lived together within a 30-mile

perimeter.

By solving the cholera mystery, asserts, Snow and Henry Whitehead

helped make the world safe for big cities. And cities are ''where the action

is'' (he really does use that phrase, alas), being ''centers of opportunity,

tolerance, wealth creation, social networking, health, population control and

creativity.'' So it seems once again that, in the long run, everything bad is

good for you -- even crowded cities, even cholera, unless you happen to be one

of the dead people on the cart.

is of course a consilient thinker himself, and a smart one, no

doubt made even smarter by all that simulated baseball. His book is a formidable

gathering of small facts and big ideas, and the narrative portions are

particularly strong, informed by real empathy for both his named and his

nameless characters, flawed only sporadically by portentousness and small

stylistic lapses. One tic, which seems to me not just a matter of careless

wording, is his overly frequent use of the word ''ironically'' and its variants:

''The tragic irony of cholera'' was one thing, ''the dominant irony of the state

of British public health'' was something else, the ''dark irony'' of the miasma

theory was this, the ''sad irony'' of Snow's argument was that -- and I could

cite many other instances. That's a little too much irony for one short book,

and it seems to reflect 's insistence that his insights, beyond being

interesting and significant, are ingenious reversals of expectation.

Sometimes they are. It's fascinating to read that because of the life history of

Vibrio cholerae, which circulates in water flowing from one human gut to

another, the bacterium never caused big trouble in Britain until crowded urban

conditions exposed people to drinking one another's sewage. But 's

account of the 1854 epidemic, along with the meditation on cities that he

extrapolates from it, doesn't need to call attention to its own cleverness.

''The Ghost Map'' is elegantly sufficient, without that, to get readers to do

some thinking on their own.

Quammen's most recent book is ''The Reluctant Mr. Darwin.''

Getting the Disease: by Ben Mathis-Lilley

's latest book, The Ghost Map, tells the story of two Londoners

whose map of a cholera outbreak helped to virtually eradicate the disease.

spoke to Ben Mathis-Lilley about what the sewers of Olde London can tell

us about the urban world of tomorrow.

How did you become interested in this case?

I'd known about the story for a long time, and I had been thinking after 9/11

about the risks associated with dense urban settlements. In 1854, when an

epidemic could kill 10 percent of a neighborhood in five days, a lot of people

quite reasonably thought London would shrink and no one would build cities that

big anymore.

But density helped stop epidemics, too?

Right. What this doctor named Snow did was create a map that showed deaths

radiating out from one pump, so you could see cholera was in the water, which

almost no one at the time believed. But the assistant curate at the local

parish, not a man of science, also played a central role in the creation of the

map; he had all the on-the-ground neighborhood expertise needed to figure out

who had or hadn't drunk from this contaminated pump.

It sounds like crime-solving on The Wire.

The Wire is a great way of thinking about this. The Wire is in many ways a

sequel to the way that Dickens thought about the city—it works across the many

scales of city life.

But can new, improved information-sharing technology be put to a greater social

good than MySpace?

311 is the best urban information management tool in a long time. During the

blackout, 311 got a lot of calls from diabetics asking how long insulin could

last in a refrigerator without power. The city had no idea that that was going

to be a concern—but within a couple hours Bloomberg got the answer and discussed

it in his radio speech.

Doesn't technology also help people spread, or even create, an epidemic?

Yes, but our understanding of genetics is advancing at a rate much faster than

the diseases themselves. The most telling example is avian flu, which can't yet

spread rapidly between human hosts. It's remarkable: There's been billions of

dollars spent planning for a disease which doesn't even exist yet. In 20 or 30

years, we might be able to create vaccines immediately, and the idea of

epidemics won't keep us up at night.

Does global warming keep you up at night?

That might actually encourage us to urbanize more. In cities, people expend

fewer resources on heating and cooling; they use mass transit. Even if global

warming becomes catastrophic, we would probably still live in cities, though we

might have to move some of them.

http://nymag.com/arts/books/profiles/23148/

`Ghost Map' tells story of London's cholera epidemic

By Joann Gutin

Tribune Newspapers: Newsday

Published December 10, 2006

The Ghost Map: The Story of London's Most Terrifying Epidemic--and How It

Changed Science, Cities, and the Modern World

By , Riverhead, 299 pages, $26.95

Reading medical history is the best nostalgia cure known to man. It takes only a

few accounts of epidemic diseases like the Black Plague, smallpox or the Spanish

influenza to remind us that life in the long ago was not a costume drama. Nobody

had a clue what caused these deadly ailments, and the supposed remedies often

did more harm than good. Our forebears woke up every morning grimly aware that a

little scratch or a weird feeling in the stomach could be the harbinger of a

sudden, nasty end.

This is the world brings to life in his quirky, ambitious account

of the London cholera epidemic of 1854, " The Ghost Map. " Well into the 19th

Century, most people believed miasmas, or bad air, caused sickness. For doctors

of the day, he says, " The idea of microscopic germs spreading disease would have

been as plausible as the existence of fairies. "

And there was bad air to burn in what was then the world's largest city: Within

pages has plunged us into the cesspools of mid-n London. Crowded

buildings sat over cellars 3 feet deep in human waste; privies perched above

streams where children splashed, communal pumps and wells were the only water

source for most people. You contract cholera by drinking sewage-tainted water,

and London--and Paris and New York and Moscow--was a cholera epidemic waiting to

happen.

And those epidemics happened repeatedly. London had seen worse than the one that

hit in August 1854, though it was certainly bad enough. By its end, 700 people

had died in a city of more than 2 million. But the London epidemic is special

because it changed the course of history, thanks to Snow.

Snow, an anesthetist who presided over one of Queen 's many labors, was

sure it was the water, not the air, that was killing his neighbors. His genius

lay in the original way he tested his idea: not by examining patients but by

poring over the street addresses of those who had died. He quickly saw that most

clustered around a particular well on Broad Street in Soho. Learning of one

cholera victim far from Soho, Snow hustles to her house and finds her sons

brought her a jar of Broad Street water weekly, because she liked the taste.

Back in Soho, he wonders why no inhabitants of a particular workhouse succumbed;

a conversation with the director reveals the workhouse water was piped from

another source. And why were all the workers of a Broad Street brewery spared?

Because, Snow learns, they quenched their thirst with a daily allotment of free

beer.

Within a week, on the strength of his findings, Snow convinced authorities to

remove the handle from the Broad Street pump. Eventually he plotted the

distribution of the cases on a street map of London, the " Ghost Map " of the

title, which earned him a place in every public-health textbook, most popular

histories of the period and a Web site dedicated to him,

www.ph.ucla.edu/epi/snow.html.

This is more than a great medical detective story. It's the triumph of reason

and evidence over superstition and theory, and tells it in loving

detail. Maybe a little too loving, in fact; the accumulation becomes

overwhelming.

Cholera newbies will be a little deflated to learn that the epidemic was on the

wane before Snow got officials to remove the pump handle.

Ultimately, I think saw in Snow's story a chance to craft a bigger

story, one linking Snow's London with post-9/11 New York, and Snow's map with

21st Century virtual maps. But his analogies feel contrived. OK, Londoners were

terrorized by microbes; we're scared of terrorists with microbes; cities are

targets for germs and terrorist attacks because they're densely populated and

they're wonderful for the same reason. That's old news.

As for the old map/new map conceit, I never really got the point.

http://www.chicagotribune.com/features/booksmags/chi-0612090020dec10,1,3546944.s\

tory?coll=chi-leisurebooks-hed