THE BLUE DEATH
DISEASE, DISASTER,
AND THE WATER WE DRINK
Dr. Robert D. Morris
To Astrid, Hana, Darwin, Sage, and Skyler,
for the joy you bring to life
CONTENTS
List of Illustrations
Prologue
PART I: Waterborne Killers
1. The Blue Death
2. Snow on Cholera
3. All Smell Is Disease
4. The Experimentum Crucis
5. The Doctor, the Priest, and the Outbreak at Golden Square
6. The Great Stink
PART II: Thirsty Cities and Dirty Water
7. The Race to Cholera
8. The Scramble for Pure Water
9. The Two-Edged Sword
10. Spring in Milwaukee
11. The Hidden Seed
PART III: At War with the Invisible
12. Drinking the Mississippi
13. Death in Ontario
14. Surviving the Storm
15. The Worst Place on Earth
16. The Future of Water: From E. Coli to al Qaeda
Epilogue:Strategies for Safe Water: A Modest Proposal
Bibliography and Notes
Acknowledgments
About the Author
Credits
Copyright
About the Publisher
ILLUSTRATIONS
Dr. John Snow, 1813–1858. A photograph in the series Literary and Scientific Portrait Club. (Bowerbank J. S. Literary and Scientific Portrait Club. London: Heinz Archive and Library of the National Portrait Gallery.)
Portrait of Sir Edwin Chadwick. (Photograph by J. Delmege. Courtesy of the Wellcome Library, London.)
Robert Koch, 1843–1910, bacteriologist, working in his laboratory at Kimberley, South Africa, 1921. (Photograph by William Osler.)
Vibrio cholerae. (Photograph from Arbeiten aus dem Kaiserlichen Gesundheitsamte, Volume III, 1887. Julius Springer Verlag, Berlin.)
Cryptosporidium. (Photograph courtesy of Dr. Saul Tzipori, Tufts University School of Veterinary Medicine.)
Carrollton Water Treatment Plant. (Photograph by Dr. Robert D. Morris, 2005.)
Collecting water in Mali. (Photograph by João Silva.)
PROLOGUE
Drinking water. In the walls, beneath the streets, around the world, it races through unseen pipes to fill tens of billions of glasses, cups, and bottles each day and to quench that most essential of human drives, thirst. For millions of years, intimate knowledge about the source of our water was among the most important bits of information our ancestors carried. Today that intimacy is lost. We turn on a tap and water flows as if by magic. We have come to accept the illusion as reality. Most of us have little awareness of the source of our drinking water. We assume it will be there. We assume it will be safe.
The road to disaster is paved with assumptions. The largest waterborne outbreak in U.S. history happened not centuries ago, but in 1993. Not only does waterborne disease still happen, but we don’t even know how often it occurs. Our system for detecting waterborne disease is so limited that drinking water is never even recognized as the cause in the vast majority of cases. Evidence suggests that drinking water may sicken millions of people every year in the United States.
For much of the developing world, waterborne disease is no secret. Like a tsunami in slow motion, unsafe drinking water is killing constantly; almost forty thousand people will die this week alone. Unlike a tsunami, it never stops.
In 1994 cholera swept through a crowded refugee camp in Goma, Zaire, and killed sixty thousand people in less than a month. It was the worst outbreak of waterborne disease in human history. The horror of Goma lies so far beyond the realm of experience for most of us that it takes on a sense of the remote and abstract. The gap between an epidemic in Goma and the sanitary comfort of the developed world seems vast, but for many reasons, this chasm may not be as immense as we imagine. Just a hundred years ago, waterborne typhoid fever was a leading cause of death in the United States. Less than fifty years before that, the major cities of Europe and North America were ravaged by waterborne cholera. The only thing that separates us from Goma is the systems we have developed to transport and treat our sewage and drinking water.
The operation of our water supplies is, to most of us, invisible. Invisibility encourages complacency. We have come to think of these systems as failsafe, but the technology we rely on for treating most of our drinking water is almost a century old and many of our water treatment plants have been in operation since the early twentieth century.
At least some of the water from these aging plants is, quite literally, treated sewage. Farm runoff, industrial waste, and sewage, both treated and untreated, routinely find their way to the intakes of our water treatment plants. Studies have shown that some of the pathogens (disease-causing microbes) from these sources can and do make their way into drinking water supplies, sometimes causing devastating outbreaks and frequently causing sporadic cases of disease. These diseases are not as deadly as cholera, but it is possible that this may not always hold true.
To understand where this story might lead, we must turn to its beginning. We must go back to a time when the difference between Goma and the developed world was far smaller, a time when we understood far less about health and disease and had no idea that a glass of water could kill.
In 1827, the industrial revolution was redefining the cities of the world. These population centers had grown over centuries from their agrarian roots into centers for commerce, education, religion, and government. Then, in a matter of decades, they had become the foundation of an uncharted industrial future, but remained propped on a rickety, haphazard infrastructure. Ill equipped to handle the influx of workers and the excreta of industry, these cities were straining at the seams. Filth and squalor grew in lockstep with urban populations. On the back of squalor rode epidemic diseases. When that happened the remarkably backward world of eighteenth century medicine would find itself scrambling to understand the causes of these diseases to identify the mechanisms for their control. At stake was nothing less than the viability of the industrial city.
Dr. John Snow
Sir Edwin Chadwick
PART I
Waterborne Killers
“Look at the water. Smell it! That’s wot we drinks. How do you like it, and what do you think of gin instead!”
CHARLES DICKENS, Bleak House
1
THE BLUE DEATH
As John Snow stood on the streets of York and bid farewell to his father, the air swirled with traces of spring, the odor of horses, and the ever-present reminders of bad sanitation. He climbed aboard the waiting coach with the few items of clothing that his father’s meager income could provide, food that his mother had prepared earlier that day, and the improbable hopes of his parents.
The crack of the driver’s whip bisected the life of young John Snow. His childhood dissolved into memories as the carriage rattled off the cobblestones of York to the ringing beat of horses’ hooves. As he bounced north along the turnpike to Newcastle, his future began.
In time John Snow would reshape medical science, invent the fundamental tools of epidemiology, and redefine our relationship with drinking water. But in that moment, he was just a fourteen-year-old boy, alone in the shadows of the carriage. Through its window, he watched the landscape of the familiar disappear. The year 1827 offered no time for the indulgence of adolescence. He would not see his parents again for seven years.
Snow had come of age amid the poverty that hugged the banks of the River Ouse. As the son of a laborer, he might well have expected to spend his life in a hardscrabble neighborhood like the one into which he had been born. The river brought
ships and barges and the opportunity for work, but it was grueling, physical labor that could grind a man to the bone with little chance for advancement. All manner of vermin, human as well as animal, scurried along the riverside. For a child, danger lurked in every darkened corner of the district.
One of the greatest hazards was the river itself. It routinely overflowed its banks, leaving behind dankness and rot. When it stayed within its course, many of the Snows’ neighbors along North Street routinely drank its water, oblivious to the hazards it carried.
John’s chances of escaping the filth and disease that clung to the working poor in Edwardian England were slim. If the daunting financial, physical, and social realities were not enough, Fanny Snow, the illegitimate daughter of a Yorkshire weaver, was heavy with her eighth child when she put her oldest son on that carriage to Newcastle. The simple demand of supporting such a large family would seem to extinguish any hope of escaping their place at the bottom of the economic ladder. The Snows, however, were not an average working class couple and John was far from a typical son.
The journey to Newcastle began when a six-year-old boy walked down Far Water Lane, turned down a narrow alley, and, for the first time, entered a remarkable world. There in the single room that comprised the Dodsworth School in St. Mary’s Parish, John Snow’s insatiable drive to understand took root. John Dodsworth, a York ironmonger, had founded three such schools to offer education to the city’s poor. The school Snow attended offered only twenty spots for boys between the ages of six and fourteen, selecting only the most talented and deserving children. With three parishes vying for just three or four openings each year, John may well have been the only child from the parish of All Saints Church chosen that year to attend. At Dodsworth School, he could learn to read and write free of charge. Arithmetic, his favorite subject, cost extra.
This was a fortuitous beginning for the bright young boy. For the eight years he attended, his parents not only made do without the assistance of their son, but also scraped together the extra money for his foray into math and science. Once he had completed those early years of schooling, he was ready to take a remarkable next step. John Snow would become a doctor.
The carriage rattled north across the English countryside for twenty-one bone-jarring hours before John Snow rolled through Gateshead, crossed the River Tyne, and rode into Newcastle. The view out the carriage window was unlike anything he had ever seen. The young man from York stared out at the grand metropolis. Great sailing ships lined the river, waiting to carry away the coal that powered the engines of the world and the booming economy of Newcastle. Ahead, on a hill, the castle keep stood watch over the bustling city as the spires of St. Nicholas and All Saints Church pierced the industrial sky.
The carriage left him in the heart of the city. From there John Snow walked up Westgate Street in the shadow of the thick stone tower of St. John’s church. There on the hillside, far from the filth and stink of the river’s edge, lived the city’s well-to-do. He had never seen such fine houses. Now he would live in one. For the next four years, he would stay in the home of William Hardcastle, just across from the church. A surgeon apothecary who had begun his practice in York before moving to Newcastle, Hardcastle was now among the most prominent doctors in the city. For a fee of one hundred guineas, he had agreed to take on Snow as an apprentice.
It seems likely that a hidden hand nudged open the door of opportunity to admit John Snow. The apprenticeship fee alone, roughly thirteen thousand in today’s dollars, would have dissuaded even the hardest-working laborer in 1827. Even with the fee in hand, it seems unlikely that an established surgeon would have taken on a poor boy from York as an apprentice. But more than five thousand miles away, in the jungles of South America, John Snow had a friend.
For three years Charles Empson had traveled deep into the Andean rain forest riding mules and small boats hundreds of miles into what would become Colombia. He had braved snakes, poisonous insects, and well-armed thieves and had dined on everything from roast armadillo to tortoise hash. He had come with the engineer Robert Stephenson to search the region’s abandoned gold and silver mines for business opportunities.
Empson was the brother of Fanny Snow. Although he would one day become a man of means, he was not yet wealthy. But he already had something far more valuable than mere money. Charles Empson had connections. He possessed a charisma that could unlock the doors of British society, which allowed him to create an ever-expanding social network. George Stephenson, the father of his traveling partner, was a visionary pioneer in the development of the British railroads. George and Robert Stephenson would go on to establish the first company to manufacture locomotives in England. The Stephensons lived just outside of Newcastle. Their family physician was another of Empson’s closest friends and John Snow’s mentor, William Hardcastle.
Empson and Snow would share a remarkable lifelong intimacy. Today the two men lie buried side-by-side in Brompton Cemetery. In 1827 Empson had connections to money, Newcastle, and Hardcastle, and he knew that his nephew, with his remarkable aptitude for math and natural science, was preparing to begin his career. It is not clear exactly which strings Empson pulled as he sat in Bogota and planned his return to England, but it is almost certain he pulled them.
If industry, ability, and a benevolent uncle launched John Snow on this mission, fate would define its course. A world away, in the ghettoes of Calcutta, another journey was beginning. An epidemic like none the world had seen before had begun to spread. As John Snow arrived to begin his medical training in Newcastle, cholera was in India, packing its bags.
In 1827 as William Hardcastle introduced his young apprentice to the vagaries of nineteenth-century surgery, cholera began to stretch its first fingers of death to the north and west of Calcutta. As John Snow learned the proper ways to slice into a patient’s veins and drain his blood, the disease climbed into the rugged mountains of central Asia.
Cholera strikes quickly. Within a day or two, its victims are writhing, immobilized in its terrifying grip. An obligate parasite, it must depend on its unfortunate host for survival. In that host, the bacteria finds food and an ideal environment to reproduce. The poor man or woman must also help cholera find a new victim.
Travel through the mountains of Afghanistan and southern Russia was arduous even under the best conditions. In the cold of winter, cholera’s messengers slowed to a crawl. The mountains were almost unpopulated. The carriers died or recovered before they could find new victims and cholera’s advance on Europe stalled.
Cholera, however, is a patient killer. By 1829 it had a second chance to spread. Improvements in the routes of transportation and the steady flow of British and Russian troops allowed cholera to reach Moscow. The great powers resorted to desperate measures to halt the disease. The Russians ordered their armies to surround any town where cholera appeared and shoot those who sought to escape. As the disease moved westward, the Germans massed troops at their border in hope of stopping the advance of the epidemic. Military might, however, was no match for cholera. By 1831, four years after John Snow began his apprenticeship, the British were under siege.
A creature that comes to life in the warmth of the human gut, the cholera bacterium thrives in hot, humid environments. Away from its home in India, it advanced in the summer and hid in the winter. During the summer of 1831, the pathogen took control of the ports of continental Europe. Britain’s vast armada of merchant ships flowed steadily into and out of those contaminated harbors. Each new load of returning cargo threatened to bring death to England.
Late in the summer, the Privy Council in London mandated that ships from Russia, Germany, or any Baltic port sit in quarantine for fifteen days. British warships patrolled the harbors of England, their cannons keeping watch over the invisible threat. As summer gave way to fall, the quarantine appeared to be working. By October the heat was fading and with it, the chances that a cholera epidemic would take hold. But Britain would not be spared. In the port city of Sunderla
nd, at the mouth of the River Wear, the defenses of the realm were unraveling.
The River Wear was William Sproat’s life. The river ran just south of Newcastle and the region’s burgeoning coal industry had been good for business. The robust keelman spent most of the fall plying the river in heavily laden barges. Occasionally he would reach a thirsty hand into its dark water. It seems that one day in the fall of 1829, as he drew his hand back from the river that had, for so long, given him life, death clung to his fingers.
In the middle of October, something took hold of William Sproat. He fought his illness for more than a week. Disease was a constant companion in nineteenth-century England. Sproat had seen all the illnesses of the day, but none had proved a match for his sturdy frame. He had never felt anything like this.
During the dark, early hours of Sunday, October 23, the disease got the upper hand. After ten days of vomiting and violent diarrhea, excruciating cramps wracked William Sproat’s body. The family doctor had no remedy. Fearing the worst, Sproat’s wife rushed to the home of the one physician who might offer hope.
Dr. James Butler Kell, the only doctor in Sunderland who had ever seen a case of cholera, was surprised to find the desperate Mrs. Sproat at his doorstep. Kell, an army surgeon, had recently come to Sunderland after twenty-eight years of military service that had taken him to the far reaches of the British Empire and into cholera’s kingdom. When Mrs. Sproat pleaded for his help, he pointed out that she had a physician already and he did not want to intrude on the practice of a local doctor. As she continued to describe the state of her husband, Kell’s memory stirred. The more he learned, the more convinced he grew that he should examine Mr. Sproat. Nonetheless he did not want to do so on his own. He immediately sent an urgent message to Dr. Reid Clanny, the most respected physician in Sunderland and a member of the newly formed Sunderland Board of Health, requesting that he join him in visiting the afflicted boatman.
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