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    John Snow and

    The Cholera Epidemic

DESCRIPTION:

    Students will learn the essential steps in an epidemiology investigation by studying John Snow’s classic investigation of the cholera epidemic in London in 1854.

RATIONALE:

    In the Mysterious Illness Outbreak scenario, students take on the roles of epidemiologists to investigate an outbreak of illness in Hydroville.

PURPOSE/GOALS:

    Students will be able to:

     Develop an understanding of the science of epidemiology and the methods of epidemiologists.

     Analyze epidemiological data.

     Develop hypotheses.

     Outline an epidemiological investigation and compare their ideas to the design of an historical investigation.

     Apply ratios and proportions to epidemiological data.

PREREQUISITE KNOWLEDGE:

     Ability to calculate ratio and proportions.

     A picture of what life was like in 19th century London, including environmental factors and lifestyles.

    th General knowledge of water and sewage systems in 19 century London: how water

    was delivered to communities, how a hand pump works, and what people did with their sewage.

TIME ESTIMATE:

    Prep: 30 minutes for photocopying

     30 minutes for listening to Part I: The Early Years: a Powerpoint slide

    presentation by Dr. Ralph Frerichs of UCLA or reading the many articles found

    at www.ph.ucla.edu/epi/snow.html.

    Activity time: Two to three 50-minute class periods

    Day 1: Introduction and Part 1

    Day 2: Parts 2 and 3

    Day 3: The Broadstreet Pump Outbreak by Dr. Ralph Frerichs, a powerpoint slide

    presentation at www.ph.ucla.edu/epi/snow.html. The site requires high speed

    internet access, computer and projector.

MATERIALS:

     Hydroville Science Journal

     MYSTERIOUS ILLNESS OUTBREAK SCENARIO John Snow and the Cholera Epidemic 1

    HYDROVILLE CURRICULUM PROJECT 2004, Oregon State University

    http://www.hydroville.org

Computer and projector

     High speed internet access

     Calculator

MATERIAL TO PHOTOCOPY:

     Transparency: Introduction to London 1850’s

     Student Instructions: John Snow’s Classic Studies of Cholera Epidemics in London

    1854 (1/student) Make a class set: These sheets can be laminated or placed in transparency sleeves to be used in all of your classes.

     Student Worksheet: (1/student)

BACKGROUND INFORMATION:

WHAT IS EPIDEMIOLOGY?

    (Adapted from: Epidemiology for Journalists. by Dr. Daniel Wartenberg)

    Epidemiology is the study of patterns of disease in human populations: who has disease, how much disease they have, and why they have it. The primary goal of epidemiology is to identify causes of disease and injury and explore ways to control and prevent them.

    Unlike physicians who study disease in individuals, epidemiologists study disease in groups of people, or populations. Where physicians address specifics, focusing on the uniqueness of each patient, epidemiologists focus on what is common and general about members of populations, inferring principles that apply to most, if not all, of the study subjects.

    Most epidemiological studies are field studies. Unlike the laboratory studies of the physicist or the chemist in which the investigator determines the conditions under which observations shall be made, epidemiologists observe the world as it is and must draw inferences that accommodate the study subjects’ particular habits (like smoking,

    drinking, and overeating).

    To further complicate matters, epidemiologists are able to study the same population under the same conditions only once. It is extremely difficultoften impossibleto

    replicate the specific history and experiences of any study group.

    In conducting an epidemiology study, epidemiologists need to know about as many characteristics of the study population as possible to make sure that every factor that affects disease is included. For example, if epidemiologists are studying the possible association between childhood leukemia and exposure to electric and magnetic fields, they need to take into account a wide range of factors other than electric and magnetic field exposures to which the child has been exposed. They might include whether the child was exposed to x-rays prenatally (a known risk factor for leukemia), whether the child was exposed to leukemogenic solvents or pesticides, or if the parents smoked cigarettes in the house. This means collecting a wide spectrum of information, which is a difficult and time-consuming process. Epidemiologists have developed carefully

     MYSTERIOUS ILLNESS OUTBREAK SCENARIO John Snow and the Cholera Epidemic 2

    HYDROVILLE CURRICULUM PROJECT 2004, Oregon State University

    http://www.hydroville.org

    designed protocols to tease out the important risk factors from the complex relationships.

WATERBORNE DISEASES AND SANITATION

    Waterborne Diseases: The first epidemic of a waterborne disease probably was caused by an infected caveman relieving himself in waters upstream of his neighbors. Perhaps the entire clan was decimated, or maybe the panicky survivors packed up their gourds and fled from the "evil spirits" inhabiting their camp to some other place. As long as people lived in small groups, isolated from each other, such incidents were sporadic.

    But as civilization progressed, people began clustering into cities. They shared communal water, handled unwashed food, stepped in excrement from casual discharge or spread as manure, used urine for dyes, bleaches, and even as an antiseptic. As cities became crowded, they also became the nesting places of waterborne, insect borne, and skin-to-skin infectious diseases that spurted out unchecked and seemingly at will.

    The ancients had no inkling as to the true cause of their misery. People believed divine retribution caused plagues and epidemics, or else bad air, or conjunction of the planets and stars, any and all of these things.

    Hippocrates, the "Father of Medicine" who lived around 350 B.C., recommended boiling water to filter out impurities - those particles that pollute its sweet taste, mar its clarity or poison the palate. He was onto something, but his advice pertained only to what the observer could taste, touch, smell or see with the naked eye. The "what you see is what you get" approach was about the extent of scientific water analysis until the late 1800s.

    That invisible organisms also thrive and swim around in a watery environment was beyond imagination until a few centuries ago, and their connection with disease wasn't established till a scant 100 years ago. Although the microscope was invented in 1674, it took 200 years more for scientists to discover its use in isolating and identifying specific microbes of particular disease. Only then could public health campaigns and sanitary engineering join forces in eradicating ancient and recurring enteric diseases, at least in developed countries of the world.

    Sanitation: From archeology we learn that various ancient civilizations began to develop rudimentary plumbing. Evidence has turned up of a positive flushing water closet used by the fabled King Minos of Crete back around 1700 B.C. The Sea Kings of Crete were renowned for their extravagant bathrooms, running hot and cold water systems, and fountains constructed with fabulous jewels and workings of gold and silver.

    Ancient water supply and sewerage systems - along with various kinds of luxury plumbing for the nobility - also have been discovered in early centers of civilization such as Cartage, Athens and Jerusalem. But it was the Roman Empire of biblical times that reigns supreme, by historical standards, in cleanliness, sanitation and water supply.

     MYSTERIOUS ILLNESS OUTBREAK SCENARIO John Snow and the Cholera Epidemic 3

    HYDROVILLE CURRICULUM PROJECT 2004, Oregon State University

    http://www.hydroville.org

    The Romans built huge aqueducts conveying millions of gallons of water daily, magnificent public baths and remarkable sewer systems. Rome spread its plumbing technology throughout many of its far-flung territories as well.

    A luxury toilet in the private houses of the well-to-do was a small, oblong hole in the floor, without a seat - similar to toilets that prevailed in the Far East and other sections of the world even today. A vertical drain connected the toilet to a cesspool below.

    Though the Roman Empire would last until the 6th century A.D., its fall was preceded by centuries of gradual decay, conflict and unrest. During the final century of Roman domination, there was a succession of earthquakes, volcanic eruptions and disease epidemics. Soon afterwards, rampaging Vandals and other barbaric tribes completed the breakdown of Western civilization, as they systematically leveled and defiled the great Roman cities and their water systems.

    Then came a thousand years of medieval squalor: a thousand years of sicknesses and plague of unbridled virulence, fanned by fleas and mosquitoes, excrement and filth, stagnant and contaminated water of every description. The typical peasant family of the aptly-named Dark Ages lived in a one-room, dirt-floor hovel, with a hole in the thatched roof to let out the smoke of the central fire. The floor was strewn with hay or rushes, easy havens for lice and vermin. Garbage accumulated within. If they were lucky, the family had a chamber pot, though more likely they relieved themselves in the corner of the hovel or in the mire and muck outside.

    Water was too precious to use for anything except drinking and cooking, so people rarely bathed. Heck, they barely changed clothes from one season to another, wearing the same set every day, perhaps piling on more rags for warmth.

    These are the conditions which spawned the infamous Black Plague in the 14th century, killing an estimated one third of the European population. Although not directly related to bad plumbing, the plague serves as the most striking example of misery caused by poor sanitation in general, and the ignorance of people in controlling the outbreak. So bad was the "Black Death," the Great Fire of London in 1666 can be viewed as a blessing in disguise. Though it killed thousands of people, the holocaust also consumed garbage, muck and black rats, effectively ending the plague.

    The Cholera Story: Among waterborne disease, cholera has proven one of history's most virulent killers. The good news is that it was through cholera epidemics that epidemiologists finally discovered the link between sanitation and public health, which provided the impetus for modern water and sewage systems.

    Now, in the 21st century, we know cholera is caused by ingesting water, food or any other material contaminated by the feces of a cholera victim. Casual contact with a contaminated chamber pot, soiled clothing or bedding, etc., might be all that's required to contract cholera. The disease is stunning in its rapidity. The onset of extreme diarrhea,

     MYSTERIOUS ILLNESS OUTBREAK SCENARIO John Snow and the Cholera Epidemic 4

    HYDROVILLE CURRICULUM PROJECT 2004, Oregon State University

    http://www.hydroville.org

    sharp muscular cramps, vomiting and fever, and then death - all can transpire within 12-48 hours. So much fluid is lost that the blood appears thick and about half of the patients will die, mainly of dehydration. It strikes so suddenly a man could be in good health at daybreak and he buried at nightfall.

    In the 19th century, cholera became the world's first truly global disease in a series of epidemics that proved to be a watershed for the history of plumbing. Festering along the Ganges River in India for centuries, the disease broke out in Calcutta in 1817 with grand-scale results.

    India's traditional, great Kumbh festival at Hardwar in the Upper Ganges triggered the outbreak. The festival lasts three months, drawing pilgrims from all over the country. Those from the Lower Bengal brought the disease with them as they shared the polluted water of the Ganges and the open, crowded camps on its banks.

    When the festival was over, they carried cholera back to their homes in other parts of India. There is no reliable evidence of how many Indians perished during that epidemic, but the British army counted 10,000 fatalities among its imperial troops. Based on those numbers, it's almost certain that at least hundreds of thousands of Indians must have fallen victim across that vast land.

    When the festival ended, cholera raged along the trade routes to Iran, Baku and Astrakhan and up the Volga into Russia, where merchants gathered for the great autumn fair in Nijni-Novgorod. When the merchants went back to their homes in inner Russia and Europe, the disease went along with them.

    Cholera sailed from port to port, the germ making headway in contaminated kegs of water or in the excrement of infected victims, and transmitted by travelers. The world was getting smaller thanks to steam-powered trains and ships, but living conditions were slow to improve. By 1827 cholera had become the most feared disease of the century.

    The worldwide cholera epidemic was aided by the Industrial Revolution and the accompanying growth of urban tenements and slums. There was little or no provision at all for cesspools or fresh water supplies. Tenements were several stories high, but cesspools were only on the ground floor with no clear access to sewers or indoor running water. It didn't make much difference, because until the 1840s a sewer was simply an elongated cesspool with an overflow at one end. "Night men" had to climb into the morass and shovel the filth and mire out by hand. In most cases, barrels filled with excrement were discharged outside, or contents of chamber pots flung from open windows to the streets below.

    Water hydrants or street pumps provided the only source of water, but they opened infrequently and not always as scheduled. They ran only a few minutes a day in some

     MYSTERIOUS ILLNESS OUTBREAK SCENARIO John Snow and the Cholera Epidemic 5

    HYDROVILLE CURRICULUM PROJECT 2004, Oregon State University

    http://www.hydroville.org

    of the poor districts. A near riot ensued in Westminster one Sunday when a water pipe that supplied 16 packed houses was turned on for only five minutes that week.

    Cholera first hit England through the town of Sunderland, on October 26, 1831. One William Sproat died that day from the disease, though nobody wanted to admit it. Merchants and officials found plenty of reasons to rationalize away a prospective 40 day maritime quarantine of the ports. England was reaping the profits of the Industrial Revolution and a quarantine of ships would be catastrophic for the textile industry.

    By the end of the first cholera epidemic, the relationship between disease and dirty, ill-drained parts of town was rather well established. This should have spurred sanitary reform. But little action followed. An out-of-sight, out-of-mind syndrome developed when the first epidemic ended. The learned Edinburgh Medical and Surgical Journal at one

    point declared they would review no more books on the subject ―because of the multitude of books which have recently issued from the press on the subject of cholera, and our determination to no longer try the patience of our readers."

    Dr. John Snow: The eminent Dr. John Snow demonstrated how cases of cholera that broke out in a district of central London could all be traced to a single source of contaminated drinking water. Sixteen years later Snow would win a 30,000 franc prize by the Institute of France for his theory that cholera was waterborne and taken into the body by mouth. But Snow's original work received little attention from the medical profession. He was attacked at the weakest point - that he could not identify the nature of the "poison" in the water.

    When the second cholera epidemic hit England in 1854, Snow described it as "the most terrible outbreak of cholera which ever occurred in this kingdom." At least it provided him with an opportunity to test his theory. By charting the incidence of the disease, he showed that over 500 cases occurred within 10 days over a radius of some 250 yards centered on London's Broad Street. He looked for some poison which he believed came from the excreta of cholera patients and swallowed by the new victims. A common factor was their use of water from the Broadstreet pump.

    By the methodical process of elimination, he proved his point: A workhouse in that area had its own private well, and there were only 5 deaths among its 535 inmates. A brewery on Broad Street likewise never used the water from the Broad Street pump. Its workers drank beer and it had no cases among its 70 workers.

But Dr. Snow died in 1858 not knowing what caused cholera. It wasn’t until 1876 that a

    German doctor, Robert Koch discovered the comma-shaped bacillus, vibrio cholera, that

    causes cholera. Through microscopic examination, he ascertained that ―excrement may

    contain cholera bacteria a good while after the actual attack of the disease."

TERMINOLOGY:

    Epidemic Epidemiologists Epidemiology

     MYSTERIOUS ILLNESS OUTBREAK SCENARIO John Snow and the Cholera Epidemic 6

    HYDROVILLE CURRICULUM PROJECT 2004, Oregon State University

    http://www.hydroville.org

Theory Hypothesis Cholera

SUGGESTED LESSON PLAN:

PART 1: INTRODUCTION AND PART I

Getting Started

    1. To introduce the students to a hand pump and the environmental conditions of

    London in the1850’s, (which is significant to understanding the cholera outbreak),

    show Transparency 1. Have students respond to the Journal Prompt in their

    Hydroville Journals or in small groups. (Transparency 1: ―When and where do

    you think this drawing is taking place? What do you think were the environmental

    and social conditions of the time?‖)

    Women are drawing water from a hand pump located on Broad Street in London during

    the 1800’s. London experienced great change during the life of John Snow. The city grew

    dramatically between 1813 and 1858, and was at the center of a financial and social empire,

    which reached around the world. Yet during these same years, residents of London suffered

    greatly from death and disease, including epidemics of cholera. In addition they faced

    extensive environmental pollution, most notably of the majestic River Thames.

    2. This activity is divided into two parts. Provide each student with a copy of the

    Student Instructions for Part 1 and Student Worksheet and then the Student

    Instructions for Part 2 and then Part 3. To save on photocopying costs, Student

    Instructions for Parts 1-3 can be laminated or placed into transparency sleeves and

    be reused by other classes.

Doing the Activity

    1. Students can work individually or in pairs. They answer questions on a copy of the

    Student Worksheet.

    2. Class Discussion: Use the information provided in the Teacher Introduction and

    at www.ph.ucla.edu/epi/snow.html to help students answer the following

    questions.

    ; What would a person living in 1840 know about the causes of disease? What

    would a doctor know? How would diseases be treated in a pioneer cabin? In an

    Indian longhouse?

    ; How would someone living in a tenement in London or New York City in 1840

    get their water?

    ; In 1840, what would the sanitation system be like in a pioneer cabin? A home in

    Chicago? An apartment in inner city London?

    3. Have students work together on the instructions for Part 1.

     MYSTERIOUS ILLNESS OUTBREAK SCENARIO John Snow and the Cholera Epidemic 7

    HYDROVILLE CURRICULUM PROJECT 2004, Oregon State University

    http://www.hydroville.org

    4. When the students have completed answering the questions from Part 1, have a

    group discussion to review what was covered and what the students learned. 5. Hand out the Student Instructions for Part 2 and repeat the process. 6. Hand out the Student Instructions for Part 3 and repeat the process.

Wrap-up

     Part 2: Broad Street Pump Outbreak (www.ph.ucla.edu/epi/snow.html) is an

    excellent review of the work of John Snow by Dr. Ralph Frerichs of UCLA. It takes

    about 45 minutes to show and requires a computer, projector, and high speed

    internet connection. Or students could view this as a homework or library

    assignment.

     Journal Prompt: Each student should write a response to the following prompt in

    his or her Science Journal: If you were investigating a cholera epidemic today,

    how would your study be different from John Snow’s? (What would you do that

    he didn’t do?)‖

ASSESSMENT:

    Collect student worksheets. Answers will vary. Assessment will be subjective, based on the thoughtfulness or reasoning evident, and on completion.

EXTENSIONS:

Science

     Microbes in the Water: Have students take a microscopic look at different types

    of water (i.e., drinking water, river water, distilled water or water from a pond

    or ditch).

RESOURCES:

    A biography of John Snow, descriptions the Broad Street pump outbreak, and drawings are included at the following web site - http://www.ph.ucla.edu/epi/snow.html: UCLA Department of Epidemiology. School of Public Health. John Snow An

    Historical Giant in Epidemiology. http://www.ph.ucla.edu/epi/snow/snowbio.html

     Broad Street Pump Outbreak:

    http://www.ph.ucla.edu/epi/snow/broadstreetpump.html

     An illustration of The Broad Street Pump

    http://www.ph.ucla.edu/epi/snow/broadstpumpwomen.htm

     BBC Online, 2001. John Snow 1813-1858.

    http://www.ph.ucla.edu/epi/snow/bbc_snow.htm

     Center for Disease Control. Biography of John Snow

    http://www.cdc.gov/ncidod/dbmd/snowinfo.htm

     University of Texas Library Online. Historical Map of London available at this

    web site: http://www.lib.utexas.edu/maps/historical/thames_river_1882.jpg

     MYSTERIOUS ILLNESS OUTBREAK SCENARIO John Snow and the Cholera Epidemic 8

    HYDROVILLE CURRICULUM PROJECT 2004, Oregon State University

    http://www.hydroville.org

    TRANSPARENCY 1:

Learning Log Prompt:

    When and where do you think this drawing is taking place?

    What do you think were the environmental and social conditions of the time?

     MYSTERIOUS ILLNESS OUTBREAK SCENARIO John Snow and the Cholera Epidemic 9

    HYDROVILLE CURRICULUM PROJECT 2004, Oregon State University

    http://www.hydroville.org

    TEACHER KEY

    STUDENT ANSWER SHEET

PART 1

    1. Using Snow’s spot map (Figure 1), what observations can you make about the distribution of the cholera cases?

    Students should notice that most of the cases are near water pump A, and very little near water pumps B and C.

    2. Which well would you pick as the most likely source of contaminated water? Well A.

3. Why wouldn’t you identify pump C as the possible source?

    Because very few cases of cholera occurred near pump C.

    4. What reasons could explain why there were no cases of cholera in the people living in the two- block area around the brewery east of pump A?

    Most teams will probably say that those people drank beer instead of water. (They are correct, but the brewery also had a deep well used by the people that worked there.)

    5. What could Snow do to test his hypothesis that the epidemic was caused by water from Pump A? (Remember that he couldn't actually test the water for bacteria.) Answers should vary, but focus on collecting data about where people got their water.

6. What did John Snow do to prove that pump A was the source of the cholera?

    He interviewed people with cholera about where they got their water.

    7. Compare your answer to question 6 with your answer for question 5. How did your plan differ from what Snow actually did?

    Based on previous student answers.

PART 2

    8. Refer to Table 2. Does this data support Snow’s hypothesis that polluted water causes cholera? Why or Why not?

    Table 2 does support Snow's theory and points to Company 1 as the source because so many people getting water from that company got cholera, and no cholera deaths occurred in the population served only by Company 2.

9. Is it conclusive proof that Snow’s hypothesis is correct? Why or why not? It is not

    conclusive proof. The large number of deaths in areas served by both water companies is not explained.

    10. What other factors might be causing the difference in cholera rates in the different London districts?

    Students must brainstorm possible causes here. They could include: Foods, animals, where

     MYSTERIOUS ILLNESS OUTBREAK SCENARIO John Snow and the Cholera Epidemic 10

    HYDROVILLE CURRICULUM PROJECT 2004, Oregon State University

    http://www.hydroville.org

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