History of cholera explained

Seven cholera pandemics have occurred in the past 200 years, with the first pandemic originating in India in 1817. The seventh cholera pandemic is officially a current pandemic and has been ongoing since 1961, according to a World Health Organization factsheet in March 2022. Additionally, there have been many documented major local cholera outbreaks, such as a 1991–1994 outbreak in South America and, more recently, the 2016–2021 Yemen cholera outbreak.[1]

Although much is known about the mechanisms behind the spread of cholera, this has not led to a full understanding of what makes cholera outbreaks happen in some places and not others. Lack of treatment of human feces and lack of treatment of drinking water greatly facilitate its spread. Bodies of water have been found to serve as a reservoir, and seafood shipped long distances can spread the disease.

Between 1816 and 1923, the first six cholera pandemics occurred consecutively and continuously over time. Increased commerce, migration, and pilgrimage are credited for its transmission.[2] Late in this period (particularly 1879–1883), major scientific breakthroughs toward the treatment of cholera develop: the first immunization by Pasteur, the development of the first cholera vaccine, and identification of the bacterium Vibrio cholerae by Filippo Pacini and Robert Koch. After a long hiatus, a seventh cholera pandemic spread in 1961. The pandemic subsided in the 1970s, but continued on a smaller scale. Outbreaks occur across the developing world to the current day. Epidemics occurred after wars, civil unrest, or natural disasters, when water and food supplies had become contaminated with Vibrio cholerae, and also due to crowded living conditions and poor sanitation.[3]

Deaths in India between 1817 and 1860 in the first three pandemics of the nineteenth century, are estimated to have exceeded 15 million people. Another 23 million died between 1865 and 1917, during the next three pandemics. Cholera deaths in the Russian Empire during a similar time period exceeded 2 million.[4]

Pandemics

The first cholera pandemic occurred in the Bengal region of India, near Calcutta (now Kolkata), starting in 1817 through 1824. The disease dispersed from India to Southeast Asia, the Middle East, Europe, and Eastern Africa through trade routes. The second pandemic lasted from 1826 to 1837 and particularly affected North America and Europe, due to the result of advancements in transportation and global trade, and increased human migration, including soldiers.[5] The third pandemic erupted in 1846, persisted until 1860, extended to North Africa, and reached South America, for the first time specifically affecting Brazil. The fourth pandemic lasted from 1863 to 1875, and spread from India to Naples and Spain, and to the United States in 1873. The fifth pandemic was from 1881 to 1896 and started in India and spread to Europe, Asia, and South America. The sixth pandemic started in India and lasted from 1899 to 1923. These epidemics were less fatal due to a greater understanding of the cholera bacteria. Egypt, the Arabian peninsula, Persia, India, and the Philippines were hit hardest during these epidemics, while other areas, such as Germany in 1892 and Naples from 1910 to 1911, also suffered severe outbreaks. The seventh pandemic originated in 1961 in Indonesia and is marked by the emergence of a new strain, nicknamed El Tor, which still persists (as of 2019[6]) in developing countries.[7]

Cholera did not occur in the Americas for most of the 20th century after the early 1900s in New York City. It reappeared in the Caribbean toward the end of that century and seems likely to persist.[8]

First, 1817–1824

See main article: 1817–1824 cholera pandemic. The first cholera pandemic, though previously restricted, began in Bengal, and then spread across India by 1820. Hundreds of thousands of Indians and ten thousand British troops died during this pandemic.[9] The cholera outbreak extended as far as China, Indonesia (where more than 100,000 people succumbed on the island of Java alone) and the Caspian Sea in Europe, before receding.[10] In 1821, it is estimated that up to 100,000 deaths occurred in Korea.[11]

Second, 1826–1837

See main article: 1826–1837 cholera pandemic. A second cholera pandemic reached Russia (see Cholera Riots), Hungary (about 100,000 deaths) and Germany in 1831;[12] it killed 130,000 people in Egypt that year.[13] In 1832 it reached London and the United Kingdom (where more than 55,000 people died)[14] and Paris. In London, the disease claimed 6,536 victims and came to be known as "King Cholera"; in Paris, 20,000 died (of a population of 650,000), and total deaths in France amounted to 100,000.[15] In 1833, a cholera epidemic killed many Pomo, which are a Native American tribe. The epidemic reached Quebec, Ontario, Nova Scotia,[16] and New York in the same year, and the Pacific coast of North America by 1834. In the center of the country, it spread through the cities linked by the rivers and steamboat traffic.[17]

In Washington D.C. Michael Shiner, an enslaved laborer at the Washington Navy Yard recorded, "The time the colery [cholera] broke out in about June and July August and September 1832 it Raged in the City of Washington and every day they wher [were] twelve or 13 carried out to they [their] graves a day."[18] By late July 1832, cholera had spread to Virginia and on 7 August 1832, Commodore Lewis Warrington confirmed to the Secretary of the Navy Levi Woodbury cholera was at the Gosport Navy Yard, "Between noon of that day, [1 August] and the morning of Friday [3 August], when all work on board her USS Fairchild stopped, several deaths by cholera occurred and fifteen or sixteen cases (of less violence) were reported."[19]

The epidemic of cholera, cause unknown and prognosis dire, had reached its peak.[20] Cholera afflicted Mexico's populations in 1833 and 1850, prompting officials to quarantine some populations and fumigate buildings, particularly in major urban centers, but nonetheless the epidemics were disastrous.[21]

During this pandemic, the scientific community varied in its beliefs about the causes of cholera. In France, doctors believed cholera was associated with the poverty of certain communities or poor environment. Russians believed the disease was contagious, although doctors did not understand how it spread. The United States believed that cholera was brought by recent immigrants, specifically the Irish, and epidemiologists understand they were carrying disease from British ports. Lastly, some British thought the disease might rise from divine intervention.[22]

Third, 1846–1860

See main article: Third cholera pandemic. The third cholera pandemic deeply affected Russia, with over one million deaths. Over 15,000 people died of cholera in Mecca in 1846.[23] A two-year outbreak began in England and Wales in 1848, and claimed 52,000 lives.[24]

In 1849, a second major outbreak occurred in France. In London, it was the worst outbreak in the city's history, claiming 14,137 lives, over twice as many as the 1832 outbreak. Cholera hit Ireland in 1849 and killed many of the Irish Famine survivors, already weakened by starvation and fever.[25] In 1849, cholera claimed 5,308 lives in the major port city of Liverpool, England, an embarkation point for immigrants to North America, and 1,834 in Hull, England. In Vietnam and Cambodia, cholera hit in summer 1849, killing approximately 589,000 to 800,000 people within one year, along with its consequential famine.[26] [27]

An outbreak in North America took the life of former U.S. President James K. Polk. Cholera, believed spread from Irish immigrant ships from England, spread throughout the Mississippi river system, killing over 4,500 in St. Louis and over 3,000 in New Orleans. Thousands died in New York, a major destination for Irish immigrants. Cholera claimed 200,000 victims in Mexico.[28]

That year, cholera was transmitted along the California, Mormon, and Oregon Trails as 6,000 to 12,000[29] are believed to have died on their way to the California Gold Rush, Utah and Oregon in the cholera years of 1849–1855. It is believed more than 150,000 Americans died during the two pandemics between 1832 and 1849.[30]

In 1851, a ship coming from Cuba carried the disease to Gran Canaria.[31] It is considered that more than 6,000 people died in the island during summer,[32] out of a population of 58,000.

In 1852, cholera spread east to the Dutch East Indies and later was carried to Japan in 1854. The Philippines were infected in 1858 and Korea in 1859. In 1859, an outbreak in Bengal contributed to transmission of the disease by travelers and troops to Iran, Iraq, Arabia, and Russia. Japan suffered at least seven major outbreaks of cholera between 1858 and 1902. Between 100,000 and 200,000 people died of cholera in Tokyo in an outbreak in 1858–1860.[33]

In 1854, an outbreak of cholera in Chicago took the lives of 5.5 percent of the population (about 3,500 people).[34] Providence, Rhode Island, suffered an outbreak so widespread that for the next thirty years, 1854 was known there as "The Year of Cholera."[35] In 1853–1854, London's epidemic claimed 10,739 lives. The 1854 Broad Street Cholera outbreak in London ended after the physician John Snow identified a neighborhood Broad Street pump as contaminated and convinced officials to remove its handle to prevent people from drawing water there.[36] His study proved contaminated water was the main agent spreading cholera, although he did not identify the contaminant. It would take many years for this message to be believed and fully acted upon.[37] In Spain, over 236,000 died of cholera in the epidemic of 1854–1855.[38] The disease reached South America in 1854 and 1855, with victims in Venezuela and Brazil. During the third pandemic, residents of Tunisia, which had not been affected by the two previous pandemics, thought Europeans had brought the disease. They blamed their sanitation practices. Some United States scientists began to believe that cholera was somehow associated with African Americans, as the disease was prevalent in the South in areas of black populations. Current researchers note their populations were underserved in terms of sanitation infrastructure and health care, and they lived near the waterways by which travelers and ships carried the disease.[39]

From November 10, 1855, to December 1856, the disease spread through Puerto Rico, claiming 25,820 victims.[40] Cemeteries were expanded to allow for the burial of victims of cholera.[41] In Arecibo, a large municipality of Puerto Rico, the number of people dying in the streets was so great that the city could not keep up. A man named Ulanga made it his responsibility to collect and carry the dead to the provisional Spanish; Castilian: Cementerio de los Coléricos.[42]

Fourth, 1863–1875

See main article: 1863–1875 cholera pandemic. The fourth cholera pandemic of the century began in the Ganges Delta of the Bengal region and traveled with Muslim pilgrims to Mecca. In its first year, the epidemic claimed 30,000 of 90,000 Mecca pilgrims.[43] Cholera spread throughout the Middle East and was carried to Russia, Europe, Africa and North America, in each case spreading from port cities and along inland waterways.

The pandemic reached Northern Africa in 1865 and spread to sub-Saharan Africa, killing 70,000 in Zanzibar in 1869–1870.[44] Cholera claimed 90,000 lives in Russia in 1866.[45] The epidemic of cholera that spread with the Austro-Prussian War (1866) is estimated to have taken 165,000 lives in the Austrian Empire, including 30,000 each in Hungary and Belgium and 20,000 in the Netherlands.[46] Other deaths from cholera at the time included 115,000 in Germany, 90,000 in Russia, and 30,000 in Belgium.[47]

In London in June 1866, a localized epidemic in the East End claimed 5,596 lives, just as the city was completing construction of its major sewage and water treatment systems (see London sewerage system); the East End section was not quite complete.[48] Epidemiologist William Farr identified the East London Water Company as the source of the contamination. Farr made use of prior work by John Snow and others pointing to contaminated drinking water as the likely cause of cholera in an 1854 outbreak. Quick action prevented further deaths. In the same year, the use of contaminated canal water in local water works caused a minor outbreak at Ystalyfera in South Wales. Workers associated with the company and their families were most affected, and 119 died.

In 1867, Italy lost 113,000 lives; and 80,000 died of the disease in Algeria.[44] Outbreaks in North America in the 1870s killed some 50,000 Americans as cholera spread from New Orleans to other ports along the Mississippi River and its tributaries. None of the cities had adequate sanitation systems, and cholera spread through the water supply and contact.[49] [50]

Fifth, 1881–1896

See main article: 1881–1896 cholera pandemic. According to A. J. Wall, the 1883–1887 part of the epidemic cost 250,000 lives in Europe and at least 50,000 in the Americas. Cholera claimed 267,890 lives in Russia (1892);[51] 120,000 in Spain;[52] 90,000 in Japan, and over 60,000 in Persia. In Egypt, cholera claimed more than 58,000 lives. The 1892 outbreak in Hamburg killed 8,600 people. Although the city government was generally held responsible for the virulence of the epidemic, it was not changed. This was the last serious European cholera outbreak, as cities improved their sanitation and water systems.

From the Russian Empire, cholera most likely spread to European countries. In Russia, cholera vibrio was found in Baku in 1892. The authorities of the city, despite the mortality of the population from cholera for a long time did not recognize the outbreak of the epidemic. The residents of Baku left the city, including traveling to Astrakhan, a city located in the delta of the Volga River. After quarantine measures were introduced in Astrakhan, rumors spread among the population that living people were being put in coffins, sprinkled with lime, and buried in cholera hospitals. These rumors provoked riots. During the riots, medical workers were killed, the cholera hospital was burned down, and the infected were sent home. The incidence of the disease increased dramatically after the riots. From June 14 to September 20, 1892, more than 3% of Astrakhan's population died of cholera, with 480 cases and 316 deaths per 10,000 inhabitants. This was the demographic maximum of the 1892 cholera epidemic. An estimate of excess mortality showed an increase of 278% in June and 555% in July over the same months in 1888–1894. Of all those admitted to Astrakhan hospitals, about 73% were workers living in hostels (shelters), about 5% were workers on ships, steamships, and barges, and 12% were artisans. The social composition by estates was as follows: 1983 peasants, 316 soldiers, 262 bourgeois, 12 Cossacks, 8 nobles and 5 clergymen. Natives of Astrakhan and the province accounted for about 11% of the cases, 89% were seasonal migrants. Many children were orphaned due to the high mortality rate. Because cholera is characterized by waterborne transmission, cholera epidemics were observed in large cities along the Volga River. Much of the empire was infested with cholera vibrio.[53]

Sixth, 1899–1923

See main article: 1899–1923 cholera pandemic. The sixth cholera pandemic, which was due to the classical strain of O1, had little effect in western Europe because of advances in sanitation and public health, but major Russian cities and the Ottoman Empire particularly suffered a high rate of cholera deaths. More than 500,000 people died of cholera in Russia from 1900 to 1925, which was a time of extreme social disruption because of revolution and warfare.[54]

Cholera broke out 27 times during the hajj at Mecca from the 19th century to 1930. The sixth pandemic killed more than 800,000 in India.[24] The 1902–1904 cholera epidemic claimed 200,000 lives in the Philippines,[55] including their revolutionary hero and first prime minister Apolinario Mabini. A 1905 governmental report mentioned he reappearance of asiatic cholera, characterized that as noteworthy, and described a "very strict marine quarentine" and other measures being imposed in the archipelago to control it.[56]

The last outbreak of cholera in the United States was in 1910–1911, when the steamship Moltke brought infected people from Naples to New York City. Vigilant health authorities isolated the infected in quarantine on Swinburne Island. Eleven people died, including a health care worker at the hospital on the island.[57] [58] [59]

In 1913, the Romanian Army, while invading Bulgaria during the Second Balkan War, suffered a cholera outbreak that resulted in 1,600 deaths.[60] [61] [62]

During the outbreak, due to cholera frequently being spread by immigrants and tourists, the disease became associated with either outsiders or marginalized groups in societies. In Italy, some blamed Jews and Romani, while in British India numerous Anglo-Indians ascribed the spread of cholera to Hindu pilgrims, and in the United States many accused Filipino immigrants of introducing the disease.[63]

Seventh, 1961–present

See main article: Seventh cholera pandemic. As of March 2022, the World Health Organization (WHO) continues to define this outbreak as a current pandemic, noting that cholera has become endemic in many countries. In 2017, WHO announced a global strategy aimed at this pandemic with the goal of reducing cholera deaths by 90% by 2030.[64]

The seventh cholera pandemic began in Indonesia, called El Tor[65] after the strain, and reached East Pakistan (now Bangladesh) in 1963, India in 1964, and the Soviet Union in 1966. From South America, it spread into Italy by 1973. In the late 1970s, there were small outbreaks in Japan and in the South Pacific. There was an outbreak in Odessa in July 1970, and there were also many reports of a cholera outbreak near Baku in 1972, but information about it was suppressed in the Soviet Union. In 1970, a cholera outbreak struck the Sağmalcılar district of Istanbul, then an impoverished slum, claiming more than 50 lives. Because this incident was notorious, the district was renamed as Bayrampaşa. Also in August 1970, a few cases were reported in Jerusalem.

Other outbreaks

Vibrio cholerae has shown to be a very potent pathogenic bacterium causing many pandemics and epidemics over the past three centuries. However, most outbreaks are known to be self-limiting, meaning they come to an end after peaking, without human intervention. One of the mechanisms significantly determining the course of epidemics is phage predation.[66] This process is strongly dependent on successful recognition of the bacteria by lytic phages, in which cell surface receptors play a crucial role. Bacteria can reduce their susceptibility by changing their surface receptors and preventing phage adsorption. In the case of V. cholerae, the changed receptor gene expression is due to an alteration in cell-density during its infection cycle, a process called quorum sensing (QS). The stool samples collected from patients contain clumps of bacterial cells, demonstrating the occurrence of cell-cell interaction in the latter stage of the infection cycle. QS is strongly regulated by two auto-inducer molecules, AI-2 and CAI-1.[67] Evidently, these molecules will have a significant effect on the success of phage predation in V. cholerae infections.

A previous study has unravelled the mode of action of auto-inducers on preventing predation on the level of phage entry.[68] The study has shown that the aforementioned auto-inducers downregulate the ten biosynthetic genes of the surface O-antigen, which is primarily used as a phage receptor for Vibriophages. This mechanism results in an increased phage resistance. It can be stated that the loss of the ability to produce the receptor, reduces the possibility of a phage-dependent limitation or even elimination of V. cholerae. This should be kept in mind when developing a treatment for enteric bacterial infections with phages as an intervention tool. Future approaches may include additional quorum regulators that operate as “quorum quenchers” to reduce quorum-mediated phage resistance.

1990s

In 1992 a new strain appeared in Asia, a non-O1, nonagglutinable vibrio (NAG), which was named O139 Bengal. It was first identified in Tamil Nadu, India, and for a while displaced El Tor in southern Asia. It decreased in prevalence from 1995 to around 10 percent of all cases. It is considered to be an intermediate between El Tor and the classic strain, and occurs in a new serogroup. Scientists warn of evidence of wide-spectrum resistance by cholera bacteria to drugs such as trimethoprim, sulfamethoxazole and streptomycin.

2000s

2010s

2020s

False reports

See main article: article and Chicago 1885 cholera epidemic myth. A persistent urban myth states 90,000 people died in Chicago of cholera and typhoid fever in 1885, but this story has no factual basis.[125] In 1885, a torrential rainstorm flushed the Chicago River and its attendant pollutants into Lake Michigan far enough that the city's water supply was contaminated. But, as cholera was not present in the city, there were no cholera-related deaths. As a result of the pollution, the city made changes to improve its treatment of sewage and avoid similar events.

In popular culture

Unlike tuberculosis ("consumption"), which in literature and the arts was often romanticized as a disease of denizens of the demimondaine or those with an artistic temperament,[126] cholera is a disease that today almost entirely affects the lower-classes living in filth and poverty. This, and the unpleasant course of the disease – which includes voluminous "rice-water" diarrhea, the hemorrhaging of liquids from the mouth, and violent muscle contractions which continue even after death – has discouraged the disease being romanticized. It is seldom presented at all in popular culture.

See also

Further reading

Notes and References

  1. "Crisis in Yemen "
  2. Tatem. A.J.. Rogers. D.J.. Hay. S.I.. 2006. Global Transport Networks and Infectious Disease Spread. Adv Parasitol. Advances in Parasitology. National Institutes of Health. 62. 293–343. 10.1016/S0065-308X(05)62009-X. 9780120317622. 3145127. 16647974.
  3. Web site: Cholera: Background. Handa. Sanjeev. Medscape. April 23, 2016. February 16, 2016.
  4. Beardsley GW . The 1832 Cholera Epidemic in New York State: 19th Century Responses to Cholerae Vibrio (part 1) . The Early America Review . 3 . 2000 . 2010-02-01 . 2 . https://web.archive.org/web/20100502025213/http://www.earlyamerica.com/review/2000_fall/1832_cholera_part1.html . 2010-05-02 . live .
  5. Book: Something New Under The Sun: An Environmental History of the Twentieth Century World (The Global Century Series).. McNeil J.
  6. Web site: Cholera – Vibrio cholerae infection Cholera CDC. 2017-05-16. www.cdc.gov. en-us. https://web.archive.org/web/20150317031930/http://www.cdc.gov/cholera/index.html. 2015-03-17. live. 2018-04-04.
  7. Book: Aberth, John. Plagues in World History. limited. Rowman & Littlefield. 2011. 978-0-7425-5705-5. Lanham, MD. 102.
  8. Blake. PA. 1993. Epidemiology of cholera in the Americas.. Gastroenterology Clinics of North America. 22. 3. 639–60. 10.1016/S0889-8553(21)00094-7. 7691740.
  9. Web site: Pike J . Cholera- Biological Weapons . Weapons of Mass Destruction (WMD) . GlobalSecurity.com . 2007-10-23 . 2010-02-01 . https://web.archive.org/web/20100323144705/http://www.globalsecurity.org/wmd/intro/bio_cholera.htm . 2010-03-23 . live .
  10. Web site: Cholera – Cholera through history. 2020-12-10. Encyclopedia Britannica. en.
  11. Book: Gómez-Diaz, Donato. Cholera Pandemics, 1816–1861. Greenwood Press. 2008.
  12. News: Asiatic Cholera Pandemic of 1826-37 . Dept. of Epidemiology University of California, Los Angeles.
  13. http://whqlibdoc.who.int/bulletin/1947-1948/Vol1-No2/bulletin_1948_1(2)_353-381.pdf Cholera Epidemic in Egypt (1947)
  14. Web site: Asiatic Cholera Pandemic of 1817. 2015-01-04. https://web.archive.org/web/20141228023856/http://www.ph.ucla.edu/epi/snow/pandemic1826-37.html. 2014-12-28. dead.
  15. Book: Rosenberg. The cholera years: the United States in 1832, 1849 and 1866. University of Chicago Press. 1987. 978-0-226-72677-9. Chicago. Charles E. Rosenberg.
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  17. News: Wilford JN. How Epidemics Helped Shape the Modern Metropolis. The New York Times. 15 April 2008. On a Sunday in July 1832, a fearful and somber crowd of New Yorker's gathered in City Hall Park for more bad news.. 2017-02-06. https://web.archive.org/web/20170314160925/http://www.nytimes.com/2008/04/15/science/15chol.html. 2017-03-14. live.
  18. Diary of Michael Shiner Relating to the History of the Washington Navy Yard 1813–1869 https://www.history.navy.mil/research/library/online-reading-room/title-list-alphabetically/d/diary-of-michael-shiner/introduction.html Naval History and Heritage Command 2015, 49 editor John G. Sharp Retrieved 7 March 2019
  19. Sharp, John G. Cholera at Gosport Navy Yard 1832 http://www.usgwarchives.net/va/portsmouth/shipyard/sharptoc/nnysharp5.html l accessed 7 March 2019
  20. News: Wilford. John Noble. 2008-04-15. How Epidemics Helped Shape the Modern Metropolis. The New York Times.
  21. Gabriela Soto Laveaga and Claudia Agostoni, "Science and Public Health in the Century of Revolution" in A Companion to Mexican History and Culture, ed. William H. Beezley. Blackwell Publishing Ltd. 2011, p. 562.
  22. Book: Hayes, J.N.. Epidemics and Pandemics: Their Impacts on Human History. 2005. ABC-CLIO. Santa Barbara, CA. 214–219.
  23. http://www.ph.ucla.edu/epi/Snow/pandemic1846-63.html Asiatic Cholera Pandemic of 1846–63
  24. http://www.cbc.ca/health/story/2008/05/09/f-cholera-outbreaks.html Cholera's seven pandemics
  25. Web site: The Irish Famine. https://web.archive.org/web/20091027105918/http://www.geocities.com/CapitolHill/Congress/2807/irishfamine.html. October 27, 2009. dead. 2014-06-09.
  26. Book: Lincoln, Martha. Epidemic Politics in Contemporary Vietnam: Public Health and the State. Bloomsbury Publishing. 2021. 978-0-755-63618-1. 29.
  27. Book: Goscha, Christopher. Vietnam: A New history. Basic Books. 2016. 978-0-46509-437-0. 60.
  28. Book: Byrne, Joseph Patrick. Encyclopedia of Pestilence, Pandemics, and Plagues: A-M. ABC-CLIO. 2008. 978-0-313-34102-1. 101. 2016-07-28. https://web.archive.org/web/20130509082859/http://books.google.com/books?id=5Pvi-ksuKFIC&pg=PA101&dq. 2013-05-09. live.
  29. Book: The plains across: the overland emigrants and the trans-Mississippi West, 1840–60. Unruh, John David. University of Illinois Press. 1993. 978-0-252-06360-2. Urbana, IL. 408–10. The Plains Across (book).
  30. Jiang . Sunny C. . 2001 . Vibrio cholerae in recreational beach waters and tributaries of Southern California . Hydrobiologia . 460 . 157–164 . 10.1023/A:1013152407425 . 20591955. free .
  31. http://coloquioscanariasamerica.casadecolon.com/index.php/CHCA/article/viewFile/9072/8523 HISTORICAL GEOGRAPHICAL APPROACH IN THE BEHAVIOR OF THE EPIDEMIC OF THE CHOLERA MORBUS OF 1851 IN THE PALMS OF GREAT CANARY
  32. http://mdc.ulpgc.es/cdm/ref/collection/MDC/id/44370 Historia de la medicina en Gran Canaria
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  37. Web site: John Snow and the removal of the Broad Street pump handle. Frerichs. Ralph R.. www.ph.ucla.edu. https://web.archive.org/web/20180628172320/http://www.ph.ucla.edu/epi/snow/removal.html. 2018-06-28. live. 2018-07-13. In 1866, twelve years after the event, Dr. Edwin Lankester wrote: 'The Board of Guardians met to consult as to what ought to be done. Of that meeting, the late Dr. Snow demanded an audience. He was admitted and gave it as his opinion that the pump in Broad Street, and that pump alone, was the cause of all the pestilence. He was not believed – not a member of his own profession, not an individual in the parish believed that Snow was right. But the pump was closed nevertheless and the plague was stayed.'.
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