Journal of Public Health Advance Access originally published online on June 13, 2008
Journal of Public Health 2008 30(3):339; doi:10.1093/pubmed/fdn043
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© The Author 2008, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved
Invited Commentary
Cholera and the Apollo
Gabriel Scally
Regional Director of Public Health, University of the West of England, Faculty of Health and Life Sciences, Glenside Campus, Stapleton, Bristol BS16 1DD, UK
Address correspondence to Gabriel Scally, E-mail: gabriel.scally{at}southwest.nhs.uk
The ability of physicians to observe and document the signs, symptoms and course of disease is a skill and practice that stretches back to antiquity. The content of the Hippocratic corpus of writings illustrates how seriously the study of the course of disease was taken in Ancient Greece. In the absence of effective therapeutic interventions for much of the medical history, the art of close observation and the ability to predict the course of an individual episode of disease were revered in its own right. In ‘Air, Water, Places’, one of the Hippocratic writings, conclusions are drawn as to the environmental and climatic conditions that are associated with health and illness. On board the Apollo, Thomas Graham had the opportunity to observe the course of a cholera outbreak at close quarters and over a period of two months. Although his approach was based on the prevailing and incorrect miasmatic theory of causation of cholera, as with the sanitary revolution that was gaining momentum at the time of the voyage, the interventions that were adopted were effective even if the mechanism of disease transmission was not understood.
It was, of course, international shipping that had enabled cholera to spread with such devastating effect to Europe and an outbreak on board ship must have been a terrifying event. In our age, it is air travel that has developed as a means of rapid dissemination of disease. The outbreak of SARS in China that spread so very rapidly to the other side of the world should serve as a warning that international travel must remain a subject for public health study. The recently adopted International Health Regulations should enable international public health to operate effectively in the 21st century.
The public health challenges arising from shipping are presently under-recognized in the modern age. They range from the contribution of ships to environmental pollution, both from normal operations and from collisions and ship wrecks. Of more specific concern are the problems caused by smuggling of tobacco and illegal drugs of misuse. A public health voice on the subject of tobacco smuggling, in particular, would add to the efforts of customs and revenue would be valuable and it would assist in the task of turning tobacco smugglers from Robin Hood characters to the major threat to public health that they truly are.
Public health problems affecting ships in passage have not unfortunately gone away. There are regular outbreaks on board ships, usually cruise ships. Outbreaks of food poisoning and the Norwalk virus in particular are often reported in the press. The age profile of cruise passengers tends to be towards the older end of the spectrum and they are therefore even more vulnerable than the troops on board the Apollo. As the popularity of vacations on cruise ships continues to grow, and the size and complexity of cruise ships grows in a commensurate fashion, the public health needs of these unique communities will continue to pose challenges just as they did in Thomas Graham's day.
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