London in the 1850s


“It was estimated that in 1839, for every person who died of old age or violence in London, eight died of disease caused by poor sanitation practices.”

London began as a Roman town in about 50 AD. By the mid-1800s, the city had become “a Victorian metropolis trying to make do with an Elizabethan public infrastructure.” Thus opens Steven Johnson’s spell-binding non-fiction book, The Ghost Map.

The Ghost Map chronicles the London cholera outbreak of 1854, and central to the story, John Snow and Henry Whitehead’s demonstration that cholera was a water-born epidemic and that the likely source of contamination of the Broad Street pump was a nearby cesspool.

The train of thought establishing the relevance of this 150 year-old story to drug prices today may seem a little erratic at first, but bear with me. As readers of The Weekly Packet know, the evidence supporting pharmaceutical pricing as an important driver of the overall increase in the cost of healthcare in the US is shaky.  On the other hand, the February, 2017 issue of Nature Reviews Drug Discovery has an opinion piece on immune-oncology that shows the huge growth of pharmaceutical research in that discipline. When they come to market, these drugs will not be inexpensive generics, and their prices will reflect the relatively limited numbers of patients for who they are appropriate.

Now, take a look at the facts on the World Health Organization website:

  •  2.4 billion people still do not have basic sanitation facilities such as toilets or latrines.
  • Of these, 946 million still defecate in the open, for example in street gutters, behind bushes or into open bodies of water.
  • The proportion of people practising open defecation globally has fallen almost by half, from 24%to 13%.
  • At least 10% of the world’s population is thought to consume food irrigated by wastewater.
  • Poor sanitation is linked to transmission of diseases such as cholera, diarrhoea, dysentery, hepatitis A, typhoid and polio.
  • Inadequate sanitation is estimated to cause 280 000 diarrhoeal deaths annually and is a major factor in several neglected tropical diseases, including intestinal worms, schistosomiasis, and trachoma. Poor sanitation also contributes to malnutrition.

In addition, WHO says, “The situation of the urban poor poses a growing challenge as they live increasingly in mega cities where sewerage is precarious or non-existent and space for toilets and removal of waste is at a premium. Inequalities in access are compounded when sewage removed from wealthier households is discharged into storm drains, waterways or landfills, polluting poor residential areas.” Sounds like London 150 years ago, doesn’t it?

Here’s how these stories are related. In terms of overall human health, and in environmental quality, the return for dollars spent on sanitation infrastructure is far greater that the return on immuno-oncology. What we are seeing here is that not only has our own US society become divided along economic lines, but our global society has as well.

OK, that’s not exactly “new news.” (I promised that Packet would focus on well-seasoned news.) But here’s a thought. The pharmaceutical industry has a serious problem with its public image. What if, just what if, the industry as a whole agreed to major reductions in direct-to-consumer advertising, focused ads on R&D, and took the lead in supporting improved public health and sanitation infrastructure? What if?

Long-term, it could be a great investment.

(PS: I photographed this mosaic in 2012 at an archaeological site in Greece. It’s not far from the famous ancient latrine often pictured on websites, but much more attractive.)