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Mapping disease: the development of a multidisciplinary field

By Andrew Cliff and Matthew Smallman-Raynor

For over two centuries, the landscape that lies on the marchland of two very ancient subjects — geography and medicine — has been explored from several directions. One of the main benefits of this intermingling has been the increased use of maps to chart the geographical distribution of diseases in the hope that the patterns revealed will give insights into the aetiologies and prevention of diseases.

Leonard Finke (1792-95) may have been the first to have written about this notion in his Attempt at a general medical-practical geography. In three volumes, this work maps out medical descriptions of the world. It contains anthropological descriptions of its peoples and their possible diseases. But the actual mapping of disease was costly even then and needed agreements on both disease definitions and adequate disease data collection. It was the 1820s before such conditions began to be put in place when the great outbreaks of cholera and yellow fever commenced in cities on both sides of the Atlantic. So some 29 cholera maps were published in the 12 years following the first great cholera pandemic of 1817 which spread from India. Most of these maps plotted routes of spread, dates, and regions of occurrence. In the following decades sophisticated maps showing the distribution of cholera within European cities began to appear. Rothenburg’s 1836 map of cholera in Hamburg and, at a local scale, John Snow’s famous map of individual cholera deaths in the Soho area of London in 1854 are examples. Although medical cartography by 1850 was beginning to be established at local and national scales, the world picture remained difficult to map except in the broadest terms.

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Filling in the world map awaited the work of the great German physician, August Hirsch, who avoided cartography himself but pioneered the global study of diseases. His two volume Handbuch der historische-geographische pathologie, the first edition of which was published between 1859 and 1864, was a monumental attempt to describe the world distribution of disease, drawing upon more than ten thousand sources. Hirsch had close links with England and dedicated his book to the London Epidemiological Society. Twenty years later, a much revised version was translated by Charles Creighton as Handbook of geographical and historical pathology. This time the adjectives in the title were reversed (a reversal approved by Hirsch) and the contents had swollen to three volumes, covering acute infectious diseases (1883), chronic and constitutional diseases (1885), and diseases of organs (1886).

Then Creighton himself went on to produce his magisterial two-volume A History of Epidemics in Britain, covering the history and geography of epidemic diseases in the British Isles from AD 664 to the end of the nineteenth century. Described at the time in The Lancet as “a great work – great in conception, in learning, in industry, in philosophic insight,” Creighton’s History began with the spread of a mysterious pestilence (pestis ictericia) in southern England in ad 664, and ended with an appended note on the emergence of a seemingly new disease in the 1800s (‘cerebrospinal fever’ or meningococcal meningitis). Creighton’s narrative is imbued with a sense of the historical ebb and flow of infection. It covered all the familiar infectious diseases such as measles, whooping cough, scarlet fever, smallpox, as well as a host of now unfamiliar infections in the British Isles like plague, cholera and typhus.

We attempt to continue the disease mapping tradition by extending Creighton’s account into the 21st century in The Atlas of Epidemic Britain. Creighton would have been recognised a number of epidemic outbreaks of infectious diseases in the first decade of the new millennium; there are also parallels with Creighton’s ‘new’ infection, cerebrospinal fever. In 2003, SARS (severe acute respiratory syndrome) reached some 30 countries around the world within a few months. In 2004, ‘Bird flu’, highly pathogenic avian influenza (A/H5N1), took the world to Phase 3 (of 6) on the World Health Organization’s (WHO) scale of alert for an influenza pandemic before it receded into the background. In 2009, swine flu, caused by a novel virus subtype of swine lineage (A/H1N1), spread globally from initial cases in Mexico to reach WHO’s Phase 6 (sustained human-to-human transmission) by 11 June. The ebb and flow of infection reveals a century of change from the historically important infections to new and re-emerging infections and a geography of epidemics of communicable diseases in the British Isles.

Professor Matthew Smallman-Raynor has been Professor of Geography at the University of Nottingham since 2004. Professor Andrew Cliff has been Professor of Theoretical Geography at the University of Cambridge since 1997 and Pro-Vice-Chancellor since 2004. They are the authors of the Atlas of Epidemic Britain, which was awarded the Public Health and Medical Book of the Year Awards at the BMA’s Medical Book Awards 2013 at the ceremony in September.

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