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John Snow's behaviorsphere.

If, in fact, individual history plays a major role in psychological behavior (Kantor 1959; Mountjoy 1976), psychologists might well claim academic disciplinary rights over the behavioral fair share of the achievements of John Snow (1813-1858), the physician who famously identified sewage-contaminated water as a source of cholera transmission and helped pioneer the science of epidemiology in the mid-nineteenth century.

Why should psychologists involve themselves with the esteemed legacy of a hero of epidemiology? After all, epidemiologists rely to a great extent on biomedical sciences to understand disease processes, and the history of public health credits Snow, among other achievements, with having anticipated the evidence of the bacterial nature of an infection, rather than something outside the disciplinary branches of biology. As a rule, despite the relevance of human behavior in biomedical disciplines, a behavioral addressing of cholera transmission might sound like psychological nonsense, even considering that epidemiology is in part a behavioral discipline.

It is all very well that the disciplinary accounts of Snow's achievements have been informed predominantly by biomedical knowledge. But it would make total sense to assert that the man who is regarded by many as a founding father of epidemiology managed to achieve the success he eventually achieved also because, at a certain point, the guiding focus of his investigations went on to be the role played by a naturally occurring psychological behavior (as distinct from biological behavior) in the ancient routine of collecting drinking water from public pumps.

It is not the aim here to discuss issues of disease causation, much less presumed psychological underlying mechanisms and other tricky questions. The intent of this essay is to bring to the fore and briefly examine, from my point of view, the not-so-noticeable spatiotemporal locus of psychological behavior in the historical accounts of Snow's investigations. Certainly, the behavioral sphere has not been duly noted by historians, but it may be well viewed through a psychologist's eyes. One may even suggest that the disciplinary context of the story of John Snow relative to cholera has as much psychology as medical geography, just to give a slightly provocative example of an interdisciplinary input unquestionably linked to the deeds of the revered English doctor.

Before I go on, though, it is necessary to bypass the conventional wisdom of psychology in order to make clear that I am not talking about mental phenomena or wanting to make interpretations, or theorize. Academic psychologists are always at loggerheads with each other because of the entrenched mind-body dualism that blurs their disciplinary object of study (Hineline 2013). However, in one way or another, all psychologists finish by observing behavior if nothing else (and this is one aspect of my Snow argument), what people say, for instance, in response to questions (Delprato and Midgley 1992). Behavior qua behavior provides an outcome that is directly "confrontable", autonomous, evident in its own right (McPherson 1992), albeit of an ontologically different type from any biological sort (Kantor and Smith 1975).

According to the late systematist Jacob Robert Kantor (1888-1984), an eminent professor and history scholar who pioneered a non-dualistic system called interbehavioral psychology (Kantor 1959, 1981; Kantor and Smith 1975), the phenomena that are commonly deemed psychological are de facto species of mutual interactions between what individuals do--i.e., behavior--and things (stimulus objects) and events of their natural and built environments in a given space-time boundary. This means, just to introduce a central aspect of my Snow argument, that when a person has to choose one of two or more functionally equivalent neighboring objects, like water pumps in a particular spatiotemporal arrangement of things and events, behavior and object are influencing each other--in a sense, the object "appeals" to the person and the person either moves towards the object or comes into contact with it or otherwise explores its surroundings (Kantor 1971; Kantor and Smith 1975).

The resemblance of such a mutuality of participating factors in a certain space-time locus with mechanistic learning frameworks, although apparent, seems to me to be nonexistent (interbehaviorists are critical of what Kantor labelled "leamology"). But, still, someone may argue that biological disciplines already study transmission of communicable disease in a person-environment interaction framework, including social environments, and that, therefore, a psychological approach to Snow's achievements in epidemiology would not ultimately be distinct from a biology-based one. This is a crucial point.

Interbehavioral psychology holds that psychological and biological interactions distinguish themselves chiefly by the historical character of the former, meaning that with the term "historical" there is an ongoing sequence of interactions between the behaving individual and its stimulating environment which encompasses not only events immediately antecedent to the behavior observed, but also the remote ones. From the standpoint of interbehaviorists, psychological interactions are distinctively historical, and whatever individuals do--whichever behavior, current or past--is engendered by their history of mutual interactions with a stimulating environment (Kantor 1959; Kantor and Smith 1975; Midgley and Morris 2006; Moore 1984; Parrott 1983; Verplanck 1998).

That is not to say there is a demarcation line between psychological and biological interactions or that they do exist as separate phenomena. Rather, an aspect of the natural world is picked out by psychologists as their object of study and, somewhat arbitrarily, called "psychological" (Hayes and Fryling 2009a). Though the vastness of the phenomena on each side of the border usually calls for biologists and psychologists to stick to their respective disciplinary fair shares, biological and psychological interactions are in reality continuous and merge naturally into each other (Mountjoy 1976).

I would like now to elaborate further on Snow's success. Speaking of behavior, a significant moment in his efforts in relation to cholera was when someone, maybe a party of workmen, after much debate and controversy, removed the handle of a street water pump. This passage, often recounted in heroic tones, has been somewhat romanticized as a happy ending to a merciless process of cholera transmission which replicated itself mortally hundreds of times under harsh, poverty-stricken living contingencies. The story, not necessarily simple, not necessarily genuine--and for the rest exhaustively re-recounted on the occasion of Snow's 200th anniversary on March 2013--goes more or less like this:
   In the late English summer of 1854 a cholera epidemic
   ravaged the Parish of St. James's, Westminster, claiming
   some five hundred lives in the first few days. Snow
   indicated to local health authorities that one potential
   source of the problem was the likely sewage-contaminated
   water of a public pump at London's now
   fashionable Soho district. He had long contended that
   some of the pump wells in the parish yielded water
   contaminated by cholera evacuations that passed along
   the sewers near to the wells. By plotting the location of
   the houses of those who died from the disease on a dot
   map (and making by way of the map the first ever spatial
   analysis of an epidemic), Snow was able to show that
   the great majority of the deaths were correlated with the
   distance that separated the dead persons' houses from
   the suspected pump. The map data were obtained from a
   house-to-house survey that Snow did himself all around
   the affected area to ascertain orally where the dead had
   collected their drinking water. Suggestive of the preference
   of most parishioners for one particular pump
   (which went down in history as the Broad Street pump)
   over others was the tendency of cholera deaths to cluster
   in the streets close to it while decreasing, roughly speaking,
   at streets that required people to walk further to
   collect water from another pump. Snow's survey reinforced
   his view that the Broad Street pump was the most
   likely source of the epidemic. Although the aquatic
   bacterium Vibrio cholerae had not yet been identified,
   the survey ended up being also instrumental in bolstering
   his assumption that water was a vehicle for transmission
   of a sort of evacuation "poison", which he
   described as "small white, flocculent particles" that
   caused cholera, once ingested. It was then that Snow
   eventually persuaded the parish authorities to remove
   the pump handle, thereby (the story goes) preventing
   people from coming into contact with the contaminated
   water.


Despite some variations here and there, the many versions of this story have in common the anecdotal account of the way in which Snow's investigations anticipated later epidemiological studies on how Vibrio cholerae is transmitted through water. His approach to the prevention and control of disease outbreaks confronted directly the then-widely disseminated belief that transmission was due to a poisonous atmosphere thought to issue from the swamps and putrid matter rife in London at the time. This, as might be expected, greatly contributed to his reputation and success (Edwards 1959).

Now, disease transmission is a fairly discussed topic, but psychological behavior, a critical component, is usually overlooked as an object of study in its own right when dealing with it (Epstein 1992). In most academic circles, even in psychology, behavior is customarily thought of not as a primary health outcome, but--to paraphrase a wry appraisal of the foremost advocate of behavioral psychology, B.F. Skinner (1904-1990)--as a mere expression of "more important happenings inside the behaving person" (Skinner 1987). Is it any wonder, therefore, that having to demonstrate his pathologic rationale, Snow endeavored to relate cholera mortality to parishioners' behavior with respect to an environing object--or, as he put it, "independently of the pathology" (Snow 1855).

In effect, Snow assumed a direct relationship between contaminated water and cholera transmission. He posited that transmission was linked to the ingestion of the evacuation poison, which reproduced itself in the abdomen, and in many cases led to death as the result of the loss of fluid through the intestinal walls. However, and importantly, his survey indicated that in 83% of the cases the dead parishioners had been drinking the water from the pump on Broad Street (Snow 2002). Since people were free to visit several pumps, this outcome means that a significant portion of those who routinely collected water for drinking and culinary purposes had developed a selective interaction with one pump over their alternatives. In other words (taking it for granted that the survey actually captured what happened), they manifestly chose, or preferred, to collect water from the Broad Street pump.

This development was an essentially psychological phenomenon. In contemporary psychological research, it could be dealt with by analyzing the observed frequency of visits to the Broad Street pump (and the operations of the handle would be an accurate measure for it) relative to the frequency of visits to other pumps at multiple time scales (e.g., Baum 2004, 2010)--something obviously unthinkable in the nineteenth century. Snow, however, as would any venturesome academic, sought to understand the behavior fact with the means at his disposal, i.e., an extensive survey of the neighborhood, plus the dot map which he made from the orally obtained information. It was through these means that he succeeded in putting the focus of his investigations on the role played by people's water collection behavior with respect to the suspicious pump.

One might wonder whether in the absence of the behavioral information Snow would have achieved his biological breakthrough. Probably not, considering that it would take some time, nearly three decades, until Vibrio cholerae was eventually identified (by Robert Koch) under the microscope. Most narratives of Snow's achievements, both popular and academic, are correct when it comes to giving credit to a likely cause-effect relationship between cholera mortality and the Broad Street pump. However, the generality of authors typically fail to notice that a psychological behavior had to evolve first, or concomitantly, in order for such a relationship to exist. Given that most scholars of epidemiology and related disciplines are generally not as familiar with a behavioral approach to health as they are with their own disciplinary approaches, this failure is not surprising. Indeed, the word "behavior" is virtually absent in Snow academic narratives (see, for instance, Brody et al. 1999; Brown 1964; Cameron and Jones 1983; McLeod 2000; Paneth 2004; Winkelstein 1995. For a comprehensive list of writings about John Snow, see Frerichs 2001).

Going back now to what I called disciplinary fair share, it seems reasonable to argue that while investigating the cholera epidemic in the Parish of St. James's, Snow moved among two juxtaposed spheres or provinces of scientific inquiry. In one, he investigated cholera by looking for a link between the ingestion of what he saw as an evacuation poison and the transmission of the disease. This quota of research efforts composed the biological fair share of his achievements, i.e., a well-recognized, responsive, and unidirectional person-environment interaction.

After much work, and still lacking direct evidence of sewage contamination of the Broad Street pump water, Snow moved on to the other sphere. He realized that to demonstrate fully his ideas about cholera transmission in the parish, he needed not only to understand how the poison was ingested and absorbed and excreted through drinking water, but also to go back in history to examine additionally a peculiar interaction, or "interbehavior", as Kantor would say, through which a street pump (albeit unsanitary) had been chosen by a great number of parishioners. Such endeavor fits in with the psychological fair share. In other words, by searching for cases in history to support his ideas, Snow naturally guided his investigations to a mutual, bi-directional and, therefore, distinct interaction which evolved during the course of people's continued contact with an object conducive to disease.

Psychology and biology have different approaches to and conceptions of behavior as an object of study (Kantor and Smith 1975; McPherson 1992). In Kantor's system, psychological behavior, in addition to being interactive, is a mutual and historical construct referring, in his words (1982), to a "complete and total operation" of individuals (see also Parrott 1983; Sa et al. 2004). Except for analytical purposes, any noninteractive, nonmutual, ahistorical, or segmented description of behavior falls outside the disciplinary fair share of interbehavioral psychologists.

The ingestion, absorption, and excretion of a bacterium may be thought of as behavior. But in a continuum of biological and psychological disciplines, they pertain to the evolutionary history of species. The choice of a stimulus object like a water pump, in its turn, however prosaic it may seem to a non-psychologist, is germane to ontogenetic evolution, that is, to individual life history--even though the stimulus function (water supply), in such a case, directly affects survival and reproduction.

Obviously, the interested psychologist can do no more than wonder how the Broad Street pump was chosen. It is unreasonable to think that the choice was a momentary collective event. Instead, one may imagine it evolved over time, perhaps while the pump attracted some word-of-mouth attention in its social surrounding--who knows? Water from Broad Street reportedly tasted better than water from other neighboring wells, a circumstance that can be loosely interpreted as an increment to the stimulus function, or to the discriminative "appeal" of the pump. Response effort, a technical term meaning the physical endeavor required to engage in a behavior, could also be a factor since Snow's map indicated that the deaths, as he wrote, "either very much diminished or ceased altogether" at every point where it was "nearer" to go to another pump than to the one in Broad Street (Snow 1855).

A valuable aspect of interdisciplinary science cooperation is the information that emerges when old subject matter is viewed from a different sphere. It may be instructive for any behavior scholar if a knowledgeable and curious author developed a psychological narrative of Snow's story, despite the mythology that surrounds the hero (e.g., Brody et al. 2000; Brown 1964; McLeod 2000; Snow 2008). However pretentious this initiative may appear to be in the eyes of a non-psychologist, it can point towards new angles of approach and perhaps suggest a novel direction for historical research on the subject (refer to Hayes and Fryling 2009a, b for a comment and a substantial review of the nature of interdisciplinary science from an interbehavioral perspective).

Of course, I cannot estimate the diversity of psychological behaviors related to water collection that there were in Snow's behaviorsphere (the name I am giving it). What I know is that, in the numerous narratives of his scientific achievements, an account of such behaviors has been overlooked, although they played an absolutely primary role in the cholera epidemic that has made him famous. This should not be read as a hostile remark toward John Snow narratives. Maybe in the moment when psychological behavior becomes more noticeable, more easily seen by public health historians, there may be room for a richer version of Snow's work on cholera than has traditionally been presented. My main goal in writing this article was to contribute to this development.

DOI 10.1007/s40732-014-0082-3

Acknowledgment Preparation of this article was supported by Fundacao de Amparo a Pesquisa do Estado de Minas Gerais and Conselho Nacional de Desenvolvimento Cientifico e Tecnologico. Correspondence should be addressed to Joao Bosco Jardim, Centro de Pesquisa Rene Rachou, Fundacao Oswaldo Cruz, Avenida Augusto de Lima 1715, Barro Preto, 30190-002 Belo Horizonte, MG, Brazil. E-mail: jardim@cpqrr.fiocruz.br

The author is grateful to Dr. Virginia T. Schall, Liz Andrade and Katherine Titley for their comments on an earlier version of this article.

Published online: 17 June 2014

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J. B. Jardim ([mail])

Laboratory of Health Education and Environment, Rene Rachou Research Center, Oswaldo Cruz Foundation, Avenida Augusto de Lima 1715, Barro Preto, 30190-002 Belo Horizonte, MG, Brazil

e-mail: jardim@cpqrr.fiocruz.br
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Date:Mar 1, 2015
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