Mapping Epidemic Diseases

1 in Britain
1.1 Introduction 2

1.2 The Nature of Diseases 2

Disease Recording: General Considerations 2
Disease Recording: British Practice 3
Role of the Office of the Registrar General 5
Changing Geographical Frameworks 5
Data Quality 6
The Public Health Impact of Infectious
Diseases 6
Data Standardisation 8

1.3 The Nature of Epidemics 9

Dening Epidemics 9
Epidemics in World History 9
Shape of Epidemics 9

1.4 Mapping Epidemic Diseases 11

The Nineteenth Century 11
Twentieth Century Mapping 12
Later Maps and Atlases 12
New Developments in Disease Mapping 12

1.5 Atlas Organisation 13

Geographical Parameters of the Study 13
Layout of the Atlas 13
Range of Diseases 14

1.6 Conclusion 14

Figure 1.1 Disease mapping. From the earliest days of the League of Nations Health Committee, which rst met in August
1921, mapping and charting of disease was central. In the very rst issue of Epidemiological Intelligence ( January 13, 1922) the
Introductory Note states the most convenient method of producing charts and maps will be determined by the nature of the
data that may be at the disposal of the Health Section in the future. Figure 1.1 shows part of the Introductory Note stressing
one of the main functions of the Health Committee was effective international exchange of intelligence on epidemic diseases,
part of the contents list of the rst issue, a proportional symbol map of the distribution of dysentery in Eastern Europe and a
choropleth map of smallpox in Europe. Sources: Epidemiological Intelligence, 1, 1922, pp. 3, 5, between pp. 367 (Introductory
Note, contents lists, dysentery); Epidemiological Intelligence, 7, 1923, p. 36 (smallpox).
ATLAS OF EPIDEMIC BRITAIN
1.1 Introduction
A nondescript express in from the South,
Crowds round the ticket barrier, a face
To welcome which the mayor has not contrived
Bugles or braid: something about the mouth
Distracts the stray look with alarm and pity.
Snow is falling. Clutching a little case,
He walks out briskly to infect a city
Whose terrible future may have just arrived.
W.H. Auden Gare du Midi (1938)
Just over a century has passed since the publication
of Charles Creightons monumental A History of Epi-
demics in Britain (Figure 1.2) which provides a singu-
lar account of the history and geography of epidemic
diseases in the British Isles from Anglo-Saxon times
until the end of the nineteenth century epidemics
generally caused by what are known as infectious
diseases. In the century which followed the conclu-
sion of Creightons account, the epidemic profile of
Britain changed dramatically, and it is the purpose of
this Atlas to characterise and illustrate these
changes. In the first half of the century, a gamut of
social, biological, medical and environmental devel-
opments contributed to the wholesale retreat of
many of the epidemic infections that figured large in
Creightons History. Such were the changes that, by
the 1950s, some writers believed the war against
these epidemics had been won. At mid-century,
Thomson (1955, p. 106) could report that mortality
from the leading infectious diseases was but a tithe
of what it was in Creightons time. Likewise, Stocks
(1950, p. 56) pointed to the extraordinary reduction
in infectious disease mortality in the first half of the
century decades which witnessed the last signifi-
cant British epidemics of human plague and small-
pox and the disappearance by 1948 of indigenous
malaria. To this list may be added measles, scarlet
Figure 1.2 Charles Creighton (18471927) and A History
of Epidemics in Britain. (Left) Charles Creighton, M.D.
(Right) Title page of volume I of Creightons two-volume
History which covers the history and geography of epidemic
diseases in the British Isles from AD 664 to the end of the
nineteenth century. Described in The Lancet (Anonymous,
1894, p. 1543) as a great work great in conception, in
learning, in industry, in philosophic insight, Creightons
History provides an account of epidemics caused by
infectious diseases. Creightons subtitle refers to the
eradication of plague but in fact the last enzootic outbreak
occurred 191018 in East Suffolk (see Section 3.3). Source:
(Left) Wellcome Library, London.
2
fever, diphtheria and whooping cough which
retreated but which did not vanish.
But the twentieth century decline of epidemic dis-
eases in Britain was not regular, smooth or uninter-
rupted. So measles, having been on the wane since
the 1840s, reasserted its dominance as a leading
cause of childhood mortality in England and Wales
during the early years of the twentieth century before
almost disappearing under the onslaught of mass
vaccination from the 1960s only to re-emerge as a
significant public health threat at the millennium.
For poliomyelitis, there is a similar story. For parents,
few infections have scored higher than poliomyelitis
on the dread factor. From the 1920s, poliomyelitis
emerged from the epidemiological background in a
succession of global waves of infection, each of which
outdid its predecessor in the number of children it
crippled and killed in Britain. However, from the
1950s, this picture abruptly changed when preventive
vaccines were developed which, by 2000, had
brought the disease to the edge of worldwide eradi-
cation. What causes diseases to wax and wane in
time and space in this fashion is a theme of contem-
porary scientific interest.
The common belief that infectious diseases had
been defeated by a combination of vaccination, diet
and general improvements in medical care proved
unfounded as the generalised retreat of many epi-
demic diseases in Britain in the first half of the twen-
tieth century was replaced in the second both by a
resurgence of some familiar foes and by the emer-
gence of wholly new agents. The former included
vaccine-preventable infections like measles and
tuberculosis, both of which re-emerged as serious
public health threats. The newly-recognised condi-
tions were sometimes associated with the expansion
of international travel ( for example, new strains of
influenza virus), sometimes with lifestyle changes
(HIV/AIDS), sometimes with technical changes
(Legionnaires disease, E. coli, vCJD), and sometimes
with developments in healthcare provision ( for
example, hospital-acquired MRSA and C. difficile).
It is the mapping and interpretation of the com-
plex timespace tapestry woven by the uneven
retreat of some infectious diseases, the emergence of
new infections and the re-emergence of certain his-
torical plagues in twentieth century Britain which
forms the subject matter of this Atlas. It updates
Creightons magisterial legacy and establishes a twen-
tieth century benchmark against which the ongoing
history of British epidemics can be set. Our aim is to
explore the geographical dynamics of these develop-
ments through the careful selection of diseases which
can either be analysed statistically over a century-
long span or which can be mapped in specific geo-
graphical settings. But Britains epidemiological
geography has not occurred in spatial isolation. As
Audens poem implies, across geographical areas and
generations, infectious diseases have been spread by
movement. And so, as well as analysing the British
scene, we nest our findings in European and global
contexts to highlight the congruences and the differ-
ences between the British epidemiological experi-
ence and that of other countries.
Paralleling Chapter 1 in Cliff, et al. (2004), to frame
the chapters which follow, we begin here by defining
terms and concepts. What do we mean by a disease
and an epidemic? How do we measure and record
sickness in Britain? How do we map epidemic dis-
eases? What data standardisation issues do we face?
What role may be played by new and evolving tech-
nologies like Geographical Information Systems
(GIS) and the power of Google EarthTM? The chapter
is concluded by outlining the structure and under-
pinning rationale for the substantive chapters which
follow in the remainder of the Atlas.
1.2 The Nature of
Diseases
The term disease literally means dis-ease, the
absence of ease, the opposite of good health.
Couched in these terms, it is a biomedical defin-
ition applied to any sickness, ailment or departure
from sound health. Most often it is applied to a spe-
cific disorder of a specified part of the body ( for
example, the gall bladder) or to a disorder caused
by a specific agent ( for example, the tuberculosis
bacillus). Some diseases may be due to external
causes: physical injury ( for example, trauma),
chemical injury ( for example, poisons), or microbi-
ological injury ( for example, by viruses). Others
may have internal causes: genetic diseases ( for
example, congenital anomalies), developmental
fatigue ( for example, cardiac arrest), or neoplasms
( for example, cancers).
The absence of health has always been easier to
define than its presence. While a biomedical model
of health defines diseases in terms of departures of
measurable biological variables from the norm, the
World Health Organizations Charter (World Health
Organization, 1979) proposes a wider definition of
health: health is a state of complete physical, social
and mental well-being, and not merely the absence
of disease and infirmity. We shall see the impact of
this broader definition manifested later in this sec-
tion when we discuss measurement of the public
health impact of diseases.
In this Atlas we have chosen to map just those dis-
eases which are broadly termed infectious diseases
and which, to a lesser or greater extent, have caused
outbreaks and epidemics in Britain. All are produced
by the interactions between micro-organisms such
as bacteria and viruses and the human population,
and it is these interactions which produce the mor-
bidity (disease cases) and mortality (disease deaths)
in space and time upon which this Atlas is founded.
Disease Recording: General
Considerations
The interactions between the invading agent and the
host (the human body) are complex. Figure 1.3 shows
Evanss (1984) iceberg concept of disease in which
clinical illness forms the upper part of the triangle
and death its vertex. Assault by a particular disease-
causing organism may cause mild symptoms, severe
symptoms, or even death. All three states are above
the plimsoll line in the sense that they are felt by the
patient. Equally the microbiological assault may be
unnoticed by the human victim (below the plimsoll
line or sub-clinical) and go either unnoticed or be

Figure 1.3 Iceberg concept of infectious disease. For
many diseases, clinically-apparent illness (above the double
horizontal plimsoll or water line and occupying the upper
part of the triangle) represents only a small proportion of the
hosts response patterns. Unrecognised and inapparent
infections (pecked part of the triangle) are a much larger
part. Responses at the level of the cell (left) and host (right)
are shown. Source: Evans (1984, Figure 2, p. 20).
picked up only in some serological or other study. It
is only the cases above the water line which are likely
to be recorded and thus be mappable. For example,
in poliomyelitis a large proportion of the invasions
are below the water line with the poliovirus only
rarely causing the classical symptoms of paralysis. In
measles, severe above-the-line effects are a usual
consequence.
The existence of a disease is a necessary but not
sufficient condition for its recording and therefore
mappability. The first requirement is that someone
registers the event. Figure 1.4 shows the reporting
routes whereby disease mortality and morbidity
finds its way from the patient level (primary data
collection) via secondary reporting to national (e.g.
in Britain, the Registrar General) to international
recording agencies like the World Health Organiza-
tion (WHO).
Standardising Disease Recognition
The second requirement for consistent mappability is
an agreed clinical definition for each disease. Disease
records for the past are often hard to match up with
the specific diseases of today. Nonetheless, the pre-
cise classification of disease has been developing for
over three centuries. In Britain, its roots lie in the sta-
tistical study of disease begun in the seventeenth cen-
tury with John Graunts analyses of the London Bills of
Mortality. It continued in the eighteenth century with
works by Francis de Lacroix, William Cullen, and the
father of biological classification systems, Linneaus.
With the start of the General Register Office of
England and Wales in 1837, attention was focussed on
the improvement of disease classifications and on
the promotion of international uniformity in their
use. Israel (1990) has traced the history of the inter-
national classification of diseases from that point.
The international importance of a statistical classifi-
cation of diseases was so strongly recognised at the
first International Statistical Congress held in Brus-
sels in 1853 that the participants assigned to Britains
William Farr in the Office of the Registrar General
and to Marc dEspine of Geneva the task of preparing
a uniform nomenclature of causes of death applica-
ble to all countries (Israel, 1990, p.43). A compro-
mise list of 138 rubrics was agreed at the next Paris
Congress in 1855.
Much revised at subsequent meetings, the Farr-
dEspine list formed a basis for the present Interna-
tional Classification of Diseases (ICD) which began
Figure 1.4 Collecting epidemic records. The sequence of events whereby a clinically-apparent disease event in an individual
(primary level data collection) is eventually recorded in official statistics up to the global level. Routine reactive data collection
(left) occurs when a patient presents to a doctor or in hospital and is recorded as a case of some disease. Proactive data
collection (right) occurs with special surveys or events to investigate a particular health issue. After primary data collection has
occurred, data make their way into secondary sources like official statistics up to the international level. Source: Cliff, et al.
(2004, Figure 1.5, p. 4).
formally in Chicago in 1893 with the adoption by the
International Statistical Institute of the Bertillon
Classification of Causes of Death. In 1898, the Ameri-
can Public Health Association recommended the
adoption of the Bertillon classification by the civil
registrars of Canada, Mexico and the United States,
adding that the classification be revised every 10
years. The subsequent history of the classification in
this century, now in its tenth revision, and its adop-
tion by the Health Organization of the League of
Nations and eventually by the World Health Organi-
zation is described at length by Israel (1990). The
twentieth-century development of the list is illus-
trated in Figure 1.5.
Disease Recording: British Practice
Useful mappability is only generally possible if the
records of deaths and/or morbidity from a disease
are collected on a sustained, systematic and timely
basis. In this way a picture of temporal and spatial
variations in disease patterns can be produced which
is not possible with one-off recording. Knowledge of
such temporal and spatial variations may in turn
lead to insights into the underlying processes which
cause the variations.
MORTALITY
In England and Wales, registration of deaths dates
back to 1538 in the reign of Henry VIII when the
clergy in every parish were required to keep a
record of these events (Benjamin, 1968, p. 43).
Except for a brief period from 1653 to the Restora-
tion, Henry VIIIs requirement did not become
statutory until the passage of the Births and Deaths
Registration Act, 1836, so that vital registration of
births, marriages and deaths began from 1837.
From then on deaths by cause can be tracked at the
registration district level. While a few countries
CHAPTER 1
Mapping Epidemic Diseases in Britain
( for example, Sweden) predated England and
Wales, the majority lagged by several decades.
Scotland commenced vital registration from 1854
(Registration of Births, Deaths and Marriages
(Scotland) Act) and Ireland from 1947. Forms are
provided for the purpose. Figure 1.6 gives some
representative examples of those used at the pri-
mary level in Britain during the twentieth century.
Because of its finality, every effort is made to cap-
ture all deaths and their cause(s).
MORBIDITY
Mortality recording in Britain predated morbidity by
several decades. From 1832, however, the great epi-
demics of cholera which swirled around the world
fuelled the public health movements in Europe. In
Britain, various Acts of Parliament provided powers
aimed at preventing the spread of epidemic, endemic
or contagious diseases, culminating in the Public
Health Act of 1875. Then, in 1889, provision was made
enabling any urban, rural or port sanitary district to
make certain infectious diseases notifiable (Infec-
tious Diseases Notification Act), although records for
a few urban areas are available for some decades ear-
lier. These powers were made mandatory in London
in 1891 and throughout the remainder of England and
Wales in 1899. The details for Scotland which began
notification in 1887 are broadly similar to England
and Wales (Ashley, et al., 1991), and those for Ireland
are given in Hensey (1979). The reason for making cer-
tain infectious diseases notifiable for forecasting
and control was incisively summarised at the time
by Tatham (1888, p. 403):
Again and again we have had to complain of the
importation of infection into Salford [England]
from non-notification outside districts imme-
diately contiguous to our boundaries . . . [E]ven
between towns which possess powers for the
3
ATLAS OF EPIDEMIC BRITAIN

Figure 1.5 International Classication of Diseases. (Upper)

Title page from the rst issue of the International
Classication of Diseases, 19013. (A) Decade of discovery
of principal infectious disease agents by taxonomic
division of agents. The switch from bacterial to viral agents
as the twentieth century progressed is evident. (B) Number
of infectious diseases of humans recorded in the A and B
lists of ICD1 to ICD10. The International Classication of
Diseases (ICD) is the standard diagnostic classication for
all general epidemiological and many health management
purposes. It is used to classify diseases and other health
problems recorded on health and vital records including
death certicates and hospital records. The idea of such a
classication is to ensure comparability of data recording
over space and time, thus facilitating the storage and
retrieval of diagnostic information for clinical and
epidemiological purposes. These records also provide the
basis for the compilation of national mortality and
morbidity statistics by country-level surveillance
organisations. The list has gone through 10 versions since
the rst. The latest classication, ICD-10, came into use in
WHO member states from 1994; see http://www.who.int/
classications/icd/en/ for a history. The number of diseases
listed remained around 100 for the rst 65 years of ICDs
existence. In the Ninth and Tenth editions, however, the
number rose sharply from around 350 (Ninth) to over
1,000 (Tenth).

compulsory notification of infectious disease,
there exists at present no organization by which
one sanitary authority may receive timely warn-
ing of the presence of infectious disease in the
district of a neighbouring authority.
Figure 1.7 shows the dates from which certain infec-
tious diseases became notifiable in England and
Wales and in Ireland.
The present situation. The current law (Section 11(1)
of the Public Health (Control of Disease) Act 1984
and the Public Health (Infectious Diseases) Regula-
tions 1988) states:
If a registered medical practitioner becomes
aware, or suspects, that a person whom [s]he is
attending within the district of a local authority
is suffering from a notifiable disease or from
food poisoning, [s]he shall, unless [s]he believes,
and has reasonable grounds for believing, that
some other registered medical practitioner has
complied with this sub-section with respect to
the patient, forthwith send to the proper officer
of the local authority (generally the local Medi-
cal Officer of Health) for that district a certifi-
cate stating:
a. the name, age and sex of the patient and the
address of the premises where the patient is;
b. the disease or, as the case may be, particu-
lars of the poisoning from which the patient
is, or is suspected to be, suffering and the
date, or approximate date, of its onset, and

4

c. if the premises are a hospital, the day on which
the patient was admitted, the address of the
premises from which [s]he came there and
whether or not, in the opinion of the person
giving the certificate, the disease or poisoning
from which the patient is, or is suspected to
be, suffering was contracted in hospital.
Role of the Office of the
Registrar General
As Figure 1.4 shows, once the primary data on mor-
tality and morbidity have been recorded, they find
their way into the public domain through a variety of
channels. In twentieth-century Britain, this second-
ary dissemination has been chiefly the responsibility
of the Office of the Registrar General. Since the 1920s,
reports of notifications (mortality and morbidity)
have been sent by Registrars of Births, Marriages and
Deaths, Medical Officers of Health and, more
recently, by proper officers (usually the Medical
Officer for Environmental Health or the Consultant
in Communicable Disease Control) to the General
Register Office (GRO). The GRO became the Office of
Population Censuses and Surveys (OPCS) in 1970.
Forms on which to make the returns are provided
each November by OPCS to the proper officer of each
local authority with instructions for their comple-
tion during the following year (Figure 1.8). All notifi-
able diseases are reported on these forms with the
exception of leprosy which is reported direct to the
Communicable Disease Surveillance Centre (now
part of the Health Protection Agency) at Colindale.
For much of the twentieth century, the primary
data were amalgamated into (reporting district
date disease) format for publication. It is these
aggregated data which form the bedrock of the anal-
yses described in this Atlas. The twentieth-century
publications include the Registrar Generals Weekly
(Quarterly/Annual) Return and their successor publi-
cations (e.g. Communicable Disease Report Weekly
since 1991) towards the close of the millennium.
Figure 1.9 illustrates some publications.
Variations in the relative ease of clinical identifica-
tion and attack rates mean that the completeness of
statistical reporting has differed considerably from
disease to disease, ranging from lows of around 20%
CHAPTER 1
Mapping Epidemic Diseases in Britain
Figure 1.6 Registration of deaths in Britain. Sample
forms used at the primary level to record mortality in
England and Wales during the twentieth century. The
upper forms from the 1920s and 1950s show how death by
cause was recorded for return to the Registrar General. The
main and contributory causes as identied in the ICD are
certied. Where insufficient or inaccurate information was
returned, clarication was sought by the Registrar General
(centre left). Accuracy of mortality returns has been a
priority and investigations have been undertaken to assess
this (centre middle). Another potential source of error arises
from the fact that registration often initially occurred in the
district of death rather than of residence. Until recently,
attempts were made to reallocate these to place of
residence (bottom right, upper) so that consistent recording
by residence was the norm throughout much of the
twentieth century. Other deaths could escape the
registration system (e.g. coroners courts and onboard
ships), and attempts were made to capture these (lower left
and right). In the case of ships, a minute was recorded in
the ships log prior to registration. Source: World Health
Organization Library archives.
for whooping cough to effectively complete for polio-
myelitis (Benjamin, 1968, p. 171). There have also been
secular changes in reporting completeness. For
example, in the case of measles, detailed clinical stud-
ies suggest that this disease was generally under-
recorded in the United Kingdom in the pre-vaccination
period prior to 1965, so that reported cases would
need to be multiplied by a correction factor of
between 1.5 and 2.0 to give a more realistic estimate of
the number of cases. In recent decades, the recording
of some common diseases has been downgraded as
their incidence and their perceived public health sig-
nificance threat has fallen. In some countries, includ-
ing Britain, simple comprehensive secondary-level
disease reporting has moved from statutory notifica-
tion of all recognised cases to one off sampling and
surveillance using devices such as sentinel medical
practices. We discuss work in this area in Section 10.5.
Changing Geographical Frameworks
Even where records are kept, a further mapping
problem is the changing infrastructure of local
5
ATLAS OF EPIDEMIC BRITAIN
boundary areas. Figure 1.10 shows a 90-year
sequence of maps of county level boundary changes
in part of eastern England. The traditional county
boundaries of 1912 were reshaped over time to
reflect population growth, a drift of people from
country to towns and political aspirations. Some old
urban areas were split (as their populations grew)
and some old rural areas were amalgamated (as
their populations dwindled). The fishing net by
which diseases are caught and recorded is rarely sta-
ble, posing a continuing puzzle for map makers
wishing to show local changes over time in a con-
sistent manner. The mesh of units can be made con-
sistent by aggregating to the finest common
framework, but this then requires heroic assump-
tions to be made about how to allocate disease data
collected for one framework to a different grid.
Unless otherwise stated, in this Atlas we have used
the geographical grids in force at the time and have
avoided reapportioning disease data to geographi-
6
cal units created artificially from existing adminis-
trative units.
Data Quality
The preceding discussion makes clear the fact that
disease data in Britain are subject to the same limi-
tations of patchy recording, missing and inaccu-
rate observations, misdiagnosis and arbitrary
collection units as any other of the worlds coun-
tries. Notwithstanding the caveats, however, Brit-
ish data remain among the best and most reliable
internationally, and to argue that data deficiencies
make analysis inappropriate is a counsel of despair.
Instead we need to be aware of the limitations of
our data, the effect errors can have upon any analy-
sis, and wherever possible follow the approach
which we have adopted in this Atlas to use robust
mapping and statistical methods which are com-
paratively unaffected by variable data. All of the
Figure 1.7 Recording of morbidity. Dates on which
recording of morbidity from notiable infectious diseases
became compulsory in parts of the British Isles. Subject to
national approval, local authorities had the power to extend
the list either temporarily or permanently to cover local
situations. Sources: compiled from data in Hensey (1973, pp.
1879) and McCormick (1993).
analyses which we describe in this Atlas are
founded upon this philosophy.
The Public Health Impact of
Infectious Diseases
The impact of disease on the British population can
be assessed in several ways and we look here at three
such measures.
MORTALITY
Death is, of course, the ultimate indicator of the
importance of a disease. But even in Britain, death
certificates give only a partial view of the cause of
death despite the recording of primary and contrib-
utory causes. Nonetheless they represent the best
evidence we have and, as we have seen in Figure 1.6,
the Registrar General goes to great lengths to collect
and codify these data. Figure 1.11 uses a stacked bar
 CHAPTER 1

Mapping Epidemic Diseases in Britain

Figure 1.8 Secondary recording of mortality and

morbidity in the United Kingdom in the twentieth
century. Sample forms for the United Kingdom to record
morbidity and mortality from notiable diseases. Separate
forms are used for the so-called Great Towns as opposed to
boroughs and urban and rural districts. Source: World Health
Organization Library archives.

chart to show the percentage of total deaths MORBIDITY they first contracted the disease (the disease preva-
recorded in England and Wales by ICD chapter at lence). Data availability means that, unless otherwise
Another way of measuring the disease burden is in stated, morbidity is plotted as incidence.
the beginning (1911) and end (1994) of the twentieth
terms of illness (morbidity) rather than death. As
century. At the opening of our time window, the
survival from epidemic diseases improved over the
infectious diseases capable of causing epidemics WEIGHTED MEASURES OF
century, morbidity trends often showed dramatic
(typhus, typhoid and paratyphoid, smallpox, mea-
differences from mortality. Accordingly, wherever MORTALITY AND MORBIDITY
sles, scarlet fever, diphtheria, whooping cough,
possible in this Atlas, when we show time trends for Although counting deaths or cases from a particu-
influenza, cholera, dysentery, tuberculosis and
specific diseases both mortality and morbidity lar cause in a particular year might seem a simple
syphilis) contributed 25% of the burden of mortality
curves are plotted. Morbidity can be measured in dif- and unambiguous way of measuring the burden of
across all age groups. By the millennium, these had
ferent ways. We can (a) count the total number of disease, it avoids a central question. Are all deaths/
fallen to less than 1%, being replaced by cancers
new cases of a particular disease each year or during cases equal? Although this may depend upon your
(26%) and diseases of the circulatory system (44%)
some other interval of time (the disease incidence). religious viewpoint, the theological view might be
as the leading causes of death. Describing and
Or (b) we can count the total people who continue to exactly that all lives and therefore all deaths are
accounting for this massive change is part of the
suffer with a particular disease, regardless of when indeed equal. Let us think about this a little more.
purpose of this Atlas.

7
ATLAS OF EPIDEMIC BRITAIN

This takes into account the year at which a death

occurs as compared with their life expectancy at, say,
birth, as given in the life tables published by most
national population agencies. If an individual dies
before their normal life expectancy, the difference
between date of death and life expectancy in years
represents one measure of YPLL. More complicated
versions of this simple model exist because life
expectancy itself changes with age. Thus, in England
in 2000, a 20-year old male could expect on average
to live for another 55 years (60 for a female) whereas
an 80-year old male could expect to live on average
for another seven years. So under YPLL, the two
deaths would be weighted differently, the younger
death having a weight much higher than the older.
Figure 1.12 shows the years of potential life lost at the
county level in the British Isles from infectious and
parasitic diseases at the millennium.
The effect of measures of this kind is to change the
order of some leading causes of death, all tending to
give greater weight to the infectious diseases (which
especially affect children) and to injuries (which
especially affect young people); where these condi-
tions cause mortality, it is most commonly in the first
two decades of life. YPLL also reduces the relative
importance of heart disease and cancers (which tend
to affect the old). With illness and disability, similar
arguments may be used, giving special weight to dis-
eases which cause a lifetime of disability (so-called
disability-adjusted life years, DALY) rather than a
brief illness. An introduction to the problem is given
in Murray, et al. (2002). Yet other weighting systems
attempt to weight morbidity data by quality of life
measures. But the difficulty with all these approaches
is defining unambiguous and generally accepted sets
of weights.

Data Standardisation
While crude mortality/morbidity rates give a pic-
ture of the geographical pattern of disease in areas
of a country, that picture can be distorted by local
variations in the age/sex composition of the popu-
lation. For example, if a town has a particularly
young population hypothetically say 23 percent
are younger than 15 years and 12 percent are 65
years or older then the crude death rate will be
low and we may also expect the mix of diseases to
be those which affect younger people. On the other
hand, if we take an area with an old population (say
a retirement town), we may expect the crude rates
of death to be much higher and the mix of diseases
Figure 1.9 Secondary reporting of morbidity and mortality by the Office of the Registrar General in twentieth- to be skewed towards those of old age. This intro-
century Britain. The core publications for most of the century are the Registrar Generals Weekly/Quarterly/Annual Return for duces the idea that we need to standardise the data
England and Wales, Scotland and Northern Ireland. Following government reorganisation, these were replaced from 1991 by
in some way, producing standardised mortality/
Communicable Disease Report/Review. In addition to the regular statistical reporting, the results of special surveys and other
health matters of public interest are also published. morbidity ratios (SMRs), to reflect the demographic
composition of the local area if we are going to
make valid inter-area comparisons. Figure 1.13 is a
county-level age standardised map of mortality
We all have to die at some time, and while the simplification and leaves many moral questions among males from infectious and parasitic diseases
death of a child might be seen as a tragedy, that of unanswered. in the British Isles at the millennium. The standard
someone who is very old and perhaps very sick European population (basically the average for
might sometimes be seen as a blessing. In other Years of potential life lost (YPLL) and disability- Europe) has been used as the benchmark. Fre-
words, an argument exists that deaths of the young adjusted life years (DALY) quently, the comparison with the standard popula-
may cut off more potential years of living than For mortality, agencies such as the World Health tion is expressed as a ratio of local:standard
deaths of the old. Or, for morbidity, that some dis- Organization and the US Centers for Disease Control population (sometimes multiplied by 100 to obtain
eases degrade life quality for longer and more and Prevention have been experimenting with statis- a percentage). See Benjamin (1968, pp. 925) for
severely than other diseases. Clearly this is a huge tics which measure years of potential life lost (YPLL). computational details.

8

1912
1974
Figure 1.10 Instability in spatial records of disease. Changes in the boundaries of counties in part of eastern England in the
twentieth century. Base maps of counties are given at the dates of major revisions to county boundaries. Red lines give
boundaries. Boundary changes occur over time by the splitting and amalgamating of districts in response to population
changes. See, for example, the changes made to Yorkshire, Leicestershire and Rutland over the century. The numbered units on
the 1999 map correspond to unitary authorities created on Teesside (Cleveland), in South Yorkshire and the West Midlands.
1.3 The Nature of
Epidemics
In the title of this Atlas we use the term epidemic
diseases. We need now to look more closely at this
term and give it greater precision.
Dening Epidemics
What exactly are epidemics? Th e term epidemic
comes from two Greek words: demos meaning
people and epi meaning upon or close to. It was
used around 500 BC as a title for one major part of
1949
1999
the Hippocratic corpus, but the section concerned
was mainly a day-to-day account of certain patients
and not an application of the word in its modern
sense. In addition to its wider usage in terms of
public attitudes ( for example, Burkes epidemick of
despair), the word has been used in the English
language in a medical sense since at least 1603 to
mean an unusually high incidence of a disease as
compared with previous experience, where unusu-
ally high is fixed in time, in space and in the per-
sons afflicted.
Thus the Oxford English Dictionary defines an
epidemic as: a disease prevalent among a people or
community at a special time, and produced by some
special causes generally not present in the affected
locality. The parallel term, epizootic, is used to spec-
CHAPTER 1
Mapping Epidemic Diseases in Britain
ify a disease present under similar conditions in a
non-human animal community.
In the sixteenth edition of the standard handbook
of human communicable diseases, Control of Com-
municable Disease Manual, Benenson (1995, p. 535)
defines an epidemic more fully as:
The occurrence in a community or region of
cases of an illness (or an outbreak) clearly in
excess of expectancy. The number of cases indi-
cating presence of an epidemic will vary accord-
ing to the infectious agent, size and type of
population exposed, previous experience or
lack of exposure to the diseases, and time and
place of occurrence; epidemicity is thus relative
to usual frequency of disease in the same area,
among the specified population, at the same
season of the year.
Benensons account goes on to stress that what con-
stitutes an epidemic does not necessarily depend on
large numbers of cases or deaths. A single case of a
communicable disease long absent from a popula-
tion, or the first invasion by a disease not previously
recognised in that area, require immediate reporting
and epidemiological investigation. Two cases of such
a disease associated in time and place are taken to be
sufficient evidence of transmission for an epidemic
to be declared.
Epidemics of communicable disease are of two
main types. A propagated epidemic is one that results
from the chain transmission of some infectious agent.
This may be directly from person to person as in a
measles outbreak, or indirectly via some intermedi-
ate vector (malaria) or a microparasite. In some
cases, indirect transmission may occur via humans
(as in louse-borne epidemic typhus fever, or in a mos-
quitomanmosquito chain with malaria). In others,
the survival of the parasite is independent of man
(thus Yersinia pestis, the cause of plague is continually
propagated through rodents and the infection of man
by an infected flea is in this respect a sideshow).
The second type of epidemic is a common vehicle
epidemic which results from the dissemination of a
causative agent. In this case, the epidemic may result
from a group of people being infected from a com-
mon medium (typically water, milk or food) which
has been contaminated by a disease-causing organ-
ism. Examples are provided by cholera and typhoid.
Epidemics in World History
Epic events like the Black Death or the 191819
Spanish influenza pandemic are extreme examples
from the tens of thousands of historically-recorded
disease outbreaks to which the term epidemic can
properly be applied. Many are discussed in Cliff, et al.
(2009, pp. 45105). For Britain, the standard source
prior to the twentieth century is Creightons two-
volume A History of Epidemics in Britain (18914).
Shape of Epidemics
In a human population, the way in which epidemics
of infectious diseases occur and are propagated in
waves through time and over space is discussed in
Cliff, et al. (2004, pp. 811) and is illustrated here in
9
ATLAS OF EPIDEMIC BRITAIN
Figure 1.11 Causes of death in England and Wales, 1911 and 1994. The percentage of deaths by ICD chapter at the
opening and close of the twentieth century. The ordering of key colours corresponds with the bars. Source: constructed
from data in Charlton and Murphy (1997, Volume 1, Table 4.4, p. 44). Charlton and Murphy s two-volume book, The
Health of Adult Britain 18411994, is an invaluable source of information on recording and trends, primarily from
mortality data.
Figure 1.12 Years of potential life lost (YPLL) from
infectious and parasitic diseases in the British Isles at
the millennium. Although the total burden of deaths from
infectious and parasitic diseases was small in the British
Isles at the millennium, the map shows the greatest
potential losses were in Scotland and the London area.
The conurbations in South and West Yorkshire, Greater
Manchester, and in the West Midlands also experienced
comparatively high risks of premature mortality from these
diseases as did the Welsh Marches. See Figure 1.10 for
names. The YPLL is estimated against an age of death of 65.
Source: redrawn from Eurostat Statistical Books (2009, part
of Figure 6.3, p. 46).
10
Figure 1.13 Age-standardised mortality from infectious
and parasitic diseases at the county scale in the British
Isles at the millennium. Although the total burden of
deaths from infectious and parasitic disease was small in the
British Isles at the millennium, as with YPLL in Figure 1.12,
the map shows especially high rates in Scotland and the
London area. The European average by age and sex has been
used as the standard population. Source: redrawn from
Eurostat Statistical Books (2009, part of Figure 6.1, p. 44).
Figure 1.14. The disease is passed from infected indi-
viduals (infectives) to those at risk (susceptibles). At
the start of an epidemic, the number of infectives is
generally small and the number of susceptibles large;
this balance between infectives and susceptibles
reverses over the course of the epidemic. Thus cases
build up over time to a peak. Beyond the peak, the
number of newly reported cases steadily falls and
eventually the epidemic wave passes. This produces
a bell-shaped (usually) single mode curve when cases
(vertical axis) are plotted against time (horizontal
axis) on a graph. The precise shape whether the
build up in cases to the peak is faster/slower than the
fade out depends upon the size of the input compo-
nent (number of infected people, and the number at
risk (susceptible) at the start of the epidemic), and a
third, output, component (rate of recovery from the
disease).
The relationship between the input and output
components has been studied by Kendall (1957). We
can summarise the magnitude of the input compo-
nent by looking at the rate at which new cases are
generated by contact between infected and suscepti-
ble people. We can call this rate a diffusion coeffi-
cient, b. The output or rate of recovery is symbolised
by a recovery coefficient, c. The ratio, c/b defines a
threshold (given by the Greek letter rho, ) in terms
of population size (the critical community size). For
example where c is 0.5 and b is 0.0001, then would
be estimated as 5000.
Figure 1.14A shows a sequence of outbreaks in a
community where the threshold () has a constant

Figure 1.14 Shape of epidemic waves in time. Kendalls (1957) model of the relationship between the shape of an epidemic
wave and the susceptible population/threshold ratio, S/. (A) Growth of a susceptible population over time showing the effect
of infections introduced into the susceptible population at the black arrows. (B) Three typical Kendall waves for times t1, t2 and
t3 in (A). Source: based on Cliff, et al. (2004, Figure 1.12, p. 10).
value, and it is therefore plotted as a horizontal
pecked line. Given a constant demographic birth
rate, the susceptible population increases and is
charted as a diagonal purple line rising over time.
Three examples of infection introductions are
shown (lower unlabelled black arrows). In the first
two, the susceptible population, S, is smaller than
the threshold (S < ) and there are a few secondary
cases but no general epidemic. In the third exam-
ple of infection introduction, the susceptible popu-
lation has grown well beyond the threshold (S >>
); the primary case is followed by many secondar-
ies and a substantial outbreak follows. The effect of
the outbreak is to reduce the susceptible popula-
tion below the threshold, as shown by the offset
curve in the diagram, causing the epidemic to
die out.
Kendall has investigated the effect of the S/
ratio on the incidence and nature of epidemic
waves. With a ratio of less than one, a major out-
break cannot be generated; above one, both the
probability of an outbreak and its shape changes
with increasing S/ ratio values. To simplify Kend-
alls arguments, we illustrate in Figure 1.14B the
waves generated at times t1, t2 and t3 in Figure 1.14A.
Waveform I is generated when the susceptible pop-
ulation has grown well above the threshold value as
at t3. The resulting epidemic wave is strongly skewed
towards the start, and it is extremely peaked with
many cases concentrated into the modal period. In
contrast, at time t1, the susceptible population is
only slightly above the threshold value. If an out-
break occurs in this zone, Waveform III will result;
the outbreak will have low incidence, will be sym-
metrical in shape, and have only a modest concen-
tration of cases in the peak period. Waveform III
approximates the Normal curve. Wave II occupies
an intermediate position occurring at t2 and is
included to emphasise that the changing wave-
forms are examples from a continuum. If we relate
the pattern of Figure 1.14B back to Kendalls original
arguments in Figure 1.14A, then we must assume
that the S/ ratio has changed over space and time.
This could have occurred in three ways: by a reduc-
tion in the value of S; by an increase in ; or by both
acting in combination.
Figure 1.15 illustrates how the shape of an epi-
demic wave changes with distance from a point
source. The energy of the wave is dissipated as the
wave swills out to occupy a larger and larger geo-
graphical area, and so it diminishes in intensity and
right skewness.
CHAPTER 1
Mapping Epidemic Diseases in Britain
Figure 1.15 Changes in the shape of epidemic waves
with distance from the origin of an epidemic, here
hypothesised to be in Essex, East Anglia. Generalised
wave model set within time and space dimensions showing
the shape of the epidemic wave at locations 1, 2 and 3.
Source: Cliff, et al. (2004, Figure 1.13, p. 10).
1.4 Mapping
Epidemic Diseases
The idea of mapping epidemic diseases in Britain is
not new and so, in this section, we look back at some
of the predecessors of this Atlas. The approach is
broadly chronological. For a fuller account, see Cliff,
et al. (2004, pp. 1115) upon which this section is
based.
The Nineteenth Century
A fillip to mapping was provided by the advent of
cholera and yellow fever outbreaks in cities on both
sides of the Atlantic. Jarcho (1970) lists 29 cholera
maps published in the 12 years after 1820 following
the emergence of the first great cholera pandemic of
1817 from India (see Section 3.6 and Cliff and Haggett,
1988, p. 5). Most of these maps plotted routes of
spread, dates, and regions of occurrence. In the fol-
lowing decades sophisticated maps showing the dis-
tribution of cholera within European cities began to
appear. In Britain, John Snows famous map of indi-
vidual cholera deaths in the Soho area of London
appeared in 1854 (Snow, 1855). At a different geo-
graphical scale, Petermann was by 1848 producing
cholera maps of England and Wales attacked by the
disease. Thus by 1850, medical cartography was
beginning to be established in Britain.
11
ATLAS OF EPIDEMIC BRITAIN
Twentieth Century Mapping
In twentieth-century Britain, more and more official
reports on epidemic outbreaks were accompanied
by disease distribution maps as the century pro-
gressed. Percy Stocks, a medical statistician at the
General Register Office, was one of the first to try to
overcome the limitations of the crude death rate in
mapping disease. His map of the regional distribu-
tion by counties of cancer prevalence in England and
Wales, 191923, used corrections for differences in
age, sex and the urban/rural balance. He concluded
that the mortalities . . . vary over such wide limits
and the counties group themselves into such definite
regions of high and low prevalence, that there can be
no question that geographical influences are in some
way concerned (Stocks, 1928, p. 518). More sophisti-
cated adjustments were included by Stocks and Karn
(1931) for both cancers and for tuberculosis. By the
late 1930s, the reports of the British Empire Cancer
Campaign routinely included maps prepared by
Stocks showing the spatial distribution for England
and Wales of cancer of various organs in different
age-groups for each sex.
Later Maps and Atlases
During the Second World War and in its immediate
aftermath, both Germany (Seuchen Atlas) and the
United States (American Geographical Society Atlas)
undertook atlas initiatives. These had an impact in
Britain through the two ancient universities and the
Royal Geographical Society. At Oxford, E.W. Gilbert
pursued his historical research on early maps of
death and disease in England (Gilbert, 1958). At Cam-
bridge, J.A. Steers, head of the Geography Depart-
ment, attended the Washington Conference of the
International Geographical Union in 1952 and was
strongly influenced by the first report there from the
IGU Medical Geography Commission. On his return,
Steers invited Leslie Banks, Professor of Human
Ecology within the Cambridge Medical School, to
give a course of lectures on medical geography in the
Geographical Tripos.
Bankss papers to the Royal Geographical Society
led to the setting up of a medical geography commit-
tee in 1959, with a medical atlas of Britain as its first
major research project. The publication of the
National Atlas of Disease Mortality in the United King-
dom (Howe, 1963) represented, for the UK, its response
to the international disease atlases noted above.
Using data for the five-year period 1954 to 1958 for
each of 320 administrative units in the UK, it plotted
standardised mortality ratios for thirteen major
causes of death from heart disease to lung cancer.
Unlike some countries, local areas could be used in
Britain since, as noted in Section 1.2, its twentieth-
century death statistics were published by the usual
residence of the deceased. Like Stocks, Howe adjusted
crude mortality ratios to allow for local age, sex, and
degree of urbanisation.
A second edition of the National Atlas (Howe, 1970)
used data from a later five-year period, from 1959 to
1963. It covered an enlarged range of diseases and used
different cartographic techniques. A demographic
(rather than an area) base map was employed to avoid
giving undue prominence to mortality ratios for
extensive and lightly populated areas of the country. A
12
system of squares for urban populations and dia-
monds for rural populations (each proportional to the
at risk population in each area) was utilised. A stylised
coastline was added to aid in reading the maps. Howes
atlases were followed by more specialised cancer
atlases ( for example, Gardner, et al., 1983) and atlases
for other selected diseases (Gardner, et al., 1984).
New Developments in Disease
Mapping
The trend towards national atlases of disease started
by Howe has continued apace. Howe himself led the
way with a world atlas of human cancers Global
Geocancerology: a World Geography of Human Can-
cers (1986). Cliff and Haggett produced an Atlas of
Disease Distributions (1988) with a wide range of dis-
eases mapped at different spatial scales. The purpose
of the atlas was to provide worked examples of the
widening range of analytical methods that could
now be applied to epidemiological data. In contrast,
in their Atlas of AIDS (Smallman-Raynor, et al., 1992),
the authors sought to catch the first decade of spread
of a rapidly expanding world pandemic. A feature of
the atlas was its heavy reliance on a unique database
of attested movements of infectives and the use of a
variety of spatial scales from world maps down to
spread within the individual districts of a city ( for
example, San Francisco and New York City).
The ready availability of powerful computers
now enables large arrays of disease data to be han-
dled so that national atlases have grown to become
continental and global atlases of disease, emanat-
ing especially from the World Health Organization
and its regional offices. Linked to GIS software and
the Google EarthTM mapping service, GIS allows
sophisticated disease maps to be produced at will.
GIS is a system for the input, storage, manipulation
and visual output of geographical information. A
plethora of GIS software packages of varying capa-
bilities is available for data processing, analysis and
display, ranging from low to high. Lozano-Fuentes,
et al. (2008, pp. 71825) have evaluated the potential
of integrated GIS/analytical frameworks to
strengthen public health capacity and to facilitate
decision-making for the prevention and control of
Figure 1.16 Integrated framework for the visualisation and analysis of geo-referenced disease data. Source: based on
Lozano-Fuentes, et al. (2008, p. 723).
diseases especially in resource-poor environments.
Figure 1.16 shows how the various elements of dis-
ease data, display and analytical software can be
combined into an integrated system.
Pioneered by Howe, the use of a demographic
rather than an areal base for disease mapping has
been carried forward in a GIS framework by Dorling
in the health maps which appear in Dorlings New
Social Atlas of Britain (1995, pp. 136169) and in Shaw,
Thomas, Smith and Dorlings The Grim Reapers
Roadmap (2008). In the former Dorling employed
maps of local authority wards in Britain (there are
over ten thousand of them). Each ward was plotted
as a circle whose area was proportional to its popula-
tion. To generate the maps, the centre of each ward
was first placed in its correct geographical location.
A computer program was then used to allow the cir-
cles to be expanded slowly and, if they touched, they
pushed each other out of the way until their correct
size was attained. This procedure distorts the shape
of the map (with large cities occupying more of the
map, empty rural areas less), but it is still possible to
draw county and district boundaries, towns and vil-
lages upon it (Figure 1.17).
Dorlings map of mortality in England and Wales
shows what appear to be areas of especially high
and low years of life lost. By making the construc-
tion of probability maps straightforward, computers
can play a role in providing objective assessments of
what we mean by these terms. In probability map-
ping, the possibility that a given location displays
unusually high or low levels of some disease is deter-
mined by comparing the observed level with the
value which would be expected if it had arisen by
chance or randomly. Deciding if a map pattern is
random or not should be the first step taken before
launching upon a search for possible explanations
of an observed distribution. We should seek causal
explanations only for those disease distributions
which have highs and lows that could not have arisen
by chance.
In The Grim Reapers Roadmap, Shaw, et al. (2008)
use the same idea of a population cartogram in
which sizes of geographical units are made propor-
tional to population size rather than spatial area but,
to ensure perfect packing of the units, make them
hexagonal rather than circular in shape (Figure 1.18).

Figure 1.17 Population proportional maps. Diseases
can be mapped using many cartographic devices. In a
conventional map, the size of spatial units is made
proportional to their geographical area. Other graticules
can be used, however. For example, Dorling in his map of
mortality in England and Wales using years of life lost,
198189, plotted individual wards as circles proportional in
size to their population and shaded according to the average
years of life lost. The effect is to enlarge on the map those
areas with large populations (e.g. London swells to foetal
proportions with closely-packed wards). Conversely lightly
peopled counties such as those of southwest England have
few dots. The contrast between the inner, poorer areas of
London (red, with high average years lost) and the affluent
suburbs (black, with lower average lives lost) is evident.
Geographical Information Systems (GISs) make different
mapping frameworks comparatively straightforward to
construct and to associate with disease data. Source: Dorling
(1995, p. 163).
Figure 1.18 Mapping frameworks. A conventional geographical framework shows spatial units proportional to their area.
The inset (bottom right) illustrates such a map for Britain at the administrative county level. Extending the population cartogram
idea of Figure 1.17, but this time using population-proportional hexagons rather than circles to ensure perfect packing of the
units (inset map, top right), Shaw, et al. (2008) have plotted standardised mortality for 99 categories of diseases in Britain in the
last two decades of the twentieth century. The main map plots one of these, deaths from all respiratory diseases, as
standardised mortality ratios (SMRs) for 1,282 neighbourhoods (each half a parliamentary constituency). The map shows both
urban (high SMRs) rural (low SMRs) and north (high) south (low) divides for mortality from respiratory illness. Source: Shaw,
et al. (2008, map 10, p. 21).
CHAPTER 1
Mapping Epidemic Diseases in Britain
1.5 Atlas Organisation
Geographical Parameters of the
Study
The primary geographical focus of this Atlas is Brit-
ain. However, where they are available, some exam-
ples are also drawn from the wider British Isles to
illustrate points of particular epidemiological inter-
est. Figure 1.19 uses a Euler diagram (left) and maps
(right) to define the spatial units to which various
geographical names apply:
1. British Isles is the name for the two large islands
and several smaller ones covering England,
Scotland, Wales, Northern Ireland, the Irish
Republic, the Isle of Man, the Channel Islands,
and numerous other smaller islands.
2. (Great) Britain is the name for England, Scotland
and Wales.
3. The United Kingdom (UK) comprises England,
Scotland, Wales and Northern Ireland.
4. Ireland is the largest island to the west of Britain.
The southern part is the Republic of Ireland and
has been an independent country since 1922. The
northern part is Northern Ireland and it is part of
the United Kingdom. Prior to 1922, both parts of
Ireland were known as Eire which was part of the
United Kingdom.
In the chapters which follow, the geographical
units used for analysis are clearly stated.
Layout of the Atlas
This Atlas begins with two general chapters to set
the stage for the detailed work on epidemic Britain
in Chapters 311. In this chapter, we have defined
epidemic diseases and shown how mortality and
morbidity from these conditions is recorded in the
British Isles. The data desiderata to permit disease
mappability have also been discussed. In Chapter
2, a century-long sweep of epidemic mortality in
the countries which comprise the British Isles is
undertaken. We compare British mortality time
series patterns with those of other European coun-
tries to provide an international context for these
islands.
Britains own twentieth-century epidemiological
experience can be conveniently divided into three
phases (Figure 1.20). The first, 190145, is covered
in SECTION I and considers the major infectious
and parasitic diseases which generated much of
British morbidity and mortality in the period
before antibiotics and mass vaccination. While
germ theory had deepened understanding of the
causes of disease from the 1880s, the means of con-
trol and a proper understanding of the bacterial
and viral agents responsible awaited the coming of
antibiotics and the electron microscope respec-
tively. The great epidemic infections of the first half
of the century included diseases of childhood ( for
example, measles, scarlet fever and whooping
cough), as well as unselective killers ( for example,
tuberculosis, typhoid and influenza). Chapter 3
completes the story begun by Creighton and covers
13
ATLAS OF EPIDEMIC BRITAIN
Figure 1.19 Dening the British Isles. Euler diagram and associated maps to dene the names of the geographical units at
the country level which comprise the British Isles.
the final years of the great plague diseases of his-
tory which so preoccupied Creighton bubonic
plague, cholera, typhus, malaria and smallpox.
Chapter 4 treats the major childhood infections
diphtheria, measles, streptococcal infections,
whooping cough and mumps. These infections
consolidated their contributions to Britains mor-
bidity and mortality during this period. Chapter 5
discusses the indiscriminate killers influenza
(under the influence), typhoid, and the emerging
disease of poliomyelitis. The geographical patterns
of these and other diseases were also shaped by
two world wars, so that Chapter 6 concludes the
first phase with a consideration of epidemics on
the home front in wartime.
A second epidemiological phase began after the
Second World War. From the middle of the century,
many of the epidemic sicknesses of the centurys first
50 years retreated under the combined onslaught of
vaccination, antibiotics and improvements in stand-
ards of living. By the 1970s, it was fashionable to think
that the time of infectious and parasitic diseases as
major causes of British mortality and morbidity was
over. Thus the biologist, John Cairns, wrote in 1975
that the western world has virtually eliminated
death due to infectious disease. But the cheering
was premature. Within the decade, a new pandemic
disease, HIV/AIDS, was emerging that killed in the
next two decades as many Britons as did smallpox in
all previous years of the twentieth century. The rec-
ognition of a generation of apparently new diseases
and the re-emergence of others as national health
problems confirmed that we needed to be cautious
14
in declaring infectious diseases to be features of
history.
SECTION II focuses upon this second phase cov-
ering, first, the retreat of some infections which dom-
inated British epidemiological history in the first half
of the twentieth century (Chapters 7 and 8); Chapter
7 treats epidemics caused by bacteria and Chapter 8
by viruses. The period from around 1980 illustrates
Cairnss false dawn. Among the newly emergent dis-
eases, the obvious example already mentioned is
HIV/AIDS. But there have been many others for
example hospital-acquired, antibiotic-resistant
strains of diseases such as MRSA and water- and
foodborne infections like Legionnaires disease and
E. coli O157. Chapter 9 deals with a selection of the
epidemics in Britain caused by these agents. The par-
ticularly geographical role of increasing travel, popu-
lation movements and lifestyle changes in spreading
diseases is illustrated.
A special British strand in the twentieth century
history of infectious diseases is the research role of
general practitioners in recording and interpreting
local disease patterns. And so, in Chapter 10, we look
at the contribution of four of the outstanding such
figures James Mackenzie and the Institute of Clini-
cal Research, Aberdeen, Will Pickles of Wensleydale,
Edgar Hope-Simpson of Cirencester, and G.I. Watson
and the RCGP Epidemic Observation Unit to this
movement. Arising from their work and that of oth-
ers, detailed information on the spacetime occur-
rence of a range of infections is available. A selection
is discussed and mapped in this chapter. We recog-
nise that the work of Mackenzie and Pickles belongs
chiefly in Section I, and Hope-Simpson and Watson
to Section II, but rather than divide the unique cor-
pus of material arising from general practice, we
have chosen to treat it all here in a single chapter.
Section III, Prospect, comprises a single chapter
and speculates upon the likely future for infectious
diseases in the British Isles in the twenty-first cen-
tury. We first set the policy context for health the
Chief Medical Officer for Englands 2002 national
strategy (Getting Ahead of the Curve) for combat-
ing infectious diseases and the creation of the
Health Protection Agency in 2003. We then discuss
the problems caused by health scares taking, as
part of a wider discussion of epidemics in educa-
tional establishments, the MMR (measles, mumps,
rubella) vaccine farrago as an example, before look-
ing at emergent zoonoses and bird and animal
infections as potential sources for new human
infections. We next consider the possible impact of
priority biological threats to the United Kingdom.
As we write, bioterrorist threats are high and are
likely to remain so for years to come. Finally, the
Atlas concludes with an assessment of geographical
variations in health inequalities and life expectancy
in the British Isles, setting these in the international
contexts of the World Health Organization and the
United Nations health-related Millennium Develop-
ment Goals.
Range of Diseases
An Atlas of this size can only cover some of the sub-
stantial range of recognisable epidemic diseases
which affected Britain in the twentieth century. We
restrict ourselves primarily to human diseases,
although some which are carried by animals but
which can affect humans are also discussed. Our
choice has been dictated by three main considera-
tions: their relative importance in the British burden
of disease as judged by the mortality and morbidity
which may be attributed to them; their economic
and demographic significance to the British Isles as
judged by years of potential life lost and disability
adjusted life years; and their mappability. This last
criterion is important because many diseases are so
rare that data simply do not exist to permit mapping.
Others are so ubiquitous that they do not display dis-
tinctive geographical patterns when mapped at the
British scale. For each disease considered, a brief dis-
cussion of its aetiology is provided along with an
annual time series, 19012000, where data are avail-
able showing the morbidity, mortality and control
measures ( for example, vaccinations administered)
taken.
1.6 Conclusion
This chapter has outlined the ways in which a num-
ber of terms and concepts are used in this Atlas
what we mean by a disease and an epidemic; how
 CHAPTER 1

Mapping Epidemic Diseases in Britain

Figure 1.20 Atlas organisation. The 11-chapter sequence of Atlas of Epidemic Britain, arranged on a broadly historical basis. The images illustrate some of the main themes of the Atlas.
Section I deals with the historic plagues, 190145. Tuberculosis was regarded as an intractable infection prior to the advent of modern antibiotics, and the poster from the World Health
Organization c. 1950 captures this historic despair, along with a positive message for the future. Section II, the era of the National Health Service, antibiotics and mass vaccination, examines the
impact of these developments upon Britains epidemic diseases in the second half of the twentieth century along with the recrudescence of some old foes. The small child is suffering from acute
whooping cough, a disease eliminated as a signicant public health threat in the British Isles during this period. Although many infectious diseases disappeared to the back burner as public
health concerns, some like tuberculosis are re-emerging as global health threats. Others, like measles, illustrate what happens when vaccination levels in the population fall as a result of
erroneous health scares. Section III, Prospect, looks forward into the new century. Smallpox still remains the only epidemic disease globally eradicated by vaccination (in 1979). Themes for the
twenty-rst century include prospects for the eradication of other infections; the use of infectious agents for bioterrorism; animal and bird diseases as potential sources of human epidemics;
and health inequalities arising, even in the British Isles, from economic poverty. The bronze statute in the photograph is by the Welsh sculptor, Martin Williams. It is outside the main World
Health Organization building in Geneva. It is a tribute to all the health workers who combined to eradicate smallpox. While it symbolises hope, smallpox virus is constantly cited as a possible
bioterrorist agent. Source: images from World Health Organization archives and by the authors.

mortality and morbidity data are collected, recorded
and disseminated in Britain; what data standard-
isation and quality issues must be confronted; how
epidemic diseases may be mapped and the role
which may be played by new technologies like Geo-
graphical Information Systems (GIS); and what we
mean by geographical terms like Britain and
United Kingdom. Although the focus of the Atlas is
epidemic diseases in Britain during the twentieth
century, Britain was coupled, and increasingly so,
into a global framework throughout the century.
Infectious diseases are spread by person-to-person
interactions and these grew dramatically during the
century with the development of mass air passenger
travel. This flux increasingly acted as the engine for
the spread of infections within and between coun-
tries. To set Britains twentieth century epidemiologi-
cal experience in a broader context, Chapter 2
compares the century-long trends of mortality in the
countries of Britain with those in the rest of Europe,
and it is to this which we now turn.

15