In 1866, the last major cholera outbreak traveled east from Europe to New York City (NYC), claiming the lives of 1,137 individuals. Although the death toll was high, it was a significant improvement compared to previous outbreaks of cholera in NYC. The population had increased dramatically since earlier cholera outbreaks to a total of approximately 1.2 million people. About 40 percent were poor Irish immigrants fleeing famine and persecution back in Europe. Such a dramatic increase in population put the death toll of this particular out break into perspective and positively reflected on the improved efforts of NYC's Sanitation Department. Equipped with new insights on cholera through the findings of Dr. John Snow, they began to take an active and vigorous position against fighting and prevention of disease in NYC. Aware of the cholera outbreaks in Europe, many New Yorkers anticipated yet another infestation to reach Manhattan. In 1864, a group of concerned wealthy New Yorkers, with connections in city government came together to form the Council of Hygiene and Public Health. Together, they wrote a survey on living conditions in Manhattan, detailing the squalor of the city ward by ward. The final document, published in 1865, was more than three hundred pages long and helped create public support for the creation of the Metropolitan Board of Health in 1866. With a stronger, well-funded and supported Sanitation Department, NYC faced the cholera outbreak in 1866 with more confidence than before. Before cholera even hit NYC, the Board of Health issued orders to clean up various sites around the city, which stored accumulated animal manure, rotting food and dead carcasses from butcheries. These posed serious sanitation threats. They also put pressure on ward bosses to stop the misuse of money meant for cleanup and maintenance of their neighborhoods. The board faced further challenges with some business owners who, reluctant to take on more responsibility and expense, failed to cooperate. However, even with the challenges they faced, Manhattan in 1866 was the cleanest it had ever been. When the first cholera-infected ship arrived in New York, it was quarantined to an uninhibited area of Staten Island. Despite this effort, cholera made its way to a handful of people in the wealthier sections of Uptown Manhattan. The epidemic progressed slower than usual, but eventually hit poorer neighborhoods downtown, where it took the lives of most of its victims. The Board of Health took many actions that limited the spread of the disease throughout the city: they trained a small army of first responders, established an emergency hospital at the Battery Army Barracks and created plans for the disinfection of the city once the cholera outbreak subsided. The establishment of the Metropolitan Board of Health was a milestone in NYC's development and history: not only did it create higher standards of living for future generations, but it also set precedence for future epidemic control procedures.