hist-234: Epidemics in Western Society Since 1600
Lecture 26 - Final Q&A [April 26, 2010]
Chapter 1. Logistics
Professor Frank Snowden: Good morning. We'll get started. As you know, this isn't — there isn't going to be a lecture this morning at all. We're going instead to have a review session, in which I'll be very much dependent on your having questions, and our having a joint discussion. So, what I'm expecting to be able to do is to, when you have questions, or want to contribute to — I've got some questions as well — we can put our heads together. And there'll be a microphone, I hope, that we can pass around, and everyone will be audible.
The first thing I should say is just to talk, just for a minute, about the exam itself; because I've now written it. So, at least we can say on that much I'm the world's authority. The exam will look like this. There will be two parts. The first part will be the ID section, and that will have — let's see, you've got the list of identifications, and I've literally just chosen ten of them, and that will constitute two points each, or a total of twenty points for the ID section. And, so, you can work out how to budget your time, in that regard. Clearly, you're not meant to write an essay; just even bullet points or a short paragraph is all that's expected with regard to the identifications.
The second part of the exam consists of three essays, and I'm — that is, three on a list of three — and I'll ask you to write on two of them. And each of the essays therefore will count forty points. So, part two of the exam will count eighty points altogether. That tells how you should budget your time. The essay questions are much more important than the identifications. That's really the structure of the exam. I can't think really of anything else that I can say about that. But let me see if anyone — before we turn to substantive issues, does anyone have any questions about the format of the exam or what's likely to be on it?
I can repeat what I've said before. The exam period itself is notionally three hours, though you also get an additional half-hour as a grace period. That, I understand, is the Yale system, and we'll adhere to that. The exam will also — I wanted to stress this — it will cover the whole of the course, from the beginning, and it won't simply be on the last part of the course, since the mid-term. It will cover everything that we've dealt with since January down to today. So, are there any questions before we turn to the substance, about the format of the exam, or what you could expect or not expect, or anything of that nature? Yes?
Student: Do we need to bring in any sort of readings on the ID section?
Professor Frank Snowden: The question was, do you need to bring in readings on the ID section? I think that depends entirely on which ID you deal with. Some of the IDs are directly based on the reading that you've done. So, for example, if I ask Daniel Defoe, to identify, it would be really odd if you didn't bring in the Journal of the Plague Year, and why it was important. Okay? But if I asked you about, say, the Paris School of Medicine, that you didn't actually have readings on, then it wouldn't be necessarily. So, it really depends on the nature of the particular ID in question. Okay?
Anything else about the exam? Okay, thanks. Then let's move on to the substantive part of the review, and the issues that we've been dealing with in the course. And I thought one way we might start would be for me to ask you a question; which is what do you think I should sensibly ask you about on the final? What would make good final exam questions for you, based on the material that you've covered? And then we could put our heads together a little bit to think about what might be some elements of the answers that you'd provide in them. Does anyone have a question that I ought to ask you? It's never too late; I could change the questions I wrote yesterday. You think I should ask you nothing? It's always a possibility, too.
Chapter 2. What Determines the Historical Significance of an Epidemic? [00:05:26]
Okay, well I've got some thoughts, if you like, for things that we might want to deal with. One was this — and I'm going to ask and see if any of you would like to help me think through this particular issue — if we're dealing with the impact of major epidemic diseases on society, what would be — is it true to think that it's really the overall mortality that provides the major way in which we can assess whether this was an important event or it wasn't? Is that how we judge the significance of the passage of an epidemic disease through society? Do we — is the body count, in other words, the most important factor? Or is it something else? How do we — what factors determine whether an epidemic disease really is a significant historical event or it isn't? Do you have any thoughts on that particular issue? Yes — please? Thank you.
Student: Morbidity. <Inaudible>
Professor Frank Snowden: Okay, thanks very much. Did everyone hear? The candidate for an answer would be that it's not just the mortality, but we need to look at the morbidity, and even more than that we need to look at the class, or the profile of the victims of the epidemic, and that it makes a big difference whether the victims of the disease are the elderly, and perhaps infants; in other words, whether it seems like a normal event in the life of that society, or whether it targets instead a different patient population. If it targets people in the prime of life, it's experienced in a very different way. So, clearly the class profile is important, and not just the mortality, or even the morbidity. Are there other factors? Yes?
Student: One argument in favor of mortality mattering is it didn't really have much of an impact on things like society, and it didn't prove lasting. Like you could control things. So you'd have like a really big morbidity but a small mortality, and so that prevented a panic.
Professor Frank Snowden: That's great.
Professor Frank Snowden: Maybe you could start again. I don't think everyone could hear you.
Student: One argument in favor of mortality mattering is that flu, which didn't really have that much of a lasting impact on society, had a really high morbidity but a really small mortality, and everyone knew that, and so they weren't panicked when it came.
Professor Frank Snowden: Okay. There's the idea then that we shouldn't retreat too much from mortality, that it really does matter. And I'm really happy that you did something very important, which was not just to leave this matter hanging in the abstract, but to tack it to a particular example. And, so, it's really important that you bring in particular diseases to clinch your argument. Talking about influenza is exactly the way that the argument ought to go, and weighing that versus other diseases that were different. That's good. Thank you. Right, someone else? Oh, there we go.
Student: At the same time, I think that what that really speaks to is more the reaction of society to something. So, that it's important to say that it's not just a number that matters; that mortality rate isn't so much the important part as much as how people were able to kind of incorporate that into their lives. Because as you were saying, flu wasn't necessarily the most striking example to people. However, I think that certain — even times like tuberculosis, where you have people who are dying but in very much longer periods. So, you have more time for reactions in literature and art, and those have just as much of an impact. And, in fact, they're really lasting impacts because we still have those pieces of epidemic art and literature to look back on, to see how they had impacts on society.
Professor Frank Snowden: Okay, yes, thanks very much. So, it's — you want to complicate the matter even more — it really depends on how it's perceived, perceptions — and also that's reflected in the arts and in literature, and you're giving the example of tuberculosis and the time period and how lasting the impact is. That tuberculosis has — one of its reasons for having such an impact was that it was such a slow event, and was with society for so long, and people reflected on that, and it impacted the arts and culture.
Absolutely, I think that would be. So, we've got now — in order to deal with this, we've dealt with influenza and tuberculosis as contrasting factors, two diseases, in very different ways. And it's certainly true that also on the exam we will be dealing — I'll be asking you to be comparative in your discussion of diseases, and to bring in more than one disease in order to deal with major questions that cut across the whole of our course. Okay, thanks. Anything else we ought to put in to our answer to this question? Would it be good to deal with just two diseases in dealing with that? Would this be — would you get an A+ for bringing in influenza and tuberculosis? What other diseases might be important in considering this question? Yes, thanks.
Student: You might consider cholera, because it was sort of the opposite of tuberculosis, in that it had a very rapid onset, and so the specifics surrounding the disease itself had an effect on how it was perceived as something frightening, and something gross.
Professor Frank Snowden: Okay. So, you would throw cholera into the mix. And I think the reason you're — if I've understood you, you're saying that this should take us into another whole realm, which is to deal with the symptoms, because there was something particularly frightening and disgusting about Asiatic cholera, and that conditioned its impact. People were really terrified by its arrival, because of the nature of its symptomatology. That's another dimension that we ought to consider.
It's not just morbidity, not just mortality, not just the profile of the victims, but the kind of suffering that the disease imposes on its victims. So, the symptomatology is tremendously important. Okay, anything else on that question? Our grade is going up all the time. Several examples, specific cases, that's comparison, that's all extremely important. Anything else anyone wants to throw in on this question? So, collectively we've got what? An A+ on this? Okay, we'll pat ourselves on the back, and let's move on and see if there are other issues we might like to discuss.
Chapter 3. Diseases of Modernity [00:14:33]
What is it — let me see, I'm wondering — I mentioned something in passing, and threw out a phrase, which was that we might want to consider some diseases in our course "diseases of modernity." I'm wondering if that's actually a useful concept. It may be that I misspoke. Or is modernity in some senses a factor that promotes our vulnerability to high-impact epidemic diseases; or at least certain ones among them? Is that true or is that wrong? Great.
Student: always like to put a finer edge on it <inaudible>
Professor Frank Snowden: You really do, yes.
Student: I might put a finer edge on it for the class by asking them if any real progress in social or medical response to epidemic disease has occurred over the time span of the course?
Professor Frank Snowden: Okay. In other words, are we more vulnerable now, or much less vulnerable, as a result of public health policies and understanding of infectious diseases, since, let's see, poor Daniel Defoe lived through the bubonic plague. That's sort of your question, right?
Student: It struck me that your definition of a disease of modernity refers to structural factors. Right? So, for instance, the role of mass transit technologies, perhaps urbanization in abetting the spread of disease. Isn't that the sense of disease of modernity?
Professor Frank Snowden: I think you're right. Who knows what I meant when I said it. But it would seem to me, if we were retrospectively to try to make sense of a phrase like that, we — and this is important and all. Here's a general point for any answers that you give in an exam. You would have to provide a definition of what it actually means. Modernity is a lovely phrase, but it doesn't really — its meaning is not self-evident, and it was only — your grade would rise very significantly if you weren't just to talk about modernity, but you were actually to do what you just did, but to say, "What does that mean?" and point to factors such as urbanization, mass transit, population growth, things like that, that give it a meaning; and possibly also the development of an understanding scientifically of the biology and the medicine of the diseases, and therefore public health policies and practices.
That, I think, would be a much better way to approach this idea of whether it's a disease of modernity or not. And I'm just wondering what would you say? Are we less vulnerable now than London was at the time of Defoe; or is it still the same; or are we vulnerable, but vulnerable to different kinds of diseases, at least here in the West? Okay, great.
Student: I would say that we're more vulnerable to the spread of disease and to diseases that are a result of over-sanitation, but that we're also more capable of dealing with them, scientifically and technologically.
Professor Frank Snowden: Okay. So, it's neither — you're rejecting that opposition of being more or less vulnerable. We're more vulnerable in certain ways, and less vulnerable in others. Perhaps we're not as susceptible to certain diseases in the same way, but we're susceptible to other diseases in different ways. Maybe the mode of transmission is an important factor. But you wanted to say something too. Let's come to you.
Student: I also think that in a way though we're sort of like shifting from one vague misconception of disease causality to another. Because the earliest modes of disease prevention were quarantine and just, like, whatever they could — like sanitation, like with Chadwick. But then we moved to this magic bullet thing, once we figured out that it was the germ theory. And for a really long time — and I think it still sort of persists — is this idea that we can cure something just by finding a magic drug. And that isn't really how it works, and there are a lot of other factors. And even though we sort of acknowledge that sometimes, I don't think that it's necessarily permeated our efforts to cure a lot of different diseases. Like with AIDS you can kind of see that there's efforts at education and things like that. But as long as there's poverty, there's going to be diseases that disproportionately affect the poor, and I don't think that we're anywhere near solving that problem.
Professor Frank Snowden: Okay. So, as I understand it, you're saying that we have made advances in understanding, and there are diseases for which there are public health measures that are effective, and there are sometimes magic bullets. But we have become rather over — we overemphasize the importance of treatments, and we underestimate the social economic determinants of disease. And, so, diseases thrive on certain social and economic conditions — and you mentioned poverty, for example — and so until those underlying substrates of epidemic diseases are dealt with, we'll always remain vulnerable.
Chapter 4. Diseases of Poverty [00:20:48]
So, that would suggest — maybe we should take that on for a second.
Is that a valid conclusion from the course, from your readings and all the rest, that diseases, all diseases, are diseases of poverty? — would seem to be something you were maybe suggesting. Or even if you weren't, I'm suggesting it on your behalf. Is that a valid conclusion to draw; that really the essential driver of epidemic disasters is poverty? All diseases are diseases of poverty; is that right? Right. Great, thanks.
Student: I would disagree with that statement because although —
Professor Frank Snowden: Okay. I would too.
Student: We see that, in some cases, notably cholera, it did only strike the poor, and the rich were pretty much unaffected by the disease, in terms of health, health-wise. There's been plenty of other diseases that really haven't shown any liking to any specific socioeconomic class. The flu just came in and, since it was so easily spread from person to person, even if you were walking into a store run by someone of a lower class, you could easily get that from them. So, I think most diseases, even though some did strike the poor to a greater extent, you can't classify them solely as being diseases of poverty. Where poverty might have — not embellished — but poverty might have — imight have made it worse. Someone in poverty would probably be worse off due to influenza than a richer person. But I don't think it caused most of the diseases we've talked about.
Professor Frank Snowden: Okay. There is the theory, then, that it really depends on which disease, and that it's a gross oversimplification to say that poverty is the cause of epidemic disease. It exacerbates the situation, probably for all. But there are clearly certain diseases that are driven by other factors — and influenza was a case in point — there's certain diseases that really do seem to be equal-opportunity afflictions, in that they seem to strike all rungs of society, rather than just certain economic and social classes. And influenza was a good — respiratory diseases perhaps veer towards that pole. But then I think you're saying that in any case it's probably not fair also completely to eliminate poverty; that it's a sort of spectrum, and some diseases are more responsive to poverty, and others less. But that even influenza — -perhaps if you're poor, you don't have access to medical care, to nursing, and to medications, and so on. And, so, it's more of a problem, but it's a universal problem nonetheless.
Have I understood you right, correctly? Okay. Good, thank you. I think you'd be right. And I think it would be good if in the answer — let's say we give a more coherent answer if we gave a range of diseases in dealing with the answer, some at one end of the spectrum and others at the other. Right? So, influenza would be great. But it would be a mistake just to put influenza into the answer. We'd want to give contrasting examples. The answer, then, as many historical answers, has to be qualified and nuanced, and just to say all diseases are diseases of poverty is probably quite wrong. Okay. There was another — you were going to —
Student: Well I was just going to ask if we could maybe take the diseases that we looked at and almost rank them in the order of how they affect — like how much certain diseases <inaudible> from flu to cholera.
Professor Frank Snowden: Okay. Well, why don't I be a really, really nasty person and ask if you could help me out? How would you rank them?
Student: I haven't got a clue. <Inaudible>.
Professor Frank Snowden: You've got lots of people to help you out. You're not on your own. Okay?
Professor Frank Snowden: No.
Student: I would start with flu and then I'd get to cholera.
Professor Frank Snowden: Okay. So, one end of the spectrum, we put influenza; and that would clearly be the least responsive to poverty as a driver. The other end of the spectrum you'd put Asiatic cholera, which is clearly very sensitive to social and economic factors, to living conditions, to dirt and filth, to lack of light, to overcrowding. I hope you would then — you see, in your essay poverty too needs — it is not self-evident what it means.
Why is poverty a factor? And I hope you would talk about filth, access to medical care, education, overcrowding, bad housing, sewage. Those are the things that cholera thrives on. So, you would be right that way, putting influenza and cholera at opposite poles of the spectrum. But once again, we have to remember that this is not absolute, because wealthy people also succumbed to Asiatic cholera, just in much smaller numbers. Okay. Right, thanks.
Student: I think I would put malaria, and to a lesser extent than plague, on the cholera side of things. Malaria, because they — it was a big working condition disease, and a lot of people who were in the lower classes worked in the rice fields where — and worked and lived in areas that they couldn't have the simple protection against mosquitoes. And I said plague to a lesser extent on the cholera side because, as we saw in Journal of the Plague Year, a lot of the richer people were able to leave London and use financial means to get away from the disease. And even though it spread, the poorer people couldn't do that and they had to stay.
Professor Frank Snowden: Okay. So, we have a couple of other examples of diseases that might be along the level of poverty — being driven by poverty. And malaria was an example because of the particularly laboring and living conditions. It's partly an occupational disease, and so it strikes peasants and people who work in conditions that make them vulnerable; and it's a house disease that depends on overcrowding and living in housing that's porous to flying insects. Poverty clearly is important to the spread of malaria.
We've seen, to some extent, that plague has some — it could be argued either way, but you're absolutely right to introduce plague as something — a case to be argued as to whether it is or isn't. I'm wondering what about some other diseases transmitted differently? One factor might be — then you might say it might depend partly on means of transmission of the disease; perhaps airborne disease is less driven by poverty. Ones that travel by the oral-fecal route, or by vectors, might be important. What about sexually transmitted disease; and is syphilis a disease of poverty? You wanted to —
Student: I would put AIDS and syphilis towards the flu end of things. Although by modern maps of where these diseases are highly prevalent, it would seem otherwise. But I think that there is actually a sort of not poverty-based reason for that.
Professor Frank Snowden: Okay. So, we have a candidate then for — two other candidates to go at the influenza end of the spectrum: syphilis and AIDS. I'm wondering if everyone would agree with that. Yes, please? Oh sorry. Go ahead first.
Student: Yes, I would put AIDS more towards the middle of the spectrum, because AIDS did have a predilection for marginalized groups. But at the same time it could affect anyone, including a heterosexual man from a wealthy family. So, I think it sort of goes in the middle. If I could add one to the list, maybe I would put SARS as closer to the flu end of the spectrum, because it did seem to — and this adds to the idea that airborne diseases are less driven by poverty — because it did seem to affect everyone. But at the same time, it did hit areas that had a strong health infrastructure, and that helped to quell the disease somewhat.
Professor Frank Snowden: Okay. I'm wondering — I like your answer and I'm just wondering if with HIV/AIDS we would want even to make distinctions, in that HIV/AIDS seems to have different phases and different epidemiologies, according to different circumstances; and that in the industrial West it seems to be a disease, more of marginal groups, at least at the moment. It used not to be. When it was first introduced into the United States, for example, it wasn't an example of socioeconomic marginality; but rather people who, because of sexual orientation, or through blood supplies and so forth. But it would seem that if you were dealing at a global level now, with AIDS in Africa for example, poverty does seem to be a very important factor in the disease. Would you not agree with that?
Student: Yes definitely. I think in countries where there is more wealth, it's seen more as a chronic disease. So, definitely.
Professor Frank Snowden: Okay. Great, well thank you. So, we could even talk — divide — break some of the diseases down into different periods in their transmission. And you wanted to add something?
Student: That was the comment.
Professor Frank Snowden: Oh, that was what you wanted to add. Okay. Well, there's another. Thank you.
Student: I was just going to say that tuberculosis should be added to the list — probably more on the end of influenza — simply because they kind of regarded it as disease of the rich for some time — and a disease of genius, I think it was — because of the people that it affected.
Professor Frank Snowden: Okay. So, there's the thought that maybe tuberculosis ought to be added to the influenza end of the spectrum, in that it seemed to be, looking back on the nineteenth-century experience of the disease, it was even described as a disease of beauty, of genius. And clearly we can make a long list of high society people — celebrities, artists, kings and queens — who were afflicted by tuberculosis. And I think that if you were dealing with the nineteenth century, that would be a splendid argument to make, and I agree with you entirely.
I'm just wondering though if we come forward, fast forward in time to today, then I think we have to say that the epidemiology of tuberculosis today is different, and that it thrives on preexisting conditions, on overcrowding. So, I think the time period can also be important. Tuberculosis has retreated to areas of poverty, I would argue, now. Would you agree with that?
Student: Yes. I was going to say that what you were just talking about; how, like, different time eras actually can delineate whether or not it is a disease of poverty or not, just by the people that it affects, the effect it has on the society at the present moment.
Professor Frank Snowden: Okay, thanks very much. Yes. I think we're seeing that describing diseases as diseases of poverty is really a complex and also debatable position, and it depends on what diseases, where, when and so forth. It's actually — one needs to break down what poverty is, and one needs to have a spectrum of diseases. But I think we're dealing with it much more effectively. And I think one of the things we see is that the more complexity, the more nuance, the better our answer is becoming; also the more interesting.
I think it's rather a bland and not very convincing answer to say simply all diseases are diseases of poverty, and I think we now see that actually the situation is much more complex than that; that poverty's an important factor but it doesn't simply — we can't reduce our course to that one variable. Okay. In the meanwhile have you thought of other questions that we ought to be dealing with in our course? Or shall I put it another way; are there major themes in our course? What — could we make maybe a shortlist of themes that you should be thinking about as you do your revision? What are the major themes that we've been dealing with this semester? Disease and poverty is an example. Are there other themes? Go for it.
Student: I guess another theme has been the magic bullet theory of combating disease, and the idea that any epidemic disease can be solved basically by coming up with some sort of scientific cure that — so just, I guess, quinine in the case of malaria. I guess in the case of — or quinine and then DDT in the case of malaria. And I guess that theme has been one that has sort of been underlying what has been sort of this triumphal age of American medicine, and one that I think, at least in emerging and remerging disease, is something that we're increasingly viewing as not exactly the most effective way of dealing with epidemic disease.
Professor Frank Snowden: Okay, thanks very much. Yes, one of the — another theme of our course has been the tendency to think of finding a magic bullet to each infectious disease. And you were just starting to do what I think would then be really important if that were a question on the final, which is to look at what is the history of magic bullets, and have they actually delivered on the promise associated with them? And examples that you gave — let's see, quinine with regard to malaria, or later on DDT with regard to malaria, and has that — would that be — would malaria be a good example of a disease that's been highly responsive to magic bullets? You're shaking your head. Do you want to add to your headshake?
Student: No. Because there were side effects to these mass treatments, and it wasn't a one-size-fits-all sort of response to malaria. And there were other social factors that weren't considered. And people were thinking at that time that if we applied DDT for a certain amount of time, then malaria would be eradicated forever. But that certainly wasn't the case, and conditions could change and the disease came back. I think it was the case near Italy where they built the dam, and then during the war the dam was broken, and then later the disease came back, during the war. So, these measures aren't permanent, as they thought they initially were. In that sense this magic bullet can't be the permanent final answer.
Professor Frank Snowden: Okay. So, we have a problem with malaria. There was this great euphoria of thinking that a magic bullet could be found, and quinine and DDT were examples, but they ended up not actually delivering on the promise. Chloroquine would be yet another example of a magic bullet, for dealing with malaria. So, I would agree entirely. Malaria would be a wonderful example of enormous expectations of a magic bullet as a solution, and yet we see that, in fact, the biology of the disease is much more complicated than being dealt with in that way, and we've seen resistance being developed by mosquitoes and by plasmodia. And, so, the promise of the magic bullets, with malaria, turned out to be a tool. And they're useful but they haven't rid the world at all of the disease. And there was — you wanted also to say something.
Student: Yes. And I think to go along with that, there's another reason why magic bullets can't entirely work — and that's another theme of the class — which is the idea of disease as a social construction. And the fact is that even if a magic bullet can have a great effect on the biology, or the symptomatology, of a disease — I think Barnes is the author who really went into the idea that in order to really attack a disease, it goes into the substratum of society and to our ideas about disease and what we place, the stigma that we place on them.
Professor Frank Snowden: Okay. So we can't just think in terms of magic bullets. We also have to think about the ideas in people's heads. How do they understand the disease? What's the social construction? And you gave the example of tuberculosis as a good example. Okay, I would entirely agree with that too. I'm wondering if there are other examples of magic bullets that have either delivered on the promise, or have failed to deliver on the promise. We've talked about malaria: quinine, DDT, chloroquine. What about other — have magic bullets played a role in our course with other diseases? Yes, go for it.
Chapter 5. Magic Bullets [00:35:47]
Student: The original magic bullet was with syphilis though — right? — with penicillin. And I think that was a pretty good example. I mean, and Brandt's point, in No Magic Bullet, is that it didn't really — I mean, it helped, but it didn't really slow the incidence. Like it would sort of go in crests and waves, where there were people who were soldiers in the army and they would get prostitutes, and then it kind of didn't really matter whether there was a cure for syphilis or not, because like they just wouldn't have had access to it; like even if they contracted the disease. So, education and other programs like that are just as important as drugs, when it comes to preventing something like an STD.
Professor Frank Snowden: Okay. The history of syphilis would be another good case study for whether magic bullets are the way to eradicate or control major diseases. And you used the example of penicillin, which is a good one. But I think we've had, with syphilis, even further back, other things that at the time were thought of as magic bullets; mercury before that, and salversan, would be other earlier ideas considered magic bullets that also didn't eliminate the disease. The diseases tend to be much more complicated than to be simply amenable to a magic bullet solution. So, syphilis is another example, along with malaria. Right? Are there other examples? Yes?
Student: One instance where this magic bullet idea did seem to work was in the case of smallpox, where a vaccine was developed and given to all the population, such that the disease no longer had a host of humans, a reserve full of hosts to infect, and the disease eventually was eradicated. And I think that's one example where this magic bullet was effective. But it was a very special case, in the case of smallpox, because the smallpox vaccine was very effective. And I think we talked about how it's very much disease-specific. And smallpox seems to be an exception rather than the rule, in terms of how magic bullets can work.
Professor Frank Snowden: Okay, thanks. So, we need to be careful, even in our skepticism about magic bullets, that there may be cases when they can actually work; and a good example being smallpox in which the vaccine has actually eradicated naturally-occurring smallpox from the world. There are examples. But then one has — you were also saying what lessons should be drawn from smallpox? And you were saying perhaps one of the lessons though is that smallpox is atypical. It had certain specific features about it that made it particularly vulnerable to attack by vaccination. But we can't throw out then the hope for finding tools that will actually eradicate diseases, and smallpox is an example of something that really did work. Yes, okay.
Any other examples that ought to be thrown into our mix? How about TB? And streptomycin would be another example, I would think, of something that seemed, after World War II, that it would be possible to close all of the sanitaria; and that largely happened, and the outlook seemed to be that TB would be eliminated by this magic bullet. But we see again the problem of drug resistance, and we're living now in a world in which there's multiple drug-resistant tuberculosis. And, so, once again we have an example of a disease that's been much more recalcitrant, because we see the — I guess that Darwin was right — the influence of evolution and its impact on the microbes surrounding us. Okay.
Is there another major theme of our course? We've seen magic bullets, we've seen poverty, we've seen modes of transmission as major impacts on disease. We've talked about mortality, morbidity, and whether — how you — what are the — symptomatology — what are the factors that contribute to the impact of a disease on society? We have just a few more minutes. So, I'm wondering if we have at least one more candidate for a major theme of our course. Yes?
Student: The evolution of public health strategies in response to epidemic disease.
Professor Frank Snowden: Okay. That's not fair. You read my mind. I was thinking of exactly that. And I did want to say that it would be unfortunate if you went to the final exam in our course without also thinking about public health as a major theme that we've covered in our course. And let me just — could we make a list now? We don't have time for discussion, but what are some of the major forms of public health strategy that we have talked about? Okay.
Professor Frank Snowden: Okay. Quarantine. And maybe we might enlarge that by saying — could we talk about plague strategies of defense against infectious disease? Meaning quarantines, sanitary cordons, possibly lazarettos and pest houses, all the rest that go with that. Yes, that's a recurrent — and that's not only against plague, but plague strategies were rolled out again and again in our course. We've seen them applied, not very helpfully, against cholera. We've seen them also — plague strategies — being applied against HIV/AIDS, in the early days. Okay, so that's one style of public health. What other measures of public health have we seen? Yes?
Student: We've seen vaccinations, concealment, educational campaigns.
Professor Frank Snowden: Okay, you've got a list here, that's three more styles. We've seen vaccination as — you remember going back to Edward Jenner and — that was a long time ago, I admit, but that's important to remember. There were — we've also seen concealment, and we saw concealment in the case of SARS. It occurred in the case of cholera, in our course. We've talked about education and its impact on public health. Are there other styles of public health that we've come across? Yes?
Student: Miasmatism, for a time.
Professor Frank Snowden: Okay. We've seen public health based on miasmatism, and with the filth theory of disease. And therefore sanitation, introducing urban cleanups, sewer systems; even the rebuilding of cites, as we saw under Haussmann in France. And we saw that in the rebuilding of Naples also. So, those are additional styles of public health. Anything else anyone wants to throw in? Or is there maybe another final sort of question or theme of the course? We've just briefly suggested public health, and a few dimensions. There are others, and I hope that you'll dig them out also. Is there any final question anyone wants to bring up? Yes?
Student: I think maybe we missed the intrusion of the modern state played a role in it; dispensaries and registries of victims of disease.
Professor Frank Snowden: Okay, okay. We could discuss also the way in which the modern state has played a role in the control of disease, and that we can see that in tuberculosis, through dispensaries, sanatoria. We can see that also playing a role through malaria, and the same sort of idea of dispensaries again. And there are other diseases as well. The state playing a role in education, the state playing a role in the plague measures also. So, I think we can see the role of the state as a major player, a central player, in public health could indeed be an important theme of our class. But having said that, another theme is stopping when we've run out of time. And, so, I'll do that, and wish you good luck on the final. And thank you this morning for helping us put our heads together. And I liked your comments. Thanks very much.
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