WEBVTT 00:01.660 --> 00:03.050 We can get started. 00:03.050 --> 00:07.220 And this morning will be a slightly different style of 00:07.222 --> 00:08.012 lecture. 00:08.010 --> 00:10.910 You'll notice that you don't have handouts, 00:10.909 --> 00:13.049 and that wasn't an oversight. 00:13.050 --> 00:16.430 It was actually because you won't need them this morning. 00:16.430 --> 00:20.330 What we're going to be doing is something of an experiment, 00:20.330 --> 00:24.460 which is that it seemed to me that it was useful, 00:24.460 --> 00:30.000 when you were reading various historical works, 00:30.000 --> 00:34.420 that sometimes the author of one of them should explain and 00:34.416 --> 00:38.296 discuss with you how they came to be as they are. 00:38.300 --> 00:41.730 So, that was one of the reasons that I put my own book, 00:41.734 --> 00:44.474 this one, on Naples, on the reading list. 00:44.470 --> 00:48.390 And I thought this morning I'd try the experiment of a 00:48.394 --> 00:52.474 different kind of lecture, where I talk to you about how 00:52.466 --> 00:55.276 it came to be the work that it is. 00:55.280 --> 01:02.770 We're moving on now from the material on the Paris School and 01:02.765 --> 01:09.225 on plague and smallpox, to our next major epidemic 01:09.230 --> 01:11.940 disease, which was the great feared 01:11.936 --> 01:13.966 disease of the nineteenth century, 01:13.968 --> 01:17.438 which was Asiatic cholera, which hit Europe-- 01:17.438 --> 01:21.968 it wasn't an endemic disease--it hit Europe for the 01:21.965 --> 01:26.865 first time around 1830, and returned in a series of 01:26.872 --> 01:29.522 pandemics in various waves. 01:29.519 --> 01:36.079 And normally the official historiography has it that about 01:36.084 --> 01:42.424 the last epidemic in Western Europe was in the 1890s. 01:42.420 --> 01:47.860 And the statistics of the WHO in the various countries of 01:47.861 --> 01:50.971 Europe support-- and the literature as 01:50.965 --> 01:55.265 well--support this conclusion, that Asiatic cholera, 01:55.269 --> 01:59.939 after the 1890s, returns again to Western Europe 01:59.940 --> 02:06.450 only in tiny little outbreaks, the last of which was 1973. 02:06.450 --> 02:11.540 So, there really isn't supposedly a history of cholera 02:11.538 --> 02:15.088 in the twentieth century in Europe. 02:15.090 --> 02:19.130 And it's that that I want to challenge and to talk with you 02:19.127 --> 02:20.587 about this morning. 02:20.590 --> 02:26.530 Now, as I began--and here we can start into how the book came 02:26.527 --> 02:28.307 to exist at all. 02:28.310 --> 02:32.620 I, at the time--well, one, there's this sort of, 02:32.620 --> 02:36.080 as I started doing research on a very different topic, 02:36.080 --> 02:41.840 I had, in a sense perhaps, been primed for an interest in 02:41.841 --> 02:42.871 cholera. 02:42.870 --> 02:50.130 I had been primed because I had lived through an outbreak in 02:50.129 --> 02:53.949 Rome in 1973, and I had noticed a number of 02:53.949 --> 02:56.499 things that had captured my attention-- 02:56.500 --> 03:00.550 because this was Italy, this world seventh industrial 03:00.545 --> 03:04.345 power at the time-- and I remember some strange 03:04.347 --> 03:05.227 phenomena. 03:05.229 --> 03:10.639 Being in Rome--the epidemic had started and found its epicenter 03:10.644 --> 03:12.744 in the city of Naples. 03:12.740 --> 03:15.630 And cars had, at that time, 03:15.631 --> 03:21.521 license plates that bore the province of origin of the 03:21.524 --> 03:25.074 vehicle, and cars in Rome that had 03:25.068 --> 03:30.528 Naples license plates were being stoned by the citizens of Rome. 03:30.530 --> 03:35.840 It was also true that in the fish and vegetable markets near 03:35.840 --> 03:39.080 the apartment where I was living, 03:39.080 --> 03:44.880 that the stalls of the fish and vegetable sellers were attacked 03:44.882 --> 03:47.412 and overturned by crowds. 03:47.410 --> 03:53.110 So, this seemed something that captured my imagination very 03:53.107 --> 03:54.087 clearly. 03:54.090 --> 03:59.300 And then the minister of health went on television and said that 03:59.301 --> 04:04.511 you really didn't need to worry because all you had to do was to 04:04.514 --> 04:07.334 squeeze-- because the Vibrio, 04:07.330 --> 04:10.280 the bacterium that causes Asiatic cholera, 04:10.280 --> 04:14.430 is highly susceptible to acid; so all you have to do is 04:14.426 --> 04:17.936 squeeze a little lemon juice on your raw mussels, 04:17.940 --> 04:21.090 and then you can quite happily eat them; 04:21.089 --> 04:24.989 which I wouldn't advise any of you. 04:24.990 --> 04:28.160 In any case, it was also true that this 04:28.163 --> 04:33.423 prime minister and the minister of health visited Naples and the 04:33.423 --> 04:36.683 infectious diseases hospital there. 04:36.680 --> 04:40.630 And there's an Italian magazine in which pictures of them 04:40.632 --> 04:44.412 appeared, and you could see them almost 04:44.406 --> 04:48.566 running down the wards, as they were visiting the 04:48.574 --> 04:51.704 patients, and behind them they had their 04:51.699 --> 04:53.799 hands-- you can imagine them 04:53.803 --> 04:58.693 trotting--with this gesture, which is a gesture to ward off 04:58.694 --> 05:01.664 the evil eye in Italian culture. 05:01.660 --> 05:05.970 So, this seemed rather strange in the world's seventh 05:05.966 --> 05:07.536 industrial power. 05:07.540 --> 05:11.570 In a sense I had, then, this subliminal message 05:11.571 --> 05:14.991 that came from an earlier experience. 05:14.990 --> 05:18.360 But there I was, a decade or so later, 05:18.360 --> 05:23.000 and my project was--I thought that I was interested in 05:22.997 --> 05:26.757 political philosophy and social history, 05:26.759 --> 05:31.809 and I was working on the disappearance of the European 05:31.814 --> 05:37.064 peasantry under the press of economic circumstances, 05:37.060 --> 05:40.750 and major transformations in the countryside, 05:40.750 --> 05:43.320 and the coming of the commercial revolution in 05:43.322 --> 05:46.612 agriculture, urbanization and the Industrial 05:46.608 --> 05:47.548 Revolution. 05:47.550 --> 05:53.120 But I began to have my imagination captured by numbers 05:53.122 --> 05:59.432 of references that I began to find around the early twentieth 05:59.432 --> 06:04.062 century to cholera in Italy around 1910. 06:04.060 --> 06:07.130 And that seemed a little surprising to me, 06:07.125 --> 06:11.085 and it really began--I began to read more about it. 06:11.088 --> 06:15.838 And it seemed to illustrate how people's lives were lived, 06:15.838 --> 06:20.588 and their standard of living, much better than the project 06:20.589 --> 06:23.339 that I originally began with. 06:23.339 --> 06:28.429 And, so, I let this medical project have a life of its own, 06:28.430 --> 06:32.380 and this is what eventually became my book. 06:32.379 --> 06:37.579 As I was working more on cholera, however, 06:37.579 --> 06:41.599 something else came to the forefront of my attention, 06:41.600 --> 06:46.110 and that was a conflict between what I read about cholera in the 06:46.113 --> 06:49.843 literature and what I was beginning to find in my own 06:49.838 --> 06:50.768 research. 06:50.769 --> 06:55.729 The literature said that there wasn't a major epidemic in the 06:55.732 --> 07:00.612 twentieth century in Europe, the last major one being in the 07:00.612 --> 07:01.442 1890s. 07:01.439 --> 07:06.059 But I was beginning to find odd references to some very strange 07:06.055 --> 07:09.795 events, particularly in the summer of 07:09.803 --> 07:13.003 1911, and I began to think that 07:13.004 --> 07:18.754 perhaps a very interesting policy of concealment was taking 07:18.747 --> 07:22.107 place; that is, an epidemic that was 07:22.112 --> 07:24.672 concealed by the authorities. 07:24.670 --> 07:28.910 And Naples once again was a very interesting place. 07:28.910 --> 07:34.290 Now, Naples is, if you're interested in cholera 07:34.286 --> 07:38.796 in the West, Naples is a very interesting 07:38.802 --> 07:43.942 place because it was the city-- it was the largest city in 07:43.940 --> 07:46.610 Europe in the nineteenth century, 07:46.610 --> 07:51.190 and it was scourged the most often by this affliction. 07:51.190 --> 07:56.080 And I'm going to be arguing that it was scourged also in 07:56.084 --> 08:01.344 times that aren't recorded in the standard historiography of 08:01.336 --> 08:05.456 the subject, and in particular in 1911. 08:05.459 --> 08:11.249 It also is an extraordinary place because it has something 08:11.254 --> 08:15.324 happen that you won't find elsewhere, 08:15.319 --> 08:18.139 and that is this is a city that was actually, 08:18.139 --> 08:21.649 after the dreadful epidemic of 1884, 08:21.649 --> 08:26.789 was rebuilt in order to make the city cholera-proof, 08:26.790 --> 08:28.530 so that it wouldn't return. 08:28.528 --> 08:33.078 So, we see an extraordinary--we talk about the impact of 08:33.077 --> 08:38.367 infectious diseases, and here we see a case study of 08:38.365 --> 08:45.025 a place where the city itself is reconstructed specifically as 08:45.029 --> 08:49.179 result of an epidemic catastrophe, 08:49.178 --> 08:51.818 in order not to make another one possible. 08:51.820 --> 08:55.060 We can directly see in bricks and mortar, 08:55.058 --> 08:58.568 and in the sewers underground and the buildings above, 08:58.570 --> 09:02.940 and in the layout of the city, you can see the impact of 09:02.938 --> 09:05.798 cholera and of the idea of miasma. 09:05.798 --> 09:09.598 Because the miasmatic interpretation was the one under 09:09.601 --> 09:13.261 which had guided the reconstruction of the city, 09:13.259 --> 09:18.399 which happened in the wake of the 1884 catastrophe. 09:18.399 --> 09:23.789 But in 1911, there was no public record of a 09:23.788 --> 09:25.918 major epidemic. 09:25.918 --> 09:32.758 I had a whiff of the fact that there was, but I couldn't prove 09:32.759 --> 09:33.319 it. 09:33.320 --> 09:38.420 So, how do you go about demonstrating an epidemic that 09:38.417 --> 09:41.107 doesn't have a literature? 09:41.110 --> 09:45.620 I thought that the first thing that would be useful to do would 09:45.620 --> 09:49.180 be to visit Naples, and in particular to visit the 09:49.184 --> 09:50.644 Naples Cemetery. 09:50.639 --> 09:54.969 The cemetery is a very large one--you can visit it 09:54.966 --> 09:59.906 yourselves--and it's a very monumental grand cemetery. 09:59.908 --> 10:05.508 And I went in the middle of the week with the idea that I would 10:05.509 --> 10:11.289 go to the registry and perhaps there find records of burials, 10:11.288 --> 10:17.188 and that I would also be able to see in stone the victims of a 10:17.193 --> 10:18.843 major epidemic. 10:18.840 --> 10:22.610 In other words, the first idea I had was that 10:22.606 --> 10:25.886 you can't-- in order to prove that there 10:25.893 --> 10:29.583 was an epidemic, you would have to have a sudden 10:29.582 --> 10:33.212 bulge in mortality in the summer months of 1911. 10:33.210 --> 10:36.380 And I thought I could demonstrate that by visiting the 10:36.381 --> 10:40.111 Naples Cemetery, and if there wasn't a sudden 10:40.105 --> 10:44.775 excess of death in the summer, then I would know that I was 10:44.779 --> 10:48.399 actually on the wrong trail entirely and I should abandon my 10:48.404 --> 10:49.084 project. 10:49.080 --> 10:53.070 Well, as I was walking through the monumental cemetery-- 10:53.070 --> 10:55.730 I think it was a Wednesday or a Thursday-- 10:55.730 --> 11:00.360 I suddenly had a car pull up alongside me, 11:00.360 --> 11:04.250 and the man inside said, "Get in, 11:04.250 --> 11:06.180 get in." 11:06.178 --> 11:09.388 I don't know exactly how you would have reacted. 11:09.389 --> 11:13.379 I hesitated; particularly as it was a 11:13.378 --> 11:18.838 cemetery in which on a Wednesday and a Thursday I found myself 11:18.839 --> 11:23.059 completely alone, except for this strange request 11:23.063 --> 11:27.453 that I get in a car with someone I had never seen before. 11:27.450 --> 11:29.910 Well, it turns out, as we talked, 11:29.914 --> 11:34.464 that he was the director of the cemetery, and he had come to 11:34.461 --> 11:35.541 rescue me. 11:35.538 --> 11:39.518 And, so, I did eventually get in, and he took me out of the 11:39.517 --> 11:42.727 cemetery, scolding me and telling me that 11:42.731 --> 11:47.271 I was obviously a stranger, an outsider and a foreigner who 11:47.268 --> 11:49.628 knew nothing, and that, in fact, 11:49.631 --> 11:53.801 the Naples cemetery is the most dangerous place you can be in 11:53.804 --> 11:56.864 the city, which has a long history of 11:56.856 --> 12:00.236 organized crime, because during the week this 12:00.235 --> 12:03.705 was, in fact, where the local mafia did its 12:03.710 --> 12:07.000 drug deals, and that everyone in Naples 12:06.998 --> 12:11.358 knew this except me, and he was possibly saving my 12:11.359 --> 12:13.219 life by removing me. 12:13.220 --> 12:15.520 It wasn't that I wasn't welcome. 12:15.519 --> 12:19.269 I was welcome to come back on Saturday and Sunday, 12:19.269 --> 12:24.289 because that's when all the people of Naples do come to pay 12:24.293 --> 12:27.503 their respects to their relatives, 12:27.500 --> 12:32.420 and there are flower stalls and gazillions of people frequenting 12:32.418 --> 12:36.348 the cemetery then, and the registry office with 12:36.351 --> 12:38.971 the records was also open then. 12:38.970 --> 12:43.950 I also discovered that there was, in fact-- 12:43.950 --> 12:47.100 by reading the newspapers surrounding the time of my 12:47.102 --> 12:49.902 visit, that that very summer there was 12:49.897 --> 12:52.087 the-- I was doing a little checking 12:52.091 --> 12:55.611 up, and it turns out that the rector of the cemetery wasn't 12:55.613 --> 12:58.833 kidding me at all-- that there was a major drug 12:58.830 --> 13:00.780 bust in this very cemetery. 13:00.778 --> 13:04.638 And the way they had done it was that they had wired the 13:04.636 --> 13:09.216 tombstones, and in this way they had pulled 13:09.224 --> 13:13.764 off a major move against the Camorra, 13:13.759 --> 13:18.189 which is the local, if we like, subset of the 13:18.187 --> 13:21.907 organized crime families in Italy, 13:21.908 --> 13:25.958 and one of the most important crime syndicates in the world, 13:25.960 --> 13:27.480 in modern times. 13:27.480 --> 13:31.520 So, that was--that brought me back on a weekend. 13:31.519 --> 13:35.839 And on the weekend I discovered that there was, 13:35.840 --> 13:41.990 in fact, a big mortality bulge; that there were lots of people 13:41.985 --> 13:46.245 who'd been buried in the summer of 1911, 13:46.250 --> 13:51.570 well in excess of the year before, 1910, 13:51.570 --> 13:55.560 1909, or the years that were succeeded, 13:55.559 --> 13:58.209 1912 or 1913. 13:58.210 --> 14:03.520 And there was a book that registered the deaths and 14:03.522 --> 14:08.412 burials, and there was a huge bulge in 1911. 14:08.408 --> 14:10.578 So, I knew something had happened. 14:10.580 --> 14:17.030 And something was interesting, because one of the features of 14:17.029 --> 14:23.799 the book that's the register of burials is that they provide the 14:23.803 --> 14:29.613 neighborhood from which the deceased was resident. 14:29.610 --> 14:34.820 But in this case they, instead of the usual record of 14:34.823 --> 14:39.373 a neighborhood, they had the marking Cotugno 14:39.365 --> 14:42.515 Hospital, was the last place that the 14:42.523 --> 14:43.993 deceased had been. 14:43.990 --> 14:46.700 And the Cotugno Hospital, then as now, 14:46.697 --> 14:50.427 was the infectious diseases hospital of the city. 14:50.428 --> 14:56.618 I suddenly knew that there was this great excess of mortality 14:56.620 --> 15:02.000 in the summer of 1911, and that the mortality was from 15:01.995 --> 15:06.125 infectious diseases, because the people had been 15:06.134 --> 15:11.004 buried in vast numbers from the Cotugno Hospital as their last 15:11.003 --> 15:12.283 port of call. 15:12.278 --> 15:17.248 Then the next thought--and I think a lot of historical work 15:17.254 --> 15:21.974 is a bit like detective work--and I found myself playing 15:21.971 --> 15:24.461 a sort of detective role. 15:24.460 --> 15:29.910 So, my next place to visit was the Cotugno Hospital of 15:29.908 --> 15:32.168 Infectious Diseases. 15:32.168 --> 15:39.408 And I made two findings there that were confirming me in my 15:39.409 --> 15:44.029 vision of what might have happened; 15:44.029 --> 15:48.889 that they were--there was in the library of the hospital, 15:48.885 --> 15:53.125 the hospital itself had preserved its own records, 15:53.134 --> 15:54.874 patient records. 15:54.870 --> 15:58.120 And after some persistence, I was allowed to look at 15:58.119 --> 16:02.309 patient records in the hospital, and found something interesting 16:02.312 --> 16:06.262 and mysterious, and that was that there were 16:06.260 --> 16:10.980 records of the patient records through 1908, 16:10.980 --> 16:16.230 '09, '10, and the first half of 1911, 16:16.230 --> 16:20.010 and then suddenly there were no records at all. 16:20.009 --> 16:24.509 There was a mysterious disappearance of the records of 16:24.514 --> 16:27.154 the patients of the hospital. 16:27.149 --> 16:31.409 Then I went to the library of the Infectious Diseases 16:31.407 --> 16:33.797 Hospital, where there was a second 16:33.802 --> 16:37.582 interesting thing, which was that the hospital had 16:37.577 --> 16:41.347 its own research journal that it published, 16:41.350 --> 16:47.100 recording the research findings of its own physicians, 16:47.100 --> 16:50.750 its own house physicians and interns and residents. 16:50.750 --> 16:55.770 The result of that was to discover that for surprise, 16:55.769 --> 17:00.639 surprise, in the summer of 1911 the physicians of the Cotugno 17:00.644 --> 17:05.524 Hospital were doing lots and lots of research on therapeutics 17:05.519 --> 17:07.469 for Asiatic cholera. 17:07.470 --> 17:10.600 They were experimenting with giving patients ice, 17:10.604 --> 17:14.594 and lots of other therapeutic procedures that we'll talk about 17:14.586 --> 17:16.346 in a couple of minutes. 17:16.348 --> 17:20.838 So, I now knew that the physicians of the Infectious 17:20.836 --> 17:25.146 Diseases Hospital were enormously preoccupied with 17:25.150 --> 17:26.910 Asiatic cholera. 17:26.910 --> 17:31.940 Then the next place was to go to the local archives, 17:31.939 --> 17:36.279 where I was told that my idea was impossible, 17:36.278 --> 17:41.698 there was no such thing; that there also--the local 17:41.695 --> 17:47.825 records had been moved during the Second World War out of the 17:47.825 --> 17:53.385 city for safekeeping, to the Sanctuary of Monte 17:53.391 --> 17:58.091 Cassino, an abbey outside of the city. 17:58.088 --> 18:01.208 But I think a number of you have heard of Monte Cassino. 18:01.210 --> 18:04.350 It became a major battle site in the war, 18:04.348 --> 18:09.238 and so the abbey itself and all of the archives went up in 18:09.240 --> 18:12.220 flames, and so all the records of the 18:12.224 --> 18:16.334 city for the period I was interested in were destroyed. 18:16.328 --> 18:20.848 And I was told that a project of the kind that I was imagining 18:20.846 --> 18:24.766 was inconceivable and also couldn't be carried out. 18:24.769 --> 18:30.599 So, what do you do next if you think there's a major epidemic 18:30.602 --> 18:34.882 and you want to demonstrate its existence? 18:34.880 --> 18:40.610 The next thing that happened was that I had the idea that 18:40.605 --> 18:45.875 this was a time, in 1911, that was the height of 18:45.883 --> 18:51.453 mass emigration of Italians-- that is, I've said that I had 18:51.448 --> 18:56.288 been studying the disappearance of the European peasantry and 18:56.286 --> 19:00.636 its transformation into workers or urban dwellers, 19:00.640 --> 19:05.680 and a part of that was the extraordinary story of Italian 19:05.680 --> 19:09.840 transoceanic migration, in large part to this country, 19:09.836 --> 19:12.256 but also to Australia and other places. 19:12.259 --> 19:18.329 So, I thought if there really was a mass movement--and Naples 19:18.329 --> 19:20.859 is and was then a port. 19:20.858 --> 19:27.088 It was one of Europe's, along with Hamburg, 19:27.085 --> 19:30.045 major port cities. 19:30.048 --> 19:34.178 And what Naples specialized in--if Hamburg specialized in 19:34.178 --> 19:37.898 goods and services, Naples specialized in the 19:37.895 --> 19:42.575 export of people, and in particular Italian 19:42.584 --> 19:46.054 emigrants to New York City. 19:46.048 --> 19:49.238 There was enormous transoceanic migration. 19:49.240 --> 19:52.810 I thought well, if this is true, 19:52.809 --> 19:56.969 and these thousands, hundreds-of-thousands of 19:56.973 --> 20:00.133 emigrants are moving through the city of Naples, 20:00.130 --> 20:02.640 and there is a major cholera epidemic, 20:02.640 --> 20:04.780 and they're arriving at Ellis Island, 20:04.778 --> 20:09.978 well surely some of them will have been afflicted with the 20:09.984 --> 20:12.614 disease, and there would be records 20:12.611 --> 20:15.201 there of that, at Ellis Island. 20:15.200 --> 20:18.070 Well, as it turns out, this was true. 20:18.069 --> 20:19.709 There were records. 20:19.710 --> 20:26.210 Cholera did break out on a series of emigrant-bearing ships 20:26.208 --> 20:30.998 in the summer of 1911, and people were quarantined for 20:31.000 --> 20:33.130 the disease-- Italians, that is, 20:33.133 --> 20:36.833 who had last been in Naples-- were quarantined for the 20:36.825 --> 20:38.525 disease on Ellis Island. 20:38.529 --> 20:41.719 And indeed, there had been a number of people who were 20:41.719 --> 20:45.089 released from quarantine and fell ill on the mainland. 20:45.088 --> 20:51.218 And, so, there are perhaps a dozen cases of people who fell 20:51.220 --> 20:57.140 sick in New York State and not on Ellis Island itself. 20:57.140 --> 21:00.830 So, we know that there was then--there were Italian 21:00.826 --> 21:05.246 emigrants coming to the United States who were afflicted with 21:05.250 --> 21:06.430 the disease. 21:06.430 --> 21:10.390 This led me to think, well, I do have a project, 21:10.387 --> 21:14.007 and now the point is to prove it further. 21:14.009 --> 21:17.479 What can I find out about its reasons? 21:17.480 --> 21:20.990 What are the politics of concealment, and so on? 21:20.990 --> 21:26.780 And I was lucky then because I was interested in a physician 21:26.784 --> 21:31.564 called Leonard Rogers, who was one of the world's 21:31.560 --> 21:37.190 experts in tropical medicine at the early years of the twentieth 21:37.186 --> 21:38.166 century. 21:38.170 --> 21:42.620 And it was he who in 1908 made a major discovery. 21:42.618 --> 21:46.608 In terms of the therapeutics of Asiatic cholera, 21:46.608 --> 21:50.868 down to 1909, there was nothing that 21:50.867 --> 21:58.047 physicians could do that was effective and helpful for their 21:58.046 --> 22:02.076 patients, and so the case fatality rate 22:02.076 --> 22:06.406 was something like fifty percent for Asiatic cholera. 22:06.410 --> 22:09.430 In 1908 and 1909, Leonard Rogers, 22:09.432 --> 22:13.972 who was a British physician working in India, 22:13.970 --> 22:19.820 had found that he could reduce the mortality from fifty to 22:19.818 --> 22:24.308 fifteen percent-- the first major advance in 22:24.306 --> 22:26.986 therapeutics-- and he did it, 22:26.990 --> 22:32.130 one by a simple building on something that had been observed 22:32.133 --> 22:37.523 from the 1830s, and that is to say that cholera 22:37.520 --> 22:40.170 kills by dehydration. 22:40.170 --> 22:45.700 The bodily fluids flow out of the rectum and the mouth through 22:45.701 --> 22:48.931 vomiting, at an extraordinary rate, 22:48.934 --> 22:53.914 so that human beings lose up to three-quarters of the fluid 22:53.913 --> 22:56.663 portion of their blood serum. 22:56.660 --> 23:02.090 And, so, from the 1830s onward, one of the therapeutic ideas 23:02.088 --> 23:05.768 was why not simply replace the fluids? 23:05.769 --> 23:10.569 There were major attempts early on to get people to drink lots 23:10.574 --> 23:11.524 of liquid. 23:11.519 --> 23:14.179 That doesn't work because you simply vomit it up. 23:14.180 --> 23:17.170 It has no effect, except to make the patient 23:17.173 --> 23:17.803 weaker. 23:17.798 --> 23:22.318 So, having discovered that, there were attempts by 23:22.318 --> 23:26.838 physicians to replace the fluids intravenously. 23:26.838 --> 23:31.058 The problem early on was that there was not a knowledge--there 23:31.058 --> 23:32.718 were several problems. 23:32.720 --> 23:36.980 How much liquid do you actually administer? 23:36.980 --> 23:41.980 And many patients died of heart failure from an excess of fluid. 23:41.980 --> 23:45.830 It was also a time before the discovery of the germ theory of 23:45.825 --> 23:49.805 disease, and so although they were given 23:49.809 --> 23:55.259 drips that had clean water, it wasn't sterile and patients 23:55.260 --> 23:56.850 died of septicemia. 23:56.848 --> 24:01.078 It was also true that another discovery, 24:01.078 --> 24:04.328 which was that the patients--what made people 24:04.333 --> 24:08.843 persist with rehydration is that this administration of liquid 24:08.844 --> 24:12.694 caused the patients to feel much better briefly. 24:12.690 --> 24:15.240 For a few hours they seemed to recover. 24:15.240 --> 24:18.610 They would sit up in their beds and feel infinitely better. 24:18.608 --> 24:21.788 So something clearly positive was going on. 24:21.788 --> 24:24.278 But what it was wasn't understood. 24:24.278 --> 24:29.968 And what happened was that the administration of fluid was 24:29.971 --> 24:36.161 trying to replace fluid that had the same salinity as the blood 24:36.162 --> 24:37.762 in the body. 24:37.759 --> 24:41.319 Unfortunately, that is not retained by 24:41.319 --> 24:46.419 tissues, and it merely pours out of the body again. 24:46.420 --> 24:48.810 And, so, the patient who had momentarily, 24:48.808 --> 24:50.998 for a few hours, felt better, 24:51.000 --> 24:54.110 relapses, and even the continuing of this 24:54.108 --> 24:57.188 therapeutic attempt had no positive effect. 24:57.190 --> 25:01.570 Well, Leonard Rogers discovered in 1909 a number of things. 25:01.568 --> 25:05.158 He measured the amount of fluid loss. 25:05.160 --> 25:10.200 He used distilled water, and he made it a 25:10.201 --> 25:16.631 hypertonic--that is, much more saline than the blood 25:16.628 --> 25:17.888 fluid. 25:17.890 --> 25:21.330 And the result of that was that it was retained--through 25:21.326 --> 25:24.886 mechanisms that aren't very well understood, the fluid was 25:24.886 --> 25:25.696 retained. 25:25.700 --> 25:29.700 And, so, Leonard Rogers was able to save the lives of the 25:29.698 --> 25:34.118 vast majority of the patients he treated for Asiatic cholera in 25:34.124 --> 25:37.504 India, and he wanted to--the problem 25:37.500 --> 25:42.860 was this was a time in medical history when there were racial 25:42.863 --> 25:46.613 ideas of disease, and it was thought the fact 25:46.606 --> 25:51.026 that he had discovered this with Indian bodies would have nothing 25:51.034 --> 25:53.114 to do with European bodies. 25:53.108 --> 25:56.678 So, partly for humanitarian reasons and partly for 25:56.678 --> 26:01.338 scientific reasons, he was looking for an outbreak 26:01.338 --> 26:05.798 of cholera in the West, in which he could apply his 26:05.801 --> 26:09.911 therapeutics and demonstrate their ability to save life, 26:09.910 --> 26:11.440 any human life. 26:11.440 --> 26:14.330 And in 1911, because he was watching very 26:14.334 --> 26:17.244 closely, he realized that there was an 26:17.243 --> 26:21.853 epidemic afoot in Italy, and he sought permission to go 26:21.853 --> 26:27.373 to Naples to demonstrate the efficacy of his new procedures. 26:27.368 --> 26:31.318 Soon I had Leonard--I was in contact with Leonard Rogers' 26:31.323 --> 26:34.173 family-- and I had access to his papers, 26:34.167 --> 26:38.167 and his discussion of what happened to him in the summer of 26:38.167 --> 26:38.717 1911. 26:38.720 --> 26:44.280 Which was that to admit him to the hospital at Naples to train 26:44.282 --> 26:48.972 physicians in saving lives, the best available practice, 26:48.974 --> 26:51.704 the only therapy that had any effect, 26:51.700 --> 26:54.710 would be to admit the presence of an epidemic. 26:54.710 --> 26:58.980 And, so, he wasn't allowed to come to mainland Italy. 26:58.980 --> 27:02.470 Instead he was allowed a two-week visit to Sicily, 27:02.468 --> 27:04.958 where the disease spread as well. 27:04.960 --> 27:07.520 And the Italian physicians there called him the 27:07.518 --> 27:10.738 "prince of medicine," because they had a survival 27:10.742 --> 27:13.572 rate, under his direction and his new 27:13.565 --> 27:16.845 rehydration method, of eighty-five percent, 27:16.854 --> 27:20.824 which was extraordinary by international standards. 27:20.818 --> 27:24.348 He had discovered the first effective therapy, 27:24.345 --> 27:28.645 one that is in fact the basis of present-day therapy for 27:28.653 --> 27:31.713 cholera, which is oral rehydration. 27:31.710 --> 27:34.930 Leonard Rogers' methods have been perfected, 27:34.933 --> 27:39.663 but he was the one who found an effective rehydration system. 27:39.660 --> 27:43.670 Soon we knew, then, that the state in Italy, 27:43.670 --> 27:48.260 for various reasons, was preserving a secret and 27:48.255 --> 27:52.835 denying its own citizens the most effective, 27:52.838 --> 27:56.488 the only effective available system of care. 27:56.490 --> 28:00.220 So, Leonard Rogers left Italy in great disappointment, 28:00.220 --> 28:04.450 after only being allowed to visit the cholera wards in 28:04.451 --> 28:08.881 Sicily, and was denied by the state the 28:08.876 --> 28:13.936 ability to visit Naples, which was the epicenter of what 28:13.941 --> 28:14.921 was happening. 28:14.920 --> 28:19.070 The next thing I was able to discover was that the records 28:19.069 --> 28:21.929 for this epidemic-- there were records, 28:21.928 --> 28:26.048 but they existed not in the usual places that scholars would 28:26.053 --> 28:28.503 think of to study public health. 28:28.500 --> 28:34.960 The first files on this that I discovered were in police 28:34.963 --> 28:36.143 records. 28:36.140 --> 28:41.900 And they happened in an odd way, which was that the prime 28:41.897 --> 28:47.857 minister of Italy ordered the state police in Italy to deal 28:47.862 --> 28:53.182 with a new offense, which was sanitary defeatism. 28:53.180 --> 28:57.720 And in order to preserve silence and not promote sanitary 28:57.715 --> 29:01.425 defeatism, they began tapping the 29:01.428 --> 29:05.898 telephone lines used by physicians, 29:05.900 --> 29:10.340 and censoring and opening physicians' mail. 29:10.338 --> 29:14.968 In the city of Venice in 1911, there were actually the police 29:14.973 --> 29:19.693 records that demonstrated the following: which was to say that 29:19.686 --> 29:23.926 the Venice Medical Society decided quite sensibly in the 29:23.934 --> 29:28.494 summer of 1911 that it would save lives and enable people to 29:28.492 --> 29:34.212 protect themselves by publishing pamphlets and distributing them, 29:34.210 --> 29:38.050 about Asiatic cholera and how you can protect yourself against 29:38.054 --> 29:38.374 it. 29:38.368 --> 29:43.058 And they printed thousands of these, and wall posters as well, 29:43.058 --> 29:45.748 to put up on the walls of Venice. 29:45.750 --> 29:51.780 Instead, the Medical Society was visited by the police, 29:51.779 --> 29:56.039 who confiscated and burned all of the pamphlets and all of the 29:56.041 --> 29:59.861 wall posters, and told the physicians of 29:59.857 --> 30:04.347 Venice, the city, that to propagate health and 30:04.353 --> 30:09.043 sanitary defeatism would be fatal to their careers. 30:09.038 --> 30:15.418 So, this was all preserved in the records of the police 30:15.423 --> 30:20.273 regarding the summer of 1911 in Venice. 30:20.269 --> 30:28.389 The next place that I visited then was the National Archives 30:28.388 --> 30:32.238 here, and discovered that Italy had 30:32.237 --> 30:35.277 signed, in 1903--and this means that 30:35.279 --> 30:39.349 all of the things that I'm telling you about marked a 30:39.347 --> 30:42.397 violation also of international law. 30:42.400 --> 30:46.560 Because in 1903 there was a Paris Sanitary Convention, 30:46.558 --> 30:53.238 which made the full disclosure of infectious diseases mandatory 30:53.236 --> 30:55.776 for-- Italy and the United States 30:55.784 --> 30:59.394 were both signatories, along with a series of other 30:59.390 --> 31:00.180 countries. 31:00.180 --> 31:05.410 And the physician who represented the United States in 31:05.406 --> 31:10.236 1903, a major cholera expert named Henry Geddings, 31:10.240 --> 31:14.680 was now stationed at Naples with the U.S. 31:14.680 --> 31:18.170 Embassy, directing the medical service there. 31:18.170 --> 31:19.230 Why Naples? 31:19.230 --> 31:23.090 Because Naples was the center of mass emigration from Italy to 31:23.089 --> 31:25.649 the United States, and there were health 31:25.651 --> 31:29.111 inspections that took place in the city before departure, 31:29.108 --> 31:31.788 and Henry Geddings was therefore in charge of 31:31.785 --> 31:35.185 protecting the health of the United States by heading off 31:35.191 --> 31:38.841 infectious diseases before people even boarded the ship. 31:38.838 --> 31:41.848 Well, in 1911, there's an extensive 31:41.854 --> 31:44.894 correspondence, and a very unhappy 31:44.892 --> 31:48.582 correspondence, by Henry Geddings and people in 31:48.577 --> 31:52.297 the United States, including his superiors and his 31:52.299 --> 31:54.819 family, about his experiences in the 31:54.821 --> 31:59.081 city, where he tried to report to the United States Government 31:59.075 --> 32:02.835 that there was a major epidemic of Asiatic cholera. 32:02.838 --> 32:07.208 He found that his life was threatened in the city of 32:07.211 --> 32:10.501 Naples, and his superiors in the United 32:10.503 --> 32:14.743 States were not at all enthusiastic about receiving his 32:14.743 --> 32:17.653 message of what was taking place, 32:17.650 --> 32:20.010 and so the United States Government-- 32:20.009 --> 32:24.879 you've met Walter Wyman in your study of the bubonic plague and 32:24.883 --> 32:27.873 the Barbary plague in San Francisco. 32:27.868 --> 32:31.878 Well, we meet him here again, actually colluding with the 32:31.883 --> 32:35.833 Italian government in the suppression of knowledge about 32:35.825 --> 32:39.045 this important major infectious disease, 32:39.048 --> 32:43.408 against international law that the United States had actually 32:43.414 --> 32:44.074 signed. 32:44.068 --> 32:47.708 Then there were--in addition to that, 32:47.710 --> 32:52.340 I then went back to the police files and discovered that there 32:52.335 --> 32:56.805 were also health statistics that were coming in to Rome, 32:56.808 --> 33:00.878 reporting events in the Italian provinces, 33:00.880 --> 33:05.010 and they included statistics for Asiatic cholera. 33:05.009 --> 33:07.839 But the prefects, who were the highest authority 33:07.839 --> 33:10.609 for law and order in each Italian province, 33:10.608 --> 33:13.858 today as then, were actually sending back, 33:13.858 --> 33:16.948 to help officers in the various provinces, 33:16.950 --> 33:19.140 the statistics they were receiving, 33:19.140 --> 33:21.630 saying that, "These aren't good 33:21.633 --> 33:23.983 statistics; we don't want them, 33:23.979 --> 33:26.369 send us something better." 33:26.368 --> 33:30.558 And, so, you actually see the process by which the state 33:30.559 --> 33:33.839 manufactured the health statistics that were 33:33.836 --> 33:37.706 subsequently published, and are the basis for the 33:37.707 --> 33:38.817 historiography. 33:38.818 --> 33:42.108 And you can read those statistics in World Health 33:42.108 --> 33:45.668 Organization reports, and Italian Government reports, 33:45.672 --> 33:46.702 and in U.S. 33:46.700 --> 33:49.850 Government reports of the summer of 1911. 33:49.848 --> 33:54.488 Now, why is this true and why was this so sensitive? 33:54.490 --> 33:59.370 This meant that I needed to go back in time. 33:59.368 --> 34:04.078 My first idea was to write the second half of the book, 34:04.084 --> 34:05.834 about concealment. 34:05.828 --> 34:09.178 And I'm introducing that--I think that's important in our 34:09.181 --> 34:11.801 course-- because we're talking about 34:11.797 --> 34:14.637 various strategies of public health, 34:14.639 --> 34:19.439 and so far we've looked at plague regulations and we've 34:19.440 --> 34:21.220 looked at vaccine. 34:21.219 --> 34:26.209 But there's--as you will remember probably from the SARS 34:26.208 --> 34:31.648 outbreak, that China practiced a policy of concealment at the 34:31.652 --> 34:32.652 outset. 34:32.650 --> 34:37.040 What I'm trying to say is that concealment is also a style of 34:37.036 --> 34:38.716 public health policy. 34:38.719 --> 34:43.159 And I think our newspapers rather misled us in leading us 34:43.161 --> 34:46.891 to believe that this was simply unique to China, 34:46.887 --> 34:49.027 something very unusual. 34:49.030 --> 34:52.310 I would argue as well that this is probably something that's 34:52.307 --> 34:54.417 been resorted to a number of times, 34:54.420 --> 34:58.720 and this epidemic of 1911 is a good example and a good case 34:58.722 --> 35:02.732 study in which one can find the actual documents of the 35:02.728 --> 35:05.598 concealment, and the reasons that it took 35:05.597 --> 35:05.997 place. 35:06.000 --> 35:08.000 Well, why this pressure? 35:08.000 --> 35:11.570 Why does the prime minister of Italy collude, 35:11.567 --> 35:15.777 and why the United States, the Surgeon General of the 35:15.782 --> 35:19.272 United States, also colluded with that? 35:19.268 --> 35:23.148 Indeed, I would tell you another little anecdote, 35:23.150 --> 35:28.880 which was that Walter Wyman had a friend who was-- 35:28.880 --> 35:33.740 friends, a couple he knew--who were the parents of young 35:33.744 --> 35:36.434 Johnny, who just finished his B.A. 35:36.429 --> 35:39.959 degree in 1911--I'm sorry not here in New Haven, 35:39.960 --> 35:43.420 but rather at that other unmentionable place in 35:43.416 --> 35:44.916 Cambridge, Mass. 35:44.920 --> 35:49.630 And having finished his degree in 1911, as a newly minted 35:49.625 --> 35:53.485 Bachelor of Arts, he was planning a grand tour, 35:53.489 --> 35:56.599 which was going to take in Italy. 35:56.599 --> 36:01.269 And Italy had--this was the fiftieth anniversary of Italian 36:01.268 --> 36:06.018 unification, and there was a major fair with a grand U.S. 36:06.018 --> 36:09.188 pavilion, and Johnny was planning to visit; 36:09.190 --> 36:12.490 until, that is, he got a letter from his 36:12.487 --> 36:14.007 friend, the U.S. 36:14.010 --> 36:17.680 Surgeon General, who wrote to Johnny's parents 36:17.675 --> 36:22.315 that this trip simply wasn't on in the summer of 1911, 36:22.320 --> 36:28.740 because due to infectious diseases it wasn't safe to visit 36:28.739 --> 36:29.639 Italy. 36:29.639 --> 36:33.049 At the U.S. Pavilion, also, the people, 36:33.045 --> 36:36.585 the organizers, wrote back to Washington, 36:36.594 --> 36:39.824 saying that they were scandalized and horrified 36:39.824 --> 36:43.974 because American citizens were not being warned that in fact 36:43.965 --> 36:47.965 there was cholera rampant in Italy and their health was at 36:47.967 --> 36:51.237 risk, and there was no knowledge of 36:51.244 --> 36:54.594 this and no coverage of it in the press. 36:54.590 --> 36:56.940 Well, why would this be happening? 36:56.940 --> 37:02.160 The first thing is that by this time there was an enormous 37:02.157 --> 37:05.907 stigma associated with Asiatic cholera. 37:05.909 --> 37:11.689 Asiatic cholera in Western Europe and in North America was 37:11.688 --> 37:17.158 supposedly vanquished by the bulwarks of sanitation and 37:17.164 --> 37:18.994 public health. 37:18.989 --> 37:22.909 Cholera is spread by the ingestion--in only one 37:22.911 --> 37:28.201 way--which is the ingestion of food and water contaminated with 37:28.199 --> 37:29.649 fecal matter. 37:29.650 --> 37:34.080 And, so, it really is an indictment of sanitary 37:34.083 --> 37:35.243 standards. 37:35.239 --> 37:38.579 And therefore one of the features was a matter of 37:38.581 --> 37:42.411 national pride for Italians not to admit that there, 37:42.409 --> 37:46.839 in fact, there were these deficiencies in sanitary 37:46.835 --> 37:50.925 standards, in a nation that was supposedly 37:50.927 --> 37:54.087 advanced and, as they would have said, 37:54.094 --> 37:54.904 civilized. 37:54.900 --> 37:57.510 So, part of it then is avoiding stigma; 37:57.510 --> 37:59.800 this was an important part of what happened. 37:59.800 --> 38:02.740 But in addition, there was a patriotism 38:02.740 --> 38:06.280 involved, because this was the fiftieth 38:06.275 --> 38:09.595 anniversary of Italian unification, 38:09.599 --> 38:12.679 and the whole world was descending on Italy; 38:12.679 --> 38:15.419 or so it seemed, and Italians hoped. 38:15.420 --> 38:20.190 And to destroy the festivities by putting them off, 38:20.190 --> 38:23.830 by warning the world that cholera was rampant in Italy at 38:23.833 --> 38:26.603 this time, would have had enormous 38:26.596 --> 38:29.676 economic repercussions for tourism, 38:29.679 --> 38:31.389 a major industry. 38:31.389 --> 38:35.379 It also would have had major repercussions in terms of 38:35.376 --> 38:39.586 Italian pride in canceling the whole of the celebrations, 38:39.590 --> 38:41.170 a second feature. 38:41.170 --> 38:44.790 Another feature has to do--is the fact that I've just said, 38:44.789 --> 38:49.839 that the Italian economy and Italian standards of living were 38:49.840 --> 38:54.640 dependent in part on the export of people at this time. 38:54.639 --> 38:57.909 These were emigrants who came to these shores, 38:57.909 --> 39:01.499 and to South America, and then sent back very 39:01.503 --> 39:05.923 large-scale remittances that were very important to the 39:05.916 --> 39:07.546 Italian economy. 39:07.550 --> 39:12.860 And what would've happened if the 1903 Sanitary Convention 39:12.862 --> 39:17.112 terms had been enforced, in Italy as it should have, 39:17.108 --> 39:19.478 and was legally committed to doing, 39:19.480 --> 39:22.620 had announced the presence of Asiatic cholera, 39:22.619 --> 39:26.289 that would have stopped emigration to these shores and 39:26.293 --> 39:27.613 to South America. 39:27.610 --> 39:31.450 And that was something that Italians did not want to risk. 39:31.449 --> 39:36.169 And this also could have had repercussions in terms of civil 39:36.170 --> 39:37.050 disorder. 39:37.050 --> 39:40.600 There was a fear that, then, too--cholera, 39:40.599 --> 39:44.209 as we'll see, is much associated with social 39:44.206 --> 39:48.516 tension and disorder, and that was another fear that 39:48.521 --> 39:51.591 was very much in the minds of Italians. 39:51.590 --> 39:53.950 But then there's something very specific, 39:53.949 --> 39:57.899 and that is that--as I said in the beginning of our talk this 39:57.896 --> 40:01.736 morning-- that Naples had been made 40:01.735 --> 40:08.215 supposedly cholera-proof after the summer of 1884, 40:08.219 --> 40:13.869 when a catastrophic epidemic had ravaged the city, 40:13.869 --> 40:18.939 and massive commitment of funds--Italian but also 40:18.940 --> 40:24.050 Neapolitan and from abroad-- had been devoted to this 40:24.050 --> 40:25.990 rebuilding of the city. 40:25.989 --> 40:31.819 The problem is--I've already said that Naples was the center 40:31.820 --> 40:36.190 of the Camorra, of a major criminal syndicate, 40:36.188 --> 40:41.188 and was a place where funds often disappeared in mysterious 40:41.193 --> 40:42.233 channels. 40:42.230 --> 40:48.830 And one of the features of the rebuilding project was that the 40:48.827 --> 40:53.797 money largely went into undisclosed and corrupt 40:53.802 --> 40:55.212 channels. 40:55.210 --> 40:59.330 Here we have a city, which has supposedly been built 40:59.333 --> 41:02.943 like the Titanic, just hitting another iceberg 41:02.942 --> 41:07.182 and discovering that, in fact, the funds that were to 41:07.175 --> 41:10.355 have made it safe have been misspent. 41:10.360 --> 41:15.270 And there was an opposition to this municipal government in 41:15.273 --> 41:20.443 Naples, which was using health as one of the complaints of the 41:20.440 --> 41:22.390 opposition parties. 41:22.389 --> 41:26.029 The opposition parties in Naples at the time were 41:26.034 --> 41:28.924 republicans, socialists, anarchists. 41:28.920 --> 41:33.300 And so part of the danger then, from the standpoint of the 41:33.298 --> 41:37.858 government of the day, was that to admit this would 41:37.856 --> 41:43.306 lead to a major local scandal, and would, if you like, 41:43.311 --> 41:48.941 legitimate the complaints and accusations of a radical 41:48.938 --> 41:51.378 leftwing opposition. 41:51.380 --> 41:56.330 So, a consideration of political stability was also 41:56.327 --> 41:58.897 part of the calculation. 41:58.900 --> 42:02.040 And this, in fact, was a motivating factor for the 42:02.039 --> 42:05.309 U.S. Surgeon General and the U.S. Government; 42:05.309 --> 42:10.449 that here was a friendly government that was being 42:10.445 --> 42:14.635 lampooned and lambasted by a radical, 42:14.639 --> 42:18.729 very left-wing opposition, and it was better to cooperate 42:18.726 --> 42:22.656 then with the government, the legitimate government, 42:22.657 --> 42:24.977 in the face of this opposition. 42:24.980 --> 42:28.300 Well, this concealment then went forward, 42:28.295 --> 42:32.685 and it was orchestrated at the very highest levels. 42:32.690 --> 42:35.210 The press was censored. 42:35.210 --> 42:40.910 Health defeatism actually then became something that the police 42:40.911 --> 42:44.961 regarded as an infringement and repressed. 42:44.960 --> 42:49.630 We've seen the way in which physicians and public health 42:49.632 --> 42:53.712 authorities were censored and were threatened. 42:53.710 --> 42:56.670 In addition, it was not discussed in 42:56.672 --> 43:01.162 parliament, and it wasn't even discussed in the Naples 43:01.157 --> 43:03.017 Municipal Council. 43:03.018 --> 43:06.298 And if you read the reports--and I read the 43:06.300 --> 43:10.600 discussions of what was being discussed in Naples in the 43:10.597 --> 43:14.837 summer of 1911-- you see a discussion of the 43:14.840 --> 43:19.010 need for hiring lots and lots of nurses, 43:19.010 --> 43:22.970 the need for many more doctors. 43:22.969 --> 43:27.569 And you see that they're importing massive quantities of 43:27.574 --> 43:31.764 snow from the Apennines and the Alps into the city, 43:31.760 --> 43:35.360 and it's taken to the Cotugno Hospital. 43:35.360 --> 43:39.430 And there, if you correlate that with what the physicians 43:39.431 --> 43:42.371 were doing, they were giving ice to cholera 43:42.373 --> 43:46.033 patients on the ward to deal with the tremendous thirst that 43:46.032 --> 43:47.842 they had, and to replace, 43:47.840 --> 43:51.710 they hoped, some of the fluid that they were losing through 43:51.713 --> 43:53.653 the course of the disease. 43:53.650 --> 43:58.740 So, that was all--this conspiracy then is not a casual 43:58.742 --> 43:59.322 one. 43:59.320 --> 44:04.640 It's organized from the top down, and is a very major and 44:04.635 --> 44:10.705 well-organized plot to conceal the existence of this epidemic. 44:10.710 --> 44:13.980 In addition then, what were the consequences of 44:13.983 --> 44:14.983 concealment? 44:14.980 --> 44:18.760 I want to argue that--throughout this 44:18.757 --> 44:25.157 course--that public health is dependent on accurate and timely 44:25.159 --> 44:26.839 information. 44:26.840 --> 44:31.480 We'll see that today, in that a major feature of 44:31.481 --> 44:37.111 public health policies is surveillance and monitoring, 44:37.110 --> 44:41.180 and the availability of information, 44:41.179 --> 44:47.799 nationally and internationally, is vital to contain and prevent 44:47.802 --> 44:50.262 pandemic afflictions. 44:50.260 --> 44:55.600 So, one of the features--and I think 1911 is a good example of 44:55.603 --> 44:59.813 what happens if you don't provide information. 44:59.809 --> 45:03.879 A first thing that happened was that this disease spread through 45:03.880 --> 45:05.560 many provinces of Italy. 45:05.559 --> 45:09.029 It was not contained domestically. 45:09.030 --> 45:12.260 Fortunately, it did not spread to these 45:12.260 --> 45:17.530 shores and to Argentina and to other places where large numbers 45:17.534 --> 45:19.324 of Italians went. 45:19.320 --> 45:24.310 But I think that was no thanks to the Italian government, 45:24.309 --> 45:28.409 it had to do with serendipity and good luck. 45:28.409 --> 45:32.139 What I could say was that the Italian government, 45:32.135 --> 45:34.615 with the collusion of the U.S. 45:34.619 --> 45:38.959 government, was placing the health of this country, 45:38.958 --> 45:43.558 and the health of Argentina in particular, at risk. 45:43.559 --> 45:48.979 It was placing at risk the health also of international 45:48.978 --> 45:53.898 visitors to Italy, tourists and people who came to 45:53.896 --> 45:57.206 see the celebrations of 1911. 45:57.210 --> 46:02.500 And one of the truly unfortunate parts of the 46:02.496 --> 46:09.586 concealment effects is that it led to thousands of deaths of 46:09.586 --> 46:11.146 Italians. 46:11.150 --> 46:15.660 Because the patients on the wards of the Cotugno Hospital, 46:15.659 --> 46:21.389 and elsewhere in Italy, were systematically denied what 46:21.393 --> 46:27.133 was then the best available international practice, 46:27.130 --> 46:30.910 which is the administration of rehydration therapy, 46:30.909 --> 46:35.239 as developed by Leonard Rogers, and Italian doctors weren't 46:35.244 --> 46:39.804 allowed to know that this was the state-of-the-art and the way 46:39.802 --> 46:43.692 in which it was possible to save Italian lives, 46:43.690 --> 46:47.460 reducing mortality from fifty to fifteen percent, 46:47.460 --> 46:48.730 or something like that. 46:48.730 --> 46:53.460 If you look at the Cotugno ward, what were the physicians 46:53.458 --> 46:54.808 doing instead? 46:54.809 --> 46:57.749 Well, instead, because cholera patients become 46:57.746 --> 47:01.986 tremendously cold and look as though they've been cadaverized, 47:01.989 --> 47:07.029 they were immersing cholera patients in hot tubs. 47:07.030 --> 47:11.410 Because for the same way as their energy was failing, 47:11.414 --> 47:15.804 they were administering them stimulants, caffeine. 47:15.800 --> 47:18.490 And there were various experiments with other things 47:18.494 --> 47:21.414 that were meant-- because there wasn't a therapy 47:21.414 --> 47:24.664 that was known to work, there were lots of experimental 47:24.655 --> 47:26.405 therapies that were being tried. 47:26.409 --> 47:30.309 Strychnine, which you know better as rat poison, 47:30.309 --> 47:33.389 was also administered to cholera patients, 47:33.389 --> 47:38.489 in an attempt to revive their energy and their flagging 47:38.489 --> 47:39.339 health. 47:39.340 --> 47:45.800 Also there were attempts at rehydration therapy. 47:45.800 --> 47:49.590 But this took the form that was now outdated, 47:49.590 --> 47:54.770 after 1908, of trying to get the patients to suck on ice, 47:54.768 --> 48:01.638 or to drink, or to be injected with isotonic 48:01.643 --> 48:07.173 saline solutions; that is, of the same content of 48:07.173 --> 48:10.963 salt, same salinity as the blood, which by 1908, 48:10.956 --> 48:14.736 through a century of experience, was known to be 48:14.739 --> 48:16.509 entirely useless. 48:16.510 --> 48:20.450 And these were the kinds of therapies that were being 48:20.452 --> 48:24.172 practiced, plus simply supportive nursing care. 48:24.170 --> 48:27.050 And as I said, the hospital was recruiting 48:27.045 --> 48:29.215 very large numbers of nurses. 48:29.219 --> 48:33.449 So, nursing care and various experimental and sometimes 48:33.452 --> 48:38.392 heroic interventions that led to a very high mortality rate, 48:38.389 --> 48:43.279 when in fact it was possible to save about eighty-five percent 48:43.277 --> 48:44.397 of patients. 48:44.400 --> 48:48.670 Well, I've run out of time, and so I'll just say then that 48:48.666 --> 48:52.106 this is how this particular book came to be. 48:52.110 --> 48:56.620 And I ended up writing, adding on, that in order to 48:56.623 --> 49:00.533 understand 1911, it was absolutely crucial to 49:00.530 --> 49:04.050 see 1884 and the steps that had been taken, 49:04.050 --> 49:06.590 unfortunately not so successfully, 49:06.592 --> 49:11.452 to make Naples cholera-proof by the early twentieth century, 49:11.449 --> 49:13.469 when sadly it wasn't. 49:13.469 --> 49:17.509 And I think there's a story there of concealment as a public 49:17.509 --> 49:21.409 health policy that I wanted to alert you to as yet another 49:21.411 --> 49:25.351 style of public health, and one that has very--it's not 49:25.349 --> 49:29.339 good for your health-- and has very dire consequences. 49:29.340 --> 49:34.000