WEBVTT

00:01.620 --> 00:03.000
Prof: Good morning.

00:03.000 --> 00:07.330
We can continue with our
subject of Asiatic cholera.

00:07.330 --> 00:12.810
And I thought we could perhaps
frame that discussion by

00:12.814 --> 00:18.304
reminding you that in the 1990s
the Nobel Prize winning

00:18.298 --> 00:21.698
microbiologist,
Joseph Lederer,

00:21.699 --> 00:25.899
coined a term,
"emerging diseases."

00:25.900 --> 00:30.330
He used it to describe
infectious diseases that are

00:30.330 --> 00:34.600
previously unknown,
at least as sources of human

00:34.604 --> 00:37.684
infection,
and emerge, as it were,

00:37.683 --> 00:41.583
for the first time to infect
human beings.

00:41.580 --> 00:47.040
These are diseases--in our own
day we can think of Ebola or

00:47.035 --> 00:50.225
Lyme's disease,
SARS, or of course,

00:50.233 --> 00:53.153
most importantly,
HIV/AIDS.

00:53.150 --> 00:58.880
Often the press--which seems,
I would argue,

00:58.880 --> 01:03.220
to suffer chronically from
historical amnesia--

01:03.219 --> 01:07.569
it often treats the appearance
of new infections as something

01:07.567 --> 01:12.907
unprecedented,
unnatural, that never happened

01:12.912 --> 01:14.012
before.

01:14.010 --> 01:18.240
But the reality is that Charles
Darwin was correct.

01:18.239 --> 01:22.829
We live in the midst of a
constantly evolving microbial

01:22.833 --> 01:28.283
world in which the microbes have
an inherent advantage because of

01:28.277 --> 01:31.507
the frequency of their
mutations,

01:31.510 --> 01:37.110
and the extremely brief length
of a microbial generation,

01:37.110 --> 01:39.380
compared with a human one.

01:39.379 --> 01:44.559
So, new diseases have always
been emerging and appearing.

01:44.560 --> 01:49.000
And Asiatic cholera is a good
example of what we might--

01:49.000 --> 01:52.460
though let's be mindful,
it would be historically

01:52.456 --> 01:55.806
anachronistic--
we might call it a great

01:55.808 --> 01:59.708
emerging disease of the
nineteenth century.

01:59.709 --> 02:05.829
There is a scholarly debate on
whether cholera had long existed

02:05.828 --> 02:11.258
on the Indian subcontinent,
and whether it went back for

02:11.257 --> 02:13.327
centuries or not.

02:13.330 --> 02:17.000
It clearly, by the early
nineteenth century,

02:17.000 --> 02:21.210
had an endemic home on the
Indian subcontinent,

02:21.210 --> 02:28.890
and particularly the area here
in the delta of the Ganges and

02:28.890 --> 02:31.580
Brahmaputra Rivers.

02:31.580 --> 02:34.070
That's that area.

02:34.068 --> 02:39.248
There are accounts of diseases
in various writings that are

02:39.250 --> 02:44.520
suggestive of cholera well
before the nineteenth century.

02:44.520 --> 02:48.840
But that particular debate is
exotic for our purposes,

02:48.840 --> 02:53.310
and what we want to know is
that by the early nineteenth

02:53.306 --> 02:57.526
century it was endemic in the
Indian subcontinent.

02:57.530 --> 03:00.790
But it was unknown elsewhere in
the world,

03:00.788 --> 03:05.518
until it burst into a major
epidemic in 1817 that then

03:05.519 --> 03:10.159
escaped India and began its
devastating international

03:10.158 --> 03:14.218
career,
reaching Europe for the first

03:14.217 --> 03:15.657
time in 1830.

03:15.658 --> 03:20.238
Cholera for the nineteenth
century was something new,

03:20.240 --> 03:23.440
something never before
experienced,

03:23.438 --> 03:28.748
and that helps to explain a
good part of the reaction to the

03:28.754 --> 03:32.994
populations that were first
afflicted by it,

03:32.990 --> 03:36.510
as the "great
cholera,"

03:36.514 --> 03:41.694
we should remember,
was the great feared disease of

03:41.690 --> 03:43.820
the nineteenth century.

03:43.818 --> 03:47.538
We've already seen that plague
was the most dreaded disease,

03:47.542 --> 03:50.952
from the fourteenth century
through the seventeenth.

03:50.949 --> 03:55.399
And we know that smallpox
succeeded it in that role in the

03:55.404 --> 03:56.424
eighteenth.

03:56.419 --> 04:00.449
Cholera, though not the great
killer of the nineteenth

04:00.448 --> 04:03.638
century, was the most feared
affliction.

04:03.639 --> 04:08.079
It was feared for a number of
reasons: its extremely sudden

04:08.082 --> 04:12.292
appearance;
its exotic and unfamiliar

04:12.294 --> 04:16.004
character;
the agonizing and gruesome

04:16.002 --> 04:21.062
nature of its symptoms;
its high case fatality rate;

04:21.060 --> 04:25.610
and its predilection for adults
in the prime of life,

04:25.608 --> 04:27.618
rather than children.

04:27.620 --> 04:30.770
It's revealing that a great
deal of the discussion

04:30.767 --> 04:33.657
surrounding the early
experiences with cholera

04:33.660 --> 04:37.130
revolved around the question of
whether this was,

04:37.129 --> 04:40.819
in fact, the return of the
plague.

04:40.819 --> 04:45.129
Some of the names that were
given to cholera capture the

04:45.129 --> 04:46.619
fear it inspired.

04:46.620 --> 04:48.470
It was known in all kinds of
ways.

04:48.470 --> 04:50.950
If you read the medical
journals of the nineteenth

04:50.952 --> 04:52.552
century,
and the press,

04:52.548 --> 04:55.518
you see it was called Asiatic
cholera,

04:55.519 --> 05:00.249
cholera morbus,
perhaps very scaringly

05:00.245 --> 05:04.775
cholera asphyxia;
it was known as "the

05:04.778 --> 05:07.278
gypsy," "the
monster,"

05:07.283 --> 05:10.973
"blue cholera"
and "King Cholera,"

05:10.971 --> 05:13.131
among other names as well.

05:13.129 --> 05:17.139
Now, since the nineteenth
century was an era of acute

05:17.136 --> 05:20.196
social tensions,
it was, as you all know,

05:20.196 --> 05:22.586
marked by a series of
revolutions,

05:22.589 --> 05:26.169
and is often dubbed the
rebellious century for that

05:26.173 --> 05:26.823
reason.

05:26.819 --> 05:30.439
You know about the revolutions
of 1830,

05:30.439 --> 05:33.849
the revolutionary wave of 1848
to 1849,

05:33.850 --> 05:37.580
across the continent,
when there were something like

05:37.584 --> 05:40.884
fifty revolutions within a
two-year period.

05:40.879 --> 05:43.699
Italian independence,
the Paris Commune.

05:43.699 --> 05:45.049
One could go on.

05:45.050 --> 05:49.290
But due to the fact that
cholera frequently accompanied

05:49.285 --> 05:53.065
those events,
and indisputably did heighten

05:53.069 --> 05:57.769
social and political tensions,
it used to be common to

05:57.766 --> 06:02.656
speculate about whether the
passage of cholera across Europe

06:02.661 --> 06:07.811
was itself a contributory factor
in the coming of revolutionary

06:07.805 --> 06:09.045
outbursts.

06:09.050 --> 06:13.900
By now it's pretty clear that
the causal chain actually worked

06:13.899 --> 06:15.729
the other way around.

06:15.730 --> 06:19.280
In other words,
the outbreak of revolution,

06:19.279 --> 06:23.759
war and social order created
conditions for cholera to

06:23.759 --> 06:24.689
thrive.

06:24.689 --> 06:27.429
Cholera moved,
I would argue,

06:27.425 --> 06:32.795
in the wake of revolution,
rather than triggering it.

06:32.800 --> 06:35.480
So, cholera,
if it didn't cause the

06:35.483 --> 06:39.433
revolutions that marked the
nineteenth century--

06:39.430 --> 06:42.550
there has been in recent
literature a swing of the

06:42.552 --> 06:44.912
pendulum in a different
direction,

06:44.910 --> 06:48.640
with a view sometimes expressed
that cholera was dramatic,

06:48.639 --> 06:54.169
yes, but not a lasting
influence on the history of the

06:54.166 --> 06:55.936
West after all.

06:55.940 --> 06:58.310
Some would say that it was
dramatic,

06:58.310 --> 07:02.780
that it led to all sorts of
short-term sound and fury,

07:02.778 --> 07:05.708
but in the long-term,
that argument runs,

07:05.709 --> 07:10.099
its legacy was small,
and clearly nowhere near the

07:10.098 --> 07:14.038
order of magnitude of plague and
smallpox.

07:14.040 --> 07:18.910
Well, we'll be deciding among
those conflicting views.

07:18.910 --> 07:21.460
But before we can assess them
properly,

07:21.459 --> 07:26.299
we should look in our usual way
at the etiology of cholera,

07:26.300 --> 07:30.230
at its epidemiology,
its symptoms and its course in

07:30.230 --> 07:33.220
European and North American
history.

07:33.220 --> 07:37.790
Then we'll be in a better
position to judge its impact.

07:37.790 --> 07:43.220
There were seven pandemics of
Asiatic cholera,

07:43.221 --> 07:49.621
the first in 1817 to '23,
which was an Asian event.

07:49.620 --> 07:54.070
The second pandemic was in the
1830s and affected Asia,

07:54.072 --> 07:58.692
but also Europe for the first
time, and North America.

07:58.690 --> 08:04.630
The third pandemic of 1846 to
'62, afflicting Asia,

08:04.627 --> 08:08.187
Europe, again North America.

08:08.189 --> 08:12.309
The fourth pandemic,
from '65 to '75,

08:12.310 --> 08:14.830
again it was global.

08:14.829 --> 08:18.309
The fifth pandemic,
from 1881 to '96,

08:18.310 --> 08:21.890
mainly a matter of Asia and
Europe.

08:21.889 --> 08:28.249
The sixth pandemic of 1899 to
'23, again primarily an Asian

08:28.247 --> 08:30.547
and European event.

08:30.550 --> 08:35.170
And then the seventh pandemic,
from 1960 onward,

08:35.168 --> 08:40.178
that went through Asia,
South America and Africa.

08:40.178 --> 08:43.828
The last pandemic,
however, has been milder and

08:43.830 --> 08:46.860
less virulent,
with a new biotype,

08:46.859 --> 08:51.539
the El Tor, which is less
dramatic and less fatal than

08:51.542 --> 08:55.172
classic cholera,
which is our subject,

08:55.173 --> 09:00.143
and which was the form of
cholera from the first pandemic

09:00.144 --> 09:02.014
through the sixth.

09:02.009 --> 09:05.589
The endemic home of cholera,
as I've said,

09:05.586 --> 09:09.156
was the Indian subcontinent,
in the delta,

09:09.163 --> 09:12.483
the Ganges and Brahmaputra
Rivers.

09:12.480 --> 09:17.970
And it was confined there until
a number of developments enabled

09:17.971 --> 09:19.281
it to spread.

09:19.278 --> 09:23.708
The bacterium that causes
cholera is extremely delicate

09:23.706 --> 09:26.246
and doesn't travel so easily.

09:26.250 --> 09:30.630
So, it required a number of
factors that enabled the disease

09:30.630 --> 09:34.270
to move beyond its original area
of endemicity.

09:34.269 --> 09:36.479
What were some of those?

09:36.480 --> 09:42.940
One was colonialism itself,
which meant large-scale troop

09:42.940 --> 09:50.320
movements and increasing contact
between the subcontinent and the

09:50.322 --> 09:52.402
outside world.

09:52.399 --> 09:58.029
The increase in trade did the
same thing in terms of

09:58.030 --> 10:00.350
increasing contact.

10:00.350 --> 10:03.170
Then there was the transport
revolution, which was very

10:03.172 --> 10:03.802
important.

10:03.798 --> 10:07.608
Because, as I said,
cholera doesn't travel so well

10:07.611 --> 10:12.151
over extended periods of time,
and it was the railroad,

10:12.149 --> 10:15.079
the steamship and,
later in the century,

10:15.076 --> 10:18.446
the Suez Canal,
that radically reduced the

10:18.451 --> 10:23.201
traveling time from the
subcontinent to other parts of

10:23.203 --> 10:24.373
the world.

10:24.370 --> 10:29.110
Another major factor was
religious pilgrimages and fairs

10:29.107 --> 10:32.207
in the Indian subcontinent
itself.

10:32.210 --> 10:37.560
And very most especially,
from the European perspective,

10:37.558 --> 10:43.008
a very important factor was the
Hajj, the voyage of pious

10:43.006 --> 10:45.046
Muslims to Mecca.

10:45.048 --> 10:49.698
Now, that cholera afflicted
Europe and North America in the

10:49.695 --> 10:54.255
nineteenth century wasn't
therefore a matter of chance.

10:54.259 --> 10:59.549
Epidemic diseases exploit
features of societies that are

10:59.552 --> 11:04.462
social, political and economic
and environmental.

11:04.460 --> 11:07.490
Cholera is spread,
as we'll see,

11:07.488 --> 11:11.198
exclusively by the oral fecal
route;

11:11.200 --> 11:19.830
that is, it's ingested by food
and water contaminated by feces.

11:19.830 --> 11:23.950
And it requires,
therefore--it clearly is among

11:23.947 --> 11:27.127
the diseases,
certainly that we've examined

11:27.126 --> 11:29.646
so far,
cholera is clearly different

11:29.647 --> 11:34.307
from plague and smallpox in that
it's much more a social disease;

11:34.308 --> 11:38.758
that is to say,
a disease that has a clear

11:38.759 --> 11:44.949
predilection for poverty and for
pathologies of social and

11:44.946 --> 11:46.896
economic life.

11:46.899 --> 11:53.409
Cholera thrived on chaotic,
rapid, unplanned urbanization,

11:53.413 --> 11:57.873
with its overcrowding and
teeming slums,

11:57.871 --> 12:02.331
with inadequate and insecure
water.

12:02.330 --> 12:07.080
This continues to be true with
cholera in our own day.

12:07.080 --> 12:14.110
It thrives on substandard
housing, on inadequate and

12:14.105 --> 12:16.995
inappropriate diet.

12:17.000 --> 12:21.600
It has a predilection for port
cities, which are usually the

12:21.600 --> 12:23.940
first places to be affected.

12:23.940 --> 12:27.470
This reminds us perhaps of
plague a little bit.

12:27.470 --> 12:30.050
Places in Europe,
like Marseilles,

12:30.051 --> 12:33.881
Hamburg, Valencia,
Naples were among the first and

12:33.884 --> 12:36.704
most frequently to be afflicted.

12:36.700 --> 12:42.560
Cholera thrives also on filth
and the absence of sewage

12:42.563 --> 12:43.653
systems.

12:43.649 --> 12:49.569
Cholera is, among many things,
a disease of poverty.

12:49.570 --> 12:54.020
Cholera also had a pronounced
predilection for the poor,

12:54.017 --> 12:55.227
as I've said.

12:55.230 --> 12:59.800
And in that way it exacerbated
social tensions.

12:59.798 --> 13:03.168
Cholera, as I said,
was associated with

13:03.173 --> 13:08.503
revolutions, though it followed
rather than provoked them.

13:08.500 --> 13:12.320
You can see that in the revolt
in Poland in 1830,

13:12.320 --> 13:17.870
the revolutions of 1848 to '49,
when cholera is often part of

13:17.873 --> 13:22.783
the movement of troops to
repress the revolutions,

13:22.778 --> 13:25.828
rather than being a factor in
their cause.

13:25.830 --> 13:31.490
It was conditioned by the 1860s
war between Austria and Prussia

13:31.486 --> 13:32.396
as well.

13:32.399 --> 13:35.029
Well, what about the disease
itself?

13:35.029 --> 13:39.959
The pathogen is this,
the Vibrio cholerae,

13:39.960 --> 13:44.380
which was discovered by Robert
Koch in 1883,

13:44.378 --> 13:49.718
helping to establish the germ
theory of disease.

13:49.720 --> 13:53.630
Now, this--we'll note the
flagellum or tail of the

13:53.625 --> 13:57.025
Vibrio,
that plays an important role in

13:57.030 --> 14:00.410
the human gut,
and we'll talk about that in a

14:00.410 --> 14:01.030
moment.

14:01.028 --> 14:05.758
Its transmission you know
pretty well because of your

14:05.755 --> 14:09.205
reading for this week of John
Snow,

14:09.210 --> 14:14.090
On the Mode of Communication
of Cholera. You know that

14:14.086 --> 14:18.716
this is one of the foundational
texts of epidemiology,

14:18.720 --> 14:23.780
where he did a brilliant
epidemiological job of detective

14:23.775 --> 14:28.105
work by finding the famous Broad
Street pump--

14:28.110 --> 14:32.700
that the people who drank the
water from that particular pump

14:32.697 --> 14:37.277
were the ones who fell ill and
took the disease back to their

14:37.284 --> 14:38.054
homes.

14:38.048 --> 14:44.028
Snow did a good job of
establishing that cholera then

14:44.027 --> 14:48.047
was ingested in water,
primarily;

14:48.048 --> 14:51.148
although it was also
demonstrated later that

14:51.147 --> 14:55.607
shellfish and vegetables--that
is food--contaminated with fecal

14:55.614 --> 14:57.924
matter can also play a role.

14:57.918 --> 15:04.938
This was--that's John Snow--and
this is the famous Broad Street

15:04.936 --> 15:12.176
pump that made such an important
moment in the history of medical

15:12.177 --> 15:15.457
science and epidemiology.

15:15.460 --> 15:18.160
Though it's important to
remember that--

15:18.158 --> 15:21.608
it may seem odd to you as you
read this book and look at all

15:21.611 --> 15:24.801
of Snow's evidence--
to remember that in fact it

15:24.802 --> 15:28.752
failed to convince the medical
profession at the time,

15:28.750 --> 15:29.870
by and large.

15:29.870 --> 15:33.700
There was a big debate about
whether cholera was contagious

15:33.696 --> 15:34.286
or not.

15:34.288 --> 15:37.978
We'll be coming back to that
debate and the reasons for and

15:37.982 --> 15:38.622
against.

15:38.620 --> 15:42.650
But one of the things was that
John Snow was unable to

15:42.652 --> 15:45.242
demonstrate an actual mechanism.

15:45.240 --> 15:49.060
There was something in the
water, but he wasn't able to

15:49.059 --> 15:52.809
establish what it was,
and therefore he didn't provide

15:52.808 --> 15:54.718
a convincing mechanism.

15:54.720 --> 15:58.540
And for people who thought that
probably it was some chemical

15:58.542 --> 16:01.122
factor,
if it was anything--that Snow's

16:01.121 --> 16:04.631
biggest chance of making an
argument was that it would be

16:04.630 --> 16:06.010
something chemical.

16:06.009 --> 16:08.799
Well, if so--and remember this
was London--

16:08.798 --> 16:12.978
if there was some sort of
chemical in the River Thames,

16:12.980 --> 16:15.900
surely it would be infinitely
diluted,

16:15.899 --> 16:20.149
and so how would it be possible
that this chemical substance,

16:20.149 --> 16:23.829
if that's what it was,
was spreading the disease?

16:23.830 --> 16:27.910
So, there was a big debate
about whether Snow was actually

16:27.907 --> 16:28.477
right.

16:28.480 --> 16:32.000
It was proved later in the
century conclusively that he

16:31.999 --> 16:32.389
was.

16:32.389 --> 16:36.849
But it's important to realize
that for a long time his writing

16:36.849 --> 16:40.719
was very far from convincing the
international medical

16:40.722 --> 16:41.822
profession.

16:41.820 --> 16:47.070
That didn't happen until the
1880s and 1890s.

16:47.070 --> 16:50.740
Well, what were some of the
factors in the transmission of

16:50.741 --> 16:52.161
cholera in the West?

16:52.158 --> 16:55.618
We've talked about trade and
the transport revolution.

16:55.620 --> 16:59.080
We've talked about pilgrimages.

16:59.080 --> 17:02.840
We've talked about the
strategic role of seaports,

17:02.842 --> 17:06.072
where once again,
as in the case of plague,

17:06.068 --> 17:07.988
it would be imported.

17:07.990 --> 17:14.160
The bacterium would gain access
to the municipal water supply,

17:14.160 --> 17:18.870
and there would also be the
danger of swimming,

17:18.868 --> 17:22.468
or of eating shellfish that fed
on sewage,

17:22.470 --> 17:26.450
especially if the custom was to
eat it raw.

17:26.450 --> 17:31.310
The disease would then spread
along inland transportation

17:31.306 --> 17:32.256
networks.

17:32.259 --> 17:37.409
We've said too that cholera was
a disease of urbanization,

17:37.407 --> 17:40.927
and of a defective urban
infrastructure,

17:40.931 --> 17:43.371
without sewage systems.

17:43.368 --> 17:45.938
And remember,
in the nineteenth century,

17:45.940 --> 17:50.810
waste in European cities was
predominantly thrown into the

17:50.809 --> 17:54.679
streets,
where there would be a seepage

17:54.684 --> 18:00.084
downward into tank wells;
that people would then drink

18:00.077 --> 18:03.737
the water and its bacterial
bounty.

18:03.740 --> 18:06.910
Remember, too,
that that many of the cities of

18:06.913 --> 18:09.193
Europe--
Naples, that you're reading

18:09.191 --> 18:12.741
about, but Paris too,
and many others--were

18:12.740 --> 18:18.390
surrounded by vegetable gardens,
and the vegetables would be

18:18.385 --> 18:22.515
brought into the city and
consumed by the population.

18:22.519 --> 18:25.859
But in the growing of the
vegetables,

18:25.858 --> 18:30.208
use was made of urban sewage,
which was collected and

18:30.210 --> 18:34.980
transported to the vegetable
gardens outside the city,

18:34.980 --> 18:38.550
and then the sewage was used as
fertilizer--

18:38.548 --> 18:42.278
it was good not to waste
anything--and the plants then

18:42.279 --> 18:46.079
grew in human sewage,
and then the vegetables were

18:46.080 --> 18:47.740
brought back to town.

18:47.740 --> 18:52.100
So, we have a wonderful way for
the bacterium to make an

18:52.097 --> 18:57.247
excellent roundtrip between the
hinterland and the city itself.

18:57.250 --> 19:01.470
This was the practice of sewage
farming, which was extensive

19:01.473 --> 19:03.053
throughout the West.

19:03.048 --> 19:07.788
And there was a good trick that
market farmers knew very well,

19:07.788 --> 19:10.848
market gardeners,
which was that if you had an

19:10.847 --> 19:13.707
open sewer--
and there were many--if you

19:13.708 --> 19:17.408
dipped your head of lettuce,
on the way to market,

19:17.410 --> 19:20.660
into the sewer,
then the ammonia from human

19:20.657 --> 19:23.937
urine would make the vegetables
look fresh,

19:23.940 --> 19:25.360
for sale in the market.

19:25.358 --> 19:29.068
So that was a good little trick
that you might want to remember.

19:29.068 --> 19:33.358
In any case,
overcrowding was also another

19:33.362 --> 19:36.192
important factor in this.

19:36.190 --> 19:39.890
And I just want you to remember
housing conditions.

19:39.890 --> 19:44.550
These are the fondachi
in Naples that you've been

19:44.553 --> 19:45.913
reading about.

19:45.910 --> 19:49.580
And you can see that this is a
place, if you use your

19:49.577 --> 19:54.017
imagination, that's a wonderful
place for a cholera epidemic.

19:54.019 --> 20:01.929
Not only the fact of lack of
sewage and wells,

20:01.930 --> 20:04.490
but the fact that it's really
dark,

20:04.490 --> 20:08.550
and it's overcrowded,
and people, lots of people,

20:08.548 --> 20:12.688
live in a single room,
and that single room is used as

20:12.690 --> 20:15.580
the sickroom,
the sleeping room.

20:15.578 --> 20:20.108
It's a place also where food
supplies are stored,

20:20.105 --> 20:24.815
and with little opportunity to
have clean hands.

20:24.818 --> 20:31.628
And remember that the Vibrio
cholerae is spread through

20:31.625 --> 20:33.295
fecal matter.

20:33.298 --> 20:36.998
But the point is that in these
conditions,

20:37.000 --> 20:40.310
and in the dark,
it's very difficult to see,

20:40.308 --> 20:45.108
and therefore it's difficult to
know when contamination was

20:45.112 --> 20:47.102
actually taking place.

20:47.098 --> 20:51.528
Or, moving from Naples--these
are streets in Nottingham,

20:51.526 --> 20:55.866
in England, where cholera also
caused a couple of major

20:55.872 --> 20:58.692
epidemics, for similar reasons.

20:58.690 --> 21:02.480
And the waste matter was simply
hurled into streets like this.

21:02.480 --> 21:06.190
And in the center of the street
would be the gutter,

21:06.190 --> 21:09.100
which would carry human waste
as well.

21:09.098 --> 21:15.438
Another source of contamination
is flies, which carry the

21:15.442 --> 21:18.842
cholera bacterium with them.

21:18.838 --> 21:23.268
The clothing of victims--that
is, the bed linen,

21:23.269 --> 21:27.909
the mattresses and so
forth--were also sources of

21:27.912 --> 21:31.502
infection,
and laundresses were people who

21:31.502 --> 21:34.592
were particularly likely to fall
victim.

21:34.588 --> 21:38.548
And remember that cholera
spread also by asymptomatic

21:38.550 --> 21:39.390
carriers.

21:39.390 --> 21:43.910
It was possible to be
spreading- shedding the

21:43.910 --> 21:48.020
bacterium without exhibiting
symptoms.

21:48.019 --> 21:51.779
Well, how was the--what were
the symptoms of cholera?

21:51.779 --> 21:55.069
And that I'm going to argue,
the symptoms,

21:55.068 --> 21:58.348
the symptomatology,
is an important factor in the

21:58.351 --> 22:01.361
social response to this dreadful
disease,

22:01.358 --> 22:05.608
and it's captured by such terms
as "blue cholera,"

22:05.607 --> 22:09.927
"cholera asphyxia,"
and "the monster."

22:09.930 --> 22:15.230
This is a picture of a
representation of a cholera

22:15.234 --> 22:20.544
victim in the agony of the
disease, and this is an

22:20.540 --> 22:25.630
imaginative idea of how
overwhelming it is.

22:25.630 --> 22:32.170
This is a cholera patient about
to be overwhelmed by the disease

22:32.173 --> 22:33.113
itself.

22:33.108 --> 22:40.118
Well, the bodily defenses
against cholera are numerous.

22:40.118 --> 22:45.858
The saliva in the mouth was an
important defense.

22:45.858 --> 22:51.598
The digestive juices of the
stomach are acidic and tend to

22:51.601 --> 22:55.631
kill the bacterium when it's
ingested.

22:55.630 --> 23:01.630
So, it's quite possible to
ingest cholera bacteria without

23:01.625 --> 23:05.725
falling victim to the disease
itself.

23:05.730 --> 23:09.980
But there are a number of
important variables that

23:09.983 --> 23:12.593
condition what happens next.

23:12.588 --> 23:18.598
One would be how great-
extensive the infective dose

23:18.601 --> 23:27.531
actually was;
how much did you swallow?

23:27.528 --> 23:32.948
The diet that you're living on
is important because such foods

23:32.949 --> 23:35.349
that the poor,
in particular,

23:35.349 --> 23:39.279
lived on in European cities,
as ripe and overripe fruit and

23:39.282 --> 23:41.262
vegetables--
in other words,

23:41.260 --> 23:45.300
the poor were likely to buy
goods that were beginning to

23:45.301 --> 23:49.531
degenerate and deteriorate,
because they'd be marked down

23:49.529 --> 23:52.549
in price,
and those would be the goods

23:52.554 --> 23:54.924
that the poor would live on.

23:54.920 --> 23:59.240
And this meant that they often
suffered from dire real

23:59.240 --> 24:03.110
illnesses,
and those reduced the digestive

24:03.114 --> 24:05.954
time,
and therefore deprived the

24:05.951 --> 24:10.531
stomach of its defensive
capacity to protect you by the

24:10.525 --> 24:13.485
acidity of the digestive juices.

24:13.490 --> 24:16.820
And the consumption of raw
fruit, for example,

24:16.818 --> 24:20.518
would be especially common in
the summer months.

24:20.519 --> 24:24.559
Another factor would be the
general health of the person who

24:24.561 --> 24:26.551
was exposed to the disease.

24:26.548 --> 24:31.158
Let's suppose that you've eaten
a very large infective dose,

24:31.164 --> 24:34.844
and it passes successfully
through your stomach,

24:34.840 --> 24:37.110
into the small intestine.

24:37.109 --> 24:39.659
What happens next?

24:39.660 --> 24:42.230
Well, there's an incubation
period.

24:42.230 --> 24:45.340
It can be as short as a few
hours.

24:45.338 --> 24:51.018
And this too was important in
the social history of cholera,

24:51.017 --> 24:54.287
and could last up to three
days.

24:54.288 --> 24:58.588
The site of infection is the
small intestine.

24:58.588 --> 25:03.148
There the flagellum,
at the tail of the bacterium,

25:03.152 --> 25:07.062
that we've seen,
propels the Vibrio,

25:07.063 --> 25:11.723
and it attaches itself to the
intestinal wall.

25:11.720 --> 25:18.930
Ironically, there the immune
system of the body is usually

25:18.931 --> 25:23.361
capable of killing the
bacterium.

25:23.358 --> 25:28.698
But when it--as the bacterium
dies, it releases a very

25:28.698 --> 25:31.718
powerful toxin,
an enterotoxin,

25:31.720 --> 25:37.160
that's one of the most powerful
poisons in nature.

25:37.160 --> 25:41.980
And its effect on the
intestinal wall is to cause it

25:41.982 --> 25:46.502
to work in reverse;
that is, to drain fluid from

25:46.501 --> 25:52.111
the bloodstream into the bowel,
and from there it's expelled.

25:52.108 --> 25:56.668
So, the mechanism by which
cholera kills first of all,

25:56.670 --> 26:01.420
and predominantly,
is a sort of hemorrhaging to

26:01.420 --> 26:05.370
death,
in which the blood serum loses

26:05.365 --> 26:09.895
its fluidly massively--
liters can be expelled in a

26:09.896 --> 26:13.596
matter of a few hours--
and the patient hemorrhages to

26:13.595 --> 26:16.925
death,
in effect, losing its blood

26:16.930 --> 26:22.950
plasma and excreting what are
called the famous rice-water

26:22.948 --> 26:27.218
stools,
and the patient goes into

26:27.217 --> 26:29.577
hypovolemic shock.

26:29.578 --> 26:34.598
Nineteenth-century physicians
said--this is no longer a

26:34.604 --> 26:40.004
fashionable term today--but they
described cholera as going

26:40.000 --> 26:42.700
through two major stages.

26:42.700 --> 26:47.810
The first was called the algid
stage, which was the time of

26:47.807 --> 26:51.947
high drama and terror,
which had a sudden onset,

26:51.948 --> 26:53.708
without warning.

26:53.710 --> 26:57.570
This was part of the social
tensions that were generated by

26:57.565 --> 26:58.225
cholera.

26:58.230 --> 27:02.230
In other words,
you could be seized suddenly

27:02.234 --> 27:07.084
with this dreadful disease out
in a public place--

27:07.078 --> 27:10.488
on a tram, in a marketplace,
in the streets itself--

27:10.490 --> 27:14.230
where you would fall down and
start writhing,

27:14.230 --> 27:18.020
vomiting and excreting
rice-water stools.

27:18.019 --> 27:22.869
This was part of the high drama
of the disease.

27:22.868 --> 27:27.488
And the algid state would last,
if you survived,

27:27.486 --> 27:31.706
normally from eight to
twenty-four hours.

27:31.710 --> 27:36.430
As a patient,
you would lose--progressively

27:36.426 --> 27:42.826
your pulse would become fainter,
or even almost absent.

27:42.828 --> 27:48.858
The body would turn cold and
would have a livid appearance.

27:48.858 --> 27:51.948
It looked, within a few
hours--and this was another of

27:51.945 --> 27:54.445
the frightening aspects of this
disease--

27:54.450 --> 27:57.610
within a few hours,
someone who had been healthy

27:57.613 --> 28:00.603
that morning,
by the afternoon looked

28:00.597 --> 28:04.337
cadaverized,
like a person who had been

28:04.342 --> 28:09.012
wasting away from a long-term
wasting illness.

28:09.009 --> 28:11.799
The breath would turn cold.

28:11.798 --> 28:15.068
The hands would look like
dishwater hands.

28:15.068 --> 28:18.998
And very distressing,
there would be a very severe

28:18.998 --> 28:22.008
cramping;
terrible cramps,

28:22.010 --> 28:27.740
terrible abdominal pain,
nausea, vomiting.

28:27.740 --> 28:30.530
And the blood
itself--physicians who were

28:30.532 --> 28:34.372
trying to treat patients by
bloodletting rapidly noticed

28:34.374 --> 28:39.894
that the blood itself,
deprived of its liquid content,

28:39.891 --> 28:46.921
was transformed into a black
tar that refused to circulate.

28:46.920 --> 28:51.910
This could lead to heart
failure, to a terrible thirst

28:51.912 --> 28:54.552
that the patient suffered.

28:54.548 --> 28:58.678
And because the blood is no
longer providing adequate

28:58.683 --> 29:02.393
oxygen,
the patient suffers--has the

29:02.386 --> 29:11.056
sense of asphyxiating,
a terrible effort to gasping

29:11.061 --> 29:13.051
for air.

29:13.048 --> 29:16.558
Those are a couple of pictures
of contemporary--

29:16.558 --> 29:22.118
I said cholera is still with
us, and so I just wanted to show

29:22.118 --> 29:29.518
you a picture of a patient,
or another, a child patient

29:29.520 --> 29:30.720
today.

29:30.720 --> 29:34.840
In any case,
if the patient survived the

29:34.843 --> 29:38.073
algid stage,
there was then the second

29:38.066 --> 29:41.986
stage, that nineteenth-century
physicians called the reaction

29:41.994 --> 29:45.644
stage,
that might last four or five

29:45.638 --> 29:46.278
days.

29:46.279 --> 29:50.169
The prognosis isn't really
better, but the symptoms are.

29:50.170 --> 29:54.650
At this time the cold body
becomes warmer.

29:54.650 --> 29:56.790
There's a fever usually.

29:56.788 --> 30:01.978
The patient suffers terrible
headache and is often delirious.

30:01.980 --> 30:06.440
The problem is that there were
terrible complications that

30:06.442 --> 30:09.732
overtook patients in the
reaction stage.

30:09.730 --> 30:13.350
Pneumonia was a frequent
complication.

30:13.348 --> 30:18.198
So was kidney failure,
uremia, gangrene of the

30:18.200 --> 30:21.970
extremities;
the ears, the nose,

30:21.968 --> 30:25.058
fingers, toes,
the penis.

30:25.058 --> 30:29.918
And there was a case fatality
rate then, from Asiatic cholera

30:29.923 --> 30:33.903
in the nineteenth century,
of something like fifty

30:33.896 --> 30:34.866
percent.

30:34.868 --> 30:39.768
Today, as we said last time,
there is an effective oral

30:39.770 --> 30:43.670
rehydration therapy,
and the death rate with

30:43.674 --> 30:47.764
treatment is less than two
percent today.

30:47.759 --> 30:51.079
That's partly because of the
effectiveness of the treatment,

30:51.078 --> 30:55.358
and partly because the El Tor
biotype is less virulent than

30:55.359 --> 31:00.659
classic Vibrio cholerae,
of the first six pandemics.

31:00.660 --> 31:04.820
In any case,
then, what were the effects on

31:04.815 --> 31:10.355
a community, on a society,
of an invasion of a disease of

31:10.355 --> 31:11.735
this type?

31:11.740 --> 31:17.510
Was this the return of the
plague, as people speculated?

31:17.509 --> 31:21.939
This disease seemed a little
bit to resemble that,

31:21.943 --> 31:27.373
in terms of the terror that it
inspired, and the social chaos

31:27.373 --> 31:30.363
it caused during an outbreak.

31:30.358 --> 31:34.478
Now, an outbreak--let's imagine
a nineteenth-century city.

31:34.480 --> 31:39.380
You can pick your own,
let it be London or Paris,

31:39.377 --> 31:41.417
or perhaps Naples.

31:41.420 --> 31:45.640
The outbreak would tend to
begin with what the

31:45.640 --> 31:50.420
nineteenth-century medical
community termed sporadic

31:50.423 --> 31:51.553
cholera.

31:51.548 --> 31:56.198
By that they meant a small
trickle of cases.

31:56.200 --> 31:59.620
These would be transmitted in a
neighborhood,

31:59.615 --> 32:01.165
a family, a house.

32:01.170 --> 32:05.690
The transmission might be by
contaminated clothing or bed

32:05.692 --> 32:07.872
linen,
contaminated food,

32:07.866 --> 32:12.766
hand to mouth transmission from
tending a patient and then not

32:12.770 --> 32:14.460
washing the hands.

32:14.460 --> 32:20.340
Let me give you an example from
Venice in 1885.

32:20.338 --> 32:23.988
There was a particularly
persistent outbreak,

32:23.994 --> 32:27.904
in a single street,
before the disease became an

32:27.898 --> 32:30.888
epidemic in the city as a whole.

32:30.890 --> 32:35.720
And what happened was that this
was traced to a single

32:35.722 --> 32:39.622
restaurant,
and the proprietor was a lovely

32:39.622 --> 32:44.872
lady who happened to be tending
to her own infant child who was

32:44.866 --> 32:48.586
sick with cholera in an upstairs
bedroom.

32:48.588 --> 32:52.938
She would go upstairs and tend
to him, and then she would go

32:52.942 --> 32:56.042
back downstairs,
without washing her hands,

32:56.041 --> 32:58.921
and prepare food for her
clientele.

32:58.920 --> 33:04.220
And that was how the disease
was spread in a single street,

33:04.218 --> 33:05.678
for some time.

33:05.680 --> 33:10.080
Now, in fortunate instances,
the disease,

33:10.078 --> 33:12.978
this outbreak,
this so-called sporadic

33:12.978 --> 33:15.638
cholera,
would just fade away,

33:15.637 --> 33:20.517
and the community would escape
a large-scale misfortune.

33:20.519 --> 33:24.139
But if the Vibrio gained
access to the city's water

33:24.144 --> 33:27.304
supply,
then the disease would flare up

33:27.299 --> 33:30.819
with epidemic force,
and this would be what the

33:30.819 --> 33:34.279
nineteenth century health
authorities called epidemic

33:34.280 --> 33:37.180
cholera,
instead of sporadic.

33:37.180 --> 33:41.080
And if you made a graph of
cases and deaths,

33:41.079 --> 33:46.069
there'd be a sudden spike in
mortality and morbidity.

33:46.068 --> 33:50.148
Well, what would be the likely
magnitude of the disaster that

33:50.147 --> 33:53.677
would follow if,
let us say, a major European

33:53.682 --> 33:57.932
city had its water supply
contaminated with cholera?

33:57.930 --> 34:03.170
The order of magnitude would be
different from that of the

34:03.172 --> 34:04.002
plague.

34:04.000 --> 34:08.700
Cholera was never responsible
for the kind of demographic

34:08.702 --> 34:12.822
catastrophe that Europe
experienced with the Black

34:12.815 --> 34:17.145
Death,
or later invasions of bubonic

34:17.148 --> 34:18.088
plague.

34:18.090 --> 34:22.710
In the nineteenth century,
Europe experienced a major

34:22.711 --> 34:26.891
population growth,
and cholera had little impact

34:26.889 --> 34:29.379
on the population surge.

34:29.380 --> 34:34.320
Let's take again the example of
Naples, a city famous for its

34:34.324 --> 34:37.624
overcrowding,
its filth and its recurring

34:37.619 --> 34:40.339
epidemics of Asiatic cholera.

34:40.340 --> 34:45.890
Let's compare it also with an
earlier experience of bubonic

34:45.887 --> 34:46.747
plague.

34:46.750 --> 34:53.340
Naples experienced a terrible
epidemic of plague in 1656.

34:53.340 --> 34:58.280
At that time the city had about
a population numbering perhaps

34:58.284 --> 35:00.234
half-a-million people.

35:00.230 --> 35:05.140
The state wasn't very good at
knowing exactly how many people

35:05.141 --> 35:08.401
lived in the city,
and its statistics for

35:08.402 --> 35:12.122
mortality are also to be taken
with a grain of salt.

35:12.119 --> 35:16.899
But there were estimates that
as many as 300,000 people died

35:16.898 --> 35:20.138
of bubonic plague in that single
year.

35:20.139 --> 35:25.259
Let's compare that with cholera
in 1837.

35:25.260 --> 35:30.420
I choose 1837 because that was
the worst epidemic of cholera

35:30.423 --> 35:32.703
that Naples experienced.

35:32.699 --> 35:37.959
The population at that time was
still round about half-a-million

35:37.956 --> 35:42.046
people, but in this worst year
of Asiatic cholera,

35:42.045 --> 35:44.795
about 12,000 people perished.

35:44.800 --> 35:50.870
Now, I don't--after our
experience of bubonic plague--I

35:50.869 --> 35:56.489
don't want that to be a basis
for insensitivity.

35:56.489 --> 36:01.879
This epidemic in which 12,000
people died is a major disaster,

36:01.880 --> 36:05.170
but it didn't have the same
long-term cultural,

36:05.170 --> 36:11.550
philosophical and religious
impact that the plague earlier

36:11.554 --> 36:14.754
had,
and it didn't seem to convince

36:14.750 --> 36:19.170
people that the end of the world
had possibly arrived.

36:19.170 --> 36:22.140
So, cholera,
compared with plague,

36:22.139 --> 36:23.849
is less virulent.

36:23.849 --> 36:27.919
The bodily defenses of healthy
adults are often effective.

36:27.920 --> 36:31.200
And it doesn't have those
efficient vectors,

36:31.195 --> 36:34.315
rats and fleas,
that enabled the plague to

36:34.320 --> 36:35.920
reach every home.

36:35.920 --> 36:40.770
Also, unlike the plague,
cholera didn't endure for five

36:40.773 --> 36:44.373
centuries, returning every
generation.

36:44.369 --> 36:48.669
Cholera first invaded Europe in
the 1830s,

36:48.670 --> 36:53.390
and by the 1860s the history of
cholera in the industrially

36:53.391 --> 36:57.871
advanced nations of Northern
Europe was largely over.

36:57.869 --> 37:04.479
And for Western Europe as a
whole, the 1890s mostly marked

37:04.483 --> 37:08.433
the end, and 1911 certainly did.

37:08.429 --> 37:13.109
So, cholera had only six
pandemic waves that ever invaded

37:13.112 --> 37:15.662
Europe,
and each wave was less

37:15.664 --> 37:20.264
widespread and claimed fewer
victims than the ones preceding

37:20.262 --> 37:20.732
it.

37:20.730 --> 37:25.450
That's a very different history
than the history of bubonic

37:25.447 --> 37:26.177
plague.

37:26.179 --> 37:29.259
How long would an epidemic last?

37:29.260 --> 37:33.570
It would normally last,
in a great European city,

37:33.570 --> 37:38.420
for the length of the warm
summer and perhaps the early

37:38.420 --> 37:39.230
fall.

37:39.230 --> 37:44.590
It would then recede and fade
away with the onset of cool

37:44.592 --> 37:45.552
weather.

37:45.550 --> 37:47.940
Now, why would it fade away?

37:47.940 --> 37:51.520
Well, Robert Koch,
who discovered the Vibrio

37:51.516 --> 37:55.056
cholerae,
said himself that this was

37:55.057 --> 37:58.647
something,
a question to which he couldn't

37:58.652 --> 38:00.942
give a satisfactory answer.

38:00.940 --> 38:05.140
He said that this was one of
the great cholera mysteries,

38:05.139 --> 38:06.489
as he called it.

38:06.489 --> 38:10.329
But we can speculate with
regard to certain factors that

38:10.331 --> 38:11.521
seem important.

38:11.518 --> 38:14.508
One would be a change in
weather.

38:14.510 --> 38:22.100
Cold dry weather is hard on the
delicate Vibrio cholerae.

38:22.099 --> 38:26.199
Like plague,
cholera too in Europe had a

38:26.197 --> 38:29.347
very pronounced seasonality.

38:29.349 --> 38:33.279
It struck during the warm
months.

38:33.280 --> 38:36.930
Another factor is that after
the disease had struck those

38:36.931 --> 38:40.911
people who were most at risk
because of their occupations,

38:40.909 --> 38:44.449
and their personal
susceptibility and their living

38:44.447 --> 38:48.097
conditions,
the epidemic was then like a

38:48.101 --> 38:50.841
fire that ran short of fuel.

38:50.840 --> 38:56.950
It ran short of people who were
most susceptible and at high

38:56.945 --> 38:57.665
risk.

38:57.670 --> 39:00.850
And then communities,
also--and this was probably

39:00.849 --> 39:03.279
important--
adopted measures of

39:03.280 --> 39:06.590
self-defense,
and those too helped to cut

39:06.588 --> 39:10.788
short the outbreak,
especially later in the century

39:10.789 --> 39:13.759
when the disease was better
understood.

39:13.760 --> 39:20.490
It's now known too that the
cholera can survive in a spore

39:20.485 --> 39:24.195
form,
in algae blooms offshore of the

39:24.195 --> 39:28.575
great port cities,
and so there is a possibility

39:28.577 --> 39:33.137
too that the disease was
re-imported from the waters

39:33.144 --> 39:34.224
offshore.

39:34.219 --> 39:38.329
In any case,
what were the reactions to

39:38.333 --> 39:41.043
cholera in a community?

39:41.039 --> 39:46.949
Here there was an analogy,
possibly with plague,

39:46.952 --> 39:52.992
in that cholera too generated
terror and fear.

39:52.989 --> 39:58.579
This is partly because of the
agonizing nature of the symptoms

39:58.579 --> 40:00.229
of this disease.

40:00.230 --> 40:05.320
And the fact was that the
symptoms of cholera suggested

40:05.315 --> 40:10.965
were analogous to something that
people were already familiar

40:10.965 --> 40:13.975
with, and that is poisoning.

40:13.980 --> 40:20.260
The symptoms of cholera had
symptoms that resembled someone

40:20.257 --> 40:26.207
who had taken strychnine,
for example--rat poisoning.

40:26.210 --> 40:31.390
And, so, people were suspicious
that perhaps this might be a

40:31.389 --> 40:34.639
crime, rather than a natural
event.

40:34.639 --> 40:40.969
Let me show you some images
that convey the sense of terror

40:40.974 --> 40:44.364
that people felt at the time.

40:44.360 --> 40:49.790
This is King Cholera;
we've said that's one of the

40:49.788 --> 40:52.848
terms that it was associated
with.

40:52.849 --> 40:56.599
And you can see King Cholera
astride the globe.

40:56.599 --> 41:01.809
This is clearly a sense of its
pandemicity.

41:01.809 --> 41:06.559
Or we can look at--this is New
York City, with cholera

41:06.556 --> 41:07.806
approaching.

41:07.809 --> 41:12.879
And again you can see the kind
of terror that was associated

41:12.880 --> 41:13.740
with it.

41:13.739 --> 41:19.089
Or let's look as well--and you
can see cholera striding over

41:19.085 --> 41:21.345
the defensive bulwarks.

41:21.349 --> 41:25.639
Those are the kinds of--this is
clearly one of the early

41:25.635 --> 41:28.415
pandemics,
and what you can see is the

41:28.418 --> 41:32.218
attempt to control this disease
with the plague measures.

41:32.219 --> 41:35.149
You can see the troops,
sanitary cordons and all the

41:35.148 --> 41:37.898
rest, trying to keep out
"the monster,"

41:37.904 --> 41:39.114
as it was called.

41:39.110 --> 41:43.610
But those in fact turned out,
for reasons we'll be coming to,

41:43.614 --> 41:47.374
to be entirely ineffective in
dealing with cholera,

41:47.367 --> 41:49.017
unlike the plague.

41:49.018 --> 41:53.388
Or we can see--and here the
analogy in people's minds that

41:53.389 --> 41:57.299
this might be the return of the
plague is clear,

41:57.300 --> 42:00.490
because here we can see the
Grim Reaper,

42:00.489 --> 42:03.609
with his scythe,
mowing down the whole

42:03.605 --> 42:04.695
population.

42:04.699 --> 42:08.739
Or here we can see,
once again in the nineteenth

42:08.735 --> 42:10.965
century, a revival here.

42:10.969 --> 42:18.359
This is the danse
macabre, with death calling

42:18.364 --> 42:19.674
people.

42:19.670 --> 42:22.420
And there you can see again the
Danse Macabre.

42:22.420 --> 42:30.070
Here's the invitation of death
to come dance.

42:30.070 --> 42:34.790
So, those are sorts of graphic
illustrations of the kind of

42:34.793 --> 42:37.403
fear that this disease caused.

42:37.400 --> 42:42.590
Well it also caused
scapegoating.

42:42.590 --> 42:49.510
Imagine, for example--let's go
back to the first arrival of

42:49.514 --> 42:52.264
cholera in the 1830s.

42:52.260 --> 42:56.170
In 1830, let's think of the
Russian Empire.

42:56.170 --> 42:58.250
When cholera struck St.

42:58.253 --> 43:02.693
Petersburg in 1830,
at that time Russia was at war

43:02.690 --> 43:06.340
with Poland,
and Russians believed at the

43:06.342 --> 43:11.142
time that the disease was an act
of terror by Polish agents.

43:11.139 --> 43:15.049
So cholera gave rise to
manhunts or witch-hunts,

43:15.050 --> 43:17.880
find--the search for
scapegoats.

43:17.880 --> 43:21.790
Foreigners, gypsies,
someone newly arriving in town

43:21.793 --> 43:26.023
could be suspicious and
therefore could be set upon and

43:26.019 --> 43:28.289
attacked, as a scapegoat.

43:28.289 --> 43:31.129
Cholera also led,
because of its fear,

43:31.130 --> 43:34.950
to mass flight,
and some cities experienced

43:34.945 --> 43:39.465
almost Biblical exoduses,
with tens-of-thousands of

43:39.469 --> 43:43.429
people evacuating cities in fear
for their lives.

43:43.429 --> 43:47.599
And just as in Defoe's account,
it was the wealthier classes

43:47.596 --> 43:51.826
who could afford the journey and
had somewhere to go who went

43:51.833 --> 43:52.543
first.

43:52.539 --> 43:57.019
A consequence would be that the
administration and public

43:57.018 --> 44:00.698
services, in the city that was
being evacuated,

44:00.699 --> 44:02.139
were in chaos.

44:02.139 --> 44:03.859
Businesses shut down.

44:03.860 --> 44:05.960
There was mass unemployment.

44:05.960 --> 44:09.790
There was hunger and shortages
of all kinds.

44:09.789 --> 44:15.009
There was also a new strain on
class relationships.

44:15.010 --> 44:18.180
Cholera was a class disease,
I would argue,

44:18.181 --> 44:22.261
in that it caused a sharply
unequal burden of death and

44:22.262 --> 44:23.322
suffering.

44:23.320 --> 44:26.620
Unlike plague,
unlike smallpox,

44:26.619 --> 44:30.469
cholera primarily chose the
poor.

44:30.469 --> 44:33.769
Now, there are reasons,
in terms of risk factors,

44:33.768 --> 44:35.898
that explain that difference.

44:35.900 --> 44:39.270
There was normally by this time
a pattern of housing

44:39.266 --> 44:41.856
segregation;
that is to say,

44:41.864 --> 44:48.454
the poor and the wealthy didn't
live next to one another,

44:48.449 --> 44:50.929
and the poor suffered from
overcrowding,

44:50.929 --> 44:53.649
filth, poor diet,
lack of light,

44:53.652 --> 44:58.922
and the wells they drank from
were not the same as those used

44:58.920 --> 45:00.590
by the wealthy.

45:00.590 --> 45:05.150
A good example of this
difference, and one that caused

45:05.152 --> 45:07.222
sinister speculations.

45:07.219 --> 45:09.979
In time of plague,
as you know,

45:09.980 --> 45:14.580
those who tended the plague
victims--physicians and

45:14.579 --> 45:19.179
priests--perished in
unimaginable proportions.

45:19.179 --> 45:22.249
During the time of cholera,
however,

45:22.250 --> 45:27.630
doctors and priests moved among
the most sordid slums,

45:27.630 --> 45:31.960
and yet mysteriously they
managed to stay healthy,

45:31.960 --> 45:35.620
for the most part,
while those around them fell

45:35.617 --> 45:36.807
ill and died.

45:36.809 --> 45:39.679
There are good epidemiological
reasons for this.

45:39.679 --> 45:43.479
Doctors didn't eat and sleep in
the sickrooms,

45:43.480 --> 45:45.000
as the poor did.

45:45.000 --> 45:46.670
They had better diets.

45:46.670 --> 45:47.930
They washed their hands.

45:47.929 --> 45:50.539
They drank different water.

45:50.539 --> 45:55.179
But to the urban poor,
the immunity of the wealthier

45:55.179 --> 45:58.089
classes was highly suspicious.

45:58.090 --> 46:01.720
It suggested to some the idea
of poisoning;

46:01.719 --> 46:05.669
particularly since the poor in
the nineteenth century weren't

46:05.668 --> 46:06.588
medicalized.

46:06.590 --> 46:09.220
That is to say,
they had little contact and

46:09.222 --> 46:11.482
experience with medical
attention.

46:11.480 --> 46:15.240
And, so, an effect,
during the cholera years,

46:15.235 --> 46:17.025
was often violence.

46:17.030 --> 46:19.490
There were assaults on doctors.

46:19.489 --> 46:25.069
In some places crowds invaded
hospitals and lazarettos.

46:25.070 --> 46:28.500
And the suspicions weren't all
in one direction.

46:28.500 --> 46:31.090
The wealthy,
at this time in the nineteenth

46:31.090 --> 46:33.540
century,
had a fear of those they called

46:33.543 --> 46:35.433
the "dangerous
classes,"

46:35.431 --> 46:38.811
and they were thinking of the
dangerous classes as dangerous

46:38.809 --> 46:41.839
politically--
this was the rebellious

46:41.840 --> 46:46.280
century--dangerous morally and
in religious terms.

46:46.280 --> 46:51.410
But also they now seemed to be
dangerous medically.

46:51.409 --> 46:57.179
And I think this is a factor in
some of the extreme violence

46:57.182 --> 47:00.512
that one sees in 1848,
for example,

47:00.510 --> 47:03.250
or in the Paris Commune.

47:03.250 --> 47:07.090
There was a strain on social
relationships.

47:07.090 --> 47:11.710
Well, what happened in terms of
public policy and organized

47:11.711 --> 47:12.511
effects?

47:12.510 --> 47:17.590
The first thing that happened
was a tendency to revive the

47:17.594 --> 47:20.544
plague measures,
to contain it.

47:20.539 --> 47:24.769
Cholera put unprecedented
pressure on authorities to do

47:24.766 --> 47:28.756
something, to take some sort of
effective action.

47:28.760 --> 47:32.550
And it was then that the states
responded--

47:32.550 --> 47:35.090
first off, Russia,
Austria, Prussia,

47:35.090 --> 47:38.610
for example--by reviving the
plague regulations:

47:38.606 --> 47:41.446
land-based and maritime
quarantine,

47:41.449 --> 47:43.999
sanitary cordons, lazarettos.

47:44.000 --> 47:45.700
One can see this in pictures.

47:45.699 --> 47:49.049
This is a cholera lazaretto.

47:49.050 --> 47:54.590
Or one can see here is cholera,
the Vibrio arriving,

47:54.590 --> 47:58.290
and you can see that the Board
of Health is trying to stop it,

47:58.289 --> 48:01.269
and there are sanitary cordons
and all the rest.

48:01.268 --> 48:04.958
This is a depiction of the
early outbreak.

48:04.960 --> 48:08.440
Or the attempt--this is
familiar to you from time of

48:08.443 --> 48:13.023
plague--to purify the atmosphere
by burning sulfur and with fire.

48:13.018 --> 48:16.228
These were--or there were
funeral regulations.

48:16.230 --> 48:19.990
And you can see here again the
people bring out your dead,

48:19.989 --> 48:25.159
and transporting the victims to
the cemetery for rapid,

48:25.159 --> 48:28.099
hasty burial,
the funeral regulations.

48:28.099 --> 48:31.789
The results then were to
maximize terror,

48:31.793 --> 48:34.843
economic disruption and flight.

48:34.840 --> 48:39.080
The plague regulations against
cholera caused political

48:39.083 --> 48:39.873
effects.

48:39.869 --> 48:42.719
But they were
counter-productive in terms of

48:42.722 --> 48:45.842
the disease, for they taught a
dangerous lesson,

48:45.838 --> 48:48.358
that outsiders could be
dangerous.

48:48.360 --> 48:52.940
And so we see then,
they don't stop the cholera.

48:52.940 --> 48:56.140
They don't stop the cholera
because they're asymptomatic

48:56.141 --> 48:58.761
carriers,
because the flight of

48:58.764 --> 49:02.784
population causes--
trying to escape the plague

49:02.782 --> 49:05.372
measures disperses the disease.

49:05.369 --> 49:08.759
Because cholera can flow in
rivers and waterways,

49:08.755 --> 49:12.065
past the troops who are trying
to contain it.

49:12.070 --> 49:15.880
So, the plague measures weren't
effective against cholera.

49:15.880 --> 49:20.040
But I'm going to argue what
were the long-term effects.

49:20.039 --> 49:24.279
And I'm running rapidly out of
time, but just say that there

49:24.277 --> 49:27.507
were, I would argue,
not just immediate drama,

49:27.509 --> 49:29.879
there were long-term effects.

49:29.880 --> 49:35.290
Cholera led to a big debate in
the medical profession about

49:35.286 --> 49:37.986
contagionism,
rapid or not.

49:37.989 --> 49:41.589
It led to the development of
epidemiology as a medical

49:41.586 --> 49:42.466
discipline.

49:42.469 --> 49:46.409
It contributed to the coming of
the germ theory of disease.

49:46.409 --> 49:50.559
In terms of public health,
it led to a new set of measures

49:50.556 --> 49:53.986
of sanitary improvement,
that we'll be talking about

49:53.994 --> 49:58.004
next time,
and even to the refitting and

49:58.001 --> 50:03.861
sanitary revolution in cities,
and even the rebuilding of

50:03.862 --> 50:08.322
places like Paris and Naples;
although cholera was not the

50:08.315 --> 50:10.755
only in fact in places like
Paris.

50:10.760 --> 50:15.740
And it caused a mortality
revolution in urban cities.

50:15.739 --> 50:17.739
We'll be talking more about
that.

50:17.739 --> 50:22.319
There are reasons then to say
that although cholera caused

50:22.322 --> 50:25.782
many of the immediate effects of
terror,

50:25.780 --> 50:29.110
like the plague,
it didn't lead to the same kind

50:29.114 --> 50:31.894
of mortality,
and it didn't have the same

50:31.885 --> 50:33.335
long-term consequences.

50:33.340 --> 50:37.220
But it did have a number of
long-term consequences that I

50:37.215 --> 50:39.565
think it's well to bear in mind.

50:39.570 --> 50:43.530
This was the great dreaded
disease of the whole of the

50:43.530 --> 50:45.100
nineteenth century.

50:45.099 --> 50:49.999