WEBVTT 00:01.560 --> 00:03.330 Prof: Good morning. 00:03.330 --> 00:05.340 We'll get started. 00:05.340 --> 00:08.090 As you know, this isn't--there isn't going 00:08.090 --> 00:10.640 to be a lecture this morning at all. 00:10.640 --> 00:13.970 We're going instead to have a review session, 00:13.969 --> 00:17.749 in which I'll be very much dependent on your having 00:17.752 --> 00:21.462 questions, and our having a joint discussion. 00:21.460 --> 00:25.690 So, what I'm expecting to be able to do is to, 00:25.690 --> 00:29.640 when you have questions, or want to contribute to-- 00:29.640 --> 00:33.020 I've got some questions as well--we can put our heads 00:33.024 --> 00:33.744 together. 00:33.740 --> 00:38.040 And there'll be a microphone, I hope, that we can pass 00:38.037 --> 00:41.197 around, and everyone will be audible. 00:41.200 --> 00:44.300 The first thing I should say is just to talk, 00:44.295 --> 00:47.315 just for a minute, about the exam itself; 00:47.320 --> 00:49.420 because I've now written it. 00:49.420 --> 00:54.250 So, at least we can say on that much I'm the world's authority. 00:54.250 --> 00:57.100 The exam will look like this. 00:57.100 --> 00:59.520 There will be two parts. 00:59.520 --> 01:03.450 The first part will be the ID section, 01:03.450 --> 01:07.530 and that will have--let's see, you've got the list of 01:07.528 --> 01:11.578 identifications, and I've literally just chosen 01:11.582 --> 01:15.412 ten of them, and that will constitute two 01:15.406 --> 01:20.136 points each, or a total of twenty points for 01:20.135 --> 01:21.895 the ID section. 01:21.900 --> 01:25.370 And, so, you can work out how to budget your time, 01:25.367 --> 01:26.567 in that regard. 01:26.569 --> 01:29.579 Clearly, you're not meant to write an essay; 01:29.580 --> 01:34.250 just even bullet points or a short paragraph is all that's 01:34.250 --> 01:38.020 expected with regard to the identifications. 01:38.019 --> 01:42.689 The second part of the exam consists of three essays, 01:42.688 --> 01:46.818 and I'm--that is, three on a list of three--and 01:46.818 --> 01:50.498 I'll ask you to write on two of them. 01:50.500 --> 01:54.030 And each of the essays therefore will count forty 01:54.028 --> 01:54.688 points. 01:54.690 --> 01:59.490 So, part two of the exam will count eighty points altogether. 01:59.489 --> 02:02.539 That tells how you should budget your time. 02:02.540 --> 02:06.900 The essay questions are much more important than the 02:06.900 --> 02:08.440 identifications. 02:08.438 --> 02:11.488 That's really the structure of the exam. 02:11.490 --> 02:14.830 I can't think really of anything else that I can say 02:14.828 --> 02:15.678 about that. 02:15.680 --> 02:18.770 But let me see if anyone--before we turn to 02:18.770 --> 02:22.550 substantive issues, does anyone have any questions 02:22.554 --> 02:26.814 about the format of the exam or what's likely to be on it? 02:26.810 --> 02:29.060 I can repeat what I've said before. 02:29.060 --> 02:33.620 The exam period itself is notionally three hours, 02:33.615 --> 02:38.645 though you also get an additional half-hour as a grace 02:38.645 --> 02:39.685 period. 02:39.690 --> 02:42.920 That, I understand, is the Yale system, 02:42.917 --> 02:45.207 and we'll adhere to that. 02:45.210 --> 02:49.090 The exam will also--I wanted to stress this-- 02:49.090 --> 02:52.620 it will cover the whole of the course, 02:52.620 --> 02:55.850 from the beginning, and it won't simply be on the 02:55.852 --> 03:00.632 last part of the course, since the mid-term. 03:00.628 --> 03:05.258 It will cover everything that we've dealt with since January 03:05.263 --> 03:06.523 down to today. 03:06.520 --> 03:09.760 So, are there any questions before we turn to the substance, 03:09.758 --> 03:14.408 about the format of the exam, or what you could expect or not 03:14.413 --> 03:19.473 expect, or anything of that nature? 03:19.470 --> 03:20.610 Yes? 03:20.610 --> 03:23.910 Student: Do we need to bring in any sort of readings on 03:23.906 --> 03:24.806 the ID section? 03:24.810 --> 03:29.240 Prof: The question was, do you need to bring in 03:29.242 --> 03:31.672 readings on the ID section? 03:31.669 --> 03:35.499 I think that depends entirely on which ID you deal with. 03:35.500 --> 03:41.790 Some of the IDs are directly based on the reading that you've 03:41.786 --> 03:42.516 done. 03:42.520 --> 03:47.110 So, for example, if I ask Daniel Defoe, 03:47.110 --> 03:49.430 to identify, it would be really odd if you 03:49.431 --> 03:52.661 didn't bring in the Journal of the Plague Year, 03:52.660 --> 03:54.570 and why it was important. 03:54.569 --> 03:55.759 Okay? 03:55.758 --> 03:59.008 But if I asked you about, say, the Paris School of 03:59.013 --> 04:02.403 Medicine, that you didn't actually have readings on, 04:02.399 --> 04:04.789 then it wouldn't be necessarily. 04:04.788 --> 04:09.718 So, it really depends on the nature of the particular ID in 04:09.723 --> 04:10.663 question. 04:10.659 --> 04:13.349 Okay? 04:13.349 --> 04:18.889 Anything else about the exam? 04:18.889 --> 04:20.069 Okay, thanks. 04:20.069 --> 04:24.329 Then let's move on to the substantive part of the review, 04:24.331 --> 04:28.901 and the issues that we've been dealing with in the course. 04:28.899 --> 04:33.759 And I thought one way we might start would be for me to ask you 04:33.759 --> 04:37.619 a question; which is what do you think I 04:37.617 --> 04:42.077 should sensibly ask you about on the final? 04:42.079 --> 04:46.529 What would make good final exam questions for you, 04:46.526 --> 04:50.516 based on the material that you've covered? 04:50.519 --> 04:54.549 And then we could put our heads together a little bit to think 04:54.553 --> 04:57.993 about what might be some elements of the answers that 04:57.990 --> 04:59.710 you'd provide in them. 04:59.709 --> 05:05.579 Does anyone have a question that I ought to ask you? 05:05.579 --> 05:12.079 It's never too late; I could change the questions I 05:12.079 --> 05:15.229 wrote yesterday. 05:15.230 --> 05:21.160 You think I should ask you nothing? 05:21.160 --> 05:26.480 It's always a possibility, too. 05:26.480 --> 05:30.270 Okay, well I've got some thoughts, if you like, 05:30.266 --> 05:33.966 for things that we might want to deal with. 05:33.970 --> 05:38.700 One was this-- and I'm going to ask and see if any of you would 05:38.696 --> 05:42.886 like to help me think through this particular issue-- 05:42.889 --> 05:49.009 if we're dealing with the impact of major epidemic 05:49.007 --> 05:54.037 diseases on society, what would be--is it true to 05:54.036 --> 05:58.426 think that it's really the overall mortality that provides 05:58.430 --> 06:02.670 the major way in which we can assess whether this was an 06:02.668 --> 06:05.288 important event or it wasn't? 06:05.290 --> 06:10.150 Is that how we judge the significance of the passage of 06:10.149 --> 06:13.569 an epidemic disease through society? 06:13.569 --> 06:17.019 Do we--is the body count, in other words, 06:17.016 --> 06:19.426 the most important factor? 06:19.430 --> 06:20.880 Or is it something else? 06:20.879 --> 06:25.589 How do we--what factors determine whether an epidemic 06:25.586 --> 06:31.286 disease really is a significant historical event or it isn't? 06:31.290 --> 06:37.290 Do you have any thoughts on that particular issue? 06:37.290 --> 06:43.650 Yes--please? Thank you. 06:43.649 --> 06:46.809 Student: Morbidity. 06:46.810 --> 07:04.870 ** Prof: Okay, 07:04.865 --> 07:05.725 thanks very much. 07:05.730 --> 07:08.060 Did everyone hear? 07:08.060 --> 07:12.700 The candidate for an answer would be that it's not just the 07:12.699 --> 07:15.539 mortality, but we need to look at the 07:15.538 --> 07:18.398 morbidity, and even more than that we need 07:18.396 --> 07:22.616 to look at the class, or the profile of the victims 07:22.620 --> 07:26.050 of the epidemic, and that it makes a big 07:26.048 --> 07:30.888 difference whether the victims of the disease are the elderly, 07:30.889 --> 07:33.609 and perhaps infants; in other words, 07:33.605 --> 07:38.285 whether it seems like a normal event in the life of that 07:38.286 --> 07:43.136 society, or whether it targets instead a different patient 07:43.137 --> 07:44.497 population. 07:44.500 --> 07:47.270 If it targets people in the prime of life, 07:47.271 --> 07:50.181 it's experienced in a very different way. 07:50.180 --> 07:54.350 So, clearly the class profile is important, 07:54.353 --> 07:59.523 and not just the mortality, or even the morbidity. 07:59.519 --> 08:00.709 Are there other factors? 08:00.709 --> 08:02.399 Yes? 08:02.399 --> 08:05.729 Student: One argument in favor of mortality mattering 08:05.725 --> 08:08.825 is it didn't really have much of an impact on things like 08:08.829 --> 08:10.719 society, and it didn't prove lasting. 08:10.720 --> 08:11.990 Like you could control things. 08:11.990 --> 08:15.370 So you'd have like a really big morbidity but a small mortality, 08:15.365 --> 08:17.075 and so that prevented a panic. 08:17.079 --> 08:19.389 Prof: That's great. 08:19.389 --> 08:32.029 ** Prof: Maybe you could 08:32.028 --> 08:32.398 start again. 08:32.399 --> 08:38.589 I don't think everyone could hear you. 08:38.590 --> 08:44.420 Student: One argument in favor of mortality mattering 08:44.422 --> 08:47.312 is that flu, which didn't really have that 08:47.307 --> 08:49.177 much of a lasting impact on society, 08:49.178 --> 08:52.978 had a really high morbidity but a really small mortality, 08:52.980 --> 08:56.700 and everyone knew that, and so they weren't panicked 08:56.696 --> 08:57.786 when it came. 08:57.789 --> 08:58.539 Prof: Okay. 08:58.538 --> 09:03.108 There's the idea then that we shouldn't retreat too much from 09:03.110 --> 09:06.160 mortality, that it really does matter. 09:06.158 --> 09:09.238 And I'm really happy that you did something very important, 09:09.240 --> 09:13.380 which was not just to leave this matter hanging in the 09:13.381 --> 09:17.681 abstract, but to tack it to a particular 09:17.681 --> 09:18.691 example. 09:18.690 --> 09:22.140 And, so, it's really important that you bring in particular 09:22.144 --> 09:24.234 diseases to clinch your argument. 09:24.230 --> 09:27.780 Talking about influenza is exactly the way that the 09:27.784 --> 09:31.414 argument ought to go, and weighing that versus other 09:31.413 --> 09:33.763 diseases that were different. 09:33.759 --> 09:34.909 That's good. 09:34.909 --> 09:36.519 Thank you. 09:36.519 --> 09:37.679 Right, someone else? 09:37.679 --> 09:38.939 Oh, there we go. 09:38.940 --> 09:42.620 Student: At the same time, I think that what that 09:42.620 --> 09:45.910 really speaks to is more the reaction of society to 09:45.908 --> 09:46.828 something. 09:46.830 --> 09:50.250 So, that it's important to say that it's not just a number that 09:50.248 --> 09:52.458 matters; that mortality rate isn't so 09:52.461 --> 09:56.141 much the important part as much as how people were able to kind 09:56.144 --> 09:58.524 of incorporate that into their lives. 09:58.519 --> 10:03.489 Because as you were saying, flu wasn't necessarily the most 10:03.493 --> 10:05.983 striking example to people. 10:05.980 --> 10:10.120 However, I think that certain--even times like 10:10.116 --> 10:13.976 tuberculosis, where you have people who are 10:13.977 --> 10:17.837 dying but in very much longer periods. 10:17.840 --> 10:21.890 So, you have more time for reactions in literature and art, 10:21.894 --> 10:24.904 and those have just as much of an impact. 10:24.899 --> 10:27.949 And, in fact, they're really lasting impacts 10:27.950 --> 10:31.710 because we still have those pieces of epidemic art and 10:31.710 --> 10:36.590 literature to look back on, to see how they had impacts on 10:36.586 --> 10:37.366 society. 10:37.370 --> 10:39.010 Prof: Okay, yes, thanks very much. 10:39.009 --> 10:43.299 So, it's--you want to complicate the matter even 10:43.298 --> 10:46.428 more-- it really depends on how it's 10:46.433 --> 10:49.833 perceived, perceptions-- and also that's 10:49.831 --> 10:53.311 reflected in the arts and in literature, 10:53.308 --> 10:57.968 and you're giving the example of tuberculosis and the time 10:57.970 --> 11:01.160 period and how lasting the impact is. 11:01.158 --> 11:06.208 That tuberculosis has--one of its reasons for having such an 11:06.206 --> 11:09.966 impact was that it was such a slow event, 11:09.970 --> 11:14.230 and was with society for so long, and people reflected on 11:14.230 --> 11:17.330 that, and it impacted the arts and 11:17.328 --> 11:18.128 culture. 11:18.129 --> 11:20.349 Absolutely, I think that would be. 11:20.350 --> 11:23.190 So, we've got now--in order to deal with this, 11:23.190 --> 11:28.920 we've dealt with influenza and tuberculosis as contrasting 11:28.923 --> 11:31.263 factors, two diseases, 11:31.255 --> 11:33.515 in very different ways. 11:33.519 --> 11:37.639 And it's certainly true that also on the exam we will be 11:37.644 --> 11:40.784 dealing-- I'll be asking you to be 11:40.775 --> 11:45.095 comparative in your discussion of diseases, 11:45.100 --> 11:49.520 and to bring in more than one disease in order to deal with 11:49.524 --> 11:53.954 major questions that cut across the whole of our course. 11:53.950 --> 11:54.880 Okay, thanks. 11:54.879 --> 12:03.479 Anything else we ought to put in to our answer to this 12:03.484 --> 12:05.274 question? 12:05.269 --> 12:09.619 Would it be good to deal with just two diseases in dealing 12:09.615 --> 12:10.525 with that? 12:10.528 --> 12:17.258 Would this be--would you get an A for bringing in influenza and 12:17.260 --> 12:18.890 tuberculosis? 12:18.889 --> 12:24.949 What other diseases might be important in considering this 12:24.950 --> 12:26.120 question? 12:26.120 --> 12:30.580 Yes, thanks. 12:30.580 --> 12:45.170 ** Student: You might 12:45.168 --> 12:47.488 consider cholera, because it was sort of the 12:47.490 --> 12:51.150 opposite of tuberculosis, in that it had a very rapid 12:51.154 --> 12:55.054 onset, and so the specifics surrounding the disease itself 12:55.049 --> 12:58.399 had an effect on how it was perceived as something 12:58.399 --> 13:01.969 frightening, and something gross. 13:01.970 --> 13:03.130 Prof: Okay. 13:03.129 --> 13:06.269 So, you would throw cholera into the mix. 13:06.269 --> 13:09.659 And I think the reason you're--if I've understood you, 13:09.658 --> 13:12.978 you're saying that this should take us into another whole 13:12.976 --> 13:15.506 realm, which is to deal with the 13:15.509 --> 13:18.189 symptoms, because there was something 13:18.187 --> 13:21.647 particularly frightening and disgusting about Asiatic 13:21.649 --> 13:25.039 cholera, and that conditioned its impact. 13:25.038 --> 13:29.218 People were really terrified by its arrival, because of the 13:29.222 --> 13:31.462 nature of its symptomatology. 13:31.460 --> 13:35.210 That's another dimension that we ought to consider. 13:35.210 --> 13:38.460 It's not just morbidity, not just mortality, 13:38.455 --> 13:42.295 not just the profile of the victims, but the kind of 13:42.303 --> 13:46.383 suffering that the disease imposes on its victims. 13:46.379 --> 13:51.089 So, the symptomatology is tremendously important. 13:51.090 --> 13:56.980 Okay, anything else on that question? 13:56.980 --> 14:00.700 Our grade is going up all the time. 14:00.700 --> 14:03.980 Several examples, specific cases, 14:03.975 --> 14:09.295 that's comparison, that's all extremely important. 14:09.298 --> 14:18.608 Anything else anyone wants to throw in on this question? 14:18.610 --> 14:21.360 So, collectively we've got what? 14:21.360 --> 14:24.240 An A on this? 14:24.240 --> 14:29.010 Okay, we'll pat ourselves on the back, and let's move on and 14:29.009 --> 14:33.619 see if there are other issues we might like to discuss. 14:33.620 --> 14:37.220 What is it--let me see, I'm wondering-- 14:37.220 --> 14:44.340 I mentioned something in passing, and threw out a phrase, 14:44.340 --> 14:48.870 which was that we might want to consider some diseases in our 14:48.871 --> 14:52.121 course "diseases of modernity." 14:52.120 --> 14:56.080 I'm wondering if that's actually a useful concept. 14:56.080 --> 14:57.960 It may be that I misspoke. 14:57.960 --> 15:04.340 Or is modernity in some senses a factor that promotes our 15:04.337 --> 15:09.917 vulnerability to high-impact epidemic diseases; 15:09.918 --> 15:12.158 or at least certain ones among them? 15:12.159 --> 15:27.179 Is that true or is that wrong? 15:27.179 --> 15:28.919 Great. 15:28.918 --> 15:31.548 Student: always like to put a finer edge on it 15:31.547 --> 15:35.147 ** Prof: You really do, yes. 15:35.149 --> 15:40.359 ** Student: I might put a 15:40.360 --> 15:44.180 finer edge on it for the class by asking them if any real 15:44.183 --> 15:48.353 progress in social or medical response to epidemic disease has 15:48.350 --> 15:51.560 occurred over the time span of the course? 15:51.559 --> 15:53.389 Prof: Okay. 15:53.389 --> 15:56.429 In other words, are we more vulnerable now, 15:56.428 --> 16:00.478 or much less vulnerable, as a result of public health 16:00.480 --> 16:04.610 policies and understanding of infectious diseases, 16:04.610 --> 16:08.670 since, let's see, poor Daniel Defoe lived through 16:08.672 --> 16:10.452 the bubonic plague. 16:10.450 --> 16:12.190 That's sort of your question, right? 16:12.190 --> 16:13.370 Student: Precisely. 16:13.370 --> 16:16.000 Student: It struck me that your definition of a 16:16.003 --> 16:18.543 disease of modernity refers to structural factors. 16:18.539 --> 16:18.829 Right? 16:18.830 --> 16:21.220 So, for instance, the role of mass transit 16:21.224 --> 16:23.334 technologies, perhaps urbanization in 16:23.326 --> 16:25.366 abetting the spread of disease. 16:25.370 --> 16:28.760 Isn't that the sense of disease of modernity? 16:28.759 --> 16:29.679 Prof: I think you're right. 16:29.678 --> 16:33.968 Who knows what I meant when I said it. 16:33.970 --> 16:37.390 But it would seem to me, if we were retrospectively to 16:37.389 --> 16:40.939 try to make sense of a phrase like that, we--and this is 16:40.940 --> 16:42.360 important and all. 16:42.360 --> 16:45.840 Here's a general point for any answers that you give in an 16:45.841 --> 16:46.271 exam. 16:46.269 --> 16:50.839 You would have to provide a definition of what it actually 16:50.837 --> 16:51.477 means. 16:51.480 --> 16:55.210 Modernity is a lovely phrase, but it doesn't really-- 16:55.210 --> 16:57.180 its meaning is not self-evident, 16:57.181 --> 17:00.761 and it was only-- your grade would rise very 17:00.759 --> 17:06.229 significantly if you weren't just to talk about modernity, 17:06.230 --> 17:09.030 but you were actually to do what you just did, 17:09.028 --> 17:11.128 but to say, "What does that mean?" 17:11.130 --> 17:15.070 and point to factors such as urbanization, 17:15.065 --> 17:18.035 mass transit, population growth, 17:18.039 --> 17:22.359 things like that, that give it a meaning; 17:22.358 --> 17:26.808 and possibly also the development of an understanding 17:26.806 --> 17:31.246 scientifically of the biology and the medicine of the 17:31.251 --> 17:34.601 diseases, and therefore public health 17:34.604 --> 17:36.524 policies and practices. 17:36.519 --> 17:39.229 That, I think, would be a much better way to 17:39.229 --> 17:42.939 approach this idea of whether it's a disease of modernity or 17:42.944 --> 17:43.454 not. 17:43.450 --> 17:46.410 And I'm just wondering what would you say? 17:46.410 --> 17:53.130 Are we less vulnerable now than London was at the time of Defoe; 17:53.130 --> 17:57.710 or is it still the same; or are we vulnerable, 17:57.707 --> 18:01.517 but vulnerable to different kinds of diseases, 18:01.515 --> 18:03.965 at least here in the West? 18:03.970 --> 18:05.410 Okay, great. 18:05.410 --> 18:14.170 ** Student: I would say 18:14.174 --> 18:18.934 that we're more vulnerable to the spread of disease and to 18:18.929 --> 18:23.099 diseases that are a result of over-sanitation, 18:23.098 --> 18:25.418 but that we're also more capable of dealing with them, 18:25.420 --> 18:28.280 scientifically and technologically. 18:28.279 --> 18:29.089 Prof: Okay. 18:29.088 --> 18:33.558 So, it's neither--you're rejecting that opposition of 18:33.558 --> 18:36.308 being more or less vulnerable. 18:36.308 --> 18:39.428 We're more vulnerable in certain ways, 18:39.430 --> 18:42.130 and less vulnerable in others. 18:42.130 --> 18:46.000 Perhaps we're not as susceptible to certain diseases 18:46.001 --> 18:49.491 in the same way, but we're susceptible to other 18:49.494 --> 18:51.854 diseases in different ways. 18:51.848 --> 18:56.178 Maybe the mode of transmission is an important factor. 18:56.180 --> 18:57.900 But you wanted to say something too. 18:57.900 --> 19:00.230 Let's come to you. 19:00.230 --> 19:07.750 ** Student: I also think 19:07.749 --> 19:10.809 that in a way though we're sort of like shifting from one vague 19:10.805 --> 19:13.215 misconception of disease causality to another. 19:13.220 --> 19:16.550 Because the earliest modes of disease prevention were 19:16.547 --> 19:19.807 quarantine and just, like, whatever they could--like 19:19.809 --> 19:22.049 sanitation, like with Chadwick. 19:22.048 --> 19:24.268 But then we moved to this magic bullet thing, 19:24.268 --> 19:26.788 once we figured out that it was the germ theory. 19:26.788 --> 19:29.258 And for a really long time--and I think it still sort of 19:29.259 --> 19:31.779 persists--is this idea that we can cure something just by 19:31.776 --> 19:32.896 finding a magic drug. 19:32.900 --> 19:35.610 And that isn't really how it works, and there are a lot of 19:35.608 --> 19:36.368 other factors. 19:36.368 --> 19:39.518 And even though we sort of acknowledge that sometimes, 19:39.520 --> 19:42.380 I don't think that it's necessarily permeated our 19:42.375 --> 19:45.225 efforts to cure a lot of different diseases. 19:45.230 --> 19:47.440 Like with AIDS you can kind of see that there's efforts at 19:47.440 --> 19:48.720 education and things like that. 19:48.720 --> 19:52.680 But as long as there's poverty, there's going to be diseases 19:52.682 --> 19:55.572 that disproportionately affect the poor, 19:55.568 --> 19:58.278 and I don't think that we're anywhere near solving that 19:58.278 --> 19:58.778 problem. 19:58.779 --> 19:59.459 Prof: Okay. 19:59.460 --> 20:04.420 So, as I understand it, you're saying that we have made 20:04.423 --> 20:08.533 advances in understanding, and there are diseases for 20:08.526 --> 20:11.836 which there are public health measures that are effective, 20:11.838 --> 20:14.848 and there are sometimes magic bullets. 20:14.848 --> 20:19.468 But we have become rather over--we overemphasize the 20:19.474 --> 20:24.554 importance of treatments, and we underestimate the social 20:24.554 --> 20:27.914 economic determinants of disease. 20:27.910 --> 20:32.650 And, so, diseases thrive on certain social and economic 20:32.650 --> 20:35.690 conditions-- and you mentioned poverty, 20:35.685 --> 20:39.945 for example-- and so until those underlying 20:39.945 --> 20:45.495 substrates of epidemic diseases are dealt with, 20:45.500 --> 20:48.610 we'll always remain vulnerable. 20:48.608 --> 20:52.058 So, that would suggest--maybe we should take that on for a 20:52.064 --> 20:52.614 second. 20:52.608 --> 20:58.378 Is that a valid conclusion from the course, 20:58.380 --> 21:00.770 from your readings and all the rest, 21:00.769 --> 21:03.159 that diseases, all diseases, 21:03.164 --> 21:07.584 are diseases of poverty?-- would seem to be something you 21:07.579 --> 21:09.059 were maybe suggesting. 21:09.058 --> 21:12.018 Or even if you weren't, I'm suggesting it on your 21:12.023 --> 21:12.583 behalf. 21:12.578 --> 21:15.878 Is that a valid conclusion to draw; 21:15.880 --> 21:22.500 that really the essential driver of epidemic disasters is 21:22.498 --> 21:23.678 poverty? 21:23.680 --> 21:26.650 All diseases are diseases of poverty; 21:26.650 --> 21:34.950 is that right? 21:34.950 --> 21:35.390 Right. 21:35.390 --> 21:41.750 Great, thanks. 21:41.750 --> 21:43.770 Student: I would disagree with that statement 21:43.772 --> 21:45.662 because although-- Prof: Okay. 21:45.660 --> 21:47.530 I would too. 21:47.529 --> 21:49.499 Student: We see that, in some cases, 21:49.500 --> 21:52.630 notably cholera, it did only strike the poor, 21:52.630 --> 21:56.440 and the rich were pretty much unaffected by the disease, 21:56.440 --> 22:00.290 in terms of health, health-wise. 22:00.288 --> 22:03.448 There's been plenty of other diseases that really haven't 22:03.448 --> 22:06.548 shown any liking to any specific socioeconomic class. 22:06.548 --> 22:09.588 The flu just came in and, since it was so easily spread 22:09.590 --> 22:13.420 from person to person, even if you were walking into a 22:13.423 --> 22:16.553 store run by someone of a lower class, 22:16.548 --> 22:18.348 you could easily get that from them. 22:18.348 --> 22:22.368 So, I think most diseases, even though some did strike the 22:22.366 --> 22:26.236 poor to a greater extent, you can't classify them solely 22:26.243 --> 22:28.573 as being diseases of poverty. 22:28.568 --> 22:35.658 Where poverty might have--not embellished--but poverty might 22:35.655 --> 22:39.735 have--imight have made it worse. 22:39.740 --> 22:42.730 Someone in poverty would probably be worse off due to 22:42.730 --> 22:44.630 influenza than a richer person. 22:44.630 --> 22:47.020 But I don't think it caused most of the diseases we've 22:47.015 --> 22:47.685 talked about. 22:47.690 --> 22:49.690 Prof: Okay. 22:49.690 --> 22:53.420 There is the theory, then, that it really depends on 22:53.423 --> 22:56.593 which disease, and that it's a gross 22:56.593 --> 23:02.273 oversimplification to say that poverty is the cause of epidemic 23:02.271 --> 23:03.281 disease. 23:03.278 --> 23:07.778 It exacerbates the situation, probably for all. 23:07.778 --> 23:14.108 But there are clearly certain diseases that are driven by 23:14.107 --> 23:17.987 other factors-- and influenza was a case in 23:17.990 --> 23:22.060 point--there's certain diseases that really do seem to be 23:22.058 --> 23:29.118 equal-opportunity afflictions, in that they seem to strike all 23:29.124 --> 23:33.844 rungs of society, rather than just certain 23:33.840 --> 23:36.140 economic and social classes. 23:36.140 --> 23:40.140 And influenza was a good--respiratory diseases 23:40.137 --> 23:43.067 perhaps veer towards that pole. 23:43.068 --> 23:47.738 But then I think you're saying that in any case it's probably 23:47.736 --> 23:51.466 not fair also completely to eliminate poverty; 23:51.470 --> 23:55.740 that it's a sort of spectrum, and some diseases are more 23:55.738 --> 23:58.918 responsive to poverty, and others less. 23:58.920 --> 24:02.520 But that even influenza---perhaps if you're 24:02.519 --> 24:06.209 poor, you don't have access to medical care, 24:06.205 --> 24:10.145 to nursing, and to medications, and so on. 24:10.150 --> 24:13.550 And, so, it's more of a problem, but it's a universal 24:13.550 --> 24:14.990 problem nonetheless. 24:14.990 --> 24:17.010 Have I understood you right, correctly? 24:17.009 --> 24:17.849 Okay. 24:17.849 --> 24:20.519 Good, thank you. 24:20.519 --> 24:22.299 I think you'd be right. 24:22.298 --> 24:27.228 And I think it would be good if in the answer-- 24:27.230 --> 24:31.310 let's say we give a more coherent answer if we gave a 24:31.310 --> 24:35.080 range of diseases in dealing with the answer, 24:35.078 --> 24:38.738 some at one end of the spectrum and others at the other. 24:38.740 --> 24:39.470 Right? 24:39.470 --> 24:41.460 So, influenza would be great. 24:41.460 --> 24:45.190 But it would be a mistake just to put influenza into the 24:45.189 --> 24:45.799 answer. 24:45.798 --> 24:48.938 We'd want to give contrasting examples. 24:48.940 --> 24:51.870 The answer, then, as many historical answers, 24:51.868 --> 24:56.288 has to be qualified and nuanced, and just to say all 24:56.288 --> 25:01.398 diseases are diseases of poverty is probably quite wrong. 25:01.400 --> 25:01.890 Okay. 25:01.890 --> 25:05.230 There was another--you were going to-- 25:05.230 --> 25:08.290 Student: Well I was just going to ask if we could 25:08.288 --> 25:11.618 maybe take the diseases that we looked at and almost rank them 25:11.618 --> 25:13.638 in the order of how they affect-- 25:13.640 --> 25:16.820 like how much certain diseases ** from flu to 25:16.820 --> 25:17.380 cholera. 25:17.380 --> 25:18.080 Prof: Okay. 25:18.078 --> 25:22.788 Well, why don't I be a really, really nasty person and ask if 25:22.794 --> 25:24.684 you could help me out? 25:24.680 --> 25:27.660 How would you rank them? 25:27.660 --> 25:28.740 Student: I haven't got a clue. 25:28.740 --> 25:31.280 **. 25:31.278 --> 25:33.588 Prof: You've got lots of people to help you out. 25:33.589 --> 25:34.829 You're not on your own. 25:34.829 --> 25:35.809 Okay? 25:35.808 --> 25:36.598 Student: **. 25:36.599 --> 25:40.259 Prof: No. 25:40.259 --> 25:42.549 Student: I would start with flu and then I'd get to 25:42.545 --> 25:42.935 cholera. 25:42.940 --> 25:44.430 Prof: Okay. 25:44.430 --> 25:47.560 So, one end of the spectrum, we put influenza; 25:47.558 --> 25:53.648 and that would clearly be the least responsive to poverty as a 25:53.651 --> 25:54.551 driver. 25:54.548 --> 25:59.108 The other end of the spectrum you'd put Asiatic cholera, 25:59.108 --> 26:06.068 which is clearly very sensitive to social and economic factors, 26:06.068 --> 26:08.908 to living conditions, to dirt and filth, 26:08.910 --> 26:11.360 to lack of light, to overcrowding. 26:11.358 --> 26:15.698 I hope you would then--you see, in your essay poverty too 26:15.701 --> 26:19.271 needs--it is not self-evident what it means. 26:19.269 --> 26:21.259 Why is poverty a factor? 26:21.259 --> 26:27.379 And I hope you would talk about filth, access to medical care, 26:27.382 --> 26:30.992 education, overcrowding, bad housing, 26:30.994 --> 26:32.104 sewage. 26:32.098 --> 26:36.598 Those are the things that cholera thrives on. 26:36.598 --> 26:41.158 So, you would be right that way, putting influenza and 26:41.162 --> 26:44.952 cholera at opposite poles of the spectrum. 26:44.950 --> 26:49.120 But once again, we have to remember that this 26:49.124 --> 26:53.204 is not absolute, because wealthy people also 26:53.202 --> 26:59.182 succumbed to Asiatic cholera, just in much smaller numbers. 26:59.180 --> 27:00.480 Okay. 27:00.480 --> 27:02.350 Right, thanks. 27:02.348 --> 27:05.258 Student: I think I would put malaria, 27:05.260 --> 27:09.030 and to a lesser extent than plague, on the cholera side of 27:09.031 --> 27:09.761 things. 27:09.759 --> 27:15.189 Malaria, because they--it was a big working condition disease, 27:15.190 --> 27:18.310 and a lot of people who were in the lower classes worked in the 27:18.311 --> 27:21.181 rice fields where-- and worked and lived in areas 27:21.176 --> 27:24.416 that they couldn't have the simple protection against 27:24.416 --> 27:25.286 mosquitoes. 27:25.288 --> 27:28.948 And I said plague to a lesser extent on the cholera side 27:28.948 --> 27:31.138 because, as we saw in Journal of the 27:31.142 --> 27:33.922 Plague Year, a lot of the richer people were 27:33.920 --> 27:37.600 able to leave London and use financial means to get away from 27:37.599 --> 27:38.519 the disease. 27:38.519 --> 27:41.579 And even though it spread, the poorer people couldn't do 27:41.580 --> 27:43.140 that and they had to stay. 27:43.140 --> 27:43.770 Prof: Okay. 27:43.769 --> 27:49.739 So, we have a couple of other examples of diseases that might 27:49.739 --> 27:54.219 be along the level of poverty--being driven by 27:54.215 --> 27:55.405 poverty. 27:55.410 --> 28:00.320 And malaria was an example because of the particularly 28:00.315 --> 28:03.365 laboring and living conditions. 28:03.368 --> 28:06.658 It's partly an occupational disease, and so it strikes 28:06.664 --> 28:10.154 peasants and people who work in conditions that make them 28:10.146 --> 28:13.886 vulnerable; and it's a house disease that 28:13.894 --> 28:19.524 depends on overcrowding and living in housing that's porous 28:19.521 --> 28:21.561 to flying insects. 28:21.558 --> 28:26.168 Poverty clearly is important to the spread of malaria. 28:26.170 --> 28:30.950 We've seen, to some extent, that plague has some-- 28:30.950 --> 28:34.760 it could be argued either way, but you're absolutely right to 28:34.756 --> 28:38.876 introduce plague as something-- a case to be argued as to 28:38.875 --> 28:40.815 whether it is or isn't. 28:40.818 --> 28:45.218 I'm wondering what about some other diseases transmitted 28:45.220 --> 28:46.340 differently? 28:46.338 --> 28:50.688 One factor might be--then you might say it might depend partly 28:50.685 --> 28:53.675 on means of transmission of the disease; 28:53.680 --> 28:58.340 perhaps airborne disease is less driven by poverty. 28:58.338 --> 29:01.508 Ones that travel by the oral-fecal route, 29:01.508 --> 29:04.358 or by vectors, might be important. 29:04.358 --> 29:07.268 What about sexually transmitted disease; 29:07.269 --> 29:10.279 and is syphilis a disease of poverty? 29:10.279 --> 29:15.799 You wanted to-- Student: I would put 29:15.798 --> 29:21.988 AIDS and syphilis towards the flu end of things. 29:21.990 --> 29:28.610 Although by modern maps of where these diseases are highly 29:28.611 --> 29:32.911 prevalent, it would seem otherwise. 29:32.910 --> 29:38.880 But I think that there is actually a sort of not 29:38.883 --> 29:42.953 poverty-based reason for that. 29:42.950 --> 29:43.630 Prof: Okay. 29:43.630 --> 29:48.710 So, we have a candidate then for--two other candidates to go 29:48.708 --> 29:53.698 at the influenza end of the spectrum: syphilis and AIDS. 29:53.700 --> 29:58.250 I'm wondering if everyone would agree with that. 29:58.250 --> 29:59.830 Yes, please? 29:59.829 --> 30:00.969 Oh sorry. 30:00.970 --> 30:02.460 Go ahead first. 30:02.460 --> 30:05.300 Student: Yes, I would put AIDS more towards 30:05.303 --> 30:08.153 the middle of the spectrum, because AIDS did have a 30:08.146 --> 30:10.476 predilection for marginalized groups. 30:10.480 --> 30:13.560 But at the same time it could affect anyone, 30:13.560 --> 30:17.360 including a heterosexual man from a wealthy family. 30:17.358 --> 30:19.718 So, I think it sort of goes in the middle. 30:19.720 --> 30:22.910 If I could add one to the list, maybe I would put SARS as 30:22.905 --> 30:25.235 closer to the flu end of the spectrum, 30:25.240 --> 30:28.210 because it did seem to--and this adds to the idea that 30:28.210 --> 30:30.900 airborne diseases are less driven by poverty-- 30:30.900 --> 30:34.560 because it did seem to affect everyone. 30:34.558 --> 30:37.998 But at the same time, it did hit areas that had a 30:38.000 --> 30:42.090 strong health infrastructure, and that helped to quell the 30:42.085 --> 30:43.585 disease somewhat. 30:43.589 --> 30:44.359 Prof: Okay. 30:44.358 --> 30:48.618 I'm wondering--I like your answer and I'm just wondering if 30:48.615 --> 30:52.795 with HIV/AIDS we would want even to make distinctions, 30:52.798 --> 30:57.538 in that HIV/AIDS seems to have different phases and different 30:57.538 --> 31:00.648 epidemiologies, according to different 31:00.653 --> 31:04.023 circumstances; and that in the industrial West 31:04.019 --> 31:07.519 it seems to be a disease, more of marginal groups, 31:07.515 --> 31:09.365 at least at the moment. 31:09.369 --> 31:10.999 It used not to be. 31:11.000 --> 31:14.620 When it was first introduced into the United States, 31:14.617 --> 31:17.097 for example, it wasn't an example of 31:17.101 --> 31:21.221 socioeconomic marginality; but rather people who, 31:21.221 --> 31:26.561 because of sexual orientation, or through blood supplies and 31:26.563 --> 31:27.653 so forth. 31:27.650 --> 31:31.290 But it would seem that if you were dealing at a global level 31:31.288 --> 31:33.468 now, with AIDS in Africa for 31:33.471 --> 31:38.191 example, poverty does seem to be a very important factor in the 31:38.192 --> 31:39.032 disease. 31:39.029 --> 31:41.059 Would you not agree with that? 31:41.059 --> 31:41.829 Student: Yes definitely. 31:41.828 --> 31:44.888 I think in countries where there is more wealth, 31:44.893 --> 31:47.373 it's seen more as a chronic disease. 31:47.369 --> 31:49.439 So, definitely. 31:49.440 --> 31:49.810 Prof: Okay. 31:49.807 --> 31:50.277 Great, well thank you. 31:50.279 --> 31:54.469 So, we could even talk--divide--break some of the 31:54.471 --> 31:59.801 diseases down into different periods in their transmission. 31:59.799 --> 32:01.249 And you wanted to add something? 32:01.250 --> 32:01.980 Student: That was the comment. 32:01.980 --> 32:03.680 Prof: Oh, that was what you wanted to 32:03.682 --> 32:03.922 add. 32:03.920 --> 32:04.690 Okay. 32:04.690 --> 32:06.440 Well, there's another. 32:06.440 --> 32:11.060 Thank you. 32:11.058 --> 32:13.218 Student: I was just going to say that tuberculosis 32:13.222 --> 32:17.042 should be added to the list-- probably more on the end of 32:17.044 --> 32:20.314 influenza-- simply because they kind of 32:20.314 --> 32:24.274 regarded it as disease of the rich for some time-- 32:24.269 --> 32:26.569 and a disease of genius, I think it was-- 32:26.568 --> 32:30.778 because of the people that it affected. 32:30.779 --> 32:32.009 Prof: Okay. 32:32.009 --> 32:36.269 So, there's the thought that maybe tuberculosis ought to be 32:36.265 --> 32:39.635 added to the influenza end of the spectrum, 32:39.640 --> 32:42.000 in that it seemed to be, looking back on the 32:42.001 --> 32:44.641 nineteenth-century experience of the disease, 32:44.640 --> 32:48.170 it was even described as a disease of beauty, 32:48.170 --> 32:49.200 of genius. 32:49.200 --> 32:53.670 And clearly we can make a long list of high society 32:53.665 --> 32:58.125 people--celebrities, artists, kings and queens--who 32:58.133 --> 33:01.263 were afflicted by tuberculosis. 33:01.259 --> 33:04.259 And I think that if you were dealing with the nineteenth 33:04.262 --> 33:06.992 century, that would be a splendid argument to make, 33:06.992 --> 33:08.852 and I agree with you entirely. 33:08.848 --> 33:11.648 I'm just wondering though if we come forward, 33:11.650 --> 33:16.390 fast forward in time to today, then I think we have to say 33:16.390 --> 33:21.380 that the epidemiology of tuberculosis today is different, 33:21.380 --> 33:25.650 and that it thrives on preexisting conditions, 33:25.650 --> 33:28.310 on overcrowding. 33:28.308 --> 33:32.778 So, I think the time period can also be important. 33:32.779 --> 33:37.829 Tuberculosis has retreated to areas of poverty, 33:37.826 --> 33:40.126 I would argue, now. 33:40.130 --> 33:42.690 Would you agree with that? 33:42.690 --> 33:43.150 Student: Yes. 33:43.150 --> 33:45.440 I was going to say that what you were just talking about; 33:45.440 --> 33:49.890 how, like, different time eras actually can delineate whether 33:49.887 --> 33:53.147 or not it is a disease of poverty or not, 33:53.150 --> 33:55.090 just by the people that it affects, 33:55.088 --> 34:00.168 the effect it has on the society at the present moment. 34:00.170 --> 34:01.260 Prof: Okay, thanks very much. 34:01.259 --> 34:01.949 Yes. 34:01.950 --> 34:07.910 I think we're seeing that describing diseases as diseases 34:07.914 --> 34:14.524 of poverty is really a complex and also debatable position, 34:14.518 --> 34:17.318 and it depends on what diseases, where, 34:17.320 --> 34:19.740 when and so forth. 34:19.739 --> 34:23.969 It's actually--one needs to break down what poverty is, 34:23.974 --> 34:27.664 and one needs to have a spectrum of diseases. 34:27.659 --> 34:31.009 But I think we're dealing with it much more effectively. 34:31.010 --> 34:34.710 And I think one of the things we see is that the more 34:34.706 --> 34:38.406 complexity, the more nuance, the better our answer is 34:38.405 --> 34:41.055 becoming; also the more interesting. 34:41.059 --> 34:46.159 I think it's rather a bland and not very convincing answer to 34:46.161 --> 34:50.501 say simply all diseases are diseases of poverty, 34:50.500 --> 34:54.610 and I think we now see that actually the situation is much 34:54.614 --> 34:58.554 more complex than that; that poverty's an important 34:58.548 --> 35:03.518 factor but it doesn't simply--we can't reduce our course to that 35:03.518 --> 35:04.778 one variable. 35:04.780 --> 35:06.530 Okay. 35:06.530 --> 35:11.500 In the meanwhile have you thought of other questions that 35:11.501 --> 35:15.411 we ought to be dealing with in our course? 35:15.409 --> 35:19.699 Or shall I put it another way; are there major themes in our 35:19.697 --> 35:20.377 course? 35:20.380 --> 35:24.250 What--could we make maybe a shortlist of themes that you 35:24.250 --> 35:27.840 should be thinking about as you do your revision? 35:27.840 --> 35:32.170 What are the major themes that we've been dealing with this 35:32.168 --> 35:32.988 semester? 35:32.989 --> 35:36.139 Disease and poverty is an example. 35:36.139 --> 35:45.119 Are there other themes? 35:45.119 --> 35:47.709 Go for it. 35:47.710 --> 35:49.800 Student: I guess another theme has been the magic 35:49.800 --> 35:51.220 bullet theory of combating disease, 35:51.219 --> 35:55.139 and the idea that any epidemic disease can be solved basically 35:55.141 --> 35:58.681 by coming up with some sort of scientific cure that-- 35:58.679 --> 36:03.549 so just, I guess, quinine in the case of malaria. 36:03.550 --> 36:07.510 I guess in the case of--or quinine and then DDT in the case 36:07.510 --> 36:08.400 of malaria. 36:08.400 --> 36:11.760 And I guess that theme has been one that has sort of been 36:11.764 --> 36:15.494 underlying what has been sort of this triumphal age of American 36:15.487 --> 36:17.487 medicine, and one that I think, 36:17.487 --> 36:19.967 at least in emerging and remerging disease, 36:19.969 --> 36:22.819 is something that we're increasingly viewing as not 36:22.822 --> 36:25.912 exactly the most effective way of dealing with epidemic 36:25.905 --> 36:26.585 disease. 36:26.590 --> 36:27.960 Prof: Okay, thanks very much. 36:27.960 --> 36:32.870 Yes, one of the--another theme of our course has been the 36:32.873 --> 36:38.233 tendency to think of finding a magic bullet to each infectious 36:38.226 --> 36:39.276 disease. 36:39.280 --> 36:42.730 And you were just starting to do what I think would then be 36:42.728 --> 36:46.118 really important if that were a question on the final, 36:46.119 --> 36:50.219 which is to look at what is the history of magic bullets, 36:50.219 --> 36:53.959 and have they actually delivered on the promise 36:53.960 --> 36:55.830 associated with them? 36:55.829 --> 36:59.299 And examples that you gave--let's see, 36:59.300 --> 37:06.170 quinine with regard to malaria, or later on DDT with regard to 37:06.170 --> 37:10.010 malaria, and has that--would that 37:10.012 --> 37:16.412 be--would malaria be a good example of a disease that's been 37:16.409 --> 37:20.529 highly responsive to magic bullets? 37:20.530 --> 37:22.220 You're shaking your head. 37:22.219 --> 37:24.959 Do you want to add to your headshake? 37:24.960 --> 37:26.000 Student: No. 37:26.000 --> 37:30.470 Because there were side effects to these mass treatments, 37:30.474 --> 37:33.674 and it wasn't a one-size-fits-all sort of 37:33.672 --> 37:35.592 response to malaria. 37:35.590 --> 37:39.180 And there were other social factors that weren't considered. 37:39.179 --> 37:42.739 And people were thinking at that time that if we applied DDT 37:42.742 --> 37:45.762 for a certain amount of time, then malaria would be 37:45.760 --> 37:47.150 eradicated forever. 37:47.150 --> 37:49.970 But that certainly wasn't the case, and conditions could 37:49.967 --> 37:51.757 change and the disease came back. 37:51.760 --> 37:57.170 I think it was the case near Italy where they built the dam, 37:57.170 --> 37:59.120 and then during the war the dam was broken, 37:59.119 --> 38:01.529 and then later the disease came back, 38:01.530 --> 38:02.410 during the war. 38:02.409 --> 38:06.139 So, these measures aren't permanent, as they thought they 38:06.137 --> 38:07.267 initially were. 38:07.268 --> 38:12.708 In that sense this magic bullet can't be the permanent final 38:12.710 --> 38:13.540 answer. 38:13.539 --> 38:14.089 Prof: Okay. 38:14.090 --> 38:19.590 So, we have a problem with malaria. 38:19.590 --> 38:23.580 There was this great euphoria of thinking that a magic bullet 38:23.581 --> 38:27.191 could be found, and quinine and DDT were 38:27.193 --> 38:32.923 examples, but they ended up not actually delivering on the 38:32.923 --> 38:34.033 promise. 38:34.030 --> 38:37.420 Chloroquine would be yet another example of a magic 38:37.418 --> 38:39.788 bullet, for dealing with malaria. 38:39.789 --> 38:41.599 So, I would agree entirely. 38:41.599 --> 38:46.549 Malaria would be a wonderful example of enormous expectations 38:46.550 --> 38:51.070 of a magic bullet as a solution, and yet we see that, 38:51.065 --> 38:55.855 in fact, the biology of the disease is much more complicated 38:55.860 --> 38:58.950 than being dealt with in that way, 38:58.949 --> 39:04.039 and we've seen resistance being developed by mosquitoes and by 39:04.038 --> 39:05.038 plasmodia. 39:05.039 --> 39:08.159 And, so, the promise of the magic bullets, 39:08.157 --> 39:11.197 with malaria, turned out to be a tool. 39:11.199 --> 39:15.739 And they're useful but they haven't rid the world at all of 39:15.742 --> 39:16.842 the disease. 39:16.840 --> 39:21.160 And there was--you wanted also to say something. 39:21.159 --> 39:21.649 Student: Yes. 39:21.650 --> 39:24.930 And I think to go along with that, there's another reason why 39:24.934 --> 39:26.964 magic bullets can't entirely work-- 39:26.960 --> 39:28.500 and that's another theme of the class-- 39:28.500 --> 39:31.770 which is the idea of disease as a social construction. 39:31.768 --> 39:36.408 And the fact is that even if a magic bullet can have a great 39:36.411 --> 39:40.111 effect on the biology, or the symptomatology, 39:40.110 --> 39:43.220 of a disease-- I think Barnes is the author 39:43.219 --> 39:47.419 who really went into the idea that in order to really attack a 39:47.422 --> 39:50.962 disease, it goes into the substratum of 39:50.963 --> 39:56.303 society and to our ideas about disease and what we place, 39:56.300 --> 39:58.460 the stigma that we place on them. 39:58.460 --> 39:59.470 Prof: Okay. 39:59.469 --> 40:03.469 So we can't just think in terms of magic bullets. 40:03.469 --> 40:06.949 We also have to think about the ideas in people's heads. 40:06.949 --> 40:08.779 How do they understand the disease? 40:08.780 --> 40:11.100 What's the social construction? 40:11.099 --> 40:16.779 And you gave the example of tuberculosis as a good example. 40:16.780 --> 40:19.800 Okay, I would entirely agree with that too. 40:19.800 --> 40:24.720 I'm wondering if there are other examples of magic bullets 40:24.717 --> 40:29.807 that have either delivered on the promise, or have failed to 40:29.809 --> 40:32.139 deliver on the promise. 40:32.139 --> 40:36.189 We've talked about malaria: quinine, DDT, 40:36.190 --> 40:37.610 chloroquine. 40:37.610 --> 40:41.230 What about other--have magic bullets played a role in our 40:41.233 --> 40:43.113 course with other diseases? 40:43.110 --> 40:51.180 Yes, go for it. 40:51.179 --> 40:54.229 Student: The original magic bullet was with syphilis 40:54.231 --> 40:55.991 though--right?--with penicillin. 40:55.989 --> 40:58.379 And I think that was a pretty good example. 40:58.380 --> 41:00.870 I mean, and Brandt's point, in No Magic Bullet, 41:00.873 --> 41:02.903 is that it didn't really--I mean, it helped, 41:02.898 --> 41:04.968 but it didn't really slow the incidence. 41:04.969 --> 41:07.109 Like it would sort of go in crests and waves, 41:07.110 --> 41:09.820 where there were people who were soldiers in the army and 41:09.824 --> 41:12.604 they would get prostitutes, and then it kind of didn't 41:12.597 --> 41:15.687 really matter whether there was a cure for syphilis or not, 41:15.690 --> 41:18.690 because like they just wouldn't have had access to it; 41:18.690 --> 41:20.670 like even if they contracted the disease. 41:20.670 --> 41:23.980 So, education and other programs like that are just as 41:23.976 --> 41:26.846 important as drugs, when it comes to preventing 41:26.847 --> 41:28.467 something like an STD. 41:28.469 --> 41:29.599 Prof: Okay. 41:29.599 --> 41:34.899 The history of syphilis would be another good case study for 41:34.896 --> 41:39.916 whether magic bullets are the way to eradicate or control 41:39.923 --> 41:41.633 major diseases. 41:41.630 --> 41:45.890 And you used the example of penicillin, which is a good one. 41:45.889 --> 41:48.579 But I think we've had, with syphilis, 41:48.581 --> 41:52.091 even further back, other things that at the time 41:52.094 --> 41:54.864 were thought of as magic bullets; 41:54.860 --> 41:58.260 mercury before that, and salversan, 41:58.264 --> 42:03.974 would be other earlier ideas considered magic bullets that 42:03.974 --> 42:07.784 also didn't eliminate the disease. 42:07.780 --> 42:12.070 The diseases tend to be much more complicated than to be 42:12.074 --> 42:15.594 simply amenable to a magic bullet solution. 42:15.590 --> 42:19.920 So, syphilis is another example, along with malaria. 42:19.920 --> 42:20.610 Right? 42:20.610 --> 42:23.100 Are there other examples? 42:23.099 --> 42:23.599 Yes? 42:23.599 --> 42:26.089 Student: One instance where this magic bullet idea did 42:26.092 --> 42:27.892 seem to work was in the case of smallpox, 42:27.889 --> 42:34.279 where a vaccine was developed and given to all the population, 42:34.280 --> 42:37.920 such that the disease no longer had a host of humans, 42:37.920 --> 42:41.430 a reserve full of hosts to infect, and the disease 42:41.431 --> 42:43.441 eventually was eradicated. 42:43.440 --> 42:47.830 And I think that's one example where this magic bullet was 42:47.826 --> 42:48.746 effective. 42:48.750 --> 42:52.960 But it was a very special case, in the case of smallpox, 42:52.960 --> 42:56.790 because the smallpox vaccine was very effective. 42:56.789 --> 43:01.259 And I think we talked about how it's very much disease-specific. 43:01.260 --> 43:04.960 And smallpox seems to be an exception rather than the rule, 43:04.956 --> 43:07.566 in terms of how magic bullets can work. 43:07.570 --> 43:09.050 Prof: Okay, thanks. 43:09.050 --> 43:13.760 So, we need to be careful, even in our skepticism about 43:13.760 --> 43:17.420 magic bullets, that there may be cases when 43:17.423 --> 43:21.723 they can actually work; and a good example being 43:21.719 --> 43:25.919 smallpox in which the vaccine has actually eradicated 43:25.920 --> 43:29.720 naturally-occurring smallpox from the world. 43:29.719 --> 43:30.889 There are examples. 43:30.889 --> 43:34.799 But then one has--you were also saying what lessons should be 43:34.804 --> 43:36.244 drawn from smallpox? 43:36.239 --> 43:40.139 And you were saying perhaps one of the lessons though is that 43:40.143 --> 43:41.643 smallpox is atypical. 43:41.639 --> 43:46.339 It had certain specific features about it that made it 43:46.342 --> 43:50.872 particularly vulnerable to attack by vaccination. 43:50.869 --> 43:55.719 But we can't throw out then the hope for finding tools that will 43:55.722 --> 44:00.492 actually eradicate diseases, and smallpox is an example of 44:00.487 --> 44:03.107 something that really did work. 44:03.110 --> 44:04.360 Yes, okay. 44:04.360 --> 44:12.250 Any other examples that ought to be thrown into our mix? 44:12.250 --> 44:13.520 How about TB? 44:13.518 --> 44:17.168 And streptomycin would be another example, 44:17.170 --> 44:21.150 I would think, of something that seemed, 44:21.150 --> 44:25.290 after World War II, that it would be possible to 44:25.286 --> 44:30.226 close all of the sanitaria; and that largely happened, 44:30.228 --> 44:35.558 and the outlook seemed to be that TB would be eliminated by 44:35.559 --> 44:37.489 this magic bullet. 44:37.489 --> 44:41.409 But we see again the problem of drug resistance, 44:41.409 --> 44:46.079 and we're living now in a world in which there's multiple 44:46.079 --> 44:48.749 drug-resistant tuberculosis. 44:48.750 --> 44:54.030 And, so, once again we have an example of a disease that's been 44:54.034 --> 44:58.764 much more recalcitrant, because we see the--I guess 44:58.764 --> 45:04.104 that Darwin was right-- the influence of evolution and 45:04.097 --> 45:08.537 its impact on the microbes surrounding us. 45:08.539 --> 45:09.609 Okay. 45:09.610 --> 45:13.560 Is there another major theme of our course? 45:13.559 --> 45:18.899 We've seen magic bullets, we've seen poverty, 45:18.900 --> 45:25.090 we've seen modes of transmission as major impacts on 45:25.092 --> 45:26.552 disease. 45:26.550 --> 45:29.920 We've talked about mortality, morbidity, 45:29.920 --> 45:33.100 and whether--how you--what are the-- 45:33.099 --> 45:36.929 symptomatology--what are the factors that contribute to the 45:36.929 --> 45:39.109 impact of a disease on society? 45:39.110 --> 45:41.370 We have just a few more minutes. 45:41.369 --> 45:50.289 So, I'm wondering if we have at least one more candidate for a 45:50.286 --> 45:54.376 major theme of our course. 45:54.380 --> 45:55.940 Yes? 45:55.940 --> 45:59.170 Student: The evolution of public health strategies in 45:59.170 --> 46:00.840 response to epidemic disease. 46:00.840 --> 46:01.630 Prof: Okay. 46:01.630 --> 46:02.320 That's not fair. 46:02.320 --> 46:03.640 You read my mind. 46:03.639 --> 46:05.959 I was thinking of exactly that. 46:05.960 --> 46:10.610 And I did want to say that it would be unfortunate if you went 46:10.610 --> 46:15.030 to the final exam in our course without also thinking about 46:15.034 --> 46:19.234 public health as a major theme that we've covered in our 46:19.228 --> 46:20.218 course. 46:20.219 --> 46:23.679 And let me just--could we make a list now? 46:23.679 --> 46:29.049 We don't have time for discussion, but what are some of 46:29.048 --> 46:35.008 the major forms of public health strategy that we have talked 46:35.014 --> 46:36.014 about? 46:36.010 --> 46:37.440 Okay. 46:37.440 --> 46:39.060 Student: Quarantine. 46:39.059 --> 46:39.889 Prof: Okay. 46:39.889 --> 46:40.989 Quarantine. 46:40.989 --> 46:45.859 And maybe we might enlarge that by saying--could we talk about 46:45.858 --> 46:50.488 plague strategies of defense against infectious disease? 46:50.489 --> 46:53.549 Meaning quarantines, sanitary cordons, 46:53.550 --> 46:58.180 possibly lazarettos and pest houses, all the rest that go 46:58.181 --> 46:59.341 with that. 46:59.340 --> 47:03.420 Yes, that's a recurrent--and that's not only against plague, 47:03.418 --> 47:07.218 but plague strategies were rolled out again and again in 47:07.222 --> 47:08.262 our course. 47:08.260 --> 47:11.340 We've seen them applied, not very helpfully, 47:11.340 --> 47:12.630 against cholera. 47:12.630 --> 47:17.150 We've seen them also--plague strategies--being applied 47:17.148 --> 47:20.388 against HIV/AIDS, in the early days. 47:20.389 --> 47:24.699 Okay, so that's one style of public health. 47:24.699 --> 47:32.419 What other measures of public health have we seen? 47:32.420 --> 47:33.280 Yes? 47:33.280 --> 47:35.800 Student: We've seen vaccinations, 47:35.804 --> 47:38.144 concealment, educational campaigns. 47:38.139 --> 47:40.639 Prof: Okay, you've got a list here, 47:40.641 --> 47:42.291 that's three more styles. 47:42.289 --> 47:47.479 We've seen vaccination as--you remember going back to Edward 47:47.478 --> 47:51.438 Jenner and--that was a long time ago, I admit, 47:51.436 --> 47:54.686 but that's important to remember. 47:54.690 --> 47:58.420 There were--we've also seen concealment, and we saw 47:58.416 --> 48:00.946 concealment in the case of SARS. 48:00.949 --> 48:06.249 It occurred in the case of cholera, in our course. 48:06.250 --> 48:12.180 We've talked about education and its impact on public health. 48:12.179 --> 48:15.349 Are there other styles of public health that we've come 48:15.351 --> 48:15.881 across? 48:15.880 --> 48:16.440 Yes? 48:16.440 --> 48:18.290 Student: Miasmatism, for a time. 48:18.289 --> 48:19.259 Prof: Okay. 48:19.260 --> 48:23.600 We've seen public health based on miasmatism, 48:23.601 --> 48:27.451 and with the filth theory of disease. 48:27.449 --> 48:34.509 And therefore sanitation, introducing urban cleanups, 48:34.507 --> 48:39.427 sewer systems; even the rebuilding of cites, 48:39.425 --> 48:42.925 as we saw under Haussmann in France. 48:42.929 --> 48:46.789 And we saw that in the rebuilding of Naples also. 48:46.789 --> 48:52.479 So, those are additional styles of public health. 48:52.480 --> 48:56.630 Anything else anyone wants to throw in? 48:56.630 --> 49:01.750 Or is there maybe another final sort of question or theme of the 49:01.748 --> 49:02.478 course? 49:02.480 --> 49:05.240 We've just briefly suggested public health, 49:05.244 --> 49:06.764 and a few dimensions. 49:06.760 --> 49:10.440 There are others, and I hope that you'll dig them 49:10.436 --> 49:11.276 out also. 49:11.280 --> 49:21.980 Is there any final question anyone wants to bring up? 49:21.980 --> 49:22.550 Yes? 49:22.550 --> 49:25.490 Student: I think maybe we missed the intrusion of the 49:25.492 --> 49:27.212 modern state played a role in it; 49:27.210 --> 49:30.730 dispensaries and registries of victims of disease. 49:30.730 --> 49:32.120 Prof: Okay, okay. 49:32.119 --> 49:36.779 We could discuss also the way in which the modern state has 49:36.782 --> 49:40.242 played a role in the control of disease, 49:40.239 --> 49:43.779 and that we can see that in tuberculosis, 49:43.780 --> 49:46.840 through dispensaries, sanatoria. 49:46.840 --> 49:52.080 We can see that also playing a role through malaria, 49:52.081 --> 49:57.221 and the same sort of idea of dispensaries again. 49:57.219 --> 49:59.179 And there are other diseases as well. 49:59.179 --> 50:03.349 The state playing a role in education, the state playing a 50:03.349 --> 50:05.909 role in the plague measures also. 50:05.909 --> 50:10.469 So, I think we can see the role of the state as a major player, 50:10.465 --> 50:13.835 a central player, in public health could indeed 50:13.844 --> 50:16.714 be an important theme of our class. 50:16.710 --> 50:20.650 But having said that, another theme is stopping when 50:20.652 --> 50:22.512 we've run out of time. 50:22.510 --> 50:25.070 And, so, I'll do that, and wish you good luck on the 50:25.068 --> 50:25.468 final. 50:25.469 --> 50:28.909 And thank you this morning for helping us put our heads 50:28.909 --> 50:29.609 together. 50:29.610 --> 50:31.860 And I liked your comments. 50:31.860 --> 50:33.360 Thanks very much. 50:33.360 --> 50:35.510 ** 50:35.510 --> 50:41.000