Prof: The first thing I
want to say is that there's a
thesis to the course,
that you don't have to share,
but that I'd like to test for
the next twelve or thirteen
weeks.
 
And that thesis is that
infectious diseases are too
important to leave solely to the
doctors.
Epidemics, in other words,
have had an impact on history
that I would regard as equal to
that of revolutions,
wars and economic crises.
 
They are part of the big
picture of historical change,
and not some exotic special
interest.
Epidemic diseases have had an
enormous impact on religion,
on the arts,
on the colonial expansion,
on the establishment of New
World slavery,
on the rise of modern medicine,
and on strategies of public
health.
 
To examine this thesis,
we won't be looking at all
diseases.
 
We'll be looking only at a
subset of high impact infectious
diseases that have affected
Europe and North America.
So this means certain
exclusions.
We won't be looking at chronic
diseases, such as cancer,
heart disease,
diabetes, asthma,
obesity.
 
We won't be examining
occupational diseases such as
miner's lung or asbestosis.
 
We'll eliminate also a whole
range of tropical diseases that
haven't had a major impact on
the industrial West,
such as dengue,
or sleeping sickness,
or Chagas disease.
 
All of these,
and other diseases,
I would agree entirely are
important and worthy of study,
but it would take far more than
a semester to examine them all,
and lumping all diseases
together would lose all
coherence.
 
Epidemic diseases-- that is,
high impact,
infectious diseases--make sense
intellectually as a separate
category of analysis.
 
That is to say they were,
and still are,
experienced differently from
chronic disease,
and give rise to distinctive
fears and anxiety.
As you can see in your own day,
having heart disease can be a
frightening and even a lethal
experience.
But it's qualitatively distinct
from being diagnosed with
HIV/AIDS,
or, up to the middle of our
century,
with syphilis,
or being stricken with Asiatic
cholera.
Cardiovascular disease can have
massive impact,
but it doesn't give rise to
scapegoating,
to mass hysteria,
to outbursts of religiosity,
to works of literature and art.
 
So, epidemic diseases are
distinctive and have left a
particular legacy in their wake.
 
And since our interest is in
history,
we need to note that throughout
human history,
until the twentieth century,
and still today in the
twenty-first century in the
developing world,
infectious diseases have been
the most important cause of
suffering and death.
 
Infectious diseases today are
the leading cause worldwide of
death, and one of the jobs of
our course is to give an
explanation of why that's so.
 
Furthermore,
we've had a number of recent
scares from new diseases like
SARS, avian flu,
swine flu.
 
We're living in the midst of a
global experience with the
persistence of HIV/AIDS,
tuberculosis,
malaria--and these events
remind us that epidemics are
still major threats,
even in the industrial world.
Indeed, how we deal with them
may be an important factor in
whether and how we survive as a
species.
So, the course will raise the
question of how prepared we are
today.
 
What are our major defenses
against microbial disasters?
How do they evolve?
 
How robust are they?
 
And what are the most important
sources of vulnerability today?
Well, then, let's think about
the geography of our course.
Our focus will be primarily on
Europe and North America;
and I wish to say entirely for
reasons of manageability.
And you'll be grateful because
if we attempted to include the
whole of the world throughout
the period,
and all tropical diseases,
you'd have a reading list that
would be four or five times as
long as the one you have.
But I would also say that when
we come to the twentieth and
twenty-first century,
and deal with such global
pandemics as HIV/AIDS,
malaria and tuberculosis,
we will look quickly a little
further afield.
It would be perverse to discuss
HIV/AIDS without paying
attention to Africa,
which is its place of origin,
its epicenter,
and the place where the disease
is causing almost unimaginable
burdens of suffering and loss.
We're inescapably part of a
global world in which microbes
refuse to recognize political
borders, and we have to take
that into account.
 
So, that's the geography,
focusing on Europe and North
America, but branching out for
the very modern part of the
course.
 
Chronology: when,
what period do we cover?
Well, really we look at the
centuries from 1600 to the
present.
 
We'll start with everyone's
idea of a worst case scenario in
terms of epidemic disease;
and by that I mean bubonic
plague.
 
And we'll end with the current
situation and the latest threats
to have emerged,
like SARS, avian flu and swine
flu.
 
As a student,
I always felt disappointed when
history classes on the modern
period didn't come right up to
date.
 
So I feel a motivation to bring
us up to the newest papers
today.
 
In fact, one of the goals of
the class is to help equip
ourselves with the critical
tools we need to confront
today's events,
in a more informed and
productive manner.
 
Since I've mentioned influenza,
we'll certainly ask in
passing--
and I hope some of you will
answer the question--
why it is that the most
threatening pandemic afflictions
of the twenty-first century seem
to be respiratory diseases?
 
Why is that?
 
How did that come about?
 
Then I want to talk with you
for a couple of minutes about
the diseases that we'll be
examining.
I've told you so far the ones
we mostly won't be looking at.
Well, first,
what are the criteria by which
I've chosen them?
 
First, I'm going to be looking
at epidemic diseases that had
the greatest social,
scientific and cultural
effects.
 
We'll call them high-impact
infectious diseases.
That's a first criterion,
their impact.
Second, I'll be looking at
diseases that have had the most
important role in the
development of public health
strategies to contain them.
 
A major concern throughout the
course is the variety of efforts
that societies have made to
prevent, contain,
cure and eradicate infectious
diseases.
Our course is not only about
disease, but also about public
health, and so we'll give that a
privileged place;
to that and to those diseases
that stimulated various styles
of organized and effective
societal responses.
A next criterion is that we're
going to look at those diseases
that were the most feared
killers of each of the centuries
that we study.
 
We'll also want a varied diet,
in other words diversity,
and to that end some of our
diseases will be bacterial,
some viral, some parasitic.
 
Some will be transmitted
sexually, some through the air,
others through food and water,
and some are carried by
insects.
 
And by these criteria,
we'll focus in particular on
bubonic plague,
on Asiatic cholera,
smallpox, syphilis,
tuberculosis,
polio, HIV/AIDS and yellow
fever,
with influenza bringing us
right up to date.
So, those are the diseases
we'll be concentrating on.
Well how do we deal with them?
 
What's our strategy?
 
What's our way forward?
 
And I want to stress that this
is not a biology course but a
history course.
 
Epidemic diseases are
biological events,
and we'll need to have some
understanding of what they are,
where they come from,
how they were transmitted,
how they affect the human body.
 
It would be inconceivable to
study the history of medicine
without coming to terms with the
medical and biological aspects
of disease.
 
Indeed, one of our goals will
be to examine major changes in
medical thinking and philosophy.
 
But the biology will be
throughout in the background,
and the exams and the papers
will not test you specifically
on that aspect of the course.
 
Our concern will be with the
impact of disease on society,
religion and culture.
 
But we want to do a lot more
than examine a series of ghastly
biological invaders;
although we will do that.
And so the course will stress a
number of long-term themes.
The first of those I've already
told you about,
and that's public health
strategies.
We'll look at vaccination as a
strategy;
quarantine and sanitary cordons;
urban cleanups and sanitary
movements;
sanatoria, as for tuberculosis;
magic bullets like quinine,
penicillin, antibiotics.
And we'll also look at an
unfortunate public health
policy,
by which I mean concealment,
to hide the presence of
disease,
as China did during SARS,
but following a long precedent
in which other governments have
a history of adopting similar
policies;
and we'll be looking at that
too.
 
Then we'll be looking at
intellectual history.
Epidemic diseases,
in other words,
had a leading role in the
development of the modern
biomedical paradigm of disease,
with the germ theory and such
disciplines as tropical medicine
and infectious diseases.
And I'll want to argue,
or at least will be testing the
idea,
that perhaps medical ideas,
one of their aspects is that
they're ideologies,
held not only for scientific
reasons,
although that's true,
but also because of the kinds
of societies they promote,
or the power they convey to
nations or strategically placed
elites within them.
That will be a question we'll
be examining.
Then we'll be looking at
ethical issues:
What are the ethics of human
experimentation?
And we'll be looking at some
horrific failures in ethical
standards, and in particular
we'll examine the Tuskegee
Syphilis Study.
 
We'll also be looking and
thinking about diseases as a
tool for the historian:
as a means of casting revealing
light on how societies are
constructed;
on the relations of human
beings to one another;
on the moral priorities of
statesmen and religious leaders;
on the relationship of human
beings with their environment,
by which I mean both the
natural environment and the
built environment,
the cities in particular in
which they live.
 
Responses to epidemic diseases
will be important to us.
How did people respond?
 
And we'll be looking at
stigmatization,
witch-hunting and scapegoating;
at flight and mass hysteria;
at upsurges in religiosity;
at changes in art and in
philosophy.
 
The course will also try to
provide some understanding of a
number of major concepts and
terminology in public health.
By the end of the class,
you should be fluent in using
words like etiology,
case fatality rate,
nosology;
and you should know the
difference between incidence and
prevalence, between an epidemic
and a pandemic,
between inoculation and
vaccination.
 
And then another theme will be
an assessment,
as I said, of where we stand
today in the twenty-first
century.
 
What have we learned as a
society from the experience of
the past four centuries of
recurring and dreadful
epidemics?
 
In 1969, the U.S. Surgeon
General had a premature surge of
optimism in the age of
antibiotics and he declared,
as he put it,
"We've turned the page on
infectious disease."
 
And medical schools and the
public health community taught
that it would be possible to
eradicate one epidemic disease
after another,
like smallpox or polio as
models.
 
But our Surgeon General turned
out to be spectacularly wrong.
Today, in 2010,
infectious diseases are the
number one cause of death
worldwide.
It's also clear that it will be
impossible to write the history
of the twentieth and
twenty-first century without
giving a central place,
at the very least,
to HIV/AIDS,
and to other pandemics as well.
Furthermore,
we know too that there's a
whole host of emerging diseases:
Ebola,
Lassa fever,
West Nile virus,
SARS,
avian flu, AIDS and,
of course, swine flu.
 
And familiar diseases have
re-emerged in resistant and
threatening manners,
such as drug resistant
tuberculosis or malaria,
and other diseases as well.
So, the threat has been made
clear in dress rehearsals we've
had in our new century:
SARS, avian flu and,
as we speak,
swine flu.
And indeed, the nature of
modern society may make us more
vulnerable, rather than less,
to such threats.
We'll want to think about some
of the factors that may make
that true,
such as a high and ever-growing
world population density,
as we rapidly reach a figure of
seven-billion people,
before very long;
rapid movements of population
by rail, road,
cruise ship,
but above all the airplane;
rapid and chaotic urbanization,
with the appearance of ever
more mega cities,
with populations in excess of
ten-million people;
places like Tokyo,
Mexico City,
Lagos, Delhi,
Mumbai, New York,
Jakarta, Buenos Aires and
others.
 
These, many of them,
conjure up images of
overcrowding,
of poverty, substandard
housing, inadequate access to
healthcare,
extensive illiteracy,
open sewers.
Then there's the perennial
problem of warfare,
and the terrible dislocations
that wars leave in their wake:
Displaced people;
refugee camps;
the collapse of health systems
and sanitation;
extensive poverty and widening
social inequalities;
climatic change and
environmental devastation;
and the failure to provide such
basics as safe and adequate
water supplies for untold
millions of people in the
developing world.
 
Unfortunately,
not one of those factors seems
likely to abate in the near
future, and some of them are
gathering momentum as we speak.
 
Well, it's possible,
and reasonable even,
to ask whether it is true that
the way we handle epidemic
diseases will be crucial to our
survival as a society.
In addition,
I would argue,
that it's important to examine
these diseases,
the ones that have been most
prevalent,
as they hold up a mirror to
ourselves.
I would argue that every
disease, and epidemic disease in
particular--
these are not random
events--that every society has
its own specific types of
affliction,
and to study them is to learn
about its living conditions,
its moral priorities and
relationships.
 
For all of these reasons we
could argue that epidemic
diseases are great bearers of
meaning,
and our job is to decipher the
meaning embedded in them as
contemporaries experienced them,
and to understand them
retrospectively.
 
Well, then, that brings us to
our first couple of weeks,
and where we go next.
 
On Wednesday we'll roll up our
sleeves and get down to work,
looking at the meanings that
Europeans gave to epidemic
diseases when they first struck
the continent and as they were
seen through the lens of the
reigning medical doctrine;
that is, the humoralism
philosophy developed by
Hippocrates and Galen.
 
At the time of plague in the
seventeenth century,
humoralism, which was the first
embodiment of what we might call
scientific medicine,
was still the dominant medical
paradigm for disease,
as it had been for nearly two
millennia.
 
And so our first task will be
to examine a topic in
intellectual history of
medicine;
a topic that will help us to
understand how the first
epidemic disease that we're
going to study,
bubonic plague,
was understood,
how it was experienced by
physicians,
statesmen and educated laymen.
 
We'll also be in a position
then to understand that epidemic
diseases fundamentally challenge
humeral notions,
and help to lead to a major
intellectual paradigm shift that
we'll discuss later in the
semester.
So, our course then will begin
with the legacy of two of the
most influential doctors who
ever lived,
both Greeks:
Hippocrates from the fifth
century B.C.,
and Galen from the second
century of the Common Era.
 
Looking at their philosophy of
medicine will give us a
framework to understand the ways
in which the experience of a
plague was a tremendous shock.
 
Most obviously it was a shock
in terms of death and suffering,
but it was also a shock because
it undermined the foundations of
medical and intellectual
understandings of disease.
The passage of bubonic plague
through European society was not
only a biological and material
event,
but also a major intellectual,
religious and psychological
one.
 
Having done that,
next week what we'll do is turn
to bubonic plague itself.
 
Now, the plague is everyone's
candidate for the worst-case
scenario.
 
A plague is synonymous with
terror.
One reason was that it was an
extraordinarily rapid and
excruciating killer,
with symptoms that were
dehumanizing and agonizing,
with no effective therapy,
and a kill rate that ensured
that the majority of its
sufferers perished.
 
It was also readily
transmissible,
so that it seemed poised at
various times to destroy the
whole population of Europe.
 
And it did kill an enormous
proportion of the population;
up to half in major European
cities.
So, here was the origin of a
terrifying cliche about plague:
that it struck down so many
that there weren't enough people
left to bury the dead.
 
So, what will we do next week?
 
Well we'll look at symptoms of
plague, its horrifying effects
on the individual human body.
 
We'll look at its devastating
impact on society,
and at the responses of whole
populations to the time of
plague: mass flight;
scapegoating;
social disorder;
upsurges in religion;
new cults of saints;
new iconographies in the arts.
But there's more to it than
that.
The plague led also to the
first successful strategies of
public health to combat
pestilence;
strategies that were often
draconian, in direct proportion
to the magnitude of the threat.
 
These strategies included,
as we'll see,
boards of health,
with almost unlimited powers
during the emergency:
quarantine;
military lines and naval
blockades to isolate cities,
or even whole countries;
and we'll see pest houses to
confine and isolate the sick and
dying.
As a guide to our experience we
have this book,
which is Daniel Defoe's
Journal of the Plague
Year;
which is the first reading
assignment.
 
And I want to talk about it for
a minute, because some of you
may want to start reading it
straight away.
I'm not too good as a salesman,
but I do think it's appropriate
to make a plug for great books.
 
And in this case,
of Defoe, I want to introduce
one of the classics of a whole
genre of what you'll become
familiar with as plague
literature.
Defoe's masterpiece is a
powerful description by a
contemporary--
in fact a survivor--of the most
dreadful outbreak of bubonic
plague in the history of the
British Isles;
the catastrophic visitation of
1665.
 
Plague had returned in
successive waves in European
history, ever since the first
visitation of 1347.
But one of the terrible
features about it is that over
the centuries it didn't become
milder,
and some of its last
visitations were the most
violent and horrendous of all,
including the epidemic that
ravaged London in 1665.
 
Now, a possible issue for some
may be overcoming the barrier of
language.
 
So I want to throw out a
challenge.
The book, I will admit,
can start out a bit slowly for
some of you.
 
So I want you to think not so
much at the outset,
as you open it up,
as to whether you immediately
enjoy it;
although I'm hoping that you
will.
 
But I want you to think instead
about why it's so important.
I'd like you to think about
what you can learn from being in
the company of someone who had
the experience of living through
the worst of all public health
calamities,
and to ask yourselves why this
book has been read avidly for
four hundred years.
 
It may interest you also to
know that during the SARS
outbreak in Toronto in 2003,
thousands of people were
quarantined in their homes,
and at the top of their list of
books that they read to pass the
time and make sense of their
experience,
was this one:
Defoe's Journal of the
Plague Year.
Well, history,
after all, is in part about
sharing a common culture and
common memories,
and reading this book then is
certainly part of that.
And if you think of it in those
ways, with those questions in
mind, I think--and this is my
secret agenda--you'll really
enjoy it.
 
I also think that you'll find
that it's a wonderful account of
how a society responded to one
of the greatest of all
challenges.
 
Defoe recounts the flight of
the king and other authorities
from London, in fear for their
lives.
He tells us about religious
enthusiasm;
about how people understood the
catastrophe they were
experiencing,
what it meant to them.
He tells us about the hunt that
was on for witches and
scapegoats and culprits.
 
He talks about plague-induced
crime;
the helplessness of physicians;
about popular culture;
and desperate attempts of
people to save themselves;
and then about the extreme
measures of shutting people up
in their homes by government
authorities, or taking them away
by force to pest houses.
 
And since this is a comparative
course, I'll hope that you'll
begin to reflect on how far
we've changed and progressed
from the time that Defoe wrote.
 
And I'll draw your attention,
for example,
to the early years of the
HIV/AIDS epidemic,
and we'll think together about
some possibly very troubling
similarities.
 
In fact, one of the constants
in the centuries since the
plague itself,
in the West,
has been a tendency in times of
public health crises to resort
to plague measures of
self-defense.
We'll see that very
dramatically in the nineteenth
century,
in the time of cholera,
when the desperate attempt was
made to stop Asiatic cholera
with measures that had worked
against plague,
but turned out to be entirely
counter-productive.
And we'll see it again in the
early years of the AIDS
pandemic, and in that case too
with haunting consequences.
So, now you know where we'll
begin: on Wednesday with medical
science,
in its first but long-lasting
embodiment,
and the way that Europeans
experienced plague,
through the lens of humoral
theory.
 
And then next week we'll deal
with the most devastating
epidemic to strike the Western
world, bubonic plague;
and in Daniel Defoe you have a
really good guide to accompany
you on your journey.
 
So, I'll see you next time.
 
 
 
