In this next module of the course, we'll be thinking about pandemics in historical perspective. I'm Helen Valier. I'm a medical historian at the honest College of the University of Houston. A director of the Medicine Society Program, which is our program in health and medical humanities. I'm also an instructional assistant professor in the College of Medicine. What we want this module to do, is to use history to really break a part, break open, and start to read from the past some lessons for the present. How we can think about the past, and think about what it can say to all questions of uncertainty, and perhaps some fear and just worry about the present and the future. How have people in the past dealt with these kinds of questions? What can we learn from them? With that in mind then, there are three objectives for this module. The first is to try to get some understanding and explain why there have been these explosive outbreaks of infectious diseases at certain points in history. Why is that the things human beings have done in terms of how we sustain ourselves, how we live in the world has changed our disease picture? But the human and the nature have interacted with each other always, and that has radically changed the nature of disease. As we will see, is the reason why these explosive outbreaks, these epidemic outbreaks of disease occurred at all. Moving on from that then, will be the connected objective and set of questions about what some of the common themes in public health responses in the past have been? How do local and regional and later national, federal, global, public health authorities respond in the advent of uncontained disease outbreak? I'm going to use two examples to talk through some of those issues. First, is the plague, the Black Death of the 14th century. The second is the so-called Spanish influenza pandemic of 1918, which lasted in fact until 1919. What I want to do with both of these objectives is to, once again, raise up and recognize the role of history in understanding our present condition. To think through what lessons it has for us, and not only understanding the present, but coming together to plan hopefully better future. Before we really get into those objectives though, I'd like to take us through a few terms. As is the case in a lot of the vocabulary and literature and language of healthcare and medicine, these are terms that are constructed using ancient languages, in this case, Greek. Endemic from the Greek en, in or within, and demos, the people or the people of a particular place. When we're describing diseases that are endemic, we're talking about infectious diseases that are following some expected pattern, that they are falling within the parameters that we would normally see. Now when they move outside of those parameters of expectation or usual pattern, then we could call that a disease outbreak. If that disease outbreak starts to spread and spread rapidly, then we start to know that as an epidemic from the Greek epi, on or upon the demos, the people. The sense of moving from that contained to the uncontained, the spreading, the rapid spread, perhaps over a large geographic area or different populations, and that's when have an uncontrolled disease outbreak, which we would call an epidemic. Another stage of that, pandemic, from the Greek pan or all. We'd see that disease then becoming even more widespread, covering more parts of the globe and being a truly all global phenomenon. That's beyond the scope of this module to talk about the differences and distinctions between what's an epidemic and what's a pandemic. I would just draw your attention to the fact that these things aren't straightforward as we might think that when to call an epidemic an epidemic and not a disease outbreak, or when to call an epidemic a pandemic. These are all choices, these are all decisions that are reached by consensus, usually after argument consideration of multiple data sources that, this is the kind of contentious world of public health and on the slide here I have a reference for those of you who would like to have more information about that, it's a fascinating area. So we know that the human experience with infectious diseases is a long one. But we also know that the beginning of mass casualty outbreaks of infectious diseases, of epidemic and pandemic disease, begins at a certain point in time and that time is in the growth of civilization, the growth of the cities. If we think about that in terms of the long human history that Homo sapiens have been around for 450,000 years, but our recorded history already begins with our civilizations in the Indus Valley, Mesopotamia, Egypt. This is when we start to have a written language and made records of our encounters with the world and each other and we started to record our disease. But it's not only for that reason that we don't have records of these mass casualty outbreaks before then. It's not that infectious diseases would have been unknown to our hunter-gatherer forbearers. It's more of the epidemic, the mass outbreak of infectious diseases, it was something that was very much related to the growth of the city, to the growth of empire, and civilization. That it is the ways in which we changed how we live in a world that changed the way in which we experience infectious diseases. Because think about where most infectious diseases come from. Now, there are certainly pathogens in the soil like botulism or anthrax and those would have been diseases that were known to our prehistoric ancestors. But when we start to settle for speed, because of the pressures of population expansion after the last ice age, about 10,000 years ago, when we start to settle the land and grain it, then we get marshy areas and malaria. When we start to domesticate cattle, dogs, ducks, and geese, then this presents this whole new reservoir of the disease and we'll see the phenomenon of zoonosis appear in which our close living our close interactions with animals, we'll see diseases jump species barrier. Some mutations will then take hold for human-to-human transmission, and this, for instance is where we have measles from. That we have measles as rinderpest, canine distemper passed between cattle, dogs, and humans. Or of course, where influenza comes from and swine flu influenza, that these are passed from birds, ducks, chickens, especially and pigs also in the other case. So it's really that domestication in human history, the last 10,000 year and then combining that with the growth of these city-states and empires in the last 5,000 years that we start to see mass casualty disease outbreaks. So this brings us to the Plague of Justinian, which is typically seen by historians of medicine as the first of the three big deadly pandemics in human history. So with the Plague of Justinian, we're talking about a Roman Empire. A place of fast transport through the new roads, the Roman roads, of troop movements, of trade, of conquest, and war. These are exactly the kinds of human activities that I reference when I talk about the ways in which we live has changed, the ways in which we experience the natural world, including in terms of the ways in which we experience diseases. Because transporting disease from population to population is absolutely critical to the reasons why endemic diseases become epidemic diseases. That is this concentration people in cities, and towns, or in army barracks, combined with high mobility. Whether we are traveling by fast ships or fast roads to trade, or to travel, or to make war, that these are the conditions, these dense populations plus high mobility that create the conditions in which disease outbreak becomes explosive, and then we have epidemics. When we have an empire that stretches beyond our shores, we can spread it across the world, and that's when we have our first pandemic. So it's with the Roman Empire then, and the Emperor Justinian that we see the first of history's deadliest plagues, the Plague of Justinian, which like the Black Death that would come centuries later in Europe, is an example of the bubonic plague. Not all plagues in history have been bubonic plague, but we call them plagues. The word plague is a metaphor as much, if it's anything, not as a metaphor that comes from a Latin root of plugger, meaning a strike or a blow. This is a Latin translation of the plagues that we see in the Hebrew Bible, Plagues of the Pharaoh. Again, I bring that up to remind us that this is a common human experience in history. That we see diseases spread so rapidly, our world turned upside down, chaos around us. The Plague of Justinian and the Black Death killed tens of millions of people. Now Spanish flu killed too more than that, 50, perhaps over a 100 million people. But thinking about Justinian and the Plague of Justinian, and thinking about the Black Death and the effect on Europe of that loss of population. But this is a world changing event, but they're also events of resilience, and endurance, and continuity. So as well as looking back at these great losses of human life and this tragedy of death, we can also look at these lessons of resilience, of adoption, and of hope for the future that they show us. Something that we will see come out of responses to plague is really public health and modern public health, as we come to know it. Here in this slide I have a couple of examples of what that looked like during the great plague outbreaks of the 17th century. On the right-hand side here, we have a leaflet issued by local authorities in Ferrara, Italy announcing restrictions on trade. This idea of mitigating and containing the outbreak of a disease, trying to stop it's spread through the use of trade prohibition, travel prohibition, quarantine. On the left-hand side, we have one of the famous bills of mortality that started to appear in the city of London during the Great Plague of London in 1665. This would be an example of the collection of what became known as vital statistics or vital data, living data, living in the dead of the city in order to try to understand the disease, to map its spread, to represent it statistically. Again, this is a way of knowing and preparing and protecting an understanding, not just health as a matter of the individual, but health as a matter of the population, of the community. That responds to health that collected data, that tried to use data to prime responses, whether those responses at the time were successful or not. We have a lot of data to say that the quarantines, whether they're of in the Black Death period or from this period, the 17th century, were not particularly effective at stopping the spread. But what endured from those approaches is something that is very resonant today, which is the efforts to collect data and to use that data to plan interventions, to mitigate, and to try eventually to stop the spread of new diseases in the absence of effective therapies. Now with the plague in London just as with the Plague of Justinian or the Black Death, collecting data was difficult. It's difficult now having good records of the vitality of a population when it's undergoing a new as a data collector or undergoing the trauma of a mass disease outbreak. That's why we're having these debates now about data and what data is collected and what it shows. Now assume if that is to do with the present, but some of it is also an enduring question to do with the past. That when we're in the midst of crisis, the data we need is often data that's hard to come by, and so it's really important that we have, of course, programs like this to produce people who are going out there and finding the vital data that we need. So moving on now to last and most recent of the three deadly pandemics of history, is the Spanish flu outbreak. The Spanish flu outbreak occurred in three waves between 1918 and 1919. It was the second wave, just often why it's just called the 1918 flu that occurred in the summer of 1918 that was the most deadly. Now, as we saw in the previous pandemic examples, a huge percentage of the world's population is affected, up to a third, but there are fewer deaths. That said, between 20-50 million people lost their lives across the world. Some historians have put that even higher at 100 million or more. But what we do know is that something of the order of 675,000 Americans lost their lives. The disease outbreak, just as we saw in the case of empire or the expansion of the European city and trade, we see human activity, in this case, World War I, being a major stimulus, a reason and setting for an outbreak of influenza, which was not uncommon, that there have been waves upon waves of influenza that lead to high death rates in epidemics of influenza before. But this one in particular, because it coincided with World War I and the movement of troops across the Theater of War. The Theater of War occurred, lots of it, on the fields of Europe, Belgium and France in particular. But this was also a war between colonial powers that involved colonial subjects and colonial spaces. So all of these conditions taken together, are again the catalyst for a disease outbreak to become a pandemic outbreak and therefore lead to mass casualty situation. Also because of World War I, you'll see now, perhaps for the American story, one of the most tragic instances of the conflicted decision-making that people have about what to prioritize in the event of a disease outbreak. We'll see the example of the differences in heeding public health advice and social distancing in the cities of Philadelphia and St. Louis. These cities with different social distancing practices, so radically different outcomes in terms of their death rates. But for the city of Philadelphia, a priority was to show patriotism and support for the war effort, to go out and visit the Liberty Loan Train that was then moving through the United States. So it's not about the advice given by public health officials was different in Philadelphia than it was in St. Louis because it wasn't. But decisions were made differently and prioritize were placed differently, and that led to tragic outcomes. But it shows again that the public health and the crisis of public health is always competing with other very urgent needs to open economies and to keep communities together. Also because of World War I, you'll see now, perhaps for the American story, one of the most tragic instances of the conflicted decision-making that people have about what to prioritize in the event of a disease outbreak. You'll see the example of the differences in heeding public health advises, social distancing in the cities of Philadelphia and St. Louis. The cities with different social distancing practices, saw a radically different outcomes in terms of their death rates. But for the City of Philadelphia, a priority was to show patriotism and support for the war effort. To go out and visit the liberty bone train that was then moving through the United States. It's not that the advice given by public health officials was different in Philadelphia than it was in St. Louis, because it wasn't. But decisions were made differently and priorities were placed differently, and that led to tragic outcomes. But it shows, again, that the public health and the crisis public health is always competing with other very urgent needs to open economies and to keep communities together. Something else that we'll also see in the public health response that should be quite familiar to us, is the ways in which we've tried to persuade publics to respond to local public health officials. As we saw just now with the cases of Philadelphia and St. Louis, a disease may be pandemic, it may be spread across the globe. There may be responses that are to do with global organizations, as will be the case with the emergence of the League of Nations and later United Nations, World Health Organization after World War II. But public health is local health. Local health is public health. It masses what we do in our neighborhoods, in our cities, in our communities. A lot of what we see with Spanish flu in particular, in terms of encouragement to wear masks, resistance to wearing masks, different ideas of persuasion, and contest public debates about what measures were reasonable, what measures not. These are things that, once again, we can look back to for historical examples and to see how those things were dealt with in those moments, and take lessons from land. On the slide also here is an example of some of the ingenious ways in which industry expanded ways to entertain ourselves during quarantine. I think that, probably, many of us relate to that too. This is an advertisement for Bell System that would become AT&T, recommending that if you want to not be isolated in quarantine, well, why don't you get yourself here, [inaudible]. As we start to bring this module to a close then, what are the lessons of history? Well, there's really two from all three objectives that we started with that I want to emphasize. The first is this idea that cities are changing, and our modern ways of living produce conditions, of course, that are necessary for pandemics to emerge, that concentrated populations of high-mobility thing again. But as we see with public health response, whether it is through collecting data, planning for interventions based on that data, that cities in modern ways of living produce both the conditions for the pandemic to emerge, and also the tools for the pandemic to be controlled. Now, catastrophic disease outbreaks always present new challenges. The circumstances in which they emerge are historical unique, but not everything about our present situation is about our present situation. There are enduring resonances and continuities with the past in everything that we see. Two of those things I've mentioned in particular, that there is a certain resilience and adaptability in the face of uncertainty that we've seen over and over again in past responses to epidemic diseases. Even when epidemic diseases have devastated whole communities and families, and regions, it's quite remarkable thing to see. It's quite remarkable too, in that even in these times, that we can look for opportunities for solidarity in these shared kinds of human experiences and I hope that we do.
