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Lecture 2

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Lecture 2: Epidemiology History of Epidemiology - WHOEVER wishes to investigate medicine properly, should proceed thus: in the first place to consider the seasons of the year .... Then the winds, the hot and the cold, especially such as are common to all countries, and then such as are peculiar to each locality. We must also consider the qualities of the waters, for as they differ from one another in taste and weight, so also do they differ much in their qualities. - On Airs, Waters , and Places - Hippocrates c. 460-377 BCE - Goes back 2500 years - Said diseases were seasonal - Beginning of medical geographies - Winds influenced health the most at this time History: Hippocrates - A Greek physician, the “Father of Medicine” - Adhered to the principles of OBSERVATION in medicine - Believed in HUMORAL theory - It is holistic, natural way of looking at the world because they didn’t have a way to study illnesses - Humoral theory body made up of 4 bloods, they correlate with directions and temp, also correlated with personalities. Good health meant having a good balance of these things - Disease comes from an IMBALANCE in nature (anything that upsets the humors) - holistic - Thought that LOCATION was very important in determining disease outcomes - Recognized seasonality of epidemics and treatments - Also believed in MIASMA (bad air) as a cause of disease - Malaria – Galen = Greek practicing in Rome. - Recognized swamps unhealthy places - Location was the middle eastern - How you treat a patient depends on the time of year - Miasma bad air causing disease - They recognized people who lived in swampy areas were getting sick, because of the smell but it was because of the mosquitos - Medical doctors today still take the Hippocratic Oath History: Anton van Leeuwenhoek 1632 – 1723 - Father of microbiology - Visualized bacteria under the lens of a rudimentary microscope - Important precursor to Germ Theory - Invented lenses that magnified tiny things moving around, maybe it’s not the air making us sick but the tiny things in it, so it’s not the air, it’s a pathogen - Beginning of the thought that maybe it isn’t the air that’s making us sick, it is a pathogens. It is the tiny things in it. History: John Graunt 1620-1674 - One of the first (not the only one!) to analyze London’s Bills of Mortality (1662) - In London people kept getting plague and they decided to keep track of everyone who got it and how long they had it. That is how the Bills of Mortality. - Everything was run by the church at this time in the 1600. The parish priest would be responsible to bury and to determine the cause of death. - Earlier: church records - Women(older women or midwives) collected information in their parish for returning to London – cause of death determined by them or priest - John Graunt looked at it numerically and made some observations between males and females and that epidemics were seasonal. - - Recognized seasonality of epidemics - Methods were rudimentary by today’s standards, but recognizing the need for numerical observation is key - The Bills of Mortality began late 1500’s after the plague, important source of demographic info (“Searchers”) - Earlier: church records - Women collected information in their parish for returning to London – cause of death determined by them or priest - People in London were getting the plague - The church ran everything back then, there was no hospital or doctors - Searchers women, midwives went from district to district asking how many people died and were sometimes asked what the cause of death was - Recognized that different epidemics were seasonal History: Edward Jenner - Father of immunology - In 1796 inoculated his gardener’s son with pus from a milkmaid’s cowpox blisters - He then injected the boy with pus from an active smallpox patient … and the boy was fine! - Vaccination eventually led to the eradication of smallpox - More on this in a later lecture - Came up with vaccines particularly for smallpox History: John Snow - Father of epidemiology (and anesthesiology) - August 1854 London was experiencing yet another cholera epidemic - Didn’t believe in miasma theory; thought cholera was spread by drinking water contaminated by fecal waste - Know the order of the people - Went door-to-door to ask where cholera cases were (shoe-leather epidemiology) - Realized that cases were concentrated around one source, the Broad Street Pump - The handle of the pump was removed (victory!) but cholera deaths were already declining so nobody believed him (failure!) - Why didn’t anyone believe him? • Everyone still a fan of miasma theory • No disease agent found (until 1883) History: Victorian London - The “Big Stink” (summer 1858) - Noisy, crowded, dirty, smelly, foggy, polluted - No sewers or clean water – human and animal waste in the streets - Windows covered up because of taxes (no sunlight) - Very, very poor people (children) everywhere - No wonder people believed in miasma theory! - Parliament closed and all the rich people went to the country - Curtains soaked with lime - Jack the Ripper, Charles Dickens, Dracula - The government put taxes on windows so people put covers on the window so they don’t have to give taxes. - They believed in the miasma theory because London stink so much and they believed it made them sick. History: William Farr - Also a Father of Epidemiology - The Registrar General of London - Emphasized consistency in Bills of Mortality - Refined the Life Table - His cause-of-death and injury classification system precursor to WHO’s International Classification of Disease (ICD) - Took the bills of mortality and posted them History: Life Tables - A form of Event History Analysis - Provides life expectancy at birth/number of years remaining - A way to see how mortality changes with age - A way of tracking major events that happen in people’s lives - Know that William Farr worked of life tables, recognize that these are life charts History: Ignac Semmelweiss - Also a Father of Epidemiology - A Hungarian Obstetrician - Drew a connection between “invisible invaders” and poor health - 1846: Compared maternal deaths in a clinic run by physicians (13%) to one run by midwives (2%) - Proposed puerperal fever was transmitted to women in labour by physicians who came directly from autopsies - Helped deliver babies - Maternity wards led by midwives vs. the ones led by doctors, he realized the ones led by midwives had a higher mortality - Mortality rate went down once they began to start washing their hands and their instruments - In 1847 advised his students to wash their hands with lime. Mortality rates dropped. - A year later expanded practice to washing instruments also - Due to personal difficulties with other doctors and his own paranoia he was largely ignored - In 1865 he had a complete breakdown and was committed to an asylum for the mentally insane where he died. - He helped deliver babies. He looked at maternity wards - They were dying from puerperal fever - He had doctors wash hands going from patient to patient and the mortality rate went down. But doctors didn’t like him and didn’t believe him History: Louis Pasteur - Father of microbiology - Demonstrated that fermentation caused by microorganisms (and not spontaneous generation) - Developed a heat treatment that killed microorganisms (ex TB) in milk … Pasteurization - His experiments supported GERM THEORY - Where does the micro-organism come from that they realized did exist? - Looking at fermentation, his work is a important precursor to germ theory - It’s not smell making us sick but something we cannot see - Developed pasteurization History: Robert Koch - Also a Father of microbiology - Identified bacterium for tuberculosis (1882) and cholera (1883) - Death to miasma theory! (He disproved miasma theory) - Koch’s postulates still used today to identify that a disease is caused by a microbe - Isolated bacteria for TB and cholera - This is when miasma theory died because he could prove that something smaller did exist that caused illness Koch’s Postulates 1. The organism must be present in every case of the disease but not in healthy individuals 2. The organism must be capable of being isolated from the sufferer and grown in pure culture 3. The specific disease must be reproduced when a pure culture of the organism is inoculated into a healthy, susceptible host. 4. The organism must be recoverable from the experimentally infected host - Fair game for exam Koch’s Postulates: Problems - Humans no longer linked to their environment (as with miasma theory) - Asymptomatic disease carriers
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