1. All MC
2. 60% comes from lecture and 40% from reading
4. Dates and names from the lecture yes but not really from the readings
5. Case control for this week is also covered
6. Tutorial will be on exam
7. About 70 questions of 4 choices
8. The class average will be 70.
Endemic constant presence of disease within an area
Epidemic occurrence of illness in an area. Unique in time, place, and space. Spread, #case, case fatality, and area be recorded
- Tried mapping the disease
- Studied everything but didnt think of people that did not get cholera. (original group)
Graunt, J. 1603
- Bills of Mortality: collecting a systematic record of death.
- Life Table: Life expectancy at birth
o Women live longer because they are biologically and genetically stronger.
o The life graph will look like U. If you are very young and very old, you are more likely to die early.
- Systematic classification of diseases
o Air/water/food/sexually transmitted
o Disease Nosology (study of disease)
- When the kids were going through teething, they rubbed mercury on their teeth so they could have died from that?
- Baby around that age gets teeth, so you will wean the child so they eat other artificial food substitutes - exposed to pathogens to diarrhea.
- 1798 smallpox/cowpox (still exists in research labs for research purposes, it has been eradicated but not totally.)
- Numeric methodology (medical statistics)
- Vulgar disease (uncontrollable)
- Concealment (perfume)
Cholera in England
- 1831- 32 (32,000 deaths)
- 1848 49 (62,000 deaths)
- 1853 - 54 (20,000 deaths)
- 1866 67 (14,000 deaths)
o Case fatality rate of 40-60%
o Death within hours
o Caused by Vibrio Cholerae
Snowden cholera is an infallible indicator of destitution (poor) and squalor (insanitary state), overcrowding and recycled clothing, defective sewage
and unwashed hands, suspect produce and impure water.***
Cholera = Shock Disease (shocked the political basis of a community.)
- 2 preventive strategies
- Cholera is air- and water-bourn
o By simple touch you can transmit disease
o Cholera imported from outside
- Non-contagionist Miasmatic Origin
o Local sanitary condition
o If you want to remove cholera, you improve local conditions.
1831 and 1832 - Temporary Boards of Health established
- Sanitary Regulation
- District inspectors, houses to be whitewashed, linens cleaned, cholera hospitals to be made
- Leeches they suck out blood and the bad things in your body. 10-12 oz
- Warm bath followed by flannel (towel) rub
- Castor (wheel) oil
- Laudanum (narcotic aka drug)
John Snow 1865 cholera.
- In the 2 pandemic of cholera when we dont know anything about the transmission.
- Most doctors believed that cholera was miasmatic it came from sewers and organic materials, the local conditions.
Opposition to current paradigm
- Snow thought wait, cholera also occurred when there was no organic substances going bad. There was no swamps or anything. If they get
cholera then there is something else in play.
- No armchair epidemiology
o Made questionnaires about water conditions to places that experienced high mortality due to cholera.
o Medical journals connection between water/sewers and cholera. (Water-bourne)
- He thought that maybe it was spread by germs
o It just took a few drops of this substance of this germ to pollute water supply.
o You could then start onset of epidemic.
- 1849, On the Mode of Communication of Cholera by Snow. ***
o No proof
- Water laid on = when you have access to water on individual basis.
o Well = common source of water.
o When the handle was removed, there was less cholera. He was trying to stop the source.
o All sewage and runoff and potential contamination water that was dumped by the street was seeping into the ground water and was
being pumped up. So removal of the handle was not a good proof and his theory was not accepted.
- Germ that is responsible for cholera.
Snows Contribution *** exam
- Geographic data - which was high or low mortality
- Causal insight this was time before the idea of germs.
- Randomized control trial.
- Believed the contagion effect.
- Tried to control modern epidemiology.
- Environmental cause water.
but the point is that he lacked proof.
Snows was not acceptable because of von Pettenkofer ***.
Charles Lyell (the man that influenced Darwin) said Snow was good
Vandenbrouche also supported Snow - 100 years later.
Frost 1936 - Snows work re-emerges
Pettenkofer (an alternative view on the origin of cholera)
- He said cholera itself doesnt cause cholera, so he drank Cholera (experimentum cruces) He was ok because he had acidic stomach
- By 1900 Pettenkofers theory started to lose scientific credibility. So he killed himself.
- His contribution: Germ-environment interactions are important. Even more appropriate than is bacteriology alone for explaining the occurrence
of cholera epidemics in populations.
Pettenkofers Boden theory of cholera ***
- a specific germ
- certain local conditions * focused
- certain seasonal conditions * focused
- certain individuals conditions - A man is pooping and it goes into soil.
- Germ is deposited in the soil (the physical environment)
- The material putrefies and comes up as miasmatic kind of bi-product.
- It comes up in the air and the individual inhales and make a disease.
- Cholera was transmissible but not contagious, because it could be transmitted from one locality to another, but not from individual to another.
localist argued that cholera patients are not infectious. Local condition was what was causing it
- In Gibraltar, he asks for: (These are all what Snow was asking.)
o Quality of ground water and wells
o Water-levels in different seasons and throughout year
o The order and thickness of the several soil strata
o From the surface to the first layer impermeable to water.
o Drinking water supply
o Chemical analysis of drinking water
o The drainage of the town
o sewage condition and how fecal matter is removed
medium temperature, the amount of rainfall in every month during the years 1864 and 1868
cholera stats - the death rate of each house and of the town, separately and collectively.
- Beak: he would put perfume-like substances, so it would prevent miasmatic odor and substances.
Crisis Mortality ***
- Sudden and dramatic increase in mortality from a single source over a very short period
- Famine, floods, war
- Opportunism: taking advantages
- Scapegoat: Blaming
- Creation of board of health
- Soup kitchens and charity
- Breakdown of the family
- Fear and anxiety
- Quarantine measures
- Loss of civil liberties
- Spiritual salvation
- Traditional values may be lost
- Increase in cost of food and provisions
Why study Epidemics
1. Re-observe a communitys social, medical, and sanitary structure
2. Reveal best/worst characteristics of community identity Charity vs. scapegoating
3. Government actions
4. Reveal the inequality of privilege and poverty
5. Prepare for future outbreaks
6. Helps study of a disease
7. Lead to change
o Biological/genetic - It doesnt want to kill its host because that means it kills itself
o Sanitary reform - Hand sanitizers were being installed in campus
Some generalization about epidemics Fox (1989) transcends time and place
- In beginning, people underestimate the severity
- Fear and anxiety as it spreads
- A shortage of physicians to treat the sick - Efforts to quarantine and isolate are usually ineffective
- Initial responses to fear and anxiety:
o Scapegoating i.e. foreigners
o Increased debt
o poor people in poverty trap
- Medical System
o Increased cost in hospital expenditures
- Individual Level
o Impact on Family Structure
o Loss of Religious Faith
- Commercial center
- Coaling station
- Naval Porter (navy move)
- Garrison Town (, )
- British Colony
Morality Rate in Gibraltar
- It is normal 95% confidence (anything below or above the bold line is considered to be unusual. = outlier.)