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Welcome to the project, How Epidemics and based at the University of Oxford.

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My name is Erica Charters. I'm an associate professor in the history faculty at the University of Oxford.

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And I'm Kristen Highton. I'm an independent scholar based in Bethesda, Maryland, which is just outside Washington, D.C.

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So over the next few weeks, Christine and I will be interviewing a range of experts to answer the big question, how at the end?

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But before we do that here, we'd like to explain why we think this question is important and the broader historical context to the end of epidemics.

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This project in some ways had its origin way back in the spring of twenty twenty in what might now be seen as the early days of covid-19.

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When Christian asked what might seem like a simple question,

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how do epidemics and Christian to remember could really do so back in January of twenty twenty,

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when it became quite clear that code was not going to be just a local outbreak.

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I remember thinking, oh, I know how this goes, because as historians we think a lot about the origins and the spread of disease

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and the broad patterns of epidemic disease are generally quite similar.

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covid followed those patterns. But then in early summer, when talk turned to how the epidemic would end and then it was time for it to end,

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I realised that I really had no clear idea at all about how epidemics ended it,

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not even about plague, which is something that I've worked on for several years now.

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So that's when I wrote to you. And I think that's something we continue to find throughout the project.

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There's a lot of attention paid to the origin, to the cause of the outbreak of an epidemic and also,

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of course, to the unfolding of an epidemic, but very little to the process of ending.

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So how do we know an epidemic has ended? Who defines an ending and how do we measure and assess that an epidemic has ended?

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And how, therefore, do we know when we can return to normal life?

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Do we take our guidance from a mathematical model or from an international health organisation or from when other people around us,

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ordinary people, return to their regular patterns of living and of working?

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So for this project, we wanted to incorporate all of these different methodologies.

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That is these different ways of measuring. But measurement and assessment is not just about numbers.

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It can be just as useful to be able to understand how and why normal people return to normal cultural practises,

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as it can be to know exact numbers of cases of disease if we want to understand how an epidemic ends.

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So for this project, we've worked with a range of researchers, over 40 scholarly experts who all work on disease.

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This includes epidemiologists, mathematical modellers, biologists,

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but it also includes people who work in politics and development to analyse the role of disease and the impact of disease on society.

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It also includes experts such as philosophers who work to define our conceptual understanding of disease.

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All of these researchers and details on them and our interviews with them can be found on the project website.

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We designed the project in two phases. First, an essay to disentangle our questions from what historians usually think about and to talk

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about the importance of including these several different approaches and methodologies.

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And then we recruited scholars for a series of online workshops which are now producing a set of essays for print publication,

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as well as these interviews. I think what we found is that each scholarly discipline has a different way of understanding disease,

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and we're both historians, so we have our specific approach.

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So for me, as a historian of medicine, when I study disease in the past, I'm not only analysing disease as a biological phenomenon.

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That is on the one hand,

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I do incorporate our modern biological understandings of disease to say when I look at smallpox in the sixteen hundreds and the seventeen hundreds,

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I do look at how it's transmitted. It's rates of deaths, it's symptoms according to modern biological understandings and smallpox.

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But on the other hand, I also examine how those at the time understood.

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So within their medical understanding, but also within their social and cultural frameworks,

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people in the past have their own strategies for controlling and avoiding disease,

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as well as ways in which they lived alongside it and interpreted that.

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So in other words, historians see disease not as separate from society, but as part of it.

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So epidemics, for example, are not events that come down impact upon society.

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We historians don't consider epidemics as external to society as if they're are aliens coming from outer space and invading society.

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Instead, historians of medicine start from the position that epidemics like disease in general should be understood as part of society.

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So in this approach, disease is part of social and cultural frameworks.

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It highlights existing inequalities, for example, or reinforces social tensions and prejudices rather than creating them anew.

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So as a historian, I use disease as a way to analyse society as a whole, to reveal and understand the ways that societies function.

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Kristen, your research is really much more focussed on the history of measurement.

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How does this relate to the disease? So I'm mostly interested in the history of science and mathematics as well as disease

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and medicine in that recently has meant looking at metrics and systems of records.

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So what gets measured, how it gets measured, and then how those data are used and understood by various individuals and communities.

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And that, too, is a great lens to look at a society or community more generally, especially interested right now in how communities,

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so scientists and practitioners as well as society at large come to any kind of consensus about what to measure,

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what measures and standards are appropriate and what to make.

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Of course, dealing with an epidemic produces a whole lot more metrics and records of its own, especially nowadays.

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But epidemics also strain and even upend ordinary recordkeeping in the kind of social order is expected to support.

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I think epidemics are very interesting as a historical phenomenon, but I also work on the history of disease more broadly,

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and one of the points that's important for me to stress is that we need to think about what is an epidemic.

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The opposite of an epidemic is not lack of disease, but rather what we might call endemic disease.

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I was really struck by this image of the global history through pandemics that's been circulated through

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covid-19 in which the all of the history of the world is represented by these balls that are each pandemics.

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And the size of the ball is meant to kind of represent the number of people killed by each disease.

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This image and what it's telling us about the histories, in some ways, this notion that there's these empty spaces between these balls.

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But what's important for me as a historian of disease is to remember that these empty spaces,

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those periods of history are not periods in which there was no disease,

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but actually in which the world was still full of disease, which is full of what we call endemic disease.

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So today in the West, the diseases that we know, such as tuberculosis, heart disease,

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diabetes and influenza and these endemic diseases can be just as fatal as epidemic disease.

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Cumulatively, for example, endemic disease kills an astonishingly high number of people in a normal year,

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and endemic disease is not defined by the type of disease.

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Right. So influenza is usually an endemic disease,

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but it can become an epidemic disease if suddenly there are higher rates than normal or it brings up in an unusual season.

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So epidemics are about diseases that are novel or unusual for that time or that place.

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For example, in the 17th and 18th centuries, smallpox in England and in Europe was considered endemic, almost normal in cities.

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But it was an epidemic disease, something that you would run away from when it appeared in the countryside.

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But if we step back and if we move to a global a global framework, so we say stand in the perspective of the Americas,

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there are smallpox was an epidemic disease everywhere, but by contrast, considered as endemic to all of Asia and Europe.

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So this notion of what is an epidemic, what is a problem disease, what is a crisis?

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Disease relies on an underlying category of endemic disease.

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What is normal or acceptable rates of disease?

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Just as current discussions, discussions of covid-19 are framed around questions of what is excess death or excess mortality.

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And I think we've discovered. Through this project, the disease most often returns to endemic levels at the end of an epidemic as well,

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with our experience with effective vaccinations, we tend to think about disease eradication as the end goal.

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But that's not usually the way even modern epidemics and.

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So, Erica, how do epidemics a question that we hope to find more answers as we develop more research on this project,

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but I think what we found so far is that one way of thinking about the end of an epidemic is that it's when society's attention turns elsewhere.

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An epidemic is a crisis. It's not just a biological crisis, though.

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It's also a political crisis and economic crisis and a social crisis, as we're witnessing now with covid-19.

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So what we've both found in our research is how the process of the end of an epidemic often isn't recorded.

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Less attention is paid to it precisely because for those who are living through an epidemic, it ends when they can return back to their normal lives.

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And so that's when they stop discussing the outbreak, stop discussing the disease, stop paying attention to it, and so stop keeping records.

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But what we've also found in our research is that most often, of course, this doesn't mean that the disease has actually ended.

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It might disappear for those who are writing records, but that doesn't mean it's gone.

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It often instead moves to say other parts of the world, as we've seen with HIV AIDS, which began as an epidemic for the entire world,

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but now has become much more of a problem disease in what we call the global

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south or a disease might become part of regular cycles or waves of disease,

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as we've seen with influenza. So it transforms into an endemic disease.

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One of the most interesting things I've learnt is how differently different groups define what the end actually is.

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So it's partly, as you say, that we as humans are attuned most to what matters to us and what is going on around us.

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And we pay less attention to what's going on somewhere else or people that we don't know.

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But in order to understand the full picture, the epidemic and especially pandemic itself,

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we have to do some work in order to pull together more points of view.

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And part of that is just access to sound information, but it's also that the end is defined differently by the various communities,

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both within a society and around the world, and also by the various groups that contribute to bringing that and about.

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So we have lots of narratives to look at, lots of ways of making sense of both the data and the experience in hand.

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The broad statistics that we're used to looking at as a general public typically see things that a more general level.

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So they talk about society as a whole and don't have that kind of specificity.

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They gloss over the fact that some communities continue to struggle with the disease long after the epidemic is declared over.

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And then by the same token, in international contexts, if there is outside aid coming in,

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those outside organisations may decide that things are good enough that they need to move on to the next big crisis,

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leaving the people in the society basically to manage on their own.

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But that difference in in endings helps make clear why these stories about how

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epidemics and epidemics end are so ragged that the endings themselves are different.

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And although the fact that they all exist in the same reality means that they interact,

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they reflect the interests and ends of the people who are putting the narratives together.

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I think this point about the rag and the rag admits of the ends of academics is very

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important epidemics and at different times for different groups within one society,

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but also within regions and across the world,

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which is precisely why studying the ends of epidemics gives us such useful insight into societies and how they work or even how they don't work.

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So thank you very much for joining us today.

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We have a number of fascinating interviews lined up over the next few weeks, including with an epidemiologist who's working on the end of malaria,

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a professor of politics who studies cholera in Africa, and a social historian who researches the history of cholera in England.

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We hope you will join us in interviewing the other researchers on the project as we work together to explain how epidemics and.

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Thank you.