Welcome to the How Epidemics and Project based at the University of Oxford.
My name is Erica Charters. And in these videos I'll be discussing with experts how they research disease and a variety of ways,
as well as their investigations into how epidemics end.
Today, I'm here with Margaret Cullin, who was reader in the social history at University of Oxford.
Maggie is now retired, but she's still research active and is a member of the history faculty.
So, Maggie,
you began researching really in the social history of medicine when it started as a discipline in universities in England right at its beginning.
Can you talk a little bit about what the history of medicine was like when you began as a researcher?
Thank you, Erica. But that time we're going back decades and of course,
there was a strong tradition of the history of medicine in Germany and subsequently in the United States and even to some extent in Canada,
with both the library at McGill and putting in Britain, it virtually didn't exist as an academic discipline.
It was a kind of focus at the Welcome Institute in London, but that was basically a library and museum not connected with universities in any way.
That didn't mean that there was no history of medicine as such, but it was established as an amateur interest,
largely by retired doctors or professional medical men defending their speciality, as with public health professionals.
They were also focuses on things like the history of hospitals, expressions of loyalty, if you like, and commitment, biography, those kinds of things.
Unfortunately, there was also a way in which medical history was used to entertain medical students.
This was not good history, in my view.
So can you explain how the social history of medicine as a professional discipline of history, how was it different?
What was it trying to do? What kind of questions was it trying to answer?
Well, if I can put it put it this way, I'm calling it the history of medicine is in some ways a misnomer.
It would be better called the history of health, disease and medicine.
And this is because logically and experientially, health comes before disease and disease comes before medicine.
And both health and disease are much larger historical phenomena than is actually medicine alone.
In terms of what you look at you like other historians, you're dependent on any given society has left for us to examine.
So you are.
Reflecting, this is necessarily the society's own priorities as to what it recorded, what it was interested in and what it it didn't record.
That means that you see disease through their perspectives and you have to make your best estimate of how you balance balance that.
So I think one way some people have discussed this in some ways I think this is what you're saying is how previously
maybe people had looked at the history of medicine according to looking for precedents of modern medicine,
to see what happened before as a kind of way to lead up to where we are today.
Whereas in some ways, the social history of medicine, when it became an academic discipline of history, was looking at it on its own terms.
So to kind of understand how those at the time understood and experienced disease.
So when you've looked at, for example, specific diseases of cholera in 19th century England,
can you explain a little bit about how you researched it or a little bit about the background of of cholera and the experience in England then?
Well. That started off with the pre-existing idea,
that colour was in some way definitive of the 19th century and in particular century reform in the 19th century,
and this has been continued since then by social historians, amongst others.
But as far as I was concerned, when I came to look at the evidence,
it seemed to me perfectly clear that sanitary reform did not begin with the first cholera epidemic in 1831.
It was already going in the 20s.
And the focus then was not, of course, cholera at all, but what they called continued fever, which we would now call a mixture of typhoid and typhus.
So the case for sanitary reform was built on that.
And there was the distinct possibility that cholera was a distraction from that because it came and went,
which meant that it was potentially subject to very temporary provisions rather than continued reform,
which was a vast labour, in fact, had to be continuous rather than sporadic.
So if I understood you correctly, in some ways we think of colour as being the most important disease for 19th century England,
but you're saying those at the time actually were concerned with a wide range of diseases and not just this epidemic disease.
So even though cholera was a new disease for those in England at the time, there are these multiple epidemics or waves of cholera.
And of course, it caused a lot of fear and I think a lot of uncertainty because there are debates about understanding it.
We actually have to understand it within a broader context of a number of diseases that people the time we're writing about.
Is that is that a correct interpretation? Oh, yes, certainly cholera was dramatic and it was new.
There were diseases recognised by 19th century people, which they called cholera, which were basically forms of extreme diarrhoea.
But this was Asiatic cholera, cholera, which was thought of as originating in India and gradually progressed, in fact, by Russia to to Britain.
So it was a kind of alien invasion. And this hadn't happened since plague had finally not come back after 16.
Sixty six. So the initial impulses were very much along the lines that they would have used in relation to plague.
So it was both interesting and scary because it was unknown before.
Once it had won, the first epidemic had been and gone.
There was a slightly more unfortunately,
rather more relaxed attitude because it wasn't nearly as dramatic and widespread as people had feared it might be.
This was part of the part of the problems of the sanitary reforms because
interest died down in the next academic did not come along for another 20 years.
So one way of thinking about this is that people at the time debated how cholera was transmitted.
We now know, of course, that it's carried through infected water supplies,
but that those at the time we're talking about something called sanitary reform.
So not just focussing on on water supplies, but thinking about social conditions, living conditions.
So when you're researching the history of cholera and thinking about trying to capture how those at the time understood it,
how do you how do you investigate it?
What sources do you look at in order to examine their approach and their understanding and their uncertainty and debates over the disease?
Well, if I can begin with a little about the way that cholera fitted into the general picture,
it was featured in the 19th century, tended to think of an epidemic, diseases along the spectrum.
At one end, there was smallpox, which was the definitive, directly contagious disease.
People were fairly confident that they knew how it behaved. At the other end of the spectrum, there was malaria, which was definitively the disease,
which related to local conditions and wasn't contagious at all.
And in the middle, there was a large group, including which cholera was then put into, which were called the Doubtful Diseases.
Now, we would now call these the diseases which are transmitted indirectly through a vector like insects or in the case of cholera and typhoid water.
But the real intellectual problem was a real one in that how much evidence you collected, the next lot of evidence seem to contradict it.
So these doubtful diseases were called that because they were inconsistent in their behaviour and unpredictable.
So you can see that this this was good ground for ongoing arguments.
And indeed, in the end, most observers and in particular medical men came to the conclusion,
which is very alien to the modern point of view, that cholera is a disease which is sometimes sometimes contagious and sometimes not.
What might resonate with us right now in the midst of covid is not only this notion
of an unknown and new disease and debates and uncertainty over transmission,
but also the debates over different kinds of causation.
I was struck by how Richard Horton, the editor in chief of the UK's medical journal The Lancet,
wrote in September 20 20 How covid-19 is not a pandemic, but it's endemic.
That is, that it's very much a disease that interacts with other diseases,
especially non communicable diseases, and therefore also interacts with socioeconomic structures.
And this kind of reminds me actually of this 19th century view that you're trying to get us to think about, which is that disease is complex.
It's a complex phenomenon. Even if it's contagious, it can still also be interacting with all sorts of other environmental or social conditions.
And we need to remember that there's multiple ways of understanding disease and
therefore multiple ways of understanding how to try to solve the problem of disease.
But the epidemics of cholera did. And in England, I think the last major epidemic was in eighteen, sixty six.
So how and why did cholera end in England?
Well, I would define this as an unexamined question.
Cholera certainly didn't end because of herd immunity and obviously there were no vaccines in the four epidemics of cholera.
It affected different places, different degrees of severity.
But I don't think you could say about any of them that it came to an end because of sanitary reform or the improvement of water supplies.
I think what you can say, although there's still a lot of argument about this,
is that cholera was prevented from returning by improvements in particularly water supply,
just as the incidence of typhoid was reduced by the improvements in water supplies.
But it really, to me, remains an open question as to why cholera came and went the way that it did in the 19th century.
Thought of it in terms as a visitation and even the religious interpretations faded as the century went on.
Now, they would have decided that cholera had ended up on the basis of mortality statistics, which the 19th century specialised in collecting.
But the other that the other agencies involved would be the foremost authority
at the time to determine when it was judicious to have a day of Thanksgiving,
say, or to end chronic forms of quarantine.
These are essentially political decisions. To my mind, unlike saying playing certain periods, I don't think that cholera could have been endemic,
that is sort of recurring at grumbling low level in between the epidemics.
It does appear to have been, you know, been and gone.
And to me, it's not actually clear why. Which makes your project very interesting one.
This is a very interesting point, because many people might have heard of John Snow,
who's often called the father of epidemiology and the story that it's really his work that ended cholera in England.
That is according to this version.
Snow basically establishes the discipline of epidemiology by mapping out the sources of water during cholera outbreaks in London,
tracing infections back to one location, even tracing it back to one specific water pond called the Broad Street Pump in London.
And in some versions,
we even have snow himself ending cholera by going and physically removing the pump handle and thereby stopping the transmission of cholera.
But you seem to be suggesting that in actual fact,
the ending of cholera in England was not due to one man or one action or the rise of a new discipline,
but instead needs to be understood within changes across very various areas of societies and thinking about medicine as a whole,
thinking about broad social and sanitary reform. So how would you tell the story of the end of cholera in England?
Well, I think at the moment, it can't actually be told,
because it's not clear that there would be other factors like which have been argued about by historians,
like improvements in nutrition, for example, or even improvements in housing.
But the. It's the sort of situation in with myths in which myths have to be created, at least for the comfort of everybody concerned,
and the curious thing is that this myth about John Snow and the pump handle persists into the present day.
And there even seems to be something called pump handle epidemiology, which I think relates to direct and straightforward,
relatively simple actions taken by humans, obviously, which bring an epidemic to an end.
Now, even Snow didn't think that he brought the epidemic to an end by removing the pump handle,
nor is it at all likely that he did actually remove the pump handle himself.
So this was a story created by a physician friend of yours called Benjamin Ward Richardson.
And it is it is basically a myth because the epidemic was declining as not fully recognised before anything was done with the pump handle.
But because this was a very dramatic, severe outbreak in central London, it has gone down in history, you could say, as something definitive.
And also Snow's making has gone down in history, something definitive, even though they were precursors in terms of disease maps.
But he's become, to use the current term, totemic. Well,
thank you very much for sharing your expertise and for helping us to understand the complexity of disease and disease theories in the 19th century.
And thank you all for joining us in this video. And I hope that you will also join us in watching some of the other videos
where we discuss other epidemics and other versions of endings of epidemics.