1 00:00:12,030 --> 00:00:16,260 Welcome to the How Epidemics and Project based at the University of Oxford. 2 00:00:16,260 --> 00:00:23,010 My name is Erica Charters. And in these videos I'll be discussing with experts how they research disease and a variety of ways, 3 00:00:23,010 --> 00:00:27,590 as well as their investigations into how epidemics end. 4 00:00:27,590 --> 00:00:33,600 Today, I'm here with Margaret Cullin, who was reader in the social history at University of Oxford. 5 00:00:33,600 --> 00:00:39,840 Maggie is now retired, but she's still research active and is a member of the history faculty. 6 00:00:39,840 --> 00:00:40,740 So, Maggie, 7 00:00:40,740 --> 00:00:49,260 you began researching really in the social history of medicine when it started as a discipline in universities in England right at its beginning. 8 00:00:49,260 --> 00:00:56,030 Can you talk a little bit about what the history of medicine was like when you began as a researcher? 9 00:00:56,030 --> 00:01:02,990 Thank you, Erica. But that time we're going back decades and of course, 10 00:01:02,990 --> 00:01:11,870 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, 11 00:01:11,870 --> 00:01:20,510 with both the library at McGill and putting in Britain, it virtually didn't exist as an academic discipline. 12 00:01:20,510 --> 00:01:32,600 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. 13 00:01:32,600 --> 00:01:42,020 That didn't mean that there was no history of medicine as such, but it was established as an amateur interest, 14 00:01:42,020 --> 00:01:51,260 largely by retired doctors or professional medical men defending their speciality, as with public health professionals. 15 00:01:51,260 --> 00:02:05,090 They were also focuses on things like the history of hospitals, expressions of loyalty, if you like, and commitment, biography, those kinds of things. 16 00:02:05,090 --> 00:02:11,010 Unfortunately, there was also a way in which medical history was used to entertain medical students. 17 00:02:11,010 --> 00:02:14,780 This was not good history, in my view. 18 00:02:14,780 --> 00:02:21,920 So can you explain how the social history of medicine as a professional discipline of history, how was it different? 19 00:02:21,920 --> 00:02:27,000 What was it trying to do? What kind of questions was it trying to answer? 20 00:02:27,000 --> 00:02:33,900 Well, if I can put it put it this way, I'm calling it the history of medicine is in some ways a misnomer. 21 00:02:33,900 --> 00:02:40,770 It would be better called the history of health, disease and medicine. 22 00:02:40,770 --> 00:02:49,050 And this is because logically and experientially, health comes before disease and disease comes before medicine. 23 00:02:49,050 --> 00:02:58,080 And both health and disease are much larger historical phenomena than is actually medicine alone. 24 00:02:58,080 --> 00:03:09,900 In terms of what you look at you like other historians, you're dependent on any given society has left for us to examine. 25 00:03:09,900 --> 00:03:13,690 So you are. 26 00:03:13,690 --> 00:03:25,090 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. 27 00:03:25,090 --> 00:03:37,820 That means that you see disease through their perspectives and you have to make your best estimate of how you balance balance that. 28 00:03:37,820 --> 00:03:44,810 So I think one way some people have discussed this in some ways I think this is what you're saying is how previously 29 00:03:44,810 --> 00:03:50,900 maybe people had looked at the history of medicine according to looking for precedents of modern medicine, 30 00:03:50,900 --> 00:03:55,220 to see what happened before as a kind of way to lead up to where we are today. 31 00:03:55,220 --> 00:04:02,530 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. 32 00:04:02,530 --> 00:04:08,840 So to kind of understand how those at the time understood and experienced disease. 33 00:04:08,840 --> 00:04:15,560 So when you've looked at, for example, specific diseases of cholera in 19th century England, 34 00:04:15,560 --> 00:04:25,340 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? 35 00:04:25,340 --> 00:04:31,110 Well. That started off with the pre-existing idea, 36 00:04:31,110 --> 00:04:39,300 that colour was in some way definitive of the 19th century and in particular century reform in the 19th century, 37 00:04:39,300 --> 00:04:45,820 and this has been continued since then by social historians, amongst others. 38 00:04:45,820 --> 00:04:50,520 But as far as I was concerned, when I came to look at the evidence, 39 00:04:50,520 --> 00:04:57,540 it seemed to me perfectly clear that sanitary reform did not begin with the first cholera epidemic in 1831. 40 00:04:57,540 --> 00:05:04,080 It was already going in the 20s. 41 00:05:04,080 --> 00:05:15,240 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. 42 00:05:15,240 --> 00:05:20,460 So the case for sanitary reform was built on that. 43 00:05:20,460 --> 00:05:28,170 And there was the distinct possibility that cholera was a distraction from that because it came and went, 44 00:05:28,170 --> 00:05:36,390 which meant that it was potentially subject to very temporary provisions rather than continued reform, 45 00:05:36,390 --> 00:05:46,480 which was a vast labour, in fact, had to be continuous rather than sporadic. 46 00:05:46,480 --> 00:05:54,200 So if I understood you correctly, in some ways we think of colour as being the most important disease for 19th century England, 47 00:05:54,200 --> 00:06:01,300 but you're saying those at the time actually were concerned with a wide range of diseases and not just this epidemic disease. 48 00:06:01,300 --> 00:06:09,310 So even though cholera was a new disease for those in England at the time, there are these multiple epidemics or waves of cholera. 49 00:06:09,310 --> 00:06:15,560 And of course, it caused a lot of fear and I think a lot of uncertainty because there are debates about understanding it. 50 00:06:15,560 --> 00:06:23,020 We actually have to understand it within a broader context of a number of diseases that people the time we're writing about. 51 00:06:23,020 --> 00:06:35,050 Is that is that a correct interpretation? Oh, yes, certainly cholera was dramatic and it was new. 52 00:06:35,050 --> 00:06:44,290 There were diseases recognised by 19th century people, which they called cholera, which were basically forms of extreme diarrhoea. 53 00:06:44,290 --> 00:06:56,230 But this was Asiatic cholera, cholera, which was thought of as originating in India and gradually progressed, in fact, by Russia to to Britain. 54 00:06:56,230 --> 00:07:06,400 So it was a kind of alien invasion. And this hadn't happened since plague had finally not come back after 16. 55 00:07:06,400 --> 00:07:15,560 Sixty six. So the initial impulses were very much along the lines that they would have used in relation to plague. 56 00:07:15,560 --> 00:07:22,870 So it was both interesting and scary because it was unknown before. 57 00:07:22,870 --> 00:07:28,930 Once it had won, the first epidemic had been and gone. 58 00:07:28,930 --> 00:07:30,820 There was a slightly more unfortunately, 59 00:07:30,820 --> 00:07:38,770 rather more relaxed attitude because it wasn't nearly as dramatic and widespread as people had feared it might be. 60 00:07:38,770 --> 00:07:45,040 This was part of the part of the problems of the sanitary reforms because 61 00:07:45,040 --> 00:07:51,200 interest died down in the next academic did not come along for another 20 years. 62 00:07:51,200 --> 00:07:58,190 So one way of thinking about this is that people at the time debated how cholera was transmitted. 63 00:07:58,190 --> 00:08:03,440 We now know, of course, that it's carried through infected water supplies, 64 00:08:03,440 --> 00:08:07,430 but that those at the time we're talking about something called sanitary reform. 65 00:08:07,430 --> 00:08:13,730 So not just focussing on on water supplies, but thinking about social conditions, living conditions. 66 00:08:13,730 --> 00:08:21,170 So when you're researching the history of cholera and thinking about trying to capture how those at the time understood it, 67 00:08:21,170 --> 00:08:23,270 how do you how do you investigate it? 68 00:08:23,270 --> 00:08:35,030 What sources do you look at in order to examine their approach and their understanding and their uncertainty and debates over the disease? 69 00:08:35,030 --> 00:08:42,110 Well, if I can begin with a little about the way that cholera fitted into the general picture, 70 00:08:42,110 --> 00:08:50,450 it was featured in the 19th century, tended to think of an epidemic, diseases along the spectrum. 71 00:08:50,450 --> 00:08:56,270 At one end, there was smallpox, which was the definitive, directly contagious disease. 72 00:08:56,270 --> 00:09:04,850 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, 73 00:09:04,850 --> 00:09:09,200 which related to local conditions and wasn't contagious at all. 74 00:09:09,200 --> 00:09:19,300 And in the middle, there was a large group, including which cholera was then put into, which were called the Doubtful Diseases. 75 00:09:19,300 --> 00:09:33,010 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. 76 00:09:33,010 --> 00:09:44,420 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. 77 00:09:44,420 --> 00:09:55,130 So these doubtful diseases were called that because they were inconsistent in their behaviour and unpredictable. 78 00:09:55,130 --> 00:10:05,240 So you can see that this this was good ground for ongoing arguments. 79 00:10:05,240 --> 00:10:13,340 And indeed, in the end, most observers and in particular medical men came to the conclusion, 80 00:10:13,340 --> 00:10:22,080 which is very alien to the modern point of view, that cholera is a disease which is sometimes sometimes contagious and sometimes not. 81 00:10:22,080 --> 00:10:27,090 What might resonate with us right now in the midst of covid is not only this notion 82 00:10:27,090 --> 00:10:32,100 of an unknown and new disease and debates and uncertainty over transmission, 83 00:10:32,100 --> 00:10:35,940 but also the debates over different kinds of causation. 84 00:10:35,940 --> 00:10:41,670 I was struck by how Richard Horton, the editor in chief of the UK's medical journal The Lancet, 85 00:10:41,670 --> 00:10:47,100 wrote in September 20 20 How covid-19 is not a pandemic, but it's endemic. 86 00:10:47,100 --> 00:10:51,390 That is, that it's very much a disease that interacts with other diseases, 87 00:10:51,390 --> 00:10:57,660 especially non communicable diseases, and therefore also interacts with socioeconomic structures. 88 00:10:57,660 --> 00:11:04,980 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. 89 00:11:04,980 --> 00:11:14,490 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. 90 00:11:14,490 --> 00:11:19,860 And we need to remember that there's multiple ways of understanding disease and 91 00:11:19,860 --> 00:11:25,830 therefore multiple ways of understanding how to try to solve the problem of disease. 92 00:11:25,830 --> 00:11:33,240 But the epidemics of cholera did. And in England, I think the last major epidemic was in eighteen, sixty six. 93 00:11:33,240 --> 00:11:39,630 So how and why did cholera end in England? 94 00:11:39,630 --> 00:11:44,370 Well, I would define this as an unexamined question. 95 00:11:44,370 --> 00:11:57,450 Cholera certainly didn't end because of herd immunity and obviously there were no vaccines in the four epidemics of cholera. 96 00:11:57,450 --> 00:12:02,100 It affected different places, different degrees of severity. 97 00:12:02,100 --> 00:12:11,700 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. 98 00:12:11,700 --> 00:12:15,630 I think what you can say, although there's still a lot of argument about this, 99 00:12:15,630 --> 00:12:23,670 is that cholera was prevented from returning by improvements in particularly water supply, 100 00:12:23,670 --> 00:12:31,410 just as the incidence of typhoid was reduced by the improvements in water supplies. 101 00:12:31,410 --> 00:12:39,960 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. 102 00:12:39,960 --> 00:12:50,160 Thought of it in terms as a visitation and even the religious interpretations faded as the century went on. 103 00:12:50,160 --> 00:13:03,010 Now, they would have decided that cholera had ended up on the basis of mortality statistics, which the 19th century specialised in collecting. 104 00:13:03,010 --> 00:13:08,440 But the other that the other agencies involved would be the foremost authority 105 00:13:08,440 --> 00:13:16,900 at the time to determine when it was judicious to have a day of Thanksgiving, 106 00:13:16,900 --> 00:13:21,220 say, or to end chronic forms of quarantine. 107 00:13:21,220 --> 00:13:34,890 These are essentially political decisions. To my mind, unlike saying playing certain periods, I don't think that cholera could have been endemic, 108 00:13:34,890 --> 00:13:41,010 that is sort of recurring at grumbling low level in between the epidemics. 109 00:13:41,010 --> 00:13:45,900 It does appear to have been, you know, been and gone. 110 00:13:45,900 --> 00:13:53,740 And to me, it's not actually clear why. Which makes your project very interesting one. 111 00:13:53,740 --> 00:13:59,320 This is a very interesting point, because many people might have heard of John Snow, 112 00:13:59,320 --> 00:14:06,070 who's often called the father of epidemiology and the story that it's really his work that ended cholera in England. 113 00:14:06,070 --> 00:14:08,170 That is according to this version. 114 00:14:08,170 --> 00:14:16,300 Snow basically establishes the discipline of epidemiology by mapping out the sources of water during cholera outbreaks in London, 115 00:14:16,300 --> 00:14:24,850 tracing infections back to one location, even tracing it back to one specific water pond called the Broad Street Pump in London. 116 00:14:24,850 --> 00:14:25,900 And in some versions, 117 00:14:25,900 --> 00:14:35,860 we even have snow himself ending cholera by going and physically removing the pump handle and thereby stopping the transmission of cholera. 118 00:14:35,860 --> 00:14:39,220 But you seem to be suggesting that in actual fact, 119 00:14:39,220 --> 00:14:47,140 the ending of cholera in England was not due to one man or one action or the rise of a new discipline, 120 00:14:47,140 --> 00:14:54,640 but instead needs to be understood within changes across very various areas of societies and thinking about medicine as a whole, 121 00:14:54,640 --> 00:15:04,270 thinking about broad social and sanitary reform. So how would you tell the story of the end of cholera in England? 122 00:15:04,270 --> 00:15:07,600 Well, I think at the moment, it can't actually be told, 123 00:15:07,600 --> 00:15:13,210 because it's not clear that there would be other factors like which have been argued about by historians, 124 00:15:13,210 --> 00:15:19,930 like improvements in nutrition, for example, or even improvements in housing. 125 00:15:19,930 --> 00:15:31,330 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, 126 00:15:31,330 --> 00:15:39,610 and the curious thing is that this myth about John Snow and the pump handle persists into the present day. 127 00:15:39,610 --> 00:15:48,910 And there even seems to be something called pump handle epidemiology, which I think relates to direct and straightforward, 128 00:15:48,910 --> 00:15:57,250 relatively simple actions taken by humans, obviously, which bring an epidemic to an end. 129 00:15:57,250 --> 00:16:03,760 Now, even Snow didn't think that he brought the epidemic to an end by removing the pump handle, 130 00:16:03,760 --> 00:16:08,800 nor is it at all likely that he did actually remove the pump handle himself. 131 00:16:08,800 --> 00:16:15,670 So this was a story created by a physician friend of yours called Benjamin Ward Richardson. 132 00:16:15,670 --> 00:16:28,390 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. 133 00:16:28,390 --> 00:16:40,720 But because this was a very dramatic, severe outbreak in central London, it has gone down in history, you could say, as something definitive. 134 00:16:40,720 --> 00:16:52,670 And also Snow's making has gone down in history, something definitive, even though they were precursors in terms of disease maps. 135 00:16:52,670 --> 00:16:58,800 But he's become, to use the current term, totemic. Well, 136 00:16:58,800 --> 00:17:07,080 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. 137 00:17:07,080 --> 00:17:12,600 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 138 00:17:12,600 --> 00:17:26,164 where we discuss other epidemics and other versions of endings of epidemics.