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Choosing our future

• Lens of history• Unsanitized version

1. Turning points in epidemiology 2. The present juncture 3. The choice we face 4. Our contribution5. A historical prototype6. Discussion

1. Turning points in epidemiology

Historical eras

Transitions

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Distinct Eras in Epidemiology

1850-1900Sanitary

2000-?Eco-

1950-2000Risk Factor

1900-1950Infectious

Up to 1850Early origins

Dates very approx and overlap

Transitions

• PH tied to political change

• Epi tied to PH

EnglandEarly industrial revolution

CrowdingFilthSocial breakdown

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Farr

William FarrScience of Social Reform

• Used statistics for reform• Health was part of reform• Social inequalities in health

Florence

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Edwin ChadwickFather of public health

The tome-Condition of Laboring Classes

The legislation-Sanitary Laws

Edwin Chadwick a.k.a. Jeckyll and Hyde

Poor laws 1834 Workhouses

Public Health Act 1848 Sanitary reform

“condition of England”

Threat of revolution

Social unrest Destitution Disease

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Edwin Chadwick

Reduce disease to —Ensure social stabilityIncrease productivity

Edwin Chadwick

Sanitary reform did not–usurp social orderaddress inequality

2. The present juncture

• The AIDS Pandemic

• Terrorism

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HIV/AIDS

• Holocaust of our times

• Greatest challenge ever

• Our legacy

THEN AND NOW

THEN 1800-1850Condition of England

NOW 2000-Global security

Public HealthAnd Terrorism

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9/11 and HIV

• Are they competing?

• Are they synergistic?

• What relation to other epi?

Our city

•1892•HIV•9/11

3. Choices we face

• Engage or detach

• Integrate or fragment

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To engageMove beyond RFE

• Levels• Time• Genes

Danger of fragmenting

• Risk factors • Social inequalities• Developmental trajectories• Genes• ID dynamics

Opportunity for integrating

• Chronic and infectious

• Health and mental health

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Chronic vs infectious outmoded

Chronic infectious: HIV

Infectious chronic: Peptic ulcer

Health vs mental health outmoded

• Brain is an organ• Epidemic is a social event• DALYS

Public Mental Health

Gap in public health

Undeveloped

Isolated

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4. Our contribution

• Health and mental health

Our DepartmentDestined to play a role

• Connection to South Africa

• Connection to 9/11

• Neuro and psych epi

A dead victim of cholera at Sunderland.

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19th century cholera

• Terror and social disruption

• Far out of proportion to death toll

• Dominated public health agenda

The terror of cholera

Paris cholera epidemic 1832

“… a reign of terror far more dreadful than the first, because the executions took place so rapidly and mysteriously…”

Heinrich Heine

The fear of cholera

• Sudden onset

• Rapid death

• Stool and vomit

• Blue corrugated skin

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A young man afflicted with syphilis .

Syphilis

Sin, syphilis and skeletons

Syphilis

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Global AIDS campaign

• Neurotropic virus

• Stigma

• Behavior

Global AIDSThe survivors

• Grief • Terror• Social breakdown• Orphans

Fighting AIDS in Africa

Vaccine development

Delivery of treatment

Individual behavior change

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What is still missing?

• social movement

• political leadership

• local PH capacity

What is still missing?

• Mental health

Defending Against theTerror of Terrorism

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A POLITICAL ACT

• Public mental health is the target

• Direct victims area means to an end

AIMS

• Unsettle people

• Demonstrate vulnerability

• Change balance of morale

WTC

• Symbol of US • World-wide• Like a flag

Anthrax

• Mailed to media• Six died• Millions anxious

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NYC AFTER 9/11PRESENT STATE

• Massive effect• High recovery rate• >200,000 ongoing cases

Enhanced Community and Individual Adaptation

Previous Level of Equilibrium

Impact

“Honeymoon”

Stigma, Mistrust,and Discrimination,

Warning

2003

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Perception of justice

• Key to social recovery

• Includes mental health care

• Presents the opportunity

5. A historical prototype

• Cholera 1892

Koch

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GOLDEN AGE OF BACTERIOLOGY 1877-1889

• Tuberculosis

• Cholera

• Typhoid

• Diphtheria

• Many others

NOT READY FOR PUBLIC HEALTH

AGENT WAS NOT ENOUGH

AGENTHOSTENVIRONMENT

Tale of two cities

Cholera epidemic of 1892

• Hamburg

• New York

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1892 Cholera NYC

• Cholera breaks out in Hamburg

• Panic breaks out in NYC

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Cholera 1892 Hamburg responds

Concealment

• Past failure of quarantine • Resistance to Koch• Fear of disrupting trade

Cholera 1892 Hamburg responds

• Hamburg-America line• Russian Jews en route • Sent to NYC

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Industrial revolution NYC

• Immigration

• Crowding

• Resources

Crowding NYC

Lower east side manure

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Street cleaning

Cholera/jews/germans

1892 Cholera New York responds

“Quarantine and a few slides”

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QuarantineNormannia

QuarantineFor steerage passengers

“Their faces and hands were soiled, their clothing dirty, the air in the place was foul … floors were offensive from soiling with filth and feces…system of simple human storage … like cattle…”

Report of advisory committee

Normannia Cabin Class

• Lottie CollinsTa ra ra boom de ay

E.L.Godkin editorLetters from Normannia“…rare among the well-fed and

cleanly class…”

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Lottie

Quarantine for the poor

Quarantine for the rich

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Quarantine in the fieldPopular resistance

• Uprooted the victims• Little explanation• Victims might not be “sick”• Targetted poor communities

Mitchell Prudden

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Biggs and Prudden

• aggressive quarantine of shipsProbably had major impactDid not fully support it

• bacteriologic diagnosisLimited if any impactProposed key role for it

Cholera 1892New York is saved

Biggs credits bacteriology“Unlike Hamburg, we used the

new science”

Hermann BiggsPolitically astute

Ties to cholera-bacteriology labdiphtheria campaign

Builds model health dept

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Hamburg demoralized

Robert Koch:“ I forget I am in Europe”

Imperial rule

Does not lead to change

1892 cholera What it exemplifies

epidemic of mental and social distress as well as disease

health systems responded to the mental and social distress as well as disease

presented opportunity for systems change —but only prepared minds could take it

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NOT READY FOR PUBLIC HEALTH

AGENT WAS NOT ENOUGH

AGENTHOSTENVIRONMENT

HOSTVon Pettenkoffer

• Swallowed a cholera cocktail

• First to formulate agent/host/env

• Challenge was never fully answered by Koch and others

Von Pettenkoffer

Lost heart

Ultimately committed suicide

History written by the victors

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Contagion could not account for disease patterns

Intimate contacts-

do not always get disease

De novo cases -

without any contact

AGENT WAS NOT ENOUGHTO EXPLAIN TRANSMISSION

Mode of transmission

Silent carriers

Insect vectors

The lens of history

• Themes recur

• Each era: one part of picture

• We need to see whole picture

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Eco-epidemiology

• Tied to public health

• Cells, individuals, societies

6. Discussion