Notes on epidemics : for the use of the public (1866)

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In London, in June [9] , a localized epidemic in the East End claimed 5, lives, just as the city was completing construction of its major sewage and water treatment systems. William Farr , using the work of John Snow, et al. Quick action prevented further deaths. During the fifth cholera pandemic , Robert Koch isolated Vibrio cholerae and proposed postulates to explain how bacteria caused disease.

His work helped to establish the germ theory of disease. Prior to this time, many physicians believed that microorganisms were spontaneously generated, and disease was caused by direct exposure to filth and decay. Koch helped establish that the disease was more specifically contagious and was transmittable through contaminated water supply.

The fifth was the last serious European cholera outbreak, as cities improved their sanitation and water systems. Cholera is an infection of the small intestine caused by the bacterium Vibrio cholerae. Cholera is transmitted primarily by drinking water or eating food [11] that has been contaminated by the cholera bacterium. The bacteria multiply in the small intestine; [12] the feces waste product of an infected person, including one with no apparent symptoms, can pass on the disease if it contacts the water supply by any means.

History does not recount any incidents of cholera until the 19th century. Cholera came in seven waves, the last two of which occurred in the 20th century. The first cholera pandemic started in , spread across India by , [13] and extended to Southeast Asia and Central Europe , lasting until A second cholera pandemic began in , reached Russia, causing the Cholera Riots.

The third cholera pandemic began in and lasted until It hit Russia hardest, with over one million deaths. In , cholera struck Mecca , killing over 15, Cholera hit Ireland in and killed many of the Irish Famine survivors, already weakened by starvation and fever.

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The pandemic spread east to Indonesia by , and China and Japan in The Philippines were infected in and Korea in In , an outbreak in Bengal contributed to transmission of the disease by travelers and troops to Iran , Iraq , Arabia and Russia. The Ansei outbreak of —60, for example, is believed to have killed between , and , people in Tokyo alone. Throughout Spain , cholera caused more than , deaths in — The fourth cholera pandemic — spread mostly in Europe and Africa.

At least 30, of the 90, Mecca pilgrims died from the disease.


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Cholera ravaged northern Africa in and southeastward to Zanzibar , killing 70, in — Outbreaks in North America in — killed some 50, Americans. In the s, cholera spread in the U. In the fifth cholera pandemic — , according to Dr A. Wall, the — part of the epidemic cost , lives in Europe and at least 50, in the Americas. Cholera claimed , lives in Russia ; [33] , in Spain ; [34] 90, in Japan and over 60, in Persia.

The outbreak in Hamburg killed 8, people. Smallpox is caused by either of the two viruses, Variola major and Variola minor. Smallpox vaccine was available in Europe, the United States, and the Spanish Colonies during the last part of the century. The words come from varius spotted or varus pimple. In England this disease was first known as the "pox" or the "red plague". Smallpox settles itself in small blood vessels of the skin and in the mouth and throat. The symptoms of smallpox are rash on the skin and blisters filled with raised liquid.

The disease killed an estimated , Europeans annually during the 19th century and one third of all the blindness of that time was caused by smallpox. It caused also many deaths in the 20th century, over — million. Wolfgang Amadeus Mozart also had Smallpox when he was only 11 years old. He survived the smallpox outbreak in Austria. Epidemic typhus is caused by the bacteria Rickettsia Prowazekii; it comes from lice. Murine Typhus is caused by the Rickettsia Typhi bacteria, from the fleas on rats. Scrub Typhus is caused by the Orientia Tsutsugamushi bacteria, from the harvest mites on humans and rodents.

Queensland tick typhus is caused by the Rickettsia Australis bacteria, from ticks. During Napoleon 's retreat from Moscow in , more French soldiers died of typhus than were killed by the Russians. Typhus appeared again in the late s, and between and during the Great Irish Famine. Spreading to England, and called "Irish fever", it was noted for its virulence.

It killed people of all social classes, as lice were endemic and inescapable, but it hit particularly hard in the lower or "unwashed" social strata. In Canada alone, the typhus epidemic of killed more than 20, people from to , mainly Irish immigrants in fever sheds and other forms of quarantine, who had contracted the disease aboard coffin ships.

This disease is transmitted by the bite of female mosquito; the higher prevalence of transmission by Aedes aegypti has led to it being known as the Yellow Fever Mosquito. The transmission of yellow fever is entirely a matter of available habitat for vector mosquito and prevention such as mosquito netting.

As a result, the historical record of these events is especially rich and provocative Briggs, ; Rosenberg, ; Rosenberg and Golden, In what follows I will link some of the lessons learned from pandemics past to the quandaries that policymakers are grappling with today in response to a potential influenza pandemic and other microbial threats. And, given that we simply do not have that much solid data on the means of mitigating or containing worst-case scenario influenza pandemics in our modern era, I will discuss why exploring the historical record of the — pandemic may help uncover a body of clues and suggestions.

What makes that record so compelling to me as a historian of infectious diseases is that the — American influenza experience constitutes one of the largest databases ever assembled in the modern, post-germ-theory era on the use of non-pharmaceutical interventions to mitigate pandemic influenza in urban centers. Policy makers, on the other hand, may find it more compelling that the record allows them to have the chance to observe how large numbers of people respond when a pandemic appears but vaccines and antivirals are neither effective nor widely available.

History suggests that when faced with such a crisis, many Americans—and more formally, American communities—will adopt, in some form or another, what they perceive to be effective social-distancing measures and other nonpharmaceutical interventions NPI. This is precisely what the nation did in —, resulting in a wide spectrum of results and outcomes. A critical question is, Can we make sense of and exploit this historical data to inform decisions today on how best to employ or discard various NPI strategies?

And, if so, can we evaluate their costs and benefits in a manner that includes a polished set of social, legal, and ethical lenses? No one can claim that history provides some magical oracle of what to expect in the future. Human history simply does not work that way. It may move in distinct and recognizable patterns, but this is quite different than repeating itself in predictive cycles. Yet despite those limitations, historians, since at least the days of Thucydides, have contributed nuanced and contextualized views of how past dilemmas emerged or evolved and have offered useful models of the resolution of those dilemmas.

These views and models merit our attention. In particular, historians have been trying for millennia to make sense of epidemics, and we can learn much from studying their conclusions. What follows are but two of the many useful models that historians have developed for analyzing the structure of epidemics. When considering the broad scheme of an epidemic or pandemic as a social phenomenon, perhaps the best study that I know of is not a study at all but is rather the remarkable novel by Albert Camus, The Plague —a text I routinely assign to all my students hoping to learn anything about epidemics.

From these considerations Rosenberg characterizes the unfolding of an epidemic as a dramaturgic event, usually in four acts, with a distinct but somewhat predictable narrative plot line:. When leaving his surgery on the morning of April 16, Dr.

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Bernard Rieux felt something soft under his foot. It was a dead rat lying in the middle of the landing. On the spur of the moment he kicked it to one side and without giving it a further thought, continued on his way downstairs. Only when he was stepping out onto the street did it occur to him that a dead rat had no business to be on his landing. In the pages that follow Dr. This lethargic response is not restricted to the pages of fiction.

Slow acceptance and delayed courses of action in the face of contagious threats are common features in the history of human epidemics. More often the delayed acknowledgment of an epidemic can be explained by the fact that acknowledging it would threaten various interests or strongly held beliefs, from the economic and institutional to the personal and emotional.

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This dichotomy in understanding deadly disease, with religion or morality on one hand and science on the other, was a hallmark of many societies in the past, and we should not discount the role that religious, spiritual and cultural beliefs and practices can play in mitigating, containing, or inflaming an epidemic in our own era. The history of epidemics is littered with tales demonstrating the importance of bold, decisive leadership and the costs of ineffective or incompetent crisis management.

Epidemics often end as ambiguously as they appear. Or, to lift a phrase from the poet T. A critical question, therefore, is how a community or government maintains credibility in its warning systems, maintains public support for costly preparedness planning, and keeps the public alert but not alarmed, panic-stricken, or completely disengaged. This four-act model of epidemics is an excellent starting point for our contemplation of pandemics, but, of course, not all microbial threats will follow such a straightforward narrative structure.

For that reason, many historians of epidemics have taken a different tack and set out to understand epidemics by identifying their major ingredients or features. This leads to a different model of the structure of epidemics and pandemics. In my own work over the past 16 years I have attempted to identify and describe critical leitmotivs that have appeared repeatedly in epidemics and pandemics across time.

Not all of the themes that I have identified in this work will appear in each epidemic or pandemic. Instead they should be viewed as major ingredients of an epidemic with the understanding that the precise mix of the themes can change from era to era and disease to disease. These leitmotivs include the following:.

Thinking about epidemics is almost always framed and shaped—sometimes in useful ways, sometimes not—by how a given society understands a particular disease to travel and infect its victims. People living in eras when microbes were not considered to be the cause of epidemic diseases responded to these threats differently from people living in eras when the role of microbes was understood. Well into the nineteenth century, for example, experts and lay people alike believed that many epidemics and contagious diseases were spread through polluted air—or miasma, from the Greek word for defilement of the air or pollution.

The miasmatic theory of disease held that toxic emanations emerged from the soil or from rotting organic material or waste products and caused specific epidemic diseases such as cholera, typhus, and malaria. Given the foul odor that pervaded every urban center of this era, the belief that it was an unhealthy force makes a good deal of sense, but when this theory was in vogue it led to public-health approaches that were very different from those taken today. Aside from calls for quarantine, most attempts to manage an epidemic centered on cleaning up and disinfecting streets, sewers, privies, and other dirty parts of the urban environment.

This trend changed markedly in the mid-to-late nineteenth century with the advent of the germ theory of disease, and it continues to be revised, refined, and fine-tuned today as we learn more and more about microbial ecology, evolution and genomics. Still, old ideas about contagion are often slow to die and, like fevers of unknown origin, have the power to recrudesce; as a result, many people today have ideas about the cause and spread of particular infectious diseases that are markedly different than the principles we teach in the medical school classroom Duffy, An order of quarantine, which closes a port or a city to foreign travelers or goods, costs communities a great deal of money and creates great hardships for individuals.

It is not surprising, then, that during the international sanitary conferences of the mid-nineteenth century, merchants were often vocal opponents of any efforts to prevent or contain disease that might have had the effect of impeding commercial enterprises and the flow of capital.

There are two sides to this equation however. While increased global commerce can certainly contribute to the spread of a pandemic, it also sets up conditions that encourage more effective responses to a pandemic. Epidemics cost the business community a lot of money, and, in particular, the cost of a human-to-human avian influenza pandemic would be, according to all reliable projections, simply staggering. The threat of such losses could therefore encourage developing nations faced with a brewing epidemic to communicate more openly with Western nations in the hope that their greater financial resources could help them rapidly contain or mitigate the outbreak Stern and Markel, The movements of people and goods and the speed of travel are major factors in the spread of pandemic disease.

It is no coincidence that the rise of bubonic plague pandemics during the Middle Ages as well as the invention of the formal concept of quarantine coincided with the advent of ocean travel and imperial conquest. As humans traveled in wider and wider circles, so too did the germs that inhabited them. During the nineteenth century, four devastating cholera pandemics were aided and abetted by the transoceanic steamship travel of millions of people.

By the close of the 19th century, journeys from Europe or Asia to North America required a travel time of 7 to 21 days, which gave most infectious diseases ample incubation periods and facilitated their recognition by health officers at the point of debarkation. It is quite different today, when the main mode of international travel, commercial jet planes, allow people to travel anywhere in the world in less than a day. Indeed, a recent study in PLoS Medicine details how seasonal influenza can mirror peaks and valleys in air travel Brownstein et al.

Yet while the natural response to a pandemic might be to limit air travel, either by an international edict or by the natural response of people to avoid travel by commercial airliner during such a crisis, such a response would pose a new set of troubling and potentially damaging consequences. Our fascination with the suddenly appearing microbe that kills relatively few in spectacular fashion too often trumps our approach to infectious scourges that patiently kill millions every year. An even more egregious example is the lack of widespread attention to the common scourges of lower respiratory tract infections and diarrheal diseases, which kill millions on an annual basis Markel and Doyle, ; Achenbach, Unfortunately, it will be impossible to know until long after the money and resources have been committed—and perhaps only after a flu pandemic has actually occurred—whether influenza was the right microbe to focus upon instead of one of the host of other emerging and re-emerging infectious threats that we face.

Perhaps the more salient question for our discussion today is how we can apply the lessons of SARS, influenza, AIDS, bioterrorism, and other microbial threats to develop a comprehensive and global plan against contagion. Widespread media coverage of epidemics is hardly new and is an essential part of any epidemic. The media has the power both to inform and to misinform.

In the early twentieth century, for instance, American consumers relied heavily on an extensive print media, whereas consumers today can turn to a panoply of newspapers, magazines, television, radio, cable, Internet sites, Web logs, and discussion groups. That does not mean that Americans today are better informed. In the early twentieth century there were multiple daily editions of newspapers in every major city and large town and a great deal of superb reporting on epidemic threats, allowing a majority of Americans to be well-informed on a wide swathe of scientific issues as they were understood at the time.

It is hardly a new phenomenon how physicians, public-health officials, and others simultaneously accommodate, inform, and, at times, correct the press. Nonetheless there is no question that the breadth of media genres—and the demographics of their consumers—is far greater today than in previous eras, and there is no doubt that the media has a far greater ability to provide consumers with both useful information and misinformation. A dangerous theme of epidemics past is the concealment of the problem from the world at large.

Across time many nations or states have concealed news of an epidemic to protect economic assets and trade. At other times concealment efforts have been motivated by nationalistic bias, pride, or politics, as was the case with South Africa and HIV in the s, China during the first months of the SARS epidemic of , and, over the past few years, Indonesia and avian influenza IOM, , Regardless of the reasons for concealment of a public-health crisis, from the political to the purely mercenary, secrecy has almost always contributed to the further spread of a pandemic and hindered public health management.

One of the saddest themes of epidemics throughout history has been the tendency to blame or scapegoat particular social groups. At many points in American history, especially during the nineteenth and early twentieth centuries, the implicit assumption that social undesirability was somehow correlated with increased risk of contagion has led to the development of harsh policies aimed at the scapegoats rather than the containment of a particular infectious microbe. There are many examples of scapegoating across time, such as the widespread American assumption during the cholera pandemic of that any case of cholera discovered in the United States had been brought from Eastern Europe in the bodies of impoverished Jewish immigrants, the demonization of the Chinese in the bubonic plague outbreak in San Francisco, and, more recently, the stigmatization of gay men and Haitians during the early years of the AIDS epidemic in the United States Markel, , ; Kraut, ; Grmek, Public-health policies that place blame on victims or, worse, on perceived victims can have many negative consequences, including the misdiagnosis of the healthy and isolating or quarantining them with unhealthy people; social unrest, legal entanglements, and infringements of civil liberties; and extremely counterproductive behaviors by those targeted as diseased.

Such negative results have the potential to detract in a major way from efforts to contain or mitigate a contagious disease. Ultimately, however, the Rosenberg model works best for a single-phase epidemic rather than a multiphasic pandemic such as the entire four-wave flu pandemic of — The leitmotiv model can also be a useful lens through which to view the pandemic, but with one key exception: the social scapegoating leitmotiv was not all that loud.

I suggest that this was because the pandemic spread so rapidly and ubiquitously among all sectors of American society especially among those 20—45 years of age. That does not mean, however, that we should assume that this unsavory feature of epidemic disease could not rear its head in the present or future. One has only to recall the SARS epidemic of and the short-lived but well-publicized ban on all Asian exchange students at the University of California at Berkeley, to name one recent example, to realize that it can still happen here.

All of the other leitmotivs described above did feature prominently in the influenza pandemic. For example, during the pandemic it was very common for local business owners to oppose nonpharmaceutical interventions that seriously affected their economic health. School and business closings, restrictions on travel, and even the use of face masks often proved to be quite contentious issues. Furthermore, many warnings of an influenza pandemic in the early summer of went unheeded; indeed, the stacks of medical libraries are filled with rarely read public health reports published in the years before the flu pandemic that urged the creation of more hospital beds and isolation wards as well the development of better diseases surveillance and containment strategies Markel, And once the flu crisis was over, little was done to rectify public health administrative problems that were exposed by the —20 pandemic.

Other leitmotivs that played significant roles in the pandemic include how the media interpreted the contagious spread of influenza and reported on these events; the role public health risk communications played in containing or mitigating the spread; the internecine rivalries between local, state, and federal health agencies and political leaders; suppression of reporting of cases in , this was often because privately practicing physicians did not want to lose control of—and remuneration from—their paying patients by reporting and referring them over to public health departments ; the unclear etiology of influenza; ineffective vaccines against the wrong organism; and, of course, issues of travel, particularly the mass movements of soldiers around the country and then to the European theater of what we now refer to as World War I.

Although historians by nature are hesitant to predict the future, I feel quite comfortable in suggesting that most or all of these themes will again be part of whatever emerging infectious disease crises we face in years to come. And while I cannot tell you what the exact proportion or precise mix of ingredients in this recipe will be, I do think history provides us with many thought-provoking, broad-brush strokes with which to think about pandemics. To investigate how historical inquiry can inform the planning of pandemic mitigation strategies, one must first be aware of the limits of this approach.

1846–1860 cholera pandemic

A good way to think about archival research is to imagine your life being recorded by a historian. Every day the scholar would file a report and store that document in a bank of file cabinets that, by the end of your life, would presumably hold many reams of paper. Imagine, then, that a fire destroys most of that room, with only occasional file folders from discrete periods of your life surviving.

With few exceptions, such spotty records are what historians deal with in their inquiries, and much of our knowledge of the past depends on the supporting archival materials that were actually saved. Furthermore, some archival materials may not be entirely reliable or may simply be unavailable, and sometimes historians may misinterpret the materials, creating yet more problems. Many times, lacunae in the historical record are so great that we can only hypothesize or speculate about what may actually have occurred. Moreover, when one studies the history of epidemic disease, a whole new set of highly specialized records becomes important.

For the — influenza pandemic there are many cases where critical numerical population and case-incidence data were not recorded or were recorded in a manner less consistent than we would demand of a prospective study conducted today. Such gaps constitute significant challenges and even roadblocks in any historical study. One also needs to be familiar with the social, cultural, and intellectual history of the region under study and to know its differences from and similarities to our contemporary era.

For example, someone studying the flu epidemic should know that the United States of that time had many similar features to the modern era: rapid transportation in the form of trains and also automobiles, although certainly many fewer automobiles than we have today; rapid means of communication in the form of telegraph and telephone; large, heterogeneous populations with substantial urban concentrations although many more Americans lived in rural environments in as compared to the present ; a news and information system that was able to circulate information on the pandemic widely; and a broad spectrum of public health agencies at various levels of government.

Conversely, there are also many striking contrasts between that era and our own. For example, the legal understanding of privacy and of civil and constitutional rights as they relate to public health and governmentally directed measures such as mass vaccination programs or medications has changed markedly over the past eight decades. Furthermore, public support of and trust in these measures—along with trust in the medical profession in general—has changed significantly over this time, especially with regard to vaccines and medications. This can be seen, for example, in the recent spate of lawsuits filed because of vaccine failures or because of perceptions that vaccines may have significant and dangerous side effects.

Other features of the modern world that need to be considered when studying the historical record of the pandemic in order to inform contemporary policymaking include the speed and mode of travel, particularly the development of high-volume commercial aviation; immediate access to information via the Internet and personal computers; a baseline understanding among the general educated population that the etiological agents of infectious diseases are microbial; and advances in medical technology and therapeutics which have vastly changed the options available for dealing with a pandemic.

Another important aspect of American society circa that was markedly different from the present is how daily commercial transactions are carried out. In there were no supermarkets, refrigeration was primitive, and a limited variety of preserved foods were available for purchase. Consequently, consumers often needed to shop daily at multiple locations, such as grocers, produce vendors, bakeries, and butchers. Moreover, there were no credit cards, and personal checking accounts were typically employed only by the affluent, so frequent visits to banks for cash were not uncommon.

Indeed, for ordinary citizens in the United States was almost entirely a cash economy. So while the closure of a bank during an epidemic in might be explained as a public health measure, for the many Americans who had lived through the Depression of as well as other boom and bust cycles, such an action might well be misconstrued as a failure of the bank itself, and, as such, it had the potential to create civil unrest. As a result, the last public spaces to close during the pandemic—after theaters, schools, churches, restaurants, and saloons—were often banks and other financial institutions.

Today, on the other hand, a number of daily functions of life can be accomplished with little or no human interaction—provided you have the economic and educational resources to carry them out. Banking and credit transactions, the ordering and delivery of food via the Internet, entertainment, and personal and business communication, to name just a few, can all be carried out by large numbers of Americans in a way that can allow them to minimize human contact and thus shield themselves somewhat from the spread of contagious disease Germain, ; Chandler, ; Blackford, ; Rothbard, Nevertheless, as recent disasters have shown, many Americans have little in the way of an economic safety net, and their restricted access to financial resources and even basic needs of living could have a deleterious affect on disaster-containment strategies.

The overwhelming majority of histories of the influenza pandemic focus on its widespread carnage. Consequently, our research group was surprised to uncover the archival remnants of a handful of American towns or institutions that emerged from the virulent second wave of the pandemic—September to December —with relatively few influenza cases and no deaths.

The crucial question we were being asked was if the historical experiences of these escape communities might reveal some strategy to keep a small, but specific, sector of the population—the U. Armed Forces—completely free of influenza. The results of this year-long, in-depth archival study proved somewhat vexing.


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Some of these so-called escape communities that we studied, such as the village of Fletcher, Vermont population were too small to suggest that their success resulted from anything more than remote location, the uneven attack rates of the virus, and good fortune. Two communities, the U. Naval base at Yerba Buena Island, one mile from the busy port of San Francisco, and the mining town of Gunnison, Colorado not only escaped the pandemic, they also had carried out a particularly extensive menu of restrictive public health measures i. Under the bold, decisive direction of astute public health officers, the still-healthy island and mountain towns essentially cut off all contact with the outside world to shield themselves from the incursion of influenza before it arrived in their vicinity, a measure we termed protective sequestration.

In a nation besieged by flu, Yerba Buena and Gunnison boasted zero mortality and almost no cases of infection over a lengthy time period. When planning for pandemics, it is tempting to focus on the apparent success of protective sequestration at Yerba Buena and Gunnison. But lest we be too eager to adopt such measures widely today, we must recall that one of these communities was literally an island directed by the bold, iron hand of a naval commander who could isolate his men from flu-ridden San Francisco.

The other was a small, homogeneous, and well-run mining town situated high in the Rockies that could barricade its roads and regulate its railways. Historical analysis of the few communities around the world that did manage to escape the influenza pandemic including Australia and American Samoa reveals an obvious but admittedly not terribly practical prescription: live in a remote area, preferably an island or mountain community, that can wall itself off from human contact.

On the other hand, there are tantalizing suggestions that all these escape communities experienced much milder third waves of the pandemic when compared to neighboring communities. During the pandemic, a broad menu of NPI was executed in different American cities that have captured our attention including making influenza a reportable disease; isolation of the ill; quarantine of suspect cases and families of the ill; closing schools; protective sequestration measures; closing worship services; closing entertainment venues and other public areas; staggered work schedules; face-mask recommendations or laws; reducing or shutting down public transportation services; restrictions on funerals, parties, and weddings; restrictions on door-to-door sales; curfews and business closures; social-distancing strategies for those encountering others during the crisis; public-health education measures; and declarations of public health emergencies.

The motive, of course, was to help mitigate community transmission of influenza. Over the next twelve months we will endeavor an historical epidemiological analysis of the application of NPIs in these communities during — with the goal of informing the potential use of NPIs in future pandemics. At present, no rigrous, systematic historical and epidemiological study exists on the relationship, positive or negative, between influenza case incidence and death rates during the pandemic and the NPIs taken at different points of time by the most-populated urban centers in the United States.

Our principal aim is to fill this intriguing and pertinent lacuna. Working with a team of epidemiologists, historians, and statisticians, based both at Michigan and the CDC , we are now engaged in the rather arduous task of digging up every municipal report from the 43 large cities in the continental United States during the — pandemic—many of which reside in dusty unmarked boxes or storage units of libraries that have rarely if ever been consulted in the secondary historical literature on the pandemic.

Further, we will analyze a wide body of U. When completed, the final report and its supplementary Web-based influenza archive will constitute a widely accessible version of the largest single collection of nonpharmaceutical intervention data taken in the United States during the — influenza pandemic. Every detail, whether it is the number of the dead in a particular city for a particular week or the political battles being reported in the press, will be compared with at least two other sources for verification.

Similarly, in each of the cities studied we will consult at least two newspapers that have been identified in terms of political party affiliation, editorial policy, and circulation figures. We do not promise any oracular commandments for pandemic preparedness, but we are confident that our fine-grained, rigorous, and scholarly historical epidemiological analysis of these American cities will significantly inform those who are considering the application, utility, policies, and design of nonpharmaceutical interventions today.

When contemplating pandemics it is clear that precise shapes and contours of the next influenza pandemic will be strikingly different from those of the past. But there is a positive side to this change over time. Specifically, this is essentially the first pandemic in human history where we will have had some semblance of advance warning—and hence, the opportunity to prepare.

As such, I am historically optimistic that lessons from both the past and present can help us devise effective and also ethically and socially appropriate strategies to mitigate the microbial threats that inevitably loom on our horizon. View in own window. For more information on the evolution of the International Health Regulations see Annex , pages 59— George E.

Wantz M. For a broader look at the history of quarantine, infectious diseases and public health, particularly as they pertain to influenza, see: Mullet CF. A century of English quarantine, — The history of quarantine in Britain during the 19th century. Bulletin of the History of Medicine 25 1 —44; Hardy A. Cholera, quarantine and the English preventive system, — Medical History 37 3 —; Rosen G. A History of Public Health. International Quarantine. Epidemics and history: ecological perspectives and social responses.

In Fee E, Fox D. The Great Epidemic. The Great Influenza.

1846–1860 cholera pandemic

New York: Viking. For more literary versions of the drama of epidemic disease and quarantine, see: Boccaccio G. The Decameron, Translated by J Payne. A Journal of the Plague Year. The Plague. Paris: Knopf. Ibsen H. An Enemy of the People. Translated by J McFarlane. Communities during the Second Wave of the — Influenza Pandemic. Defense Threat Reduction Agency: U. Department of Defense.

To consult all of the primary source materials that comprised this report, see: The University of Michigan Center for the History of Medicine. Nonpharmaceutical influenza mitigation strategies, U. Emerging Infectious Diseases 12 12 : — Turn recording back on. National Center for Biotechnology Information , U. Search term. David Heymann, M. Issues Between Governments: Infectious Disease and Commerce Humans have long transmitted diseases over great distances. Securing Equitable Access to Health-Care Resources Some epidemics recur year after year because the affected populations do not have access to the appropriate vaccines and drugs.

Public Health Measures: Balancing Individual Rights and the Common Good During the smallpox eradication campaign, vaccines were offered to targeted populations using a ring vaccination strategy: vaccinating all households around that of the infected person and vaccinating any contacts that could be traced. Global Alert and Containment On February 26, , the WHO office in Hanoi reported the case of a year-old businessman with high fever, atypical pneumonia, and respiratory failure who had recently traveled to China and Hong Kong.

Revision of the International Health Regulations Within four months of beginning containment activities, and without the use of novel drugs or vaccines, all chains of human-to-human transmission were broken, the SARS virus was driven out of its new human host, and the outbreak was declared over.

The Four Acts Model of an Epidemic When considering the broad scheme of an epidemic or pandemic as a social phenomenon, perhaps the best study that I know of is not a study at all but is rather the remarkable novel by Albert Camus, The Plague —a text I routinely assign to all my students hoping to learn anything about epidemics.

Major Leitmotivs of Pandemics In my own work over the past 16 years I have attempted to identify and describe critical leitmotivs that have appeared repeatedly in epidemics and pandemics across time. These leitmotivs include the following: Thinking about epidemics is almost always framed and shaped—sometimes in useful ways, sometimes not—by how a given society understands a particular disease to travel and infect its victims. The Power and Limits of Historical Inquiry To investigate how historical inquiry can inform the planning of pandemic mitigation strategies, one must first be aware of the limits of this approach.

Conclusion When contemplating pandemics it is clear that precise shapes and contours of the next influenza pandemic will be strikingly different from those of the past. Can we stop the next killer flu? Washington Post. Dec 7, Blackford MG. A History of Small Business in America.

Briggs A. Cholera and society in the nineteenth century. Past and Present. Empirical evidence for the effect of airline travel on the inter-regional influenza spread in the United States. PLoS Medicine. Chandler AD. Cambridge, MA: Belknap Press; Crosby AW. Duffy J. Urbana: University of Illinois Press; Evans RJ. New York: Penguin Books; Germain RN.

Westport, CT: Greenwood Press;