tag:theconversation.com,2011:/au/topics/typhoid-10270/articles
Typhoid – The Conversation
2021-08-09T12:26:52Z
tag:theconversation.com,2011:article/164827
2021-08-09T12:26:52Z
2021-08-09T12:26:52Z
Shutting down school vaccine clinics doesn’t protect minors – it hurts people who are already disadvantaged
<figure><img src="https://images.theconversation.com/files/414824/original/file-20210805-13-9sbvnr.jpg?ixlib=rb-1.1.0&rect=11%2C0%2C3982%2C2556&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A high school student gets his COVID-19 shot at a pop-up vaccine clinic at a public charter school in Los Angeles.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/year-old-aaron-delgado-receives-his-pfizer-covid-vaccine-news-photo/1234436892">Al Seib / Los Angeles Times via Getty Images</a></span></figcaption></figure><p><a href="https://www.newspapers.com/image/119585257/">A 1918 newspaper article</a> captures public attitudes toward a typhoid vaccine clinic at the Oakdale schoolhouse in Louisville, Kentucky. “Everybody comes – railroad men, children, young girls, old people, housewives,” it reads, “all with sleeves that roll up and arms ready for the brief stick with the fine needle.” </p>
<p>Until recently, school-located vaccination clinics, or SLVs, have been applauded, or <a href="https://doi.org/10.1177/1059840510369231">simply taken for granted</a>. That changed in mid-July of 2021, when Tennessee <a href="https://www.tennessean.com/story/news/health/2021/07/13/tennessee-halts-all-vaccine-outreach-minors-not-just-covid-19/7928701002/">halted COVID-19 vaccination clinics on school property</a>. The decision was part of a broader effort to cease vaccine messages geared toward children and adolescents. The pause lasted only 10 days and has since been <a href="https://www.tennessean.com/story/news/health/2021/07/23/tennessee-restart-vaccine-outreach-paused-amid-gop-pressure/8043482002/">somewhat reversed</a>, limiting vaccine promotion to messages geared at parents and holding some vaccine events on school property.</p>
<p>Those who want to eliminate school-located COVID-19 vaccination clinics say the sites exist to immunize children without parental consent. However, even before the Food and Drug Administration expanded eligibility to include 12-to-15-year-olds, school-located sites offered COVID-19 vaccines to school staff and other eligible adults.</p>
<p>I am an <a href="https://scholar.google.com/citations?user=KeAdSmgAAAAJ&hl=en">expert on the history of epidemics</a>, and my research shows that this current move is an unprecedented detour from schools’ historical promotion of routine vaccines. Preventing school vaccination clinics does not keep waves of teenagers from getting immunized without consent. Rather, it penalizes those who want to get vaccinated but struggle with access. </p>
<h2>Partisan divide</h2>
<p>Tennessee’s “pause” stemmed from the <a href="https://www.kff.org/policy-watch/the-red-blue-divide-in-covid-19-vaccination-rates-is-growing/">Republican Party’s resistance</a> to publicly embracing COVID-19 vaccination, paired with overhyped attention to the <a href="https://www.tn.gov/content/dam/tn/health/documents/Mature_Minor_Doctrine.pdf">Mature Minor Doctrine</a>. </p>
<p>The Mature Minor Doctrine is a Tennessee law allowing “medical treatment and vaccinations to patients as young as 14,” enabling adolescents to make <a href="https://mckinneylaw.iu.edu/ihlr/pdf/vol13p1.pdf">decisions</a> about their own health. It is especially useful for those who don’t live with their parents, are in situations of neglect or abuse or face emergency circumstances. However, it also covers preventive health care and treatment including vaccinations. Many states hold similar consent exceptions.</p>
<p>Whether minors can get the COVID-19 vaccination without parental approval has <a href="https://www.kff.org/policy-watch/covid-19-vaccination-and-parental-consent/">varied by city and state</a>. After the Pfizer vaccine’s emergency authorization expanded to include ages 12 to 15, <a href="https://www.nytimes.com/2021/06/26/health/covid-vaccine-teens-consent.html">news coverage</a> called attention to teenagers receiving COVID-19 vaccines without consent, in some cases questioning the practice without addressing its prevalence or the <a href="https://www.tennessean.com/story/news/american-south/2021/08/04/teen-covid-19-vaccinations-fight-continues-increase-rate-schools-reopen/5430513001/">risk of not immunizing this age group</a>. In Tennessee, the public health department has stated that only <a href="https://www.tennessean.com/story/news/health/2021/07/23/tennessee-restart-vaccine-outreach-paused-amid-gop-pressure/8043482002/">eight adolescents</a> had received a COVID-19 vaccine without parental consent. Furthermore, no evidence has suggested that SLVs have contributed to these cases. </p>
<p>In other words, misplaced ideology, not data on teenagers getting vaccinated without consent, has been the driving force against SLVs, including COVID-19 vaccine clinics at schools. </p>
<h2>From smallpox to HPV</h2>
<p>Since the mid-19th century, schools have been common sites for vaccine clinics to respond to outbreaks and also provide catch-up immunizations. </p>
<p>In 1875, <a href="https://doi.org/10.1177/1059840510369231">17,505 children</a> were immunized against smallpox in New York City school clinics. Temporary <a href="https://www.newspapers.com/image/66584082/">typhoid vaccine clinics</a> emerged in the 1910s and 1920s across the U.S. And the 1954 polio vaccine field trials took place at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1804435/">15,000 public schools</a> across 44 states. </p>
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<img alt="Nurse puts arm around boy as another nurse administers a polio vaccine shot" src="https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=460&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=460&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=460&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=578&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=578&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414832/original/file-20210805-27-9nnji6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=578&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A boy is injected with polio vaccine at a school, circa 1955.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/boy-grimaces-while-being-injected-with-polio-vaccine-news-photo/587497982">USC Libraries/Corbis Historical Collection via Getty Images</a></span>
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<p>Even before Jonas Salk’s polio vaccine received approval in April 1955, <a href="https://www.newspapers.com/image/359079723/">SLVs were scheduled in anticipation</a>. They became the main locations for children to receive their vaccines. In the 1960s, SLVs across the country hosted “Sabin Sundays,” providing the oral polio vaccine developed by Albert Sabin to any unvaccinated <a href="https://ohiomemory.org/digital/collection/p267401coll36/id/19113">adult or child</a>. During this time, school campaigns also expanded to offer immunizations against <a href="https://www.newspapers.com/clip/82726551/schools-to-provide-free-vaccine-1971/">rubella and measles</a>. </p>
<p>Since then, SLVs have continued to be used for public health outreach, protecting children against hepatitis B, seasonal influenza and HPV. Many sites emerge for a short window each year, <a href="https://www.newspapers.com/image/523426147/">providing catch-up immunizations</a> for kids who are behind on other vaccines as well as shots against seasonal flu. Others spring up as needed, as demonstrated with H1N1 immunizations in 2009. Even the pop-up clinics at schools typically require parental consent for participation. </p>
<p>Moreover, SLVs are often available to whole communities – not just school attendees. They are widely effective in addressing <a href="https://www.doi.org/10.2105/AJPH.2009.176628">disparities in immunization</a> linked to income and insurance status. Like other mass vaccination sites, SLVs can immunize large numbers of people in a short period of time and <a href="https://doi.org/10.1371/journal.pmed.1003238">reduce disease in a community</a>. </p>
<p>They have <a href="https://www.cdc.gov/vaccines/covid-19/planning/school-located-clinics.html">additional benefits</a>, too. SLVs are convenient for families and school staff, provide a large, temperature-controlled space, create awareness of the importance of vaccines and <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00032366.htm#00000621.htm">boost rates of completion</a> for vaccines given in a series.</p>
<h2>Pandemic disruptions</h2>
<p>The COVID-19 pandemic caused global disruptions in children’s vaccinations. In 2020, <a href="https://www.who.int/news/item/15-07-2020-who-and-unicef-warn-of-a-decline-in-vaccinations-during-covid-19">routine vaccinations decreased</a> because of stay-at-home orders, <a href="https://www.who.int/news/item/15-07-2020-who-and-unicef-warn-of-a-decline-in-vaccinations-during-covid-19">delay or cancellation of immunization programs</a> and other reasons connected to the global health crisis. </p>
<p>For the diphtheria, tetanus and pertussis vaccines, known as DTaP, New York City experienced a decrease of <a href="https://www.nytimes.com/live/2021/06/10/world/covid-vaccine-coronavirus-mask">16% for children under 2 and 60% for ages 2 to 6</a>. Researchers estimate that routine vaccinations need to increase <a href="https://doi.org/10.1016/j.vaccine.2020.11.074">as much as 15%</a> for vaccine rates to return to pre-pandemic levels. </p>
<figure class="align-center ">
<img alt="A toddler sits in chair with sleeve pulled down to receive flu shot" src="https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414835/original/file-20210805-19-1vmi0re.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A nurse gives a 3-year-old a flu shot at a mobile immunization clinic set up behind John Ruhrah Elementary/Middle School in Baltimore in October 2020.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nurse-hellen-lougon-gives-a-flu-shot-to-3-year-old-sofia-news-photo/1229662559">Katherine Frey/The Washington Post via Getty Images</a></span>
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<p>It’s important to remember that vaccine-preventable diseases are not distant memories. Only smallpox has been globally eradicated – polio, diphtheria, rubella and other dangerous viruses still exist.</p>
<p>Vaccination reductions can produce costly community outbreaks. A single measles case in 2018 erupted into <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1912514">over 600 cases</a> in an undervaccinated community in New York, costing US$8.4 million in public health response efforts, medical expenses and productivity loss. Similarly, Washington state’s <a href="https://doi.org/10.1542/peds.2020-027037">2019 Clark County measles outbreak</a> cost an estimated $3.4 million. </p>
<p>[<em>Understand new developments in science, health and technology, each week.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-understand">Subscribe to The Conversation’s science newsletter</a>.]</p>
<h2>SLVs for COVID-19</h2>
<p>Starting in March 2020, schools across the country began offering COVID-19 vaccines – first for staff and community members, and in May for those ages 12 and up. Such sites have been <a href="https://doi.org/10.1177/1942602X21991643">especially important</a> for <a href="https://edsource.org/2021/new-l-a-school-vaccination-sites-to-open-for-families-of-students-in-hard-hit-communities/652263">low-income and other underserved communities</a> significantly affected by the pandemic. </p>
<p>Once the eligible age expands to include children ages 11 and younger, school vaccine clinics can serve entire families. The <a href="https://www.nytimes.com/2021/08/05/us/politics/school-vaccinations-biden.html?smid=tw-nytimes&smtyp=cur">White House has encouraged</a> every school district to host at least one pop-up vaccination clinic. As with the typhoid and polio clinics before them, the intention is to curb the spread of disease and improve overall public health – the message that should underscore all vaccination decisions for this pandemic.</p><img src="https://counter.theconversation.com/content/164827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katherine A. Foss does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
For decades, US schools have been common sites for vaccine clinics to respond to outbreaks and provide catch-up immunizations. So why are they suddenly controversial?
Katherine A. Foss, Professor of Media Studies, Middle Tennessee State University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/137204
2020-04-29T12:09:09Z
2020-04-29T12:09:09Z
As states weigh human lives versus the economy, history suggests the economy often wins
<figure><img src="https://images.theconversation.com/files/330864/original/file-20200427-145560-1tiukdq.jpg?ixlib=rb-1.1.0&rect=122%2C122%2C4158%2C2729&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A 1620 engraving depicts tobacco being prepared for export from Jamestown, Virginia.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/tobacco-being-exported-from-jamestown-virginia-engraving-news-photo/629437721?adppopup=true">Universal History Archive/Universal Images Group via Getty Images</a></span></figcaption></figure><p>Policymakers are beginning to decide <a href="https://www.nbcnews.com/health/health-news/live-blog/2020-04-21-coronavirus-news-n1188466/ncrd1189061#blogHeader">how to reopen the American economy</a>. Until now, they’ve largely prioritized human health: <a href="https://www.wsj.com/articles/a-state-by-state-guide-to-coronavirus-lockdowns-11584749351">Restrictions in all but a handful of states</a> remain in effect, and trillions have been committed to help shuttered businesses and those who have been furloughed or laid off. </p>
<p>The right time to start opening up sectors of the economy <a href="https://www.nytimes.com/2020/04/10/magazine/coronavirus-economy-debate.html">has been up for debate</a>. But history shows that in the wake of calamities, human life often loses out to economic imperatives.</p>
<p>As a historian of early America <a href="https://doi.org/10.2307/3986264">who has written about tobacco</a> and <a href="https://yalebooks.yale.edu/book/9780300230109/trials-thomas-morton">the aftermath of an epidemic in New England</a>, I’ve seen similar considerations made in the face of disease outbreaks. And I believe that there are crucial lessons to be drawn from two 17th-century outbreaks during which economic interests of a select few won out over moral concerns.</p>
<h2>Tobacco, a love story</h2>
<p>During the 16th century, Europeans fell in love with tobacco, an American plant. Many enjoyed the sensations, like increased energy and decreased appetite, that it produced, and most who wrote about it emphasized its medicinal benefits, seeing it as a wonder drug that could cure a variety of human ailments. (Not everyone celebrated the plant; King James I of England <a href="https://edu.lva.virginia.gov/dbva/files/original/895baf5ed071ac678610228773313ba7.jpg">warned</a> that it was habit-forming and dangerous.)</p>
<p>By the early 17th century, the English grew increasingly eager to establish a permanent colony in North America after <a href="https://www.americanheritage.com/roanoke-lost">failing to do so</a> in places like Roanoke and Nunavut. They saw their next opportunity along the James River, a tributary of Chesapeake Bay. Following the establishment of Jamestown in 1607, the English soon realized that the region was perfect for cultivating tobacco.</p>
<p>The newcomers, however, didn’t know they had settled in an ideal breeding ground for the bacteria that cause typhoid fever and dysentery. From 1607 to 1624, approximately 7,300 migrants, most of them young, traveled to Virginia. By 1625 <a href="https://www.loc.gov/collections/thomas-jefferson-papers/articles-and-essays/virginia-records-timeline-1553-to-1743/1620-to-1629/">there were only about 1,200 survivors</a>. A 1622 uprising by local Powhatans and <a href="https://www.sciencemag.org/news/1998/04/drought-struck-first-colonistslink">drought-induced shortages of food</a> contributed to the death toll, but most perished from disease. The situation was so dire that some colonists, too weak to produce food, <a href="https://www.nationalgeographic.com/news/2013/5/130501-jamestown-cannibalism-archeology-science/">resorted to cannibalism</a>.</p>
<p>Aware that such stories might dissuade possible migrants, the Virginia Company of London circulated a pamphlet that acknowledged the problems <a href="http://www.virtualjamestown.org/exist/cocoon/jamestown/fha/J1059">but stressed that the future would be brighter</a>.</p>
<p>And so English migrants continued to arrive, recruited from the armies of young people who had moved to London looking for work, only to find scant opportunities. Jobless and desperate, many agreed to become indentured servants, meaning they would work for a planter in Virginia for a set period of time in exchange for passage across the ocean and compensation at the end of the contract.</p>
<p>Tobacco production soared, <a href="https://www.nps.gov/articles/plantationsystem.htm">and despite a drop in the price due to the overproduction of the crop</a>, planters were able to amass substantial wealth. </p>
<h2>From servants to slaves</h2>
<p>Another disease shaped early America, even though its victims were thousands of miles away. In 1665, the bubonic plague struck London. The next year, the <a href="https://www.historic-uk.com/HistoryUK/HistoryofEngland/The-Great-Fire-of-London/">Great Fire</a> consumed much of the city’s infrastructure. Bills of mortality and other sources reveal that the city’s population may have dropped <a href="https://doi.org/10.1111/ehr.12098">by as much as 15% to 20%</a> during this period.</p>
<p>The timing of the twinned catastrophes couldn’t have been worse for English planters in Virginia and Maryland. Though demand for tobacco had only grown, many indentured servants from the first wave of recruits <a href="https://www.encyclopediavirginia.org/indentured_servants_in_colonial_virginia#start_entry">had decided to start their own families and farms</a>. Planters desperately needed labor for their tobacco fields, but English workers who might have otherwise emigrated instead found work at home rebuilding London.</p>
<p>With fewer laborers coming from England, an alternative started to seem increasingly attractive to planters: the slave trade. While the first enslaved Africans <a href="https://uncpress.org/book/9781469651798/virginia-1619/">had arrived in Virginia in 1619</a>, their numbers grew significantly after the 1660s. In the 1680s, <a href="https://www.nps.gov/articles/quakerpetition.htm">the first anti-slavery movement appeared in the Colonies</a>; by then, planters had come to rely on imported slave labor.</p>
<p>Yet planters didn’t need to prioritize labor-intensive tobacco. For years, Colonial leaders <a href="http://www.loc.gov/teachers/classroommaterials/presentationsandactivities/presentations/timeline/colonial/virginia/">had been trying to convince planters</a> to grow less labor-intensive crops, like corn. But enamored by the allure of profits, they stuck with their cash crop – and welcomed ship after ship of bound laborers. The demand for tobacco outweighed any sort of moral consideration. </p>
<p>Legalized slavery and indentured servitude are no longer familiar parts of the American economy, but economic exploitation persists. </p>
<p>Despite <a href="https://www.washingtonpost.com/politics/how-do-you-stop-these-people-trumps-anti-immigrant-rhetoric-looms-over-el-paso-massacre/2019/08/04/62d0435a-b6ce-11e9-a091-6a96e67d9cce_story.html">the heated anti-immigration rhetoric</a> that has come from the Oval Office in recent years, the United States continues to rely heavily on immigrant workers, <a href="https://blogs.scientificamerican.com/anthropology-in-practice/what-are-the-jobs-that-immigrants-do/to">which includes farm workers</a>. Their importance has become even more apparent during the pandemic, and the government has even declared them “<a href="https://www.nytimes.com/2020/04/02/us/coronavirus-undocumented-immigrant-farmworkers-agriculture.html">essential</a>.” After Trump <a href="https://twitter.com/realDonaldTrump/status/1252418369170501639">announced his immigration ban</a> on April 20, the executive order <a href="https://www.politico.com/news/2020/04/21/trump-immigration-green-card-coronavirus-198498">exempted</a> farm workers and crop pickers, <a href="https://www.pbs.org/newshour/economy/how-trump-has-already-changed-migrant-worker-programs">whose numbers have actually grown</a> under his administration. </p>
<p>So even before states were weighing whether to reopen nonessential businesses, these laborers were on the frontlines, <a href="https://theconversation.com/how-coronavirus-threatens-the-seasonal-farmworkers-at-the-heart-of-the-american-food-supply-135252">working and sleeping in close proximity, immunocompromised due to chemical exposure, with little access to proper medical care</a>. </p>
<p>And yet rather than reward them for performing this essential work, <a href="https://www.epi.org/blog/trump-administration-reportedly-looking-to-cut-the-already-low-wages-of-h-2a-migrant-farmworkers-while-giving-their-bosses-a-multibillion-dollar-bailout/">some in the government are reportedly trying to slash their low wages even further</a>, while giving farm owners a multi-billion-dollar bailout. </p>
<p>Whether it’s a plague or pandemic, the story tends to remain the same, with the quest for profits eventually prevailing over concerns for human health.</p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>.]</p><img src="https://counter.theconversation.com/content/137204/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter C. Mancall does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
During two 17th-century medical calamities, economic imperatives outweighed moral concerns.
Peter C. Mancall, Andrew W. Mellon Professor of the Humanities, USC Dornsife College of Letters, Arts and Sciences
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/136571
2020-04-24T12:21:23Z
2020-04-24T12:21:23Z
#TyphoidMary – now a hashtag – was a maligned immigrant who got a bum rap
<figure><img src="https://images.theconversation.com/files/329566/original/file-20200421-82658-hqay0c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mary Mallon, after being institutionalized on Brother Island in New York.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/new-york-ny-mary-mallon-known-as-typhoid-mary-she-was-the-news-photo/514968616?adppopup=true">Getty/Bettman</a></span></figcaption></figure><p>The country’s most notable healthy carrier of a deadly disease, Mary Mallon, is back – not in person, but as a hashtag: #TyphoidMary. </p>
<p>In the current pandemic, people may unknowingly harbor and spread the coronavirus before they feel sick, largely because it has an incubation period of between two and 14 days. The Centers for Disease Control and Prevention now says that one in four people could be <a href="https://www.npr.org/sections/health-shots/2020/03/31/824155179/cdc-director-on-models-for-the-months-to-come-this-virus-is-going-to-be-with-us">asymptomatic carriers</a>, never showing symptoms even as they infect others. </p>
<p>But there are also those who, knowing they could be carriers, refuse to cover their mouths or practice social distancing. They include the <a href="https://www.nbcboston.com/news/coronavirus/spring-breakers-flood-florida-beaches-undeterred-by-coronavirus/2093922/">spring breakers who crowded Florida beaches</a> and the <a href="https://www.theguardian.com/us-news/2020/apr/20/us-protests-lockdown-coronavirus-cases-surge-warning">protesters gathering in some state capitals</a>.</p>
<p>Mary Mallon, known as Typhoid Mary, was until now the most prominent example in the U.S. of the unknowing disease carrier. She spread typhoid fever to at least 53 people, <a href="https://www.britannica.com/biography/Typhoid-Mary">causing three deaths</a> between 1900 and 1915. </p>
<p>But Mallon has long been unfairly characterized as knowingly spreading the deadly disease she carried. Her memory has been resurrected recently, largely on Twitter, as a shorthand description of those who intentionally infect others with the coronavirus, #TyphoidMary.</p>
<p>As the author of “<a href="https://www.umass.edu/umpress/title/constructing-outbreak">Constructing the Outbreak: Epidemics in Media and Collective Memory</a>,” I can attest to the media’s past and continuing distortion of the Mary Mallon case. It’s unfair to Mallon to attach her name to such consciously bad behavior.</p>
<h2>Mary Mallon, the healthy carrier</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/329556/original/file-20200421-82666-8necdd.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/329556/original/file-20200421-82666-8necdd.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/329556/original/file-20200421-82666-8necdd.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1454&fit=crop&dpr=1 600w, https://images.theconversation.com/files/329556/original/file-20200421-82666-8necdd.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1454&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/329556/original/file-20200421-82666-8necdd.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1454&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/329556/original/file-20200421-82666-8necdd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1827&fit=crop&dpr=1 754w, https://images.theconversation.com/files/329556/original/file-20200421-82666-8necdd.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1827&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/329556/original/file-20200421-82666-8necdd.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1827&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Story from The Evening World, April 1, 1907, which used an alias for Mallon’s last name.</span>
<span class="attribution"><a class="source" href="https://chroniclingamerica.loc.gov/lccn/sn83030193/1907-04-01/ed-1/seq-3/">Library of Congress</a></span>
</figcaption>
</figure>
<p>Contrary to popular belief, Mallon never perceived herself to be contagious. During her famous trial of 1909, <a href="https://newspaperarchive.com/rock-island-argus-jun-30-1909-p-1/">newspapers quoted her saying</a>, “I was cook for Mr. Stebbins’ family and other families, and nobody fell sick while I was there.” </p>
<p>Like many people in her era, Mallon could not fathom that a healthy-looking person could transmit disease. Throughout her life, she swore her innocence, claiming that she had never had the disease. </p>
<p>The popular – and mistaken – beliefs about Mallon came primarily from media accounts during her life. But the mischaracterization of Mallon continued long after. </p>
<p>Mallon unknowingly spread typhoid fever through the dishes she prepared, mostly for wealthy families in New York. In the summer of 1906, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959940/">she cooked for the Warren family</a> at their rental house at Long Island’s Oyster Bay. From Aug. 26 through Sept. 3, typhoid fever struck six out of 11 members of the household. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959940/">The homeowners hired George Soper</a>, a self-proclaimed “sanitary engineer,” to investigate. He eventually traced the Oyster Bay outbreak to the new cook, along with typhoid at six of her other places of employment. </p>
<p>Soper’s discovery prompted the <a href="https://cfmedicine.nlm.nih.gov/physicians/biography_19.html">New York City Health Inspector Dr. Josephine Baker</a> and the <a href="https://www.penguinrandomhouse.com/books/204178/typhoid-mary-by-judith-walzer-leavitt/">police department to take Mallon by force</a> to a nearby hospital. </p>
<p>Against her will, she underwent multiple physical examinations that included stool samples, which revealed the <em>Salmonella typhi</em> bacteria. Mallon was then quarantined at <a href="https://www.thedailybeast.com/the-secret-of-north-brother-island-the-abandoned-new-york-city-island-where-typhoid-mary-was-held-captive">North Brother Island, a refuge for those ill with tuberculosis and other contagious diseases</a>, for two years without a charge or trial. </p>
<p><a href="http://www.samaritanid.com/TyphoidMaryLetter.html">Mallon hired attorney George O’Neill</a>, who petitioned for her release on June 28, 1909. Before a judge, she testified that she was healthy and had never made others ill. The judge denied her request on the grounds that she was a threat to public health and ordered her to continue living isolated at North Brother Island. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/329563/original/file-20200421-82650-1zqp6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/329563/original/file-20200421-82650-1zqp6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/329563/original/file-20200421-82650-1zqp6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=774&fit=crop&dpr=1 600w, https://images.theconversation.com/files/329563/original/file-20200421-82650-1zqp6a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=774&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/329563/original/file-20200421-82650-1zqp6a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=774&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/329563/original/file-20200421-82650-1zqp6a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=973&fit=crop&dpr=1 754w, https://images.theconversation.com/files/329563/original/file-20200421-82650-1zqp6a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=973&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/329563/original/file-20200421-82650-1zqp6a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=973&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Illustration from the New York American of Mary Mallon, known pejoratively as Typhoid Mary, breaking skulls into a frying pan.</span>
<span class="attribution"><a class="source" href="https://digitalcollections.nypl.org/items/85674452-ba9e-6934-e040-e00a180606cf">New York Public Library</a></span>
</figcaption>
</figure>
<h2>Becoming ‘Typhoid Mary’</h2>
<p>Approximately <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3959940/">400 other healthy carriers</a> had also been identified in New York at the time of Mallon’s trial. Unlike Mallon, they were not arrested, tried and imprisoned for years. </p>
<p>It was Mallon’s status as a poor, Irish immigrant woman that made her susceptible to becoming the city’s scapegoat. Soper himself initially described her as “<a href="https://jamanetwork.com/journals/jama/article-abstract/463876">an Irish woman about 40 years of age, tall, heavy, single</a>.” Newspapers treated Mallon as either a “germ receptacle” or as a wild animal to be contained. “Woman ‘Typhoid Factory’ Held As a Prisoner,” <a href="https://www.loc.gov/rr/news/topics/typhoid.html">stated one headline</a>. <a href="https://chroniclingamerica.loc.gov/lccn/sn88085187/1915-04-06/ed-1/seq-1/?date1=1899&index=6&date2=1922&searchType=advanced&proxdistance=5&rows=20&ortext=&proxtext=typhoid+mary&phrasetext=&andtext=&dateFilterType=yearRange#words=Typhoid%2BMary">“Witch In N.Y.” read a Tacoma Times headline</a>. The story included this description of Mallon: “Legendary witches of old used to build red fires…and brew deadly potions…But poor ‘Typhoid Mary’… requires no cauldron. She manufactures WITHIN HERSELF the evil potions which she spreads about.” </p>
<p>Facts about the case came from Soper and public health authorities to medical journals and newspapers, mentioning her ethnicity, appearance and marital status. Such characteristics were not identified in stories of other healthy carriers. Mallon was never interviewed and therefore did not get to give her perspective, other than in <a href="http://www.samaritanid.com/TyphoidMaryLetter.html">reprinted segments of a single letter to her attorney</a>, in which she declared her innocence. </p>
<p>Government officials and the media justified Mallon’s loss of civil liberties by framing her as a particular danger to public health, more than other <a href="https://www.jstor.org/stable/234261">healthy carriers</a>.</p>
<p>Her infamous nickname, coined at a 1908 medical conference and then repeated in an <a href="https://jamanetwork.com/journals/jama/article-abstract/428137">edition</a> of the Journal of the American Medical Association, shifted Mallon’s public persona from human incubator to villain – an image introduced in the New York American newspaper on June 20, 1909. </p>
<p>The headline “<a href="https://www.pbs.org/wgbh/nova/article/typhoid-mary-villain-or-victim/">‘Typhoid Mary’: The Extraordinary Predicament of Mary Mallon, a Prisoner on New York’s Quarantine Hospital Island</a>,” extended over a full-page drawing of a cook sautéing a cluster of skulls in her cast-iron skillet. This introduction forever cemented the misconception that Mallon’s disease transmission was murderously intentional.</p>
<p>From that point, news stories compared <a href="https://www.newspapers.com/image/83880426/?terms=%22typhoid%2Bsally%22">“Typhoid Sally,”</a> <a href="https://www.newspapers.com/image/54328277/?terms=%22diphtheria%2Bmildred%22">“Diphtheria Mildred”</a> and other healthy carriers to “Typhoid Mary.” While some were briefly detained at hospitals after unintentionally causing outbreaks, no one was treated as poorly as Mallon. </p>
<h2>Perpetuating ‘Typhoid Mary’</h2>
<p>Mallon was finally released in 1910. With a lack of options (and without an understanding of healthy carriers), Mallon began cooking again, this time at restaurants, hotels and, lastly, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1911442/pdf/bullnyacadmed00595-0063.pdf">the Sloane Hospital for Women</a>. When more than 20 cases of typhoid erupted at the hospital, authorities identified Mallon as the source.</p>
<p>On March 26, 1915, the New York City Department of Public Health escorted Mallon back to North Brother Island. She lived and worked at the hospital there until she died in 1938. There is no record of typhoid outbreaks during her stay.</p>
<p>Even after her final detention and death, newspapers and popular culture perpetuated the misconception that Mallon infected people intentionally, channeling her natural poison (typhoid) through the food she cooked. Books like “<a href="https://www.hmhbooks.com/shop/books/Terrible-Typhoid-Mary/9780544313675">Terrible Typhoid Mary: A True Story of the Deadliest Cook in America</a>,” television references and the eponymous <a href="https://www.marvel.com/articles/comics/the-comics-history-of-typhoid-mary">comic book character</a> have preserved this image of a villainous Mallon.</p>
<p>Across media platforms, “Typhoid Mary” is still casually applied to contemporary menaces of public health, ignoring the ethically dubious practice of blaming healthy carriers and Mary Mallon’s persecution as a poor immigrant at the turn of the 20th century.</p>
<p>[<em>You need to understand the coronavirus pandemic, and we can help.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-help">Read The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/136571/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katherine A. Foss does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
TyphoidMary is shorthand today for those who defy social distancing orders. The real Typhoid Mary is perhaps the most prominent example in the US of the unknowing disease carrier.
Katherine A. Foss, Professor of Media Studies, Middle Tennessee State University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/121282
2019-10-30T07:26:15Z
2019-10-30T07:26:15Z
Decades neglecting an ancient disease has triggered a health emergency around the world
<figure><img src="https://images.theconversation.com/files/295801/original/file-20191007-121060-1qz2f8o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A young girl is inoculated with typhoid, Texas, 1943.</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Typhoid_inoculation2.jpg">Wikimedia Commons</a></span></figcaption></figure><p>New extensively drug-resistant variants of an ancient and deadly disease – typhoid fever – are <a href="https://www.who.int/csr/don/27-december-2018-typhoid-pakistan/en/">spreading</a> across international borders. Cases have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6405270/">reported</a> in Pakistan, India, Bangladesh, the Philippines, Iraq, Guatemala, UK, US, and Germany, as well as more recently in <a href="https://www.mja.com.au/journal/2019/211/6/first-reported-case-extensively-drug-resistant-typhoid-australia">Australia</a> and <a href="https://www.sciencedirect.com/science/article/pii/S2214250918302282">Canada</a>. In recent years, drug resistant and travel-associated typhoid variants have also been spreading through the <a href="https://academic.oup.com/cid/article/68/Supplement_2/S165/5371231">African continent</a>. Under-reporting and international surveillance gaps mean that drug-resistant typhoid is probably even more extensive than we think.</p>
<p>Causing fever, headache, abdominal pain and constipation or diarrhoea, typhoid is a bacterial disease. <em>Salmonella enterica serovar</em> Typhi – the organism behind typhoid – kills up to <a href="https://www.nhs.uk/conditions/typhoid-fever/">one in five patients</a> if left untreated. <em>S.</em> Typhi spreads from person to person in water and food, which have been contaminated by faeces. As a consequence, typhoid is often associated with inadequate sanitation and water systems, as well as with poor hygiene <a href="https://www.nhs.uk/conditions/typhoid-fever/">practices</a>.</p>
<p>The rapid rise of increasingly difficult to treat typhoid is a very worrying prospect. During an age of unparalleled international trade and travel, it is inevitable that any regional rise of antibiotic resistance will have global knock-on effects.</p>
<p>In Europe, Australia and North America isolated extensively drug-resistant variants (or XDR strains) were travel-related. Travellers had become infected while visiting Pakistan, where a large-scale outbreak of XDR typhoid is ongoing. Having caused at least 5,274 cases in the Sindh Province <a href="https://www.who.int/csr/don/27-december-2018-typhoid-pakistan/en/">since 2016</a>, the Pakistani XDR strain is proving resistant to all commonly available antibiotics except for one: azithromycin.</p>
<p>The coming years will likely see further travel-related resistant cases occur throughout the world. In Britain, strong demographic and historical ties to South-East Asia mean that about <a href="https://www.nhs.uk/conditions/typhoid-fever/">500 typhoid cases</a> (mostly travel-associated) are reported every year. In the US, at least <a href="https://www.cdc.gov/typhoid-fever/surveillance.html">309 cases occurred in 2015</a> with almost 80% of confirmed cases reporting a history of travel to endemic areas. In Germany, <a href="https://www.rki.de/DE/Content/Infekt/EpidBull/Merkblaetter/Ratgeber_Typhus_Paratyphus.html">56 cases</a> were reported in 2018 – 96% of which were travel associated.</p>
<p>The return of typhoid is something of a shock to health systems in richer countries. Between the late 19th century and the 1950s, sanitary improvements, effective vaccines and antibiotics eliminated endemic typhoid from most high-income countries. But after a lifetime of relative security, the prospect of typhoid again causing death in high-income hospitals is no longer an outlandish idea. </p>
<p>So how did this happen? The answer is uncomfortable and tied up in the inward-looking nature of Western disease eradication campaigns over the last century. Because, contrary to popular conceptions of typhoid as a disease of the past, typhoid never really left. As our <a href="https://academic.oup.com/cid/issue/69/Supplement_5">new research</a> shows, because typhoid control often stopped at high-income borders, it became a neglected disease in other, poorer countries. This global neglect is now proving costly. </p>
<p>Controlling typhoid depends in part on new technologies to prevent, diagnose and treat the disease. But it is also crucial that we keep a clear eye on the past so that we are able to rewrite the policies that enabled typhoid’s resurgence – in other words, old mistakes should not be repeated.</p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption"></span>
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<p><strong><em>This article is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.</em> </p>
<hr>
<h2>Killer of paupers and kings</h2>
<p>Genomic analysis and archaeological evidence <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz556">makes it clear</a> that the disease has been circulating in human populations for millennia. </p>
<p>While we cannot make accurate retrospective diagnoses using written sources alone, typhoid has been referenced as the mysterious killer of princes, presidents and paupers around the world. Typhoid was also a renowned scourge of armies and war. During the <a href="http://www.bbc.co.uk/history/british/victorians/boer_wars_01.shtml">Second Boer War</a> (1898-1902), the British Army reported more than <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz672">8,000 typhoid deaths</a>.</p>
<p>Despite its prominence, typhoid’s cause and mode of transmission remained a mystery. Many experts initially believed that typhoid was caused by “bad air” originating from decaying matter and pungent-smelling filth. There was also no clear way to distinguish typhoid from other contemporary fevers. Modern notions of typhoid as a disease with a distinct clinical picture, a mostly water and food-borne mode of transmission, and with a bacterial cause, only <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz610">gradually emerged</a> during the 19th century after repeated pandemics of cholera kick-started investigations into waterborne modes of transmission.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/294857/original/file-20190930-194819-jvhx0a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/294857/original/file-20190930-194819-jvhx0a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=570&fit=crop&dpr=1 600w, https://images.theconversation.com/files/294857/original/file-20190930-194819-jvhx0a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=570&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/294857/original/file-20190930-194819-jvhx0a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=570&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/294857/original/file-20190930-194819-jvhx0a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=716&fit=crop&dpr=1 754w, https://images.theconversation.com/files/294857/original/file-20190930-194819-jvhx0a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=716&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/294857/original/file-20190930-194819-jvhx0a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=716&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Bacilli of typhoid fever from a culture.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/qbq4wgrm">© Wellcome Collection</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
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<p>The emerging concept of typhoid as a distinct bacterial disease that could be carried by contaminated water and food was accompanied by a parallel revolution of sanitary infrastructure in Europe, North America and parts of Asia, Africa, South America and Oceania. New waterborne ideas of typhoid transmission subsequently played <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz610">an important role</a> in justifying ongoing expenditure on improved sewage and drinking water systems.</p>
<h2>Alice in Typhoidland</h2>
<p>For example, in the British university city of Oxford, sanitarians like <a href="https://www.oxforddnb.com/view/10.1093/ref:odnb/9780198614128.001.0001/odnb-9780198614128-e-16640">Henry Liddell</a>, Dean of Christ Church College and father of Alice Liddell – the girl who inspired <a href="https://typhoidland.org/">Alice in Wonderland</a>, Lewis Carroll’s famous children’s book – used the spectre of typhoid to lobby for radical interventions into the city’s infrastructure and hydrology.</p>
<p>He did this with his close friend Henry Acland, professor of medicine, physician to the royal family (and alleged inspiration for the <a href="https://www.independent.co.uk/news/uk/home-news/who-was-who-in-alices-wonderland-1588168.html">White Rabbit</a>).</p>
<p>Liddell, whose wife had nearly died from typhoid in London, also oversaw improvements of his college’s grounds and sanitary infrastructure. This included redirecting the <a href="https://www.british-history.ac.uk/vch/oxon/vol4/pp284-295">Trill Mill Stream</a> – an open sewer – underground in 1863, the same year that Carroll began to write his first iconic book.</p>
<p>Although initial sanitary progress in Oxford was slow, growing public criticism, new government credits and scandals like the death of three undergraduates from typhoid encouraged city and university authorities to take decisive action during the 1870s. Within little over a decade, they constructed a new sewage system, closed down leaking cesspools, stopped pumping drinking water from below the main sewer outlet and created an affordable rate-financed and municipally-owned filtered drink water supply.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/294846/original/file-20190930-194824-jcw8kt.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/294846/original/file-20190930-194824-jcw8kt.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/294846/original/file-20190930-194824-jcw8kt.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=718&fit=crop&dpr=1 600w, https://images.theconversation.com/files/294846/original/file-20190930-194824-jcw8kt.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=718&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/294846/original/file-20190930-194824-jcw8kt.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=718&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/294846/original/file-20190930-194824-jcw8kt.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=902&fit=crop&dpr=1 754w, https://images.theconversation.com/files/294846/original/file-20190930-194824-jcw8kt.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=902&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/294846/original/file-20190930-194824-jcw8kt.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=902&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">John Tenniel, Alice Rows the Sheep. This river was allegedly based on Trill Mill Stream.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/a/af/John_Tenniel_Alice_Rows_the_Sheep.jpeg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>The case of Oxford is far from unique. By the turn of the century, high-income cities across the world were investing substantial amounts of money in their water and sanitary infrastructures. While early interventions were often hit-and-miss and could vary significantly between cities, there is a <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz610">clear correlation</a> between rising expenditure on the provision of safe water services and declining mortality from waterborne diseases like typhoid.</p>
<h2>From prevention to eradication</h2>
<p>New technologies further aided attempts to curb what was increasingly described as a preventable disease. In 1897, Maidstone became the first British town to have its entire water supply <a href="https://www.encyclopedia.com/science/encyclopedias-almanacs-transcripts-and-maps/advent-and-use-chlorination-purify-water-great-britain-and-united-states">treated with chlorine</a>. </p>
<p>Vaccination emerged as another way to protect populations in areas without sanitary infrastructure. Devised by German and British researchers in 1896, early typhoid vaccines consisted of killed typhoid strains and were among the first bacterial vaccines. During the Second Boer War, British troops leaving the fold of “civilisation” could opt for inoculation against typhoid. This first roll-out of heat-killed vaccines was marred by quality problems and adverse side effects that made early vaccination extremely unpleasant. But by World War I, <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz672">all major powers</a> used improved bacterial typhoid vaccines to effectively protect troops and travellers.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/294859/original/file-20190930-194832-1hr7ngv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/294859/original/file-20190930-194832-1hr7ngv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=392&fit=crop&dpr=1 600w, https://images.theconversation.com/files/294859/original/file-20190930-194832-1hr7ngv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=392&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/294859/original/file-20190930-194832-1hr7ngv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=392&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/294859/original/file-20190930-194832-1hr7ngv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=493&fit=crop&dpr=1 754w, https://images.theconversation.com/files/294859/original/file-20190930-194832-1hr7ngv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=493&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/294859/original/file-20190930-194832-1hr7ngv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=493&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Anti-typhoid vaccination in World War I.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/yy2bdqh4">© Wellcome Collection</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Typhoid’s emerging status as a preventable disease was celebrated as a great success story of “rational Western science”. It also led to calls to move from prevention to eradication. Leading the hunt was the new profession of bacteriology.</p>
<p>This research soon showed that typhoid was far more complex than initially thought. Although its mode of transmission via water and contaminated food was becoming increasingly clear, it emerged that the bacterium could also be excreted by seemingly healthy people. So-called asymptomatic – or healthy – carriers have no symptoms but can still excrete <em>S.</em> Typhi through their faeces for years after the initial infection.</p>
<p>This concept of <a href="https://www.ncbi.nlm.nih.gov/pubmed/20934644">healthy carriers</a>, advanced by the German bacteriologist <a href="https://www.ncbi.nlm.nih.gov/pubmed/20934644">Robert Koch in 1902</a>, significantly complicated hopes for typhoid eradication. How was one supposed to deal with seemingly healthy members of the community, whose typhoid-contaminated faeces could put others at risk?</p>
<p>Answers reflected prevailing socio-cultural values. While most typhoid carriers were allowed to remain in their communities if they agreed to follow precautionary hygiene measures (abstaining from working in food preparation and waterworks), some were forcibly detained and isolated. Decisions about who could be trusted and who had to be isolated were far from neutral and reflected contemporary concerns about immigration, racism, chauvinist gender norms and rising militarism.</p>
<p>For example in Germany, bacteriologists tried to “cleanse” military deployment zones identified for an attack on France by testing communities, creating lists of carriers, and placing some in mandatory isolation from around <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz672">1904 onward</a>. While communities in the centre of the Reich mostly escaped this practice, Prussian experts had few qualms about implementing mandatory isolation in the Franco-German periphery on the grounds of military need. During World War I, German soldiers were routinely screened for typhoid and strict controls were set up to stop potential carriers – like soldiers or displaced civilians – from infecting civilian populations in Germany. Once again not everybody was treated equally, with certain groups like Eastern Jews being disproportionately accused of carrying diseases of “filth” like typhoid.</p>
<p>In the United States, Irish immigrant Mary Mallon (who became known as “<a href="https://www.pastmedicalhistory.co.uk/the-terrible-tale-of-typhoid-mary/">Typhoid Mary</a>”) became the most prominent typhoid carrier to be detained after infecting the families she cooked for. Mallon was quarantined between 1907 and 1910 and again between 1915 and her death in 1936 after breaching the terms of her initial release and working as a cook under an assumed name.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/295800/original/file-20191007-121088-1yyldz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/295800/original/file-20191007-121088-1yyldz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/295800/original/file-20191007-121088-1yyldz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=474&fit=crop&dpr=1 600w, https://images.theconversation.com/files/295800/original/file-20191007-121088-1yyldz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=474&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/295800/original/file-20191007-121088-1yyldz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=474&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/295800/original/file-20191007-121088-1yyldz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=596&fit=crop&dpr=1 754w, https://images.theconversation.com/files/295800/original/file-20191007-121088-1yyldz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=596&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/295800/original/file-20191007-121088-1yyldz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=596&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An illustration that appeared in 1909 in The New York American.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Mallon-Mary_01.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>British authorities, meanwhile, <a href="http://news.bbc.co.uk/1/hi/uk/7528045.stm">detained</a> predominantly female carriers deemed mentally incapable of upholding sanitary standards in the Long Grove Asylum in Epsom between 1907 and 1992. Doubts about the women’s alleged insanity subsequently emerged.</p>
<p>But with typhoid continuing to decline in high-income countries, such treatment of carriers rarely made headlines. By the end of World War II, there was instead growing optimism about the prospect of eventual typhoid elimination. In Europe and North America, functioning sanitation systems, chlorination, fine-grained national surveillance for typhoid outbreaks and carriers by public health authorities, vaccines, and the advent of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4923770/">effective therapies</a> for both typhoid victims (chloromycetin, 1948) and carriers (ampicillin, 1961) had turned the once feared disease into a negligible health threat.</p>
<p>Although individual outbreaks on ocean liners, in resorts, and <a href="https://www.bbc.co.uk/news/uk-scotland-north-east-orkney-shetland-26957972">occasionally towns</a>, continued to attract public interest, typhoid was increasingly portrayed as a disease of the past, one which had been defeated with heroic sanitary and medical interventions. During an age of widespread confidence in the imminent scientific defeat of infectious disease, there seemed little reason to fear its return.</p>
<h2>An infectious divide</h2>
<p>This confidence was misplaced. While typhoid had almost vanished from high-income countries, it remained endemic in other parts of the world.</p>
<p>Over the next half century, the resulting infectious divide was reinforced by a relative neglect of international campaigns to tackle typhoid. Sustained large-scale investment in the supply of safe drinking water, safe sewage disposal, and basic healthcare services would have gone a long way to curb not only typhoid but many other diseases in the Global South. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/295797/original/file-20191007-121071-104bx2y.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/295797/original/file-20191007-121071-104bx2y.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/295797/original/file-20191007-121071-104bx2y.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/295797/original/file-20191007-121071-104bx2y.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/295797/original/file-20191007-121071-104bx2y.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/295797/original/file-20191007-121071-104bx2y.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/295797/original/file-20191007-121071-104bx2y.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The various ways that a water well may become infected by typhoid fever bacteria, 1939.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/File:ForskeligeVeje_ad_hvilkenBroen_kan_inficeres_medTyfusbaciller.png#/media/File:ForskeligeVeje_ad_hvilkenBroen_kan_inficeres_medTyfusbaciller.png">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>But actual investment often remained ad hoc, uncoordinated, and insufficient. Instead, many rich countries focused on protecting their own populations. They prioritised vaccines, antibiotics and put surveillance-based biosecurity regimes in place, designed to stop typhoid from crossing back into high-income countries via travellers and migrants. This strategy was cheap in the short term but very costly in the long term.</p>
<p>Although governments and non-governmental organisations on both sides of the Iron Curtain provided infrastructural and medical aid to allies in the so-called “developing world” during the Cold War era, typhoid did not feature high on the international agenda and was frequently superseded by other, more prominent, or fast-burning diseases like malaria and smallpox. Meanwhile, a mix of population growth, resource constraints and inadequate access to water, sanitation and health infrastructures created perfect breeding grounds for typhoid in the Global South. This also led to an over-reliance on comparatively cheap antibiotics to keep the disease in check. The result was an evolutionary surge of <a href="https://www.sciencedaily.com/releases/2006/11/061128092129.htm">increasingly antibiotic-resistant</a> typhoid strains.</p>
<p>This surge had been predicted. Resistance against the first antibiotic treatment for typhoid, chloramphenicol, had been reported <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2937522/">within two years</a> of the antibiotic’s first use against typhoid in 1948. Individual strains had also <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz556">proven resistant</a> against ampicillin within years of its 1961 launch. </p>
<h2>Typhoid outbreaks increase</h2>
<p>In 1967, researchers in <a href="https://www.microbiologyresearch.org/docserver/fulltext/jmm/44/5/medmicro-44-5-317.pdf?expires=1564494207&id=id&accname=guest&checksum=31E60BE5B768AAF0B328A26781086CC8">Israel and Greece</a> reported the isolation of typhoid strains with transferable chloramphenicol resistance. In the same year, British experts analysing typhoid strains from Kuwait detected transferable resistance not only against chloramphenicol but also against ampicillin and the tetracyclines. Five years later, an explosive typhoid outbreak that infected more than 10,000 people in Mexico City was resistant to <a href="https://cmr.asm.org/content/28/4/901">several antibiotics</a> including chloramphenicol – but fortunately not ampicillin. India and Vietnam reported parallel outbreaks.</p>
<p>Western responses to the outbreaks were ad hoc, again focusing on biosecurity measures like traveller surveillance and vaccination rather than on concerted international campaigns to combat the factors driving the surge of resistant typhoid in low-income areas.</p>
<p>In response to the outbreaks in India and Mexico, Western media commentators accused local populations of relying on antibiotics too much and using drugs inappropriately. Rarely addressed were the underlying factors, such as insufficient access to affordable healthcare, clean drinking water and effective sewerage systems – or the fact that many of the drugs in use had been exported by Western producers. </p>
<p>The prioritisation of national biosecurity over collective responsibility was echoed in government policies. Western countries and non-governmental organisations provided limited laboratory, sanitation, and medical aid in response to natural disasters and acute outbreaks. But international support remained inadequate to compensate for existing financial, infrastructural, and organisational constraints or to keep up with population growth and rapid urbanisation in endemic areas. </p>
<p>Meanwhile, concerns about the import of resistant “foreign strains” encouraged governments to devote significant resources to monitoring borders, travellers, and migratory populations for typhoid. Resulting monitoring efforts remained influenced by culturally ingrained stereotypes of typhoid as a disease of uncivilised people. In response to the Mexican outbreak, US public health officials not only focused on monitoring non-American strains and intensifying the community surveillance of people with “Hispanic surnames” but also <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz556">highlighted risk factors</a> like alleged “Hispanic hygiene habits” even though no empirical research was conducted to test whether these culturally-biased associations were true.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/294855/original/file-20190930-194873-1nsf70.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/294855/original/file-20190930-194873-1nsf70.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/294855/original/file-20190930-194873-1nsf70.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/294855/original/file-20190930-194873-1nsf70.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/294855/original/file-20190930-194873-1nsf70.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/294855/original/file-20190930-194873-1nsf70.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/294855/original/file-20190930-194873-1nsf70.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Antibiotics are in widespread use in agriculture.</span>
<span class="attribution"><span class="source">Rat007/Shutterstock</span></span>
</figcaption>
</figure>
<h2>Continued neglect</h2>
<p>The neglect of international efforts to combat typhoid on a global level carried over into the 1980s. This neglect was facilitated by international disease surveillance networks with <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz611">large coverage gaps</a> in areas outside the Global North. It was also the result of overconfidence in <a href="https://www.ncbi.nlm.nih.gov/pubmed/3726393">newly available treatments</a>.</p>
<p>Marked by political and economic instability, the following two decades experienced a rollback of healthcare provision. This happened in large parts of the Soviet sphere and also in Western-affiliated “developing countries” undergoing World Bank monitored programmes to implement free market policies. Without access to effective and affordable healthcare and sanitary services, local populations frequently turned to cheaper antibiotics to control disease.</p>
<p>The result was a further global surge of antimicrobial resistance right at a time when an increasing number of international drug companies began to withdraw investment in new antibiotic development due to <a href="https://www.ncbi.nlm.nih.gov/pubmed/26971595">a lack of profitability</a>. In 1988, a typhoid outbreak <a href="https://www.ncbi.nlm.nih.gov/pubmed/8406648">in Kashmir</a> proved resistant to all three first-line antibiotics. Similar outbreaks were soon reported from Shanghai, Pakistan, and the Mekong Delta. New genetic sequencing revealed that a large part of rising antibiotic resistance was associated with the spread of a specific haplotype (a distinct group of genes clustered together on a single inherited chromosome). </p>
<p>Designated “H58”, organisms with this haplotype were undergoing a significant population expansion and conferred bacterial resistance not only against older first-line drugs but increasingly against new reserve antibiotics (like the fluoroquinolones and cephalosporins). By the late 1990s, the majority of strains isolated from a large-scale outbreak involving thousands of patients in formerly Soviet Tajikistan proved resistant to the fluoroquinolones. Sporadic cephalosporin resistance was reported from the <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz556">early 2000s onwards</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/294639/original/file-20190928-185407-jkzuj1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/294639/original/file-20190928-185407-jkzuj1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=476&fit=crop&dpr=1 600w, https://images.theconversation.com/files/294639/original/file-20190928-185407-jkzuj1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=476&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/294639/original/file-20190928-185407-jkzuj1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=476&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/294639/original/file-20190928-185407-jkzuj1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=598&fit=crop&dpr=1 754w, https://images.theconversation.com/files/294639/original/file-20190928-185407-jkzuj1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=598&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/294639/original/file-20190928-185407-jkzuj1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=598&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Wellcome-Sanger Map: Population structure of the <em>S.</em> Typhi H58 lineage.</span>
<span class="attribution"><span class="source">PATH</span></span>
</figcaption>
</figure>
<p>The current Pakistani <a href="https://www.sanger.ac.uk/news/view/typhoid-outbreak-genetic-cause-extensive-drug-resistance-found">outbreak of XDR typhoid</a>, which began in 2016, is caused by a variant of H58 that is resistant to all antibiotics (except azithromycin) commonly used against typhoid. Total pan-resistance to locally available drugs may only be one mutation away.</p>
<h2>A new generation of vaccines</h2>
<p>This uneven history shows the limitations of making policy on a national or regional level when it comes to curbing border-crossing threats. Whether we choose to justify action out of ethical considerations of collective responsibility or out of enlightened self-interest, the global threat posed by XDR typhoid and the conditions producing multiple resistant pathogens like it will only be overcome by more – and not less – international involvement.</p>
<p>Fortunately, a new generation of vaccines could now provide a crucial cornerstone for new international efforts for typhoid control. New typhoid “Vi conjugate vaccines” (TCVs) have overcome <a href="http://www.gavi.org/library/news/press-releases/2017/millions-of-children-set-to-be-protected-against-typhoid-fever/">many hurdles</a>. One of these vaccines (Typbar-TCV®) only requires a single dose, is approved for children of six months and older (previous vaccines weren’t suitable for children under two) and was recently licensed in India, Nepal, Cambodia, and Nigeria. Other advanced TCV candidates are in manufacture and development. </p>
<p>These vaccines are no longer primarily designed to protect foreign travellers and limit acute outbreaks. They are also no longer being developed in areas of the world that need them the least; <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz483">Typbar-TCV</a> was developed and manufactured by the Indian company Bharat Biotec.</p>
<p>And in another twist of history that takes us back to Alice in Wonderland’s Oxford, Typbar-TCV was not tested on Indian but on British populations. In 2017, around 100 closely-observed participants drank live typhoid bacteria to test the vaccine for safety and efficacy. The carefully controlled Oxford “outbreak” is the largest recently recorded typhoid outbreak in the UK and provided critical data for the WHO’s decision <a href="https://www.who.int/immunization/newsroom/press/who_recommends_use_first_typhoid_conjugate_vaccine/en/">to recommend</a> the vaccine in 2018. This situation is a reversal of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5617553/">current trend</a> for vaccines created in high-income countries but <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciz630">tested</a> in low and middle-income countries. </p>
<p>The long-term implications of this geographic shift of vaccine development are significant. As Samir Saha at the Child Health Research Foundation at Dhaka, Bangladesh, <a href="https://www.jhsph.edu/ivac/2018/03/27/the-new-typhoid-conjugate-vaccine-marks-the-dawn-of-a-unique-beginning/">describes</a> it:</p>
<blockquote>
<p>We Bangladeshis, like any other low middle-income countries, usually receive a vaccine after 20-25 years of its introduction in the developed world – pneumococcal vaccines took 20 years and <a href="https://www.nhs.uk/conditions/hib/">Hib</a> vaccine took 25 years to travel here. This is the first time that a vaccine will be first introduced in a country where it is needed the most. </p>
</blockquote>
<h2>A bio-social problem</h2>
<p>The arrival of the new vaccines is fantastic news during a time of failing antibiotics. But their roll-out will have to be accompanied by other measures if we are to move towards sustainable control of <a href="https://www.publichealthontario.ca/en/diseases-and-conditions/infectious-diseases/enteric-foodborne-diseases">diseases</a> that cause intestinal illnesses in low-income countries. As the long history of typhoid makes clear, effective health strategies have to integrate all available aspects of typhoid control.</p>
<p>Since around 1900, vaccines have played an important role in protecting travelling populations and military personnel <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4607109/">from typhoid</a>. But wider control has always also depended on the provision of robust drinking water and waste-water systems to prevent typhoid from spreading, an effective surveillance network to monitor typhoid incidence and the targeted provision of effective high-quality drugs to treat the disease. Over-reliance on any one intervention has repeatedly undermined wider control efforts. </p>
<p>At the same time, control efforts have to take place at multiple levels. Not only is there ample proof that ambitions for typhoid control cannot be limited to high-income countries alone, there is also strong evidence highlighting the importance of collaborations between local institutions for typhoid control. While 20th-century aid efforts primarily targeted nation states, a close look at the early “heroic age” of typhoid control reveals the importance of municipal and local actor coalitions in developing effective locally-tailored sanitary solutions. The provision of cheap affordable credit to facilitate initiatives with local buy-in was equally important. </p>
<p>Like any disease, typhoid is a complex phenomenon, driven by a bacteria but also the peculiarities of societal structures. Passing from one human to another over millennia, <em>Salmonella</em> Typhi has not only perfectly adapted to our living habits and environments but also bears the imprint of our antimicrobial interventions in its genetic code. Controlling it will require both biological and social interventions.</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em>For you: more from our <a href="https://theconversation.com/uk/topics/insights-series-71218?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insights series</a>:</em></p>
<ul>
<li><p><em><a href="https://theconversation.com/for-a-sustainable-future-we-need-to-reconnect-with-what-were-eating-and-each-other-123490?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">For a sustainable future, we need to reconnect with what we’re eating – and each other</a></em></p></li>
<li><p><em><a href="https://theconversation.com/they-put-a-few-coins-in-your-hands-to-drop-a-baby-in-you-265-stories-of-haitian-children-abandoned-by-un-fathers-114854?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">‘They put a few coins in your hands to drop a baby in you’ – 265 stories of Haitian children abandoned by UN fathers</a></em></p></li>
<li><p><em><a href="https://theconversation.com/the-new-right-how-a-frenchman-born-150-years-ago-inspired-the-extreme-nationalism-behind-brexit-and-donald-trump-117277?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">The New Right: how a Frenchman born 150 years ago inspired the extreme nationalism behind Brexit and Donald Trump</a></em></p></li>
</ul>
<p><em>To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. <a href="https://theconversation.com/uk/newsletters/the-daily-newsletter-2?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK"><strong>Subscribe to our newsletter</strong></a>.</em></p><img src="https://counter.theconversation.com/content/121282/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claas Kirchhelle receives funding from the New Venture Fund and the Wellcome Trust (University Award, University College Dublin 2020-2025). </span></em></p><p class="fine-print"><em><span>Samantha Vanderslott receives funding from the National Institute for Health Research (NIHR) and the New Venture Fund. She is also a steering committee member for the Vaccination Acceptance Research Network (VARN).</span></em></p>
We’ve known how to control typhoid for over 100 years. The rapid current increase of drug-resistant variants in both rich and poor countries is down to decades of short-sighted global health policies.
Claas Kirchhelle, Lecturer in the History of Medicine, University College Dublin
Samantha Vanderslott, Postdoctoral Researcher in Social Sciences, University of Oxford
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/91447
2018-02-19T17:21:48Z
2018-02-19T17:21:48Z
It’s poverty, not individual choice, that is driving extraordinary obesity levels
<figure><img src="https://images.theconversation.com/files/206256/original/file-20180213-44657-1d5r96h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-overweight-symbolic-photo-beer-belly-623414777?src=LkZ-VVZgvyvrT0wshwYfaQ-1-1">Sharomka/Shutterstock.com</a></span></figcaption></figure><p>The “obesity epidemic” deserves much more serious attention than it is getting. It is, after all, thought to be killing nearly <a href="http://easo.org/education-portal/obesity-facts-figures/">3m people</a> a year worldwide. It is putting huge pressure on health services, yet the public policy response in developed countries such as the US and UK is pitiful, largely confined to finger-wagging at children’s sugary treats.</p>
<p>The story that has not been getting out is that there is a clear and extraordinary correlation between obesity and social inequality. Obesity is invariably presented as a diet issue for nutritionists, whereas social inequality is deemed the domain of sociologists and economists. Put another way, even as the inequality gap becomes <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/6871/1871208.pdf">more and more obvious</a> there’s been a medicalisation of a social problem. Yet obesity is not just a matter for nutritionists: rather, it is a product of social inequality and requires a collective social response.</p>
<p>This failure to face up to the underlying causes of obesity is all the more striking as issues of social inequality and justice are dominating the news agenda. Despite vast increases in total wealth in the world today, the health issue remains a marker for a general political problem about inequality in society, even in the most affluent societies.</p>
<p>The tragedy is that obesity is usually treated as a problem and responsibility of individuals or families – not as a social problem like, say, low-educational achievement or delinquency. And so the solutions are pitched at that individual or family level.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"949798142228090881"}"></div></p>
<p>And yet the statistics point remorselessly towards obesity being a symptom with an underlying social cause. That should completely change the approach to dealing with it. But so far, it hasn’t.</p>
<h2>Vital statistics</h2>
<p>Take the US. Here, the most “obese” state, <a href="http://healthyamericans.org/reports/stateofobesity2017/release.php?stateid=AR">Arkansas</a>, is also the fourth poorest state overall, whereas the poorest state, <a href="http://healthyamericans.org/reports/stateofobesity2017/release.php?stateid=MS">Mississippi</a>, is also the third most overweight. </p>
<p>The picture in the nation’s second poorest state, New Mexico, is less clear because here it is complicated by another factor: ethnicity. <a href="http://healthyamericans.org/reports/stateofobesity2017/release.php?stateid=NM">New Mexico</a> has “only” the 33rd highest adult obesity rate – apparently bucking the trend. Yet even in “The Land of Enchantment”, the correlation of wealth and health still leaves its unmistakable fingerprint. Here, the adult obesity rate is 34.4% among black adults, 31.3% among Latino adults and a comparatively sprightly 23.9% among white adults, again reflecting wealth distribution. </p>
<p>Recall that in terms of relative income, a <a href="https://prosperitynow.org/files/PDFs/road_to_zero_wealth.pdf">2017 study</a> found that it would take 228 years for the average black family to reach the same level of wealth that white families have today, while for Latino families, it would take 84 years. Meanwhile, colour correlates to poor health and reduced life expectancy.</p>
<p><a href="http://digital.nhs.uk/catalogue/PUB22269">Recent studies</a> in England also illustrate this link between obesity and income. As you can see in the interactive graph below (toggle the options to see how they compare), of the ten worst areas in terms of overweight or obese children, half are also in the worst ten for child poverty. England’s most obese council, Brent, is also its ninth poorest, whereas England’s wealthiest council, Richmond, despite being a neighbouring council in London, is one of the sprightliest, with a relatively low rate of obesity. And England’s poorest council? Another London borough, Newham, is also the eighth most affected by childhood obesity.</p>
<iframe src="https://datawrapper.dwcdn.net/hYGrG/3/" scrolling="no" frameborder="0" allowtransparency="true" width="100%" height="500"></iframe>
<p>In its way, these figures are as disgraceful an indictment of social priorities and inequality as the 19th-century mortality levels due to epidemics of rickets or typhoid. And the solutions needed are every bit as collective rather than individual.</p>
<h2>Victorian parallels</h2>
<p>Imagine that the Victorians had tried to tackle typhoid by advising everyone to live in the countryside near clean wells, rather than by building sewers and water treatment plants. Today’s response to an epidemic that kills so many people around the world that it has become the <a href="http://easo.org/education-portal/obesity-facts-figures/">fifth leading cause</a> of early death, is just as unrealistic.</p>
<p>In the early years of the 19th century, the industrial towns of the West were characterised by overcrowding, poor housing, bad water and disease. Epidemics, even in the modern cities of New York and London, were – it was assumed – a part of life. The fact that they caused significantly greater suffering in the poorer, slum neighbourhoods only contributed to the blasé responses of city leaders. Epidemics were interpreted as punishments for moral turpitude – in much the same way that today’s illnesses linked to being overweight are. It was only very slowly that such attitudes – deeply rooted in religious notions of individual guilt – <a href="https://jhupbooks.press.jhu.edu/content/great-stink-paris-and-nineteenth-century-struggle-against-filth-and-germs">gave way</a> to public health measures.</p>
<p>But then this was an era before the mechanisms for the transmission of diseases was understood, indeed in an era before even the idea of germs as tiny, invisible life-forms was fully accepted. And so it seemed only reasonable to middle-class New Yorkers that diseases like cholera would hit working-class neighbourhoods the hardest. It was seen as proof of their moral depravity.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/206743/original/file-20180216-131003-3ffksv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/206743/original/file-20180216-131003-3ffksv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=407&fit=crop&dpr=1 600w, https://images.theconversation.com/files/206743/original/file-20180216-131003-3ffksv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=407&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/206743/original/file-20180216-131003-3ffksv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=407&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/206743/original/file-20180216-131003-3ffksv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/206743/original/file-20180216-131003-3ffksv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/206743/original/file-20180216-131003-3ffksv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hand bill from the New York City Board of Health, 1832.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Cholera_outbreaks_and_pandemics#/media/File:Cholera_395.1.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>Meanwhile, businesses fought against public sanitation proposals fearing increased costs – in much the same way that the food industry <a href="https://www.npr.org/sections/thesalt/2013/02/26/172969363/how-the-food-industry-manipulates-taste-buds-with-salt-sugar-fat">resists or subverts public health initiatives</a> as the investigative journalist, Michael Moss, in particular has detailed. And like today, the business interest was often backed by politicians. The hazards back then were not ambiguous things such as sugary soda drinks or ready meals, but rotting animal carcasses and mountains of refuse. Yet the opposition to change was similar – every improvement had to be fought for.</p>
<p>So what are the factors that push poorer people towards unhealthy eating? Food and health policy expert Martin Caraher <a href="https://www.euractiv.com/section/economy-jobs/interview/professor-there-is-a-link-between-poverty-and-unhealthy-diets/">has explained</a> that food choices are massively influenced by factors such as income, knowledge and skills. Others <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464955/">have highlighted</a> the fact that eating well invariably involves more food preparation time. Yet such explanations don’t fit many cases, indeed seem dangerously retrospective. What is sure is that you cannot deal with the obesity epidemic by taxing popular snacks, anymore than you could deal with rocketing suicide rates by taxing sales of rope.</p>
<p>The point is that we need to collectively tackle the places where obesity germs breed – in stressed communities characterised by insecure and erratic employment, inadequate education, stress, depression and a lack of social cohesion. That this requires an enormous shift in public priorities is only to be expected – but the consequences of not acting are far worse.</p><img src="https://counter.theconversation.com/content/91447/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Martin Cohen does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
The statistics point remorselessly towards obesity being a symptom with an underlying social cause. That should completely change the approach to dealing with it.
Martin Cohen, Visiting Research Fellow in Philosophy, University of Hertfordshire
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/85939
2017-10-30T14:23:26Z
2017-10-30T14:23:26Z
What really killed Prince Albert?
<figure><img src="https://images.theconversation.com/files/192439/original/file-20171030-18735-nwogpt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=6659052">Royal Collection/Wikimedia Commons</a></span></figcaption></figure><p><strong><em>Spoiler alert. Those following ITV’s epic costume drama, Victoria, starring Jenna Coleman and Tom Hughes, should look away now – unless you want to know what happens to Albert…</em></strong></p>
<p>It was Queen Victoria’s darkest day. On December 14, 1861, her husband of 21 years, Prince Albert, died at the age of just 42. She never got over his death, and dressed in black for the rest of her life. On the death certificate, the registrar-general gave the cause of death as <a href="https://www.ncbi.nlm.nih.gov/pubmed/6750292">“typhoid fever: duration 21 days”</a>. </p>
<p><a href="https://www.nhs.uk/Conditions/Typhoid-fever/Pages/Introduction.aspx">Typhoid</a> is caused by the bacterium <em>Salmonella typhi</em>. It is <a href="http://www.open.edu/openlearncreate/mod/oucontent/view.php?id=118&printable=1">spread</a> by consuming food or water contaminated with the faeces of an infected person. The disease is therefore associated with poor sanitation and unhygienic preparation of food. It is still a <a href="https://www.ncbi.nlm.nih.gov/pubmed/20014951">serious problem</a> in many of the poorer parts of the world, but in the Victorian era, it could strike anyone, anywhere – even a prince. </p>
<h2>The Great Stink</h2>
<p>Only a few years before, during the hot summer of 1858, the sluicing of raw sewage into the Thames had reached crisis point, producing the <a href="https://www.choleraandthethames.co.uk/cholera-in-london/the-great-stink/">“Great Stink”</a>. For all Victorians, even the aristocracy, typhoid was an ever-present menace that could kill up to a third of those infected. Death was usually a result of intestinal ulceration – if one of the ulcers perforated, <a href="https://www.nhs.uk/Conditions/Typhoid-fever/Pages/complications.aspx">peritonitis would follow</a>, as happens in the case of a burst appendix.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/192066/original/file-20171026-13311-17jgzz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/192066/original/file-20171026-13311-17jgzz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/192066/original/file-20171026-13311-17jgzz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/192066/original/file-20171026-13311-17jgzz5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/192066/original/file-20171026-13311-17jgzz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/192066/original/file-20171026-13311-17jgzz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/192066/original/file-20171026-13311-17jgzz5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Death rows on the Thames, claiming the lives of victims who have not paid to have the river cleaned up.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=4465060">Punch Magazine</a></span>
</figcaption>
</figure>
<p>Despite the daily reality of typhoid in the 1860s, a stunned public almost immediately began to express scepticism regarding the diagnosis, with <a href="https://www.ncbi.nlm.nih.gov/pubmed/6750292">letters</a> appearing in The Lancet and the British Medical Journal. No autopsy was performed – whatever the uncertainty regarding the much respected Prince’s tragically premature end, there were no suspicious circumstances and the curiosity-driven dissection of a royal corpse was regarded as a step too far. </p>
<p>The royal doctors also had to consider the effect further public discussion of the Prince’s illness would have had on the <a href="http://www.dailymail.co.uk/news/article-2073792/Queen-Victorias-unbearable-grief-death-Prince-Albert.html">distraught state of his widow, Queen Victoria</a>, which later deepened into a lifelong state of mourning that today we might call clinical depression. As far as the royal medical team were concerned, it was case closed.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/192069/original/file-20171026-13311-1ndo1zy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/192069/original/file-20171026-13311-1ndo1zy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=786&fit=crop&dpr=1 600w, https://images.theconversation.com/files/192069/original/file-20171026-13311-1ndo1zy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=786&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/192069/original/file-20171026-13311-1ndo1zy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=786&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/192069/original/file-20171026-13311-1ndo1zy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=988&fit=crop&dpr=1 754w, https://images.theconversation.com/files/192069/original/file-20171026-13311-1ndo1zy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=988&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/192069/original/file-20171026-13311-1ndo1zy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=988&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Queen Victoria and Prince Albert, 1854.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=8001129">Roger Fenton</a></span>
</figcaption>
</figure>
<p>Recent biographies of Prince Albert have either tended to gloss over the exact cause of death as <a href="https://books.google.co.uk/books/about/Albert.html?id=NrZ1AAAAIAAJ&redir_esc=y">unimportant</a> or <a href="https://www.abebooks.co.uk/book-search/title/uncrowned-king-life-prince-albert/author/stanley-weintraub/">actively dispute it</a>. One of the most favoured alternative theories is that <a href="https://books.google.co.uk/books?id=4Z1S6CSXV2UC&pg=PA435&lpg=PA435&dq=prince+albert+stomach+cancer&source=bl&ots=8YKQHSrKvG&sig=ceNqjVRsUVE8_jyc4q_BrJRdhfY&hl=en&sa=X&ved=0ahUKEwj9hqnLtfrWAhXBCBoKHdInAkoQ6AEIjwEwGQ#v=onepage&q=prince%20albert%20stomach%20cancer&f=false">Albert had stomach cancer</a> (a disease that killed his mother at the age of 30), or perhaps <a href="http://www.dailymail.co.uk/news/article-2074595/Prince-Alberts-death-finally-solved-150-years-suffering-Crohns-disease.html">Crohn’s disease</a>. </p>
<p>Certainly, Albert’s health had been deteriorating intermittently for several years. Although he and his wife were almost purely constitutional monarchs in the modern sense, with the reins of government held firmly by the prime minister and the cabinet, Albert insisted on taking a very active role in decision-making. </p>
<p>Nineteenth-century deference to the aristocracy and the Prince Consort’s assertive personality meant that he was rarely denied this privilege, and he frequently distressed himself acutely over matters well beyond his official job description. Nor did he use his dabbling in government as an excuse to avoid the ceremonial aspects of his role. Albert’s life became a whirlwind of public engagements and private office work over long hours; he was a man driving himself to the brink.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/HwaZb-s6Mb4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<h2>Jenner’s diagnosis</h2>
<p>Nevertheless, the typhoid fever diagnosis ought not to be completely discounted. The junior of the main pair of royal physicians was William Jenner, the world’s acknowledged expert on typhoid fever. His theoretical superior, the 72-year-old Sir James Clark, had first become known as the doctor who <a href="https://www.theguardian.com/books/2009/oct/26/doctors-mistakes-keats">treated the poet John Keats during his final illness</a> in Rome 41 years previously. In 1861, however, Clark’s contribution to Prince Albert’s care went little beyond the reassurance provided by his eminent presence in the sickroom. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/192067/original/file-20171026-13349-mx9df3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/192067/original/file-20171026-13349-mx9df3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=809&fit=crop&dpr=1 600w, https://images.theconversation.com/files/192067/original/file-20171026-13349-mx9df3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=809&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/192067/original/file-20171026-13349-mx9df3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=809&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/192067/original/file-20171026-13349-mx9df3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1016&fit=crop&dpr=1 754w, https://images.theconversation.com/files/192067/original/file-20171026-13349-mx9df3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1016&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/192067/original/file-20171026-13349-mx9df3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1016&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">William Jenner.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=19054609">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>Instead, Jenner took the lead, basing his diagnosis of typhoid on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2104228/">previous observation of hundreds of cases</a>. If anybody knew typhoid, Jenner did, and he saw the same pattern playing out in Albert.</p>
<p>Albert had been well and in relatively good spirits on the royal family’s annual outing to Balmoral in late summer 1861, but after the holiday he returned to his old habits of obsessive working. Psychologically he was under great strain due to the recent deaths of three of his cousins in the Portuguese royal family, <a href="https://books.google.co.uk/books?id=GdpJ3xILErYC&pg=PA408&lpg=PA408&dq=portuguese+royal+family+typhoid&source=bl&ots=vo-c_CD2cv&sig=qeUthKGp6669-6akTqZdV0Fc6kk&hl=en&sa=X&ved=0ahUKEwjprM-LuPrWAhVFtxoKHWVvDo4Q6AEIZDAO#v=onepage&q=portuguese%20royal%20family%20typhoid&f=false">coincidentally also all from typhoid</a>. The Queen noted his depression <a href="http://www.queenvictoriasjournals.org/home.do">in her diary</a> on November 12. One of his daughters also later recollected that he ate very little during this time. </p>
<p>On November 22, Albert had been soaked to the skin by a rainstorm on a morning visit to Sandhurst military academy. The following day, he began to complain of rheumatic pains and feeling very unwell. </p>
<p>But on November 25, instead of resting and recuperating, he went off to Cambridge to upbraid his eldest son, Albert Edward, the Prince of Wales, on his liaison with what Albert called a “low, common woman” – the actress Nellie Clifden, who had become the student prince’s first mistress. </p>
<p>They went for a long walk, considerably lengthened by a wrong turning in the rain. Albert returned exhausted, once again soaked to the skin, and in his native German “recht elend” (quite miserable). Despite this extreme tiredness, Albert recorded in his diary that day that he had scarcely slept for a fortnight.</p>
<p>A few days later, at an Eton College parade on November 29, witnesses recorded that the Prince Consort looked very unwell and he complained to one of his daughters of “very heavy catarrh” and a headache as well as rheumatic pain. He later suffered from a violent coughing fit. </p>
<p>Jenner examined him that evening but did not initially suspect anything serious. The following day, Albert was back at his desk, but once again soon exhausted. From December 4, he began to go badly downhill, exhibiting signs of breathlessness with occasional vomiting and episodes of delirium. His insomnia continued and Jenner and Clark became, between themselves, increasingly worried, although the nervous Queen was kept reassured. </p>
<p>On December 7, Jenner noticed the characteristic pink-purple <a href="https://www.ncbi.nlm.nih.gov/pubmed/6750292">“rose spots” of typhoid</a> on the Prince Consort’s abdomen. The last piece of the jigsaw had slotted into place, and the diagnosis of typhoid was made. </p>
<p>There was a slight improvement from December 8-11, but on December 12 the fever, breathing difficulties and delirium returned with greater force and he coughed up a large quantity of mucus. On December 14, the fever intensified further, his hands and face began to darken (possibly a <a href="https://www.nhs.uk/conditions/cyanosis/pages/introduction.aspx">cyanosis</a> from circulatory failure) and his breathing became more rapid. Just before 11pm, he died.</p>
<p>Can this have been a description of typhoid? The slow progress of the disease over three weeks is very characteristic. Likewise the sporadic delirium, rose spots, headache, coughing and progressive exhaustion are all typical symptoms. </p>
<p>Mid-19th century doctors had virtually no laboratory diagnostic resources and relied almost exclusively on observation of the patient. The <a href="https://www.ncbi.nlm.nih.gov/pubmed/10644383">first blood test for typhoid</a> was not developed until 1896. In Albert’s case, the key sign was the <a href="https://www.skinsight.com/skin-conditions/atlas/typhoid-fever">rose spot rash</a>.</p>
<p>Infectious diseases often exhibit distinctive rashes or other skin lesion patterns – measles, chickenpox, smallpox, roseola, scarlet fever, syphilis, scabies, coxsackievirus, herpesvirus, Zika virus and papillomavirus as well as typhoid. Where the other symptoms are diffuse and general, <a href="https://www.futuremedicine.com/doi/full/10.2217/fmb-2016-0147">it is often the rash that clinches things</a>.</p>
<h2>Biographers disagree</h2>
<p>But if we accept Jenner’s observational experience and expertise in typhoid and agree with his diagnosis, the question then arises of when the Prince contracted it. Biographers who disagree with the typhoid theory often point to the fact that December 1861 was a relatively quiet time for the disease. There were no cases reported in any of the locations where Albert was to be found in the three weeks or so before his death – neither in Windsor, Cambridge nor Sandhurst. Albert was also eating virtually nothing at this time, also minimising the opportunities for typhoid transmission. </p>
<p>However, this critique fails to consider the issue of the incubation period of the disease. Typhoid has a clinical course of three to four weeks, but a wide incubation period of six to 30 days. To find the places where the Prince Consort was potentially infected, we need to look at his diary not in late November but from late October to mid-November. </p>
<p>The royal party left Edinburgh by train for London on October 23, having travelled the day before from Balmoral, where they had been since August 31. En route from Balmoral to Edinburgh, <a href="http://www.queenvictoriasjournals.org/home.do">the only meal was a lunch taken at Stonehaven</a>, on the coast near Aberdeen. In Edinburgh, all dining was at Holyrood Palace, where several eminent guests joined the royal party. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/192074/original/file-20171026-13315-eg6wv7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/192074/original/file-20171026-13315-eg6wv7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=796&fit=crop&dpr=1 600w, https://images.theconversation.com/files/192074/original/file-20171026-13315-eg6wv7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=796&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/192074/original/file-20171026-13315-eg6wv7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=796&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/192074/original/file-20171026-13315-eg6wv7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1000&fit=crop&dpr=1 754w, https://images.theconversation.com/files/192074/original/file-20171026-13315-eg6wv7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1000&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/192074/original/file-20171026-13315-eg6wv7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1000&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Prince Albert, 1860.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=11939975">John Jabez Edwin Mayal/Wikimedia</a></span>
</figcaption>
</figure>
<p>After that, Albert was based at Windsor until his death, the only trips of any distance being four to London on October 26, October 30, November 6 and November 11, and the visit to his son in Cambridge on November 25. It is possible that Albert was infected with typhoid during that Stonehaven lunch break, or perhaps on one of his London trips but that is, of course, purely speculative. </p>
<p>The London Morning Post, on December 18, 1861 <a href="https://www.britishnewspaperarchive.co.uk/search/results/1861-01-01/1861-12-31?basicsearch=typhoid&somesearch=typhoid&retrievecountrycounts=false&newspapertitle=morning%20post&page=1">recorded just 39 cases of typhoid fever in London in the previous month</a>. The only mention of typhoid in the Press and Journal, the local newspaper in Stonehaven, in 1861 was to report the death of the Prince Consort. So further investigation of the possible incubation period does not lend any obvious support to the typhoid theory.</p>
<p>A third possibility remains. Albert may have had an illness that is still unknown today. It is easy to be dismissive of the comparatively primitive medicine of the 1860s, but the medicine of our own age will be similarly dismissed 150 years from now. We can be sure that there are some things we still do not fully understand, and perhaps Albert’s fatal decline is one of them.</p><img src="https://counter.theconversation.com/content/85939/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Derek Gatherer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
Although some experts still disagree about the cause of Prince Albert’s untimely demise, the most likely culprit seems to be the bacterium Salmonella typhi.
Derek Gatherer, Lecturer, Lancaster University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/75061
2017-07-12T20:06:38Z
2017-07-12T20:06:38Z
How infectious diseases have shaped our culture, habits and language
<figure><img src="https://images.theconversation.com/files/171398/original/file-20170530-16303-1clhh37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Bubonic plague slowed urbanisation, industrial development and economic growth in Europe for many years.</span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p><em>This is the last article in our four-part package looking at infectious diseases and how they’ve influenced our culture and evolution. Read the other articles <a href="https://theconversation.com/au/topics/infectious-diseases-package-40443">here</a>.</em></p>
<hr>
<p>Despite being so small they can’t be seen with the naked eye, pathogens that cause human disease have greatly affected the way humans live for centuries. Many infectious diseases have been significant enough to affect how and where we live, our economies, our cultures and daily habits. And many of these effects continue long after the diseases have been eliminated.</p>
<p>Infectious diseases have changed the structure and numbers of people living in communities. </p>
<p>The European bubonic plague, or “Black Death” (1348-1350), identified by painful swollen lymph nodes and dark blotches on the skin, killed 80% of those infected. At <a href="http://www.coloradotech.edu/resources/blogs/november-2012/pandemic-2">least 20 million people died</a>, which was about two-thirds of the European population at the time. It <a href="http://www.abc-clio.com/ABC-CLIOCorporate/product.aspx?pc=A1507C">slowed urbanisation, industrial development and economic growth</a> as people left cities and reverted to rural and agricultural life. Those who survived, however, were highly sought after for work.</p>
<p>The accidental introduction of measles to Fiji (1875) by people travelling between Fiji and the West caused massive numbers of deaths in communities previously not exposed to the disease. In a few months <a href="http://jmvh.org/article/pacific-island-societies-destabilised-by-infectious-diseases/">20-25% of Fijians</a> and nearly all of the 69 chiefs died. The leadership vacuum and loss of working-age population <a href="http://jmvh.org/article/pacific-island-societies-destabilised-by-infectious-diseases/">became an opportunity</a> for the colonial government to import labourers from other nations to work in the agricultural industries.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/171402/original/file-20170530-16310-1vx7zg8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/171402/original/file-20170530-16310-1vx7zg8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/171402/original/file-20170530-16310-1vx7zg8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/171402/original/file-20170530-16310-1vx7zg8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/171402/original/file-20170530-16310-1vx7zg8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/171402/original/file-20170530-16310-1vx7zg8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/171402/original/file-20170530-16310-1vx7zg8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/171402/original/file-20170530-16310-1vx7zg8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Plague slowed economic growth in Europe as people left the cities in droves.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>In the Caribbean island Hispaniola <a href="http://web.monroecc.edu/scholarsday/SDRhome">it’s estimated</a> that within 50 years of the arrival of Columbus, his crew and their “pathogens” (like measles, influenza and smallpox), the indigenous Taino people were virtually extinct. This pattern of large death tolls among Indigenous populations in the Americas is repeated in many locations, causing loss of traditional ways of life and cultural identity, and changing the course of their history.</p>
<p>Unfortunately, introduction of an infectious disease into a susceptible population was not always accidental. “Germ warfare” was a strategy used in many colonisation and war efforts. This includes North American Indigenous populations (<a href="http://onlinelibrary.wiley.com/doi/10.1038/sj.embor.embor849/abstract">there are reports</a> of blankets from smallpox-infected corpses being deliberately distributed in the late 1700s); bodies of dead animals or humans being thrown into water supplies <a href="http://onlinelibrary.wiley.com/doi/10.1038/sj.embor.embor849/abstract">during warfare in Italy in the 12th century</a>; and saliva from rabid dogs or the blood of leprosy patients being used by the Spanish against <a href="http://onlinelibrary.wiley.com/doi/10.1038/sj.embor.embor849/abstract">French enemies in Italy in the 15th century</a>. </p>
<h2>Changing global economics</h2>
<p>Infectious diseases, as well as the search for cures, have had many influences on economies over the centuries. In 1623, the <a href="https://books.google.com.au/books/about/Quinine.html?id=K8Q53xW1ie8C&redir_esc=y">death of ten cardinals</a> and hundreds of their attendants led Pope Urban VII to declare that a cure for malaria must be found.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/171404/original/file-20170530-16306-bjcz2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/171404/original/file-20170530-16306-bjcz2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/171404/original/file-20170530-16306-bjcz2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/171404/original/file-20170530-16306-bjcz2t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/171404/original/file-20170530-16306-bjcz2t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/171404/original/file-20170530-16306-bjcz2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/171404/original/file-20170530-16306-bjcz2t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/171404/original/file-20170530-16306-bjcz2t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Once it was discovered quinine could treat malaria it became more valuable than gold.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>This was a common risk in Rome, where <em>mala aria</em> (“bad air” from marshes thought to be its origin) had existed since late antiquity. Jesuit priests travelled from Europe to South America to learn about local treatments. <a href="https://books.google.com.au/books/about/Quinine.html?id=K8Q53xW1ie8C&redir_esc=y">In 1631, they identified quinine</a>, made from the bark of the local cinchona tree in Peru, as a cure. </p>
<p>After that discovery there was a race to control quinine in order to keep armies fighting European wars, including the Napoleonic, and attempting to capture territories. At this time quinine <a href="https://books.google.com.au/books/about/Quinine.html?id=K8Q53xW1ie8C&redir_esc=y">became a commodity more precious than gold</a>.</p>
<p>In the late 1880s Tunisia experienced severe infectious disease epidemics of cholera and typhoid, and famines, which so badly depleted its economy that it was unable to pay off its debts. This made it <a href="https://www.amazon.co.uk/Empires-Sun-Struggle-Mastery-Africa/dp/1780226187">vulnerable to French occupation</a> and then colonisation.</p>
<p>In recent times, it has been estimated that the HIV epidemic in South Africa may have <a href="https://www.cgdev.org/publication/economic-implications-epidemics-old-and-new-working-paper-54">reduced its gross domestic product (GDP) by 17%</a> (from 1997 to 2010) and that SARS cost East Asia <a href="https://www.cgdev.org/publication/economic-implications-epidemics-old-and-new-working-paper-54">around $US15 billion</a>, (0.5% of GDP).</p>
<h2>Changing the foods we eat</h2>
<p>The origins of many food taboos appear to be linked to infectious diseases. These include prohibitions on drinking raw animal blood, on sharing cooking and eating utensils and plates between meat and other foods, and on eating pork in Judaism and Islam (most likely concerned about <a href="https://www.ncbi.nlm.nih.gov/pubmed/19563636">dangerous pig tapeworms</a>).</p>
<p>Newer examples of these food exclusions that are still the norm today include:</p>
<ul>
<li><p>consumption of raw milk being illegal in many countries, to prevent spread of bovine (cow) tuberculosis</p></li>
<li><p>not eating soft cheeses when pregnant to avoid contracting listeria, which can cause miscarriages and stillbirths</p></li>
<li><p>trying to stop people licking the cake bowl because of the risk of egg-borne salmonella bacteria.</p></li>
</ul>
<h2>Adding words to our languages</h2>
<p>Many words and expressions commonly used in English have origins linked to an infectious disease. One such common phrase, used for a person who may not have symptoms of an infectious disease but can transmit it, is to call them a Typhoid Mary. In 1906 Mary Mallon, a cook, was the first healthy person identified in the USA as a carrier of the typhoid bacilli that causes typhoid fever, a serious disease for the Western world in the 19th century (but which globally exists and has often existed in poor communities). </p>
<p><a href="http://www.abc-clio.com/ABC-CLIOCorporate/product.aspx?pc=A1507C">One public health engineer traced an outbreak in Oyster Bay</a> and a path of outbreaks wherever Mary worked. In New York, she was put into isolation where she stayed until she died nearly three decades later.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/171406/original/file-20170530-16303-chzz37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/171406/original/file-20170530-16303-chzz37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/171406/original/file-20170530-16303-chzz37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=473&fit=crop&dpr=1 600w, https://images.theconversation.com/files/171406/original/file-20170530-16303-chzz37.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=473&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/171406/original/file-20170530-16303-chzz37.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=473&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/171406/original/file-20170530-16303-chzz37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=595&fit=crop&dpr=1 754w, https://images.theconversation.com/files/171406/original/file-20170530-16303-chzz37.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=595&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/171406/original/file-20170530-16303-chzz37.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=595&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Feeling ‘lousy’ comes from the poor feeling experienced when suffering a lice infestation, perhaps caused by anaemia.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>Other such additions to our everyday conversations include:</p>
<ul>
<li><p>“God bless you” after someone sneezes is said as it signalled that someone was unwell, perhaps seriously. It’s credited to St Gregory the Great, although words wishing the sneezer safety from disease have been found in ancient Greek and Roman.</p></li>
<li><p>the phrase “off colour” appears to have derived from the late 1800s where a diamond and then other items that were not their natural or acceptable colour were “off colour”, or defective. It soon extended to describe being unwell.</p></li>
<li><p>feeling lousy means feeling poorly. A person infested with lice often scratches, may be anaemic from the lice feeding on their blood, and doesn’t feel well.</p></li>
</ul>
<p>The 14th-century French brought us two terms used in infectious diseases: “<em>contagion</em>” meaning touching/contact; and disease from <em>des</em> (lack of) <em>ease</em> (comfort). And the 16th-century term epidemic is from the French <em>epi</em> – among, <em>demos</em> – people.</p>
<p>So pathogens evolve with us and have shaped our lives and will remain one of the forces that we adapt to as we progress through human history.</p>
<hr>
<p><em>Read the first three instalments in the series:</em></p>
<p><em><a href="https://theconversation.com/four-of-the-most-lethal-infectious-diseases-of-our-time-and-how-were-overcoming-them-78101">Four of the most lethal infectious diseases of our time and how we’re overcoming them</a></em></p>
<p><em><a href="http://theconversation.com/how-infectious-diseases-have-driven-human-evolution-75057">How infectious diseases have driven human evolution</a></em></p>
<p><em><a href="http://theconversation.com/how-we-change-the-organisms-that-infect-us-74625">How we change the organisms that infect us</a></em></p><img src="https://counter.theconversation.com/content/75061/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maxine Whittaker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
Despite being so small they can’t be seen with the naked eye, pathogens that cause human disease have greatly affected the way humans live for centuries.
Maxine Whittaker, Dean, Public Health, Medical and Veterinary Sciences, James Cook University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/53645
2016-01-25T14:06:33Z
2016-01-25T14:06:33Z
Explainer: causes, symptoms and cures of typhoid fever
<figure><img src="https://images.theconversation.com/files/109140/original/image-20160125-19675-v0kacd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A child collects clean water in Delmas, east of Johannesburg, an area vulnerable to outbreaks of the deadly typhoid virus.</span> <span class="attribution"><span class="source">Reuters/Mujahid Safodien</span></span></figcaption></figure><p><strong>Typhoid <a href="http://allafrica.com/stories/201604191347.html">remains a risk</a> in a number of African countries. The Conversation Africa’s editor Caroline Southey asked Lucille Blumberg, deputy director of the South Africa’s <a href="http://www.nicd.ac.za/">National Institute of Communicable Diseases</a>, about typhoid fever.</strong></p>
<p><strong>What is typhoid and how would I know I’ve got it?</strong></p>
<p>Typhoid is an illness caused by infection with a specific bacteria called <em>Salmonella typhi</em>. It has its origins in humans, not animals. It is found in the faeces of infected persons and spreads to others through faecal contamination of food and water. This occurs in situations where there is poor hygiene related to food preparation, where there is poor sanitation with inadequate ablution facilities and where drinking water is drawn from informal water sources. Hand hygiene after ablutions and before food preparation are critical in preventing the transmission of the bacteria to other people. </p>
<p>The danger with typhoid is that the symptoms are quite insidious, not specific, and mimic those of other infectious diseases. Symptoms include fever, headache, abdominal pain, cold shivers, hot sweats and loss of appetite. Symptoms usually increase over a number of days.</p>
<p>Importantly the symptoms are not specific and overlap with other infectious diseases like malaria, tick bite fever and meningitis. Malaria is the number one infectious disease to be considered when someone presents with a high fever because it really needs emergency treatment. But the possibility of typhoid needs to be considered in any patient who presents a high fever, particularly in areas where typhoid is more prevalent or where there are concerns about sanitation and water.</p>
<p><strong>How do you get it?</strong></p>
<p>Typhoid is transmitted through handling food and water if there is poor hygiene or poor sanitation. The most obvious source is where ablution facilities and drinking water are not separate and where water and sanitation is inadequate. The best protection against it is to wash your hands after going to the bathroom. And to avoid fresh produce from areas known to have cases of typhoid. Informal water sources for drinking should be avoided, or alternatively the water should be boiled before drinking. </p>
<p><strong>How prevalent is it?</strong></p>
<p>Typhoid affects about 21.5 million <a href="http://www.cdc.gov/nczved/divisions/dfbmd/diseases/typhoid_fever/">people</a> a year, nearly all living in developing countries. It is endemic to Africa, South East Asia and South America, occurring all the time though there is much less of it now than 30 years ago. In Africa there are several thousand cases every year.</p>
<p>There is always a higher risk in places where the quality of water is poor and where sanitation isn’t optimal. There have been large-scale <a href="http://www.nicd.ac.za/?page=alerts&id=5&rid=632">outbreaks</a> in South Africa and Zimbabwe. Contaminated water was identified as the reason. A small town called Delmas in the north east of the South Africa’s Mpumalanga province experienced a number of large outbreaks of typhoid fever in 1995 and 2005 but no outbreaks have been reported since <a href="http://www.randwater.co.za/Pages/Home.aspx">Rand Water</a> took over the domestic water supply. There was an outbreak in Zimbabwe’s capital Harare in 2012 which is ongoing with 4000 cases having been diagnosed to date. A number of South African cases have over time been linked to this outbreak.</p>
<p>Typhoid is a notifiable disease. This allows the origin of cases to be investigated and also that authorities can be alerted if there is an increase in cases. In addition, the National Institute for Communicable Diseases in South Africa has a laboratory-based monitoring system. This includes monitoring for antibiotic resistance.</p>
<p>In South Africa an alert was put out when four cases were reported over a two-week period in the greater Johannesburg area. This was a little higher than usual and prompted a follow up investigation, especially given that one of the patients died. </p>
<p><strong>Is there a cure?</strong></p>
<p>In the pre-antibiotic era, people were terrified of getting typhoid fever. Then it carried a mortality of <a href="http://www.nicd.ac.za/?page=alerts&id=5&rid=632">5% to 20%</a>. But today it is treatable. Antibiotics can be used although there are resistant strains in certain parts of the world.</p>
<p>It is something that needs to be treated early although it doesn’t carry the same high risk as malaria. </p>
<p>You need to get quite a high dose of the bacteria to become infected. And it’s not that easily transmitted. For example, you can’t get it by being next to somebody. You only get it if you eat or drink something that’s been contaminated. </p>
<p>But in situations where sanitation conditions are poor, and where fresh water isn’t available it can spread very quickly. That’s why there’s always the fear of an epidemic.</p>
<p>We are nowhere near such a situation now. The response to the one death in Johannesburg was prompted by media reports and we wanted to pre-empt concerns people might have. As the institute we get reports of between 110 and 120 cases of typhoid in the country a year. </p>
<p>A vaccine is available and can be considered for travellers to high risk areas, but the vaccine efficacy is only around 70%.</p><img src="https://counter.theconversation.com/content/53645/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucille Blumberg works for South Africa's National Institute of Communicable Diseases which is funded by the National Department of Health. </span></em></p>
The danger with typhoid is that symptoms are quite insidious and mimic those of other infectious diseases.
Lucille Blumberg, Deputy Director of the National Institute for Communicable Diseases and a member of the joint staff, University of the Witwatersrand
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/25759
2014-05-06T14:26:44Z
2014-05-06T14:26:44Z
Our ability to cope with food poisoning outbreaks has not improved much in 50 years
<figure><img src="https://images.theconversation.com/files/47886/original/sm79h464-1399382347.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The E.coli bug at close quarters</span> <span class="attribution"><a class="source" href="http://en.wikipedia.org/wiki/File:E_coli_at_10000x,_original.jpg">Agricultural Research Service</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>On May 7 1964 a catering-size can of corned beef from <a href="http://www.lonelyplanet.com/argentina/northeast-argentina/rosario">Rosario, Argentina</a>, was opened in a supermarket in central Aberdeen. Half the contents were put on a shelf behind the cold meat counter and the other half went into the window. </p>
<p>The weather was warm. The sun shone on the meat. Corned beef is cooked in the can and should be sterile. But it wasn’t. It had been contaminated after cooking when the can was cooled with untreated water from the River Parana. </p>
<p>Into this river, 66 tons of human faeces and 250,000 gallons of urine were discharged every day from Rosario, where typhoid was common. The bacteria in the corned beef in the window grew vigorously.</p>
<h2>Toll rising</h2>
<p>The first person to fall ill developed symptoms on May 12. Making an initial diagnosis is not easy; it usually starts with a high fever, which can have many causes. </p>
<p>In Aberdeen the first definitive diagnoses were made on May 20. By midnight 12 were in hospital, and until June 13 daily hospitalisations never fell below double figures. The outbreak then fizzled out. At its end 503 had been admitted to hospital with typhoid, 403 with bacteriological confirmation.</p>
<p>Among those affected, there was a significant over-representation of women aged 15 to 25 living in the more prosperous west end of the city. The probable explanation is that a slimming regime incorporating cold meats and salad was popular at the time. </p>
<p>Nobody died from typhoid in the outbreak, thanks to antibiotics, so in that regard it was modern. Its media coverage, by TV, would be recognisable today too. But some aspects of its management were conducted as though World War II was still in progress. The names and addresses of those admitted to hospital were published in the local paper and the end of the outbreak was announced as the “all clear”. </p>
<p>Dr Ian MacQueen, then Aberdeen medical officer of health, took control of the outbreak. Opinion in Aberdeen is still divided about how he handled it. Some say he saved the city, others that his antics verged on the ridiculous.</p>
<p>I belong to the latter camp. MacQueen believed that dramatic statements of risk were necessary to prevent the spread of infection. Thus Aberdeen became <a href="http://www.nytimes.com/1964/06/28/queens-visit-assures-aberdeen-that-typhoid-ordeal-is-over.html?_r=0">in his description</a> the “beleaguered city”, and beef cattle raisers in Paraguay, Kenya and Tanzania suffered economically as importing meat came to be seen as high risk in the initial panic about the source. </p>
<p>MacQueen recommended that nobody should paddle in the sea, and the main thoroughfare, Union Street, was <a href="http://books.google.co.uk/books?id=gL72g21APeEC&pg=PA112&lpg=PA112&dq=aberdeen+%26+union+street+disinfectant+1964&source=bl&ots=GunHXegeEy&sig=n8hfbX8mE1xT_MFqMvMZzfquLG8&hl=en&sa=X&ei=FMBoU8W_BYzqOL2ngfAB&ved=0CCwQ6AEwAA#v=onepage&q=aberdeen%20%26%20union%20street%20disinfectant%201964&f=false">sprayed with disinfectant</a>. There was an obsession with “wave after wave of infections” occurring because of poor personal hygiene. </p>
<p>In truth this was always very improbable. There was no person-to-person spread. All the infections were caused by eating contaminated corned beef or cold meats cut with the same slicer. New cases continued to appear not because the source of infection was still active but because the incubation period – the time between being infected and falling ill – was often long.</p>
<h2>The modern picture</h2>
<p>Could the kind of events that happened in Aberdeen 50 years ago be repeated? Cans of food are unlikely to be the source nowadays because canning practices are almost certainly better (even if as we saw in the <a href="http://www.bbc.co.uk/news/business-25715666">horse meat scandal</a>, the label does not always accurately describe the contents). Typhoid is still common in countries whose drinking water is regularly contaminated with human faeces – <a href="http://www.who.int/csr/don/2005_01_19/en/">the 2004/2005 outbreak</a> in Kinshasa affected 42,564 and killed 214. </p>
<p>But an even nastier organism caused the most recent big food-borne outbreak in Europe. Like the Aberdeen outbreak, it started in May and went on until the end of June, and like Aberdeen it also affected women much more commonly than men. But it <a href="http://www.foodsafetynews.com/tag/german-e-coli-outbreak/#.U2jCqRZFKfQ">happened in 2011 in Germany</a>.</p>
<p>The organism was E.coli O104:H4, a brand-new bacterium that had evolved as a hybrid of two other disease-causing E.coli strains. More than 3500 fell ill, 855 developed serious complications and 53 died.</p>
<p>Just as in Aberdeen, the organism was imported. It came on the surface of fenugreek seeds which had left Egypt by boat on November 24 2009, eventually arriving at an organic sprout producer near Hamburg on February 10 2011.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/47889/original/wwh3gf75-1399382667.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/47889/original/wwh3gf75-1399382667.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/47889/original/wwh3gf75-1399382667.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/47889/original/wwh3gf75-1399382667.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/47889/original/wwh3gf75-1399382667.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/47889/original/wwh3gf75-1399382667.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/47889/original/wwh3gf75-1399382667.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/47889/original/wwh3gf75-1399382667.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Fenugreek seeds wreaked havoc in Germany.</span>
<span class="attribution"><a class="source" href="http://en.wikipedia.org/wiki/File:E_coli_at_10000x,_original.jpg">Sanjay Acharya</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Seed sprouting is ideal for bacterial growth. But identifying the seed sprouts as the cause of the outbreak was difficult and slow, because were used as a salad garnish and many victims were not aware that they had eaten them. That women were more commonly ill pointed to salads, but photographs taken at meals were invaluable. </p>
<p>It was all very embarrassing for the German public health authorities, particularly when the Hamburg health minister <a href="http://www.bbc.co.uk/news/world-europe-13605910">mistakenly announced</a> that the organism that had caused the outbreak had been found on Spanish cucumbers, causing serous economic damage to that industry. Shades of Dr MacQueen!</p>
<h2>Lessons from Hamburg</h2>
<p>This mistake illustrated the limits of modern lab technology. We might now be in a position where we could genome-sequence E.coli 0104:H4 quickly, but because it was a new strain, the authorities initially confused it for the more prevalent E.coli 0157:H7. When they found this latter bug on the cucumbers, they thought they had found the culprit. New bugs will always make life difficult for scientists. </p>
<p>The German outbreak also pointed to another unavoidable issue: the Egyptians initially denied responsibility. Whatever your technological advances, politics is still likely to slow you down. One bright spot here though is that the Chinese are much more cooperative than they once were. This is vital given that the country’s size and relative concentration of people makes it quite a likely source for outbreaks. </p>
<p>Another important step forward has been global food safety standards. The worldwide adoption of the hazard analysis critical control points system – HACCP – originally <a href="http://history.nasa.gov/sp4801-chapter12.pdf">developed by NASA</a> to protect astronauts from food poisoning, makes it less likely that the world food supply could lead to a major epidemic – even if some countries are still more diligent than others. </p>
<p>Having said that, food poisoning is <a href="http://www.bmj.com/content/315/7116/1111.8">more common than a century ago</a> (albeit not dysentry spreading from person-to-person or tuberculosis in milk). The Ministry of Health for England and Wales recorded 59 food poisoning incidents during the years 1931-1935, compared to more than 73,000 in 2012, itself a gross underestimate because most people with food poisoning don’t seek medical advice. </p>
<p>The number of sufferers from the UK’s number one cause, campylobacter, has been convincingly <a href="http://www.ehn-online.com/news/article.aspx?id=5274">estimated at 500,000</a> people each year. To some extent this is down to better diagnosis, but probably not entirely. The realities of 21st century mass production of cheap meat are likely to have driven up infection, for example. </p>
<p>Above all else, the big lesson from Germany was that a major outbreak could still take us completely by surprise. With microbes evolving as they do, we can be certain it will happen again.</p><img src="https://counter.theconversation.com/content/25759/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hugh Pennington does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
On May 7 1964 a catering-size can of corned beef from Rosario, Argentina, was opened in a supermarket in central Aberdeen. Half the contents were put on a shelf behind the cold meat counter and the other…
Hugh Pennington, Emeritus Professor of Bacteriology, University of Aberdeen
Licensed as Creative Commons – attribution, no derivatives.