Behind every disease is a story, a complex narrative woven of multiple threads, from the natural history of the disease, to the tale of its discovery and its place in history. But what is vital in all of this is how the disease spreads and develops. In The Atlas of Disease, Sandra Hemple reveals how maps have uncovered insightful information about the history of disease, from the seventeenth century plague maps that revealed the radical idea that diseases might be carried and spread by humans, to cholera maps in the 1800s showing the disease was carried by water, right up to the AIDs epidemic in the 1980s and the recent Ebola outbreak. Crucially, The Atlas of Disease will also explore how cartographic techniques have been used to combat epidemics by revealing previously hidden patterns. These discoveries have changed the course of history, affected human evolution, stimulated advances in medicine and shaped the course of countless lives.
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About the Author
Sandra Hempel is an esteemed medical journalist who has written for many newspapers and journals, including The Times, The Guardian and The Lancet. Her previous books include The Medical Detective: John Snow, Cholera and the Mystery of the Broad Street Pump, which won the British Medical Association's prize for the public understanding of science, and The Inheritor's Powder: A Cautionary Tale of Poison, Betrayal and Greed, which was serialised on Radio 4 as Book of the Week.
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Causal agent Bacterium Corynebacterium diphtheriae
Transmission Respiratory route and direct contact
Symptoms Weakness, sore throat, fever, swollen neck glands, thick grey coating in the throat or nose
Incidence and deaths Around 5,000 cases a year worldwide. Fatal in 5–10 per cent of cases.
Prevalence Endemic in many countries in Asia, the South Pacific, the Middle East, Eastern Europe and in Haiti and the Dominican Republic. Rare in industrialised countries.
Treatment Antitoxins and antibiotics
Global strategy Childhood vaccination programmes but the World Health Organization (WHO) describes diphtheria as a 'forgotten' disease
In 1859, The Lancet published a report on the sudden appearance of 'a strange type of disease'. The author, a surgeon at the West London Hospital called Ernest Hart, described the unknown sickness as 'distressing in its symptoms, rapid in its progress, intractable, and communicable by infection and by contagion'. It also 'acted with severity in confined areas of population' and left 'terrible traces of its passage', he wrote.
Hart said it was important to find out if this malady was entirely new to the world or had, in fact, re-emerged from foreign lands and previous centuries. One thing, however, was clear: 'The most experienced surgeons ... find themselves called upon to combat an unknown enemy, and one whose mode of attack is new to them.'
The return of an old disease
While diphtheria's origins and its route into Europe are unknown, it was not new to Britain in the 1850s. Various medical reports in previous centuries describe what appear to be its symptoms, and in 1821 the French physician Pierre Bretonneau had identified diphtheria as a separate disease from other childhood illnesses.
The German scientist Friedrich Loeffler – who identified the bacterium Corynebacterium diphtheriae as being responsible for the disease in 1884 – claimed there were no descriptions of diphtheria in the writings of any of the great classical Greek physicians. But others believe that Hippocrates, the 'father of Western medicine', referred to it in the fifth century BC. Regardless, many experts, including Loeffler, accept that the infection was well-known in ancient Egypt, Syria and Palestine.
Some of the more recent accounts in the West of a disease that appears to be diphtheria date from sixth-century France, from Rome in 856 and 1004, and from parts of the Byzantine empire in 1039. Loeffler also refers to what he believed was an outbreak in England in 1389, which he said killed many children. As with scarlet fever – with which it was often confused – diphtheria favours the young.
The first recorded major epidemic seems to have been in France in 1562–98 during the religious wars between the Catholics and the Huguenots. It reached Paris in 1576. It was followed by an infamous epidemic in Spain in 1583–1618, where it was dubbed El garrotillo – 'The Strangler' – and the year of 1613 was referred to as Ano de los garrotillos, the 'Year of the Strangler'.
Diphtheria was known as 'the Strangler' because of its unpleasant tendency to suffocate its victim. The bacterium destroys the lining of the throat, causing dead tissue and pus to merge together over the site, forming a tough leathery membrane known as a pseudomembrane. Any attempt to remove it rips at the live tissue beneath, causing massive bleeding. If it is left in place, however, the membrane blocks the patient's airway. Even if the sufferer manages to survive the effects of the membrane, the toxin can invade the body, damaging organs and nerves.
Something in the air?
In the great medical science breakthroughs of the second half of the nineteenth century, doctors were beginning to understand the role germs played in spreading epidemic disease. In the late 1800s and early 1900s, bacteriologists like Loeffler were fast identifying the different pathogens responsible for different diseases and the infections' various means of transmission. Diphtheria, which is highly infectious, is mainly caught by inhaling droplets released into the air by an infected person's coughs or sneezes. It can also be passed on through direct contact with bacteria, for example, in mucous or on surfaces and objects.
Back in the 1850s, however, when the mystery epidemic hit Britain, the centuries-old theory of miasmatism still held sway. Foul smells, or miasma, from decaying organic matter – bad food, rotting carcasses and excreta, for example – or emanating from marshlands and stagnant water, were thought to contain the 'poisons' that caused disease. Other factors such as the climate determined which particular disease prevailed.
This may explain why in 1859 Ernest Hart looked to the weather and the environment for clues. He could find none and waxed lyrical in his bafflement. The disease 'has swept across the marshy lowlands of Essex and the bleak moors of Yorkshire', he noted. Of other parts of the country, he wrote:
It has traversed the flowery lanes of Devon and the wild flats of Cornwall that are swept by the sea-breeze. It has seated itself on the banks of the Thames, scaled the romantic heights of North Wales and descended into the Cornish mines. Commencing in the spring months, it has continued through the summer, and if extremes of temperature have appeared to lend it fresh vigour and the heat of the dog-days, or the severe frosts and sleet of winter have fostered its strength, yet moderate temperature has not greatly abated its influence, and it has struck a blow here and there through all the seasons.
As late as 1908 the medical officer for Croydon in south London still thought it worth inspecting all 310 houses where the disease had struck on his patch, to see if there was a link between diphtheria and defective drains. As he already suspected, however, no such connection could be found.
An escalation of deaths
Until the nineteenth century, the disease commonly struck in tightly contained outbreaks; for example, in a hamlet, a school or a family. It might cause terrible losses within those small confines but tended not to spread further.
All this changed in Britain during the nineteenth-century Industrial Revolution when people flocked into the towns in search of work and were crowded into slum housing. The pattern of disease was still localised outbreaks within communities or districts, but those out breaks were now numerous, more widely spread and affected many districts at the same time. In the late nineteenth and early twentieth centuries, diphtheria turned from an occasional tragedy into a major killer. The explosion of disease led to claims it had been imported from overseas and for a while it was known as 'Boulogne sore throat'.
But as well as the change in living conditions, a more virulent strain of the bacterium may well have been involved: between 30 and 50 per cent of children who caught diphtheria in the nineteenth century died from it. In 1885 the medical officer for the parish of Hanover Square in central London reported: 'Diphtheria caused no less than 35 deaths, being the largest number recorded in the parish in any year, and nearly 2 1/2 times the annual average for the preceding 10 years; being also an increase of 10 on the number for 1884.' Diphtheria had been 'exceedingly prevalent' throughout London since 1883.
In the following year, the medical officer for St Mary Abbott's in Kensington reported thirty deaths from diphtheria, more than for any year for a decade. He couldn't account for the increase but wondered if it might be due to better diagnosis rather than a real increase. Both factors probably had a part to play.
From the late nineteenth century and into the twentieth century, great progress was made both in the treatment and prevention of diphtheria. The first advance was the development of what is known as an antitoxin that harnesses the body's own attempts to neutralise the bacterium's poison. This made the disease much less lethal and in many cases curable. There was also another important benefit: the need to mass-produce antitoxins played a strong part in integrating pharmaceutical production with research.
Then in 1923, in France, came a vaccine. An epidemic in the United States in 1921–5 killed around 15,500 people, with 206,000 cases at its peak in 1921. In the middle of the decade, however, the US government licensed the newly available vaccine and the number of cases plum meted.
Diphtheria is now rare in industrialised countries, where infants are routinely given the diphtheria/tetanus/pertussis vaccine. However, epidemics have broken out in post-Soviet countries in the 1990s, and today diphtheria is still found world wide. In 2017 a panel of WHO experts described diphtheria as a 'forgotten disease' in large parts of the world and said it needed global attention. Their research showed that progress in reducing its incidence had stalled over the previous five years, at around five thousand cases a year.
Causal agent Several strains of virus, with new strains emerging
Transmission Mainly respiratory but also through contact with objects or surfaces
Symptoms Fever, cough, sore throat, runny nose, muscle aches, headaches, fatigue
Incidence and deaths Up to 650,000 deaths a year worldwide from respiratory diseases linked to seasonal flu
Prevalence Worldwide, with the constant risk of a new pandemic
Prevention Vaccination, but not always effective and protection is short lived. Infected cases isolated if detected early on. Advice for general population on avoiding infection during an outbreak.
Treatment Antiviral drugs
Global strategy Multi-factored, including surveillance to detect first signs of an epidemic and rapid response to contain it
The influenza pandemic that swept the world in the autumn of 1918 killed more people than the First World War. Estimates put the death toll at around fifty million.
The event was even more extraordinary in that it came from such an unexpected source. Until then, flu had been seen as something unpleasant rather than frightening. People rarely died from it, and those who had were largely the very young, the old and those with weakened immune systems. But in 1918 that suddenly changed. For the first time, fit young adults died in droves.
Who was patient zero?
Some historians have blamed one unfortunate individual for the whole massive global tragedy. Private Albert Gitchell, a mess cook at a US army base in Kansas, stands accused of being 'patient zero' – in other words, the first person to fall sick in an epidemic. How Gitchell himself caught the infection, no one has ventured to explain.
On 11 March 1918, the soldier complained of a sore throat, headache and fever. Within hours, the infirmary was full of soldiers with the same symptoms and a month later, the medical officer had to requisition an aircraft hangar to accommodate all of his patients. Mean while, those men who seemed to be healthy were sent over to Europe to fight, some presumably harbouring the infection.
The Private Gitchell theory makes for a good story but not all experts are con vinced. An alternative hypothesis is that the pandemic began in 1917 at the main transit camp for the British Expeditionary force in Étaples in northern France. The camp has been described as the ideal cauldron for producing a new influenza virus, because large numbers of people, pigs and fowl were living in close proximity.
Although human beings are the main reservoir for the virus, other mammals such as pigs (swine flu) and birds such as chickens (avian flu) are also a source for some human types. The infection spreads mainly through the air when people are crowded together in enclosed spaces, and because the virus can survive for some days outside a host, it can also be spread by contact with infected surfaces such as door handles. This explains why people who nowadays work in offices or use public transport frequently, for example, are more likely to get flu.
Regardless of how the 1918 flu started, soon the pandemic was killing millions on every continent, its virulence and speed of attack causing terror worldwide. The Russian dancer Léonide Massine, giving a performance at the Coliseum in London, described how he was terrified that he would catch flu because he had to lie down on the stage wearing nothing but a loin cloth 'while the cold penetrated to my bones'. He survived the ordeal and awoke the next morning in good health, only to arrive at the theatre and discover that the policeman who usually stood at the entrance, 'a hulk of a man', had died in the night.
Influenza has been described as a 'sly, nimble, deceptive sort of disease'. Sly because it infects so many people that, although only a small percentage die, these deaths add up to large numbers, and also because, unlike many other infectious diseases, it gives its victims only short-term immunity. At the height of the pandemic, there have been points at which most of the world's population was infected, although in some people the disease was subclinical – in other words, they had no symptoms.
Earlier outbreaks of flu
Influenza was probably well-established in the human population by around 5000 BC when people in some parts of the world, such as China and the Middle East, began living together and herding animals.
The Greek physician Hippocrates is thought to have described influenza in the fifth century BC, but after that there are no clear records until the fifteenth and sixteenth centuries when reports began coming out of Europe. In the summer of 1510 a disease broke out in Modena in Italy. A chronicler wrote:
there appeared an illness that lasts three days with a great fever, and headache and then they [the victims] rise ... but there remains a terrible cough that lasts maybe eight days, and then little by little they recover and do not perish.
Not long afterwards large-scale epidemics appeared to hit the continent, with an outbreak in 1580 identified as the first definite pandemic, spreading to Africa, Asia, Europe and North America. There were at least three more pandemics in eighteenth-century Europe and several epidemics, two of them extensive. An outbreak in 1781–2 is thought to have hit two-thirds of the population of central Italy and three-quarters of that in Britain. And disease also spread widely in North America, Latin America and the Caribbean.
The pattern continued into the nineteenth century. In 1889 influenza attacked Europe from the east, earning it the name Russian flu. From here, ships carried it across the Atlantic to the United States. Two months later, it was in Canada, Brazil, Argentina and Uruguay before moving on to Singapore, Australia and New Zealand. Soon it was widespread across Asia and Africa. In parts of Africa, the infection became known as a 'white man's disease'. Mortality rates – the number of deaths during a particular incidence or period – were quite low, as in previous outbreaks, but because of the large numbers of cases, the total number of deaths was high: at least 250,000 people in Europe and twice as many across the world.
The 1918 episode was known as the Spanish flu, not because it was thought to have originated in Spain or because its ravages were any worse there, but because of the timing. The First World War dominated the agenda for the combatants, while at the same time censorship restricted reporting of any news that might damage morale or make a country appear vulnerable. In Spain, however, which had stayed neutral, there were no such constraints.
At first the flu seemed to be following its usual pattern, with high morbidity rates – the number of infections during a particular incidence or period – but fairly low mortality. In the autumn, however, that changed. A second wave of disease hit hundreds of millions of people and killed millions. It subsided towards the end of the year but then returned yet again the following winter and spring. By now about half of the deaths were of people between twenty and forty years old.(Continues…)
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Table of Contents
SECTION 1 AIRBORNE, 10,
Scarlet fever, 52,
Tuberculosis (TB), 80,
SECTION 2 WATERBORNE, 90,
SECTION 3 INSECTS & ANIMALS, 118,
Yellow fever, 150,
SECTION 4 HUMAN TO HUMAN, 170,
HIV and AIDS, 194,
Most Helpful Customer Reviews
The Atlas of Disease: (oct 2018)Mapping deadly epidemics and contagion from plague to the zika virus By Sandra Hempel October 2018 Nonfiction, health I received a digital ARC copy of this book for review from NetGalley and Quarto Publishing in exchange for an unbiased review. This is an interesting review of the history and spread of contagious disease. It is well organized and provides basic information which is easy to read. The history and location of origin is fascinating and beneficial information. There are helpful maps to help visualize the information.
Being a physician albiet a Radiologist, I decided to check this book out called " The Atlas of Disease" and to be honest it brought back all those memories of medical school Microbiology lectures. I have to admit I barely remember a fraction of what I knew about the subject matter from back in med school.but this book provided a quick refresher. Obviously this time I enjoyed reading the book rather than trying to cramp for some exam. The pathogens are categorized depending on their origin with brief historic significance regarding their origin, geographical distribution, signs, symptoms and just fun tit-bits about the entity. If you are a student of infectious diseases getting a PhD or a medical resident/fellow or a medical student this book will make a good addition to your book shelf.
*I have received this book from NetGalley, but didn't finish in time, so I purchased it on Amazon* I'm a fan of various medical stories, the more real they are, the better. Non-fiction accounts of doctors or researchers are the best, but books about diseases are also amazing. This book is great in telling the stories of the various contagious diseases and how they spread, where do they come from and so on. Additional maps help visualize everything. Illustrations of awareness posters and art about given diseases were very interesting, too. I've learned a few things from this book and I think it's a great book to come back to from time to time, just for a short reminder of basic facts.