The Burdens of Disease: Epidemics and Human Response in Western History (Revised Edition)


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The Burdens of Disease: Epidemics and Human Response in Western History

First, many of them will die of pneumonia and the other killers that strike down people whose immune systems have been rendered useless. Very often their deaths will be recorded as having been caused by something other than AIDS. Second, and more difficult to capture statistically, millions of young Africans are becoming orphans through the AIDS deaths of their parents, aunts and uncles, and other potential care-givers. In several countries in southern Africa, where nearly half the adult population is HIV-positive, orphans have little chance of survival.

For this reason, many of these who do survive do not acquire the veneer of civilization and instead become teenaged mercenary soldiers, drug-dealers, extortionists, or all-purpose terrorists. As of , the AIDS epidemic continues, and in the next two or three years is expected to make its presence heavily felt in China and in India, nations which between them are the home of half the world's population. Because many non-Western countries are burdened with debt repayment to financial institutions based in the West and are thus unable to fully fund proper health services, the AIDS epidemic may well become the non-Western world's principal childhood killer.

The prognosis is not good. Cohn, Samuel K. De Waal, Alex. Gould, Tony. New Haven : Yale University Press. Joralemon, Donald. Lovell, W. Mercer, Alex.

Epidemics and History: Disease, Power, and Imperialism. London: Yale University Press.

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World Health Organization. World Health Report Geneva: World Health Organization. Epidemic diseases break out, reach a peak, and subside; endemic diseases cause a relatively constant amount of illness and death over time see Figure 1. Epidemic diseases can be new or normally endemic to a community. They break out on a local level and remain localized, or spread out in diffusion waves to surrounding communities.

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Very large-scale epidemics that strike several continents or the entire globe are called pandemics. Although relatively infrequent, pandemics are exceptionally disruptive; the economic, social, and demographic damage they do insures that they receive the lion's share of attention from both contemporaries and historians. The most familiar epidemic diseases are propagated by direct contact between infected and uninfected persons, as is the case with tuberculosis, smallpox, measles, polio, syphilis, and AIDS, among others.

But some of the most devastating epidemic diseases were and are transmitted to human beings by insect vectors, such as bubonic plague, malaria, typhus, and yellow fever.

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Among the epidemic diseases spread by water-borne pathogens are cholera, typhoid, and dysentery. Some epidemic outbreaks do not involve microorganisms at all; these common vehicle epidemics can be caused by food-borne or other toxins e. Under certain circumstances, even vitamin deficiency diseases like scurvy Vitamin C or night blindness Vitamin A can break out suddenly in certain populations. Every epidemic disease has its own distinctive etiology, and its own complex relationship with both natural and social environments.

In theory, if zero cases of a specific disease are expected in a normal year, then even one observed case can signal an epidemic and call for a public health response. This reasoning was used in to declare a national public health emergency in the United States , based on a single unexpected death from a type of influenza that seemed similar to the outbreak. By using statistical criteria alone, more and more diseases have been perceived as taking epidemic form.

Around , several chronic diseases were classified as epidemics, including lung and breast cancer and ischemic heart disease. Some slowly-developing "social" diseases—like alcoholism and drug addiction —and a few mental diseases like depression have also been described as epidemics.

But instead of erupting and subsiding in a year or less, chronic-, social-, or mental-disease epidemics rise and fall over several decades. The existence of epidemics has been recorded since the beginning of written history, and in all probability they predate it. Just as epizootics epidemic animal diseases have always been part of the demography. It is widely supposed that during the transition from hunting and gathering to agriculture, when human beings began to live in larger groups and at higher densities, the frequency—and possibly the severity—of epidemics increased.

Subsequently, the development of cities made epidemic disease an even greater threat to human life. But knowledge about epidemics and mortality in history is necessarily limited by the relative absence of reliable quantitative data.


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Although the Black Death is one of history's most famous and well-researched epidemics, data problems have kept everything about the epidemic controversial, except for the fact that it arrived in Southern Europe in and spread to Northern Europe by Historians continue to disagree on whether or not the "plague" was one disease or several. Before the seventeenth century, plague was still a generic concept used in connection with any sudden outbreak of disease. Accounts from the time often describe the plague as killing the majority of the living.

Most historians, however, believe that about one third of Europeans died in the first outbreak, although estimates range from less than a fifth to more than two thirds. Subsequently, major epidemics seem to have erupted with sufficient frequency and intensity in Europe that the continent's population was cut in half.

Demographic recovery took two centuries or more. It was the continuing social and economic disruption caused by recurrent outbreaks of plague that led city officials in Europe, particularly in Renaissance Italy, to develop novel measures of disease management, including the formal surveillance of mortality.

By , several cities in Italy were tracking deaths on a week-by-week basis, and trying to distinguish between those that were and were not caused by plague. These data have been used to estimate that, on average, plague outbreaks in the s and s multiplied the normal number of urban deaths by a factor of four to seven Del Panta and Livi Bacci , p. In Sienna, when the normal death rate was about 35 per 1, per year, mortality increased by a factor of five to ten during a plague year Livi-Bacci , p. In Florence, it has been estimated that epidemic disease caused 38 percent of the total number of deaths among girls under age 15 in the two centuries after the first outbreak of bubonic plague Morrison, Kirshner and Molho ,p.

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The ancient Greek concept of epidemic was revived in connection with increasingly sophisticated disease surveillance systems, and was used by leading physicians to speculate on the natural causes of any sudden outbreak of disease. Outbreaks of "influenza" received that name because university-educated physicians once thought they were caused by astral influences.

Eventually all the other diseases thought to be causes of death were tracked as well. London followed the example of cities in Italy, and by the early s its officials had institutionalized the continuous surveillance of death and its causes. Thus, when John Graunt — published demography's founding text in Natural and Political Observations Made Upon the Bills of Mortality , he could draw on more than a half-century of annual data on about 70 diseases that were thought to be causes of death. The data made it very clear that, while bubonic plague remained the most lethal epidemic disease, smallpox epidemics seemed to be getting worse.

In , London, with a population of about ,, could still lose some 80, lives to plague, while Copenhagen lost 20, people out of its total population of 60, in There were no more major outbreaks of bubonic plague in Europe after the s. Historians still disagree about the relative importance of human agency particularly in the form of public health measures versus exogenous natural causes in its disappearance. The evidence is inconclusive for Europe, but it is worth noting that outside Western Europe , in countries such as Russia, Turkey, Egypt, China, and India, bubonic plague continued to erupt on a large scale long after It ceased to do so only after European-style public health measures were adopted and enforced.

When T. Malthus published the first edition of his essay on population in , there was enough mortality data—both urban and rural—to hypothesize about the role played by more ordinary epidemics in the regulation of population growth. To Malthus, sudden outbreaks of disease were just one of a set of four mortality-related positive checks on growth, the others being poverty, war, and famine which he regarded as the last and most deadly positive check. Subsequent historical research suggests that before the twentieth century most deaths that occurred during wars and famines were caused by epidemic disease, not by battle casualties or starvation.

Since the poor are often but not always hardest hit by epidemic disease, there seems limited value in distinguishing between poverty, war, famine, and epidemic disease as separate checks on population growth, at least before Modern demographic historians tend to study epidemic disease as part of "crisis mortality," those sudden increases in deaths or death rates that were a general feature of pre-modern mortality patterns.

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In theory, mortality crises can be caused by natural disasters as well as by wars, persecution, genocide, and famine; but in practice most crises were caused by epidemics, at least before the early twentieth century. Using historical data, demographers have attempted to gauge how much death rates must rise above some "normal" or background level of mortality in order to constitute a mortality crisis. No agreement has been reached on how to measure either "normal" or "crisis" mortality—especially in cities, where death rates were exceptionally volatile.

Thus the relative importance of crisis mortality, and by implication, epidemic disease, in keeping life expectancy levels low below 40 years before the modern era remains a matter of controversy. In theory, the extent to which epidemics as mortality crises can regulate population growth depends on their frequency, amplitude, and duration. But with respect to amplitude, using a high threshold to identify a mortality crisis for example, requiring that the crisis death rate must be at least five times the "normal" level would mean that mortality crises and, by implication, major epidemics were too infrequent to check population growth in most places and times.

In contrast, if death rates must only exceed normal levels by 10 percent, then frequent mortality crises caused mostly by epidemics would clearly have been the major brake on population growth in the past. In general, the importance of mortality crises, or epidemics, cannot be assessed independently of the demographic criteria used to identify them.

The uncertainties connected with crisis mortality stimulated demographic research on all short-term fluctuations in pre-modern populations, including marriages and births as well as deaths. In some localities, harvest failures could cause grain shortages, rising prices, and with a lag rising death rates, mostly in connection with epidemic disease. But in other cases, a steep rise of grain prices has been observed to lag behind the sharp rise in death rates associated with an outbreak of epidemic disease.

Historical research suggests that up to half of all epidemics in early modern Europe broke out and caused mortality crises for reasons unconnected to harvest failures, high prices, or food shortages. The implication is that some epidemics were Malthusian—meaning that they were related to increasing poverty and malnutrition—while others were not. From a biological standpoint, this conclusion is not surprising, since those diseases that take epidemic form are differentially, not equally, sensitive to the nutritional status of the individuals exposed.

This observation is relevant to the study of economic development, where it is still widely but mistakenly assumed that whenever per capita incomes rise, nutrition will improve and death rates will fall automatically without public health reforms. This overlooks the extent to which economic development stimulated urbanization, and thus the frequency with which density-dependent, air-and water-borne diseases broke out.

The empirical evidence is that death rates rose during Europe's development, despite rising income levels, until effective measures were taken to control infectious diseases that often took epidemic form. During the twentieth century, the same story can be told on a global scale: it is primarily the decline of the infectious and parasitic diseases as leading causes of death that produced the global rise of life expectancy. These diseases were first targeted for control through public health measures because of their close connection to epidemic outbreaks of disease and death.

Wherever common epidemics were prevented by effective measures of disease control, death rates declined and remained relatively flat from year to year. The last traditional mortality crisis in the developed countries occurred in as part of a worldwide pandemic of influenza. This one outbreak was estimated to have caused more deaths in one year than World War I did in several years.

Estimates range from 20 to 40 million deaths caused by influenza, versus 15 million for war-related losses. Nevertheless, in America and Europe influenza was not particularly lethal; many more people were infected than died.

Predicting and preventing infectious disease epidemics
The Burdens of Disease: Epidemics and Human Response in Western History (Revised Edition) The Burdens of Disease: Epidemics and Human Response in Western History (Revised Edition)
The Burdens of Disease: Epidemics and Human Response in Western History (Revised Edition) The Burdens of Disease: Epidemics and Human Response in Western History (Revised Edition)
The Burdens of Disease: Epidemics and Human Response in Western History (Revised Edition) The Burdens of Disease: Epidemics and Human Response in Western History (Revised Edition)
The Burdens of Disease: Epidemics and Human Response in Western History (Revised Edition) The Burdens of Disease: Epidemics and Human Response in Western History (Revised Edition)
The Burdens of Disease: Epidemics and Human Response in Western History (Revised Edition) The Burdens of Disease: Epidemics and Human Response in Western History (Revised Edition)

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