Susan christian mcmillen, uva historian and associate dean for social sciences, author of the book on pandemics. I wanted to ask you as we start out, are there any historical precedents for what the world is its appearance in right now with covid19 . Christian yeah, there are several. I think the most recent one that comes to mind, and probably comes to most everyone elses mind, is the 1918 influenza pandemic in terms of its rapidity, how fast it spread across the world, and its scope and span. In the 19th century the cholera epidemic would be the most, the clearest analogy. Susan we are going to have an opportunity to dig into some of those lessons of history a bit more, but when you look at the response, of course things are so much different for society now. You talk about how important it is to learn lessons from past pandemics and epidemics. What lessons have we clearly learned . Christian what lessons have we clearly learned . That is a good lesson. Im only smiling because as an historian, it is not always clear we have learned lessons from the past. The one lesson we probably envisioned most is to roll out things as methodically as possible, to Pay Attention to reliable news sources, to do our best to hold off on blaming im only smiling because as an historian, it is not always clear we have learned lessons from the past. The one lesson we probably envisioned most is to roll out certain sectors of society from spreading pandemics. We are not seeing a tremendous amount of that at this time, so the clampdown on misinformation perhaps is one of the lessons we have learned that i see playing out now. That is not to say there is not misinformation. Susan the flipside of the question is, are you seeing patterns being repeated . Christian yeah. The patterns i think that are being repeated are you look at the 1918 epidemic, is the tremendous variety of responses. From within countries, from within states, within around the world. You have italy responding in one way, you have china responding in another way. That is not to say there are examples from the past where the entire world responded the same way. That is clearly not the case. Its a mixture of fear, anxiety, and panic. Some examples of panic. But on the other hand, not taking things seriously quickly enough, especially in the United States during 1918, the range of responses was quite remarkable, from taking it seriously to thinking up as just an extreme version of the common cold. Susan staying with that, one of the debates people were seeing on social media, and probably still continuing today, is theres flu every year, thousands of people die from it. So what can we learn from history about the difference between a novel virus like this and the seasonal flu . Christian i think i understand the question. It seems to me that thinking analogizing, medically the coronavirus as a flu, and suggesting it is no worse than the common yearly flu seems to me a bad idea in several respects. The flu, as we know, morphed into a Global Pandemic on multiple occasions. So, in my mind, actually the analogy should be more to be concerned about comparisons to the flu, rather than the reaction to be not concerned when we compare it to the flu. In other words, the flu in 1918 in particular, but the 1892 also are two of the worst pandemics in world history. Comparing it to flu in my mind is cause for concern, not cause into a Global Pandemic on multiple occasions. So, in my mind, actually the analogy should be more to be for complacency. Susan the nih has a graph that helps people understand when things become pandemics. They include these metrics. Wide geographic extension high , attack rates and explosiveness, minimal immunity, novelty, effectiveness, contagiousness, and severity. All the ones from history we are going to talk about clearly fit into that criteria. I am wondering about the infectiousness versus contagiousness. What is the difference there . Christian well, you know, im a historian so i hesitate to answer questions that have no that have real medical meanings behind them. That refers to the ease which one can catch a disease. On medical questions i would like to leave it at that. O be responsible susan i understand. He referenced one aspect of it, the role of fear in pandemics. On a continuum i would say on one level, Public Health officials and government officials want the public to be anxious enough that they can Pay Attention but not move all the way to panic. So can you talk about the role of fear in harnessing past pandemics . Christian yeah. In every past pandemic from the black death through the plague, to cholera in the 19th century, yellow fever, etc. , fear is a clear element of every single one. You are right. There has got to be a balance between informing the public in a way that makes them want to Pay Attention, but theres a balance of course between setting off waves of panic. You know, in the pandemics i just noted, cholera, influenza, and the plague, thats been an unsuccessful balance. In every single one of those there has been a quite remarkable wave of panic and fear. It seems to me it comes from the way people naturally react to things that are novel, fastmoving, not well understood, and that cause obviously disease and anxiety and death. In the case of all three of those fear has played an enormous role in the progress of those pandemics. During the 1918, in Great Britain theres clear examples of suppressing information to not cause fear. The same was true in italy. Susan one question, since you susan one question, since you are currently teaching courses on the history of disease. Are there more pandemics today than there have been in history . Christian that is a good question. Honestly i have never really thought about it in that way. It is a good question, and it is difficult for me to quantify. In the book that you referred to that i wrote, pandemics a very short introduction, its a small little book. I talked about, at least from an Historical Perspective, the difference between pandemics like what we are seeing right now, coronavirus, thinking back to the flu, and what i talk about in the book as persistent pandemics, malaria, cholera, tuberculosis, hivaids. These pandemics, particularly tuberculosis and hiv, that by all measures, by the eight criteria you read before, are pandemics, but they are very different. They are not acute. They do not have a clear beginning and end. When you factor those in, it seems to me we are quite possible we are dealing with more pandemics than we had in the past. 1918, 1900, 1850, we did not have hiv, for example. But to be honest i have never quantified it in the way you are asking. It is an interesting question. Susan one thing that has happened with every pandemic, the world has become more digitally interconnected and physically interconnected. People and populations are moving more. What impact does that have on pandemics . Christian well, it is the single most important driver of pandemics since the black death, since 1347 when the black death arrived in europe. Its been very, very clear since then that the interconnectedness then that the interconnectedness of the world, even at that time, the 1340s, early 1350s, was the principal driver of getting the epidemic of plague into almost all parts of europe because of trade networks, travel networks. And that has been absolutely the case for all pandemics since. Cholera, when it first arrived in england and the United States in the early 1830s, it would not necessarily have arrived with the speed it did in 1730 as opposed to 1830. So, all pandemics rely entirely on human movement. Pandemics themselves only move based on human movement. Susan and the coronavirus, we saw the first instance of it in january of 2020. There was a waiting by the World Health Organization to declare it a pandemic. I wanted to have you talk a little about the role of the World Health Organization, and how it came into being and how it functions. Christian sure. So, the World Health Organization emerged, like other United Nations organizations, in the wake of world war ii. And initially, its role has changed over the last 60plus, 70plus years. But initially it emerged as a way to deal with the clear Health Problems as a result, a, of the war, but b, as a way to start thinking about what is now called the developing world, and the way in which the developing world could meet the developed world in terms of its health infrastructure, its response to Infectious Disease and so forth. The World Health Organization initially focused on countries particularly hardhit by world war ii and then quickly branched by the late 1940s into india and southeast asia, and then subsequently into africa. And they really worked on the major diseases that were flourishing in those parts of the world. Again, particularly africa and south asia. Other parts of the world as well, but focusing on diseases like tuberculosis and malaria, for example. Environmental sanitation. For the first couple of decades in the postworld war ii period, the w. H. O. Was, by any measure, the principal world health authority, both in terms of research, in terms of setting policy, and in terms of setting up responses on the ground. There really was nothing else like it. There were some organizations let the medical Research Council of Great Britain that also deployed doctors around british colonies and so forth. And the w. H. O. Maintained this role as the principal driver of Health Care Policy around the world, intervention, research, throughout the 1960s, running the malaria Eradication Campaign, running the bcg Vaccination Campaign for tuberculosis, the largest enterprise in world history. And the Smallpox Eradication Campaign throughout the 1970s until its successful eradication in the late 1970s. Beginning in the 1980s, the w. H. O. Started to be more and more underfunded, and other competing not necessarily competing in the literal sense of the world, but world banks invested more and more in Global Health, private philanthropies started to emerge, most recently the bill and Melinda Gates foundation. The w. H. O. Maintains its position as an of authority in terms of directives, direction, defining pandemics and so forth, but does not have the same on the Ground Response capacity or role it had in the 1950s, 1960s, and 1970s. It is also as i said, in the , last generation or so, its been increasingly less wellfunded. Susan do american Public Health agencies have International Status . And are they superseding the role of the w. H. O. . Christian that is a good question. The cdc, in some instances i would say yes. The nih has superseded the World Health Organization in terms of its research capacity. I think in terms of the number one leading body, when the world looks to define things like pandemic, and what should be done on a global scale, i think people still turn to the w. H. O. For that first line of advice, first line of policy direction. Susan so, i want to dig in a little more with what you have referenced. Let me start by asking a question. As an historian with a specialty in pandemics and epidemics, how did you get into this . Christian that is a good question. Originally i and i still teach and write on American Indian history, and that was my first area of research. As you may or may not know, and as others may or may not know, Infectious Disease, crowdbased diseases, epidemic diseases, has had a unique effect on American Indian history in a variety of different ways over time. So in my classes i was beginning to teach more and more on Infectious Diseases amongst American Indians. But really specifically, my research has always been on the 20th century. It became clear to me as i became more and more interested in disease in my teaching, in my research areas, disease was having a tremendous impact still well into the 20th century. And im thinking about diseases like crowd diseases, really, as a result of living in poverty on indian reservations, particularly tuberculosis, the number one killer of American Indians up until the 1960s. Historians had not spent a lot of time looking at these things, more contemporary diseases. And i started seeing analogies between the experience of people in, for example, south africa or east africa, india, American Indians. Why were these kinds of populations being more ravaged by tuberculosis than others . As historians tend to do, it cascaded from there into a series of questions. I began to look at the interventions that Health Authorities were designing around tuberculosis, particularly vaccinations, antibiotics. Many of those drug regimens were tested on American Indians and then rolled out around the world. Some of the most Pioneering Research into vaccination and antibiotics was done on American Indian communities and those were rolled out across the planet. Susan a question. Do the Public Health organizations turn to people like yourself have Historical Context in helping to develop future responses . Christian you know, once in a while. I have a good friend and colleague at Johns Hopkins who has written extensively on malaria and Global Health since world war ii. I know that he has been consulted. Historians like Howard Markel at the university of michigan has written extensively in the american journal of Public Health, the american medical association, on a variety of things. What comes to mind most recently is really a classic article on the nonpharmaceutical responses and interventions into the 1918 flu pandemic that he wrote with medical doctors. Its an extraordinary article. So, historians do get involved in trying to think through how history can help contemporary Public Health responses. But you know, as i write in my book, the pandemics book, and more extensively in my tuberculosis book, there does not seem to be a tremendous appetite for learning from the past. Susan and clearly society would benefit if there were. Christian i think so, but a historian would say that. Susan let me ask, what is the earliest reported pandemic . What do historians turn to . Christian sure. So, the plague of justinian, and then the first instance of what we think, almost certainly in the 6th century, was the first instance of plague. Now, doing what is called retrospective diagnosis to determine what a disease was that occurred 1500 to 2000 years ago, in some instances, is really challenging. You have text evidence that describes diseases that sound like what we know now as the plague. But there has been some research on fossil remains, skeletal remains and so forth, thats largely confirmed this justinian epidemic was the plague. The epidemic pandemic really that historians have focused on, the earliest one that historians have focused on more than any other is the black death that arrived in europe in 1347 and lasted until 1352. Thats the one really that, when i teach, i begin there because it really kicks off this period, even though it was so long ago, of responses to epidemics that we still see, things like quarantine, fear, and so forth. Susan one of the interesting aspects of the history of civilization being related to the history of disease, you write in the book at that period of time, being ill was looked at as a punishment from god, and at some point that began to shift into understanding contagion, which then gave less power to churches and more power to the state. I found that an interesting concept. Would you talk about that . Christian sure. You can imagine at a time when Something Like the plague for example arrives in europe in 1347 let me say briefly if it is ok, that the black death really is the first instance of plague in the second wave of plague. A concentrated period between 1347 and 1352. That really defines what we think of as the black death, those years. And the plague itself remained in epidemic and pandemic in europe through the end of the 17th century, and in some isolated instances into the 18th century, before it really vanished in europe. And so over that period of time, you have the first arrival, people having no idea what is going on here, very different conceptions of how diseases are transmitted than what we have now, and they would even have 100 years hence. Also a society that largely believed in god and look for direction and how the world worked. Over time, of course, as early modern life in europe developed, god started to be replaced by science. I do not want to over characterize the classic battle between faith and religion, but you can see it played out in the ways in which people began to respond to plague. So for example, in one of my favorite books, faith, reason, and the plague, a classic of the history of epidemics. He does it all in about 76 pages. It is one of the best books you can read on how epidemics affect a small place. He looks at how when plague arrived in a small town in tuscany in the mid1630s, it was at a time when the town itself in many respects was still governed by religious authorities, and the church was the center of all social activity, to an extent economic activity, and obviously religious activity. But at the same time, italy has begun to really form a, what we would think of as a modern Public Health infrastructure. Some of the first examples of Public Health infrastructure, specific hospitals to contain disease within, placing restrictions on travel, official restrictions on travel, quarantine. And these measures being run by the state, and not by the church. And what he does in this extraordinary book, this tiny little book, is show how the forces of faith and the forces of science and reason i do not want to say that people cannot and body all those things at one time, but how churches and state authorities clashed over how to best respond to the plague as understandings of transmission began to change. And so, the church was very committed to the notion that prayer and gathering together in a mass would be the best way for the community to come together to fight off the ravages of plague and tamp down this epidemic in this tiny little place. Where Public Health authorities in italy at the time thought otherwise, that in fact getting together, as emerging ideas about contagion started to take hold, but getting together was the single worst thing people could do. So it became this clash within the state authority and church authority. For the time being in the 1630s, Church Authorities won out. The power of the church and the power of peoples beliefs were more powerful than the emerging doctrines of state Public Health. By the time cholera arrived, relying on ones religious beliefs to explain all that occurred in the world had diminished even further from the 17th century. So in the 1830s and into the 1840s and 1850s, the explanations for how cholera was being transmitted relied less on explanations based on faith than it did on competing explanations based in science. Susan carrying that all the way to today, you write about the laboratory revolution, which certainly began in the 20th century, early 20thcentury. This is a quote, cultivated an undue amount of confidence in the role of biomedicine. What are you saying . Christian that is a great question. Something i try to focus on in the book, and also something i try hard to focus on with my students in my class on epidemics, and pandemics, and history. And imagine in the mid19th century, before diseases like tuberculosis, etc. , were isolated and defined as the single diseases. You would try to get rid of cholera by broad measures, by cleaning the water, quarantine, other forms of isolation, to broad scale epidemiological research. Fastforward 100 years later to the 1950s and 1960s. And you are trying to deal with tuberculosis in kenya, for example. And youve got antibiotics. The impulse from almost all Public Health officials, the World Health Organization, british medical Research Council, is to focus entirely on an antibiotic approach to curing tuberculosis. So, not necessarily focusing on malnutrition, or the problems with housing that are causing the disease in the first place, for example. It is focusing solely on curing the disease rather than trying to get rid of the conditions that are giving rise to the disease in the first place. So it is a change in approach from a broadbased Public Health approach to changing the conditions that give rise to disease, to treating the disease itself was it has already arrived. I mean, you can see the same way of approaching cholera, for example, in the late 1960s and early 1970s as oral hydration therapy occurs. It is miraculous and inexpensive, but it does not do anything to treat conditions that give rise to the disease. So it was a shift after the laboratory revolution to thinking, again, less about the conditions that give rise to a disease, and more how to cure and get rid of diseases once they have already arrived. In the 1918 flu pandemic, you see this most clearly in Great Britain, in parts of central africa, in india and elsewhere, where its not quite height of the laboratory revolution, but it is a time when it is taking over. And when many medical professionals are convinced the influenza is a bacterial infection. And you see a tremendous efflorescence of what we would now see as quack remedies to influenza based on this hubristic approach to this disease, that medical science will take care of it rather than broad Public Health measures. Susan digging more deeply into the history of the flu, which you do write about in your book, the major flu season that became pandemics often cited, 1918, mortality rate of 50 million. The asian flu, h1n2. 1. 1 million mortality. 2009, this one flu, 575,000. Comfort inake some the fact that the mortality rates have been dropping so much . Or is there other causality . Christian i hate to repeat myself on this one, but i hate to but i hesitate to offer prognostications outside my realm of expertise. With that caveat in mind the fact that the mortality was one 1918 thing and it seems to have gone and decreased and decreased in the subsequent flu pandemic doesnt strike me as a reason to think that the coronavirus will be any less or more virulant. And present anymore or this rate of mortality. I say that because of different diseases. This is novel. Its not something we have seen before. I think taking comfort in the reduction in mortality over the 20th century and influenza pandemics would be a mistake. Thinking about the novel coronavirus. Susan what we know from history about the origin of flu . Christian what we know about no from history about the origins of the flu . But we know this from virologist and biomedical scientists who have studied samples of particularly the 1918 flu to determine its origins. It is largely now determined to be in waterfowl and birds. It was an avian influenza. At the time, 1918, 1890 and nobody knew where it came from. 1892, we still dont know why flu with severe violent. Was so verlander. As you have already suggested, we know that subsequent pandemics were less verlander but we dont know why. Irelent flu with severe violent. But we dont know why. Susan what was the role of the military and spreading the flu . Christian particularly because of world war i the the philippines, france, everywhere in the world. From a military camp in kansas in the spring of 1918 throughout the rest of the world, the first wave died down over the summer of 1918 and then reemerged in the fall in france and quickly transmitted itself across the world. I think in some places, the increase or the correlated troop movements clearly spread flu into places, parts of india and into iran and other places. But in africa, most of the transmission was done not so much because of the war, per se, but because in south africa, for example, which had one of the most extensive rail lines for trade and transportation of goods and people, you can almost there is a great article, i am blanking on the authors name, but they map out the transmission routes of flu in africa and it overlays with river and rail networks. It shows that these networks in africa for the exact routes by which flu was transmitted. It would have traveled across most of the world i would , imagine, counterfactually speaking, without the war, just because Transportation Networks had become so robust by that point. Susan i want to move onto to a more recent one, the ebola virus. 2014 to 2016. You write about that as well. I want to play a video that is very recent, the current head of thed of the w ho World Health Organization emergency program, on the lessons the world learned from ebola. Lets listen. [video clip] what we have learned is you need to react quickly and go after the virus. You need to stop transmission. You need to engage with communities very deeply. Community acceptance is hugely important. You need to be coordinated and coherent, you need to look at the other impacts, schools and security and economics. The lessons i have learned after so many ebola outbreaks in my career are be fast and have no regrets. You must be the first mover. The virus will always get you if you dont move quickly. Susan you write that the whos Lessons Learned about ebola was a striking document. What did you observe and what are you hearing from the doctor there and dr. Ryan . Christian if it is easy for you, maybe you could read exactly what i wrote. I know what you are talking about. I focused on this in the epilogue and im happy to respond. My point in the book and what i would reiterate now and i would to thes the same thing doctor he was interviewed, although to be fair to him, he is responding to interview questions. In talking presumably somewhat off the topic and the official who document is the more powerful example of the point i wanted to make in the book that im happily happy to reiterate. In 2015, it is difficult to imagine those could have been Lessons Learned in 2015. I was somewhat struck those lessons had not been learned earlier. We need to have the capacity to take care of Public Health emergencies strikes me as a lesson we learned over and over again. That marketbased solutions to Public Health crises in under resourced areas is something we have learned over and over again. The need to engage with local communities to get by, to make people understand why particular interventions are being rolled out. If there is a vaccine available, the power, if there is a cure available. Historians have learned that many times and i know Public Health officials have learned those lessons many times. It struck me as i was finishing that book and reading that document that this is a perfect way to end a book on the history of pandemics, to illustrate the point that historical consciousness is somewhat superficial. Susan you have already referenced the role of smallpox and the development of society. Chronic until eradicated in the does it remain eradicated . 1980s. Christian it does, yes. There is no real caveat to that. I will get some of the details wrong and i apologize but within the last three or four years i , remember reading in the newspaper, and again, im getting some details mixed up, that someone found a sample of smallpox in a storage room somewhere at the nih. There are these examples. It is stored in secure facilities in the u. S. And elsewhere. It has been eradicated from the world, yes. Susan that Eradication Program was led by the World Health Organization in the 1970s. What can Society Learn from that big effort, the pluses and minuses we can apply to contemporary issues . Christian thank you. That is a good question. On the minus side, its not so a reflection or criticism about the way the eradication effort was being handled but i wanted , to point out that the example of eradicating smallpox, while heroic, is not necessarily a useful analogy for eradicating Something Like the flu or coronavirus or tuberculosis because of the peculiarities that i and others have pointed out of smallpox. It is easily identifiable, has a relatively short incubation period, and is very susceptible to a vaccine. There are particular things about the disease that made it than othercable diseases. One does not want to lump Infectious Diseases together and say we eradicated smallpox so we can eradicate other Infectious Diseases. Disease identity matters. Lessons to be learned about the smallpox eradication effort, and i would say the early years in the effort to control tuberculosis is that in both cases and i can say more about the tuberculosis efforts if you like but in both cases, there was this tremendous and you see this in many intervention efforts across the 40s through the 70s, a tremendous amount of energy and goodwill and dedication and particularly not in all instances or in all places but followthrough and sustainability, for lack of a better way to put it. The Smallpox Eradication Campaign, the w. H. O. Had been working on smallpox for some time, but when they launched the official campaign in the late 1960s, they worked at it until it was done in the late 1970s. A little more than 10 years. The point of that is that it was a sustained effort that had a goal, and there was a sustained support until the goal was reached. That sounds like a really simple point, but too often it seems to me that collectively we respond to something, and once there is an initial flurry of activity and things start to look better, interest is lost, momentum is lost, and people move on. And i think the ways in which w. H. O. , medical Research Council responded to tuberculosis throughout the 40s, 50s, 60s and through the 70s is another example of the extraordinary longevity. This group of researchers and Public Health officials worked on the problems associated with vaccination and antibiotics for decades. Rather than giving up quickly. Susan talking about smallpox or tb, it seems the place to ask about the historic perspective do you have thoughts on the antivaccination movement . Is this unique to this time . Have we seen other similar responses by substeps of subsets of the public in the past . Christian we have seen other examples of antivaccination movements. I will say, and i hope i can be slightly i dont think it is impolitic. I will say the current antivaccination movement seems based entirely on misinformation and fear mongering. I think it is frankly a bankrupt movement that should have no credibility. I apologize if i sound a little too intemperate about it but it has no credibility whatsoever. Thinking about it historically, when vaccination was new and poorly understood, you can imagine why people would react in fear. Similar to the way, i will say, the way people may react in fear now. They understand them poorly. Thats not because of lack of information available. In the past, people reacted poorly to vaccination for a couple of different reasons. I will say in two different instances in england in the late 19th century when vaccination became compulsory, people reacted poorly to that because and not a tremendous amount of the population, but people reacted poorly to that because just like now my people dont want the state meddling in what many people perceive to be a private decision. To compel someone to get vaccinated. It strikes many people as overstepping by the state. In my tuberculosis book, i write at length about an antivaccination movement in india. When the w. H. O. Rolled out a vaccination bcg campaign in the late 1940s and into the 1950s. It was organized by a group of people who really questioned the efficacy of the vaccination. The effort was largely targeted at what they perceived to be almost the imperial behavior of the w. H. O. You can imagine in india, they just gained independence and within two years, the w. H. O. Is in the country insisting on vaccinating hazards of thousands and eventually millions of children with a vaccine that is not very well understood and people there was a significant antivaccination movement, particularly in south india as a result of what many perceived to be imperial like behavior of the w. H. O. Because they did not do what they say they should do in response to ebola, it did not engage with the local community, it did not get community buyin to the degree they should have. There was significant antivaccination movement resulting in many places in india when it came to tb vaccination, almost zero Response Rate to Vaccination Campaigns in the midtolate 1950s. Susan we are doing an overview of these complex diseases, which does not do them enough justice. You referenced malaria and i want to talk about that and i want to talk about hivaids. So on malaria some facts from , the who, the persistence of this is impressive. 220 8 million cases worldwide. 405,000 deaths from 2018. Children under five account for 67 of the deaths, and africa is home to over 90 of the cases and deaths. You trace the disease to as long as 10,000 years ago. It has been with us for a long time. You write that successful efforts to eradicate malaria have been elusive. The Gates Foundation is one of the private sector players getting very involved in this. What can we take away from the global efforts to address malaria and the lack of success to date . Christian boy. Malaria is the reason i am hedging is because it has been one of the most difficult diseases to deal with as the numbers you cited suggest. It is so difficult because it has so much to do with the environment and the mosquito vector, and the emergence of Drug Resistance to malaria. Mosquitoes and the disease itself become resistant to the drugs designed to fight it. That happens over and over again. It has proven to be a disease that frankly resists human efforts in many places, particularly in tropical countries, to its spread. I eluded earlier to the efforts by the who in regards to tuberculosis for a long time, and then smallpox for a more limited period of time in the 1960s and 1970s. One of the things i find useful lessons is in both of those instances, the who and others persisted for a long period of time. Mistakes were made and tuberculosis is still with us. We did not get rid of tuberculosis. But in the case of malaria, the who also attempted to eradicate malaria beginning in the late and it was the first 1950s, Eradication Campaign for any Infectious Disease. It failed in places for a variety of reasons, but in places like india, for example, you can see very clearly historically, when the Eradication Campaign was at its height and household spraying was robust and Infection Control was robust, you could see malaria rates dropping. The second all of that was pulled back and interest was lost in controlling malaria disease rates skyrocketed again. Yes it has been one of the most , difficult diseases to control in human history. There have been successes in southern italy in the 20th century, also in the United States in the 20th century, but there have been far more cases of failure in controlling malaria than successes. Susan on hivaids, it seems like much more of a Success Story. Here are statistics. Was first identified in 1981 and it took 11 years for a test. With hivaids, it was once a death sentence, and now for people with access to drugs, a manageable chronic illness. The United States made a major commitment especially to africa during the bush administration. We have a brief clip we are going to watch. [video clip] pres. Bush hivaids is a tragedy for millions of men, women and children, and a threat to stability. Entire countries and regions of two our world. Our nations have the ability and therefore the duty to confront this grave Public Health crisis. We are here today to urge both houses of the United States congress to pass the emergency plan for aids relief, which will dramatically expand our fight against aids across the globe. Susan what would you say are the greatest contributors to the Success Story i just relayed . Christian i remember, and you may as well vividly when george bush first announced the aids relief during the state of the union. I show these clips and i read his remarks in my class when im giving my lectures, and i have to say, for his faults, it was one of the most remarkable pieces of legislation. A moving speech he gave as shows and extorting her commitment that is hard to find an analogy for in our current crisis. Successes in aids i want to think about this for a second because if you periodize the response to aids, the 1980s through the emergence of antiretroviral therapy and its release onto the market in the 1996, where 1991 to Global Response was chaotic. The recognition of it as a disease that would profoundly affect the heterosexual population, the realization it would affect women as much if not more so than men, these things took a very long time to catch on. The Global Response was chaotic. There was a lot in the first 15 years that one could point to as a lack of success. I dont mean to be a downer about it because you are right, after 1996, in places where drugs have been available, rates have been successfully taken down. Pepfar was the first global effort to get antiretro viral therapy into communities where it would otherwise be completely unaffordable. After pepfar, we saw a rates of hiv going down in Subsaharan Africa in particular. There really was a beforeandafter period. The one thing i think has been, one significant thing i would point to that has not been a success and has gotten better in recent times is the relationship between hiv and tuberculosis, hiv and tuberculosis, whereby in the very early years of the aids pandemic, it was very clear these diseases would have a synergistic relationship. That hiv, because it attacks the immune system, would leave people much more susceptible to tuberculosis. Where hiv first emerged was where tb was not under control and Health Officials realized very early in the emerging hiv pandemic and attempted to work on it. Ultimately, the efforts were unsuccessful and largely forgotten and ignored and not given funding. Tb and hiv were treated as two separate diseases operating on if not parallel paths, at least contemporaneous ones. Was anppened in my view hiv tb pandemic could have been better contained if they were thought of as working synergistically. Because they feed off of one another. Where hiv emerged and tb almost always skyrocketed. By the early 1990s, hiv related tuberculosis was threatening particularly in east africa, to erase all efforts of the previous several decades in getting tb manageable. Susan our time is running out and i want to bring this full closure. I want people to know that your book is widely available online. If they want to read more about the diseases we have talked about and get a deeper look at them. To bring it to current times, if you are looking back at all of the lessons we have discussed, what is most important for people to think about with the current pandemic as the world approaches it . Christian as a citizen, of people to think about with the course, and i have a family and at my current job, we are trying to manage how to get all of our Classes Online and take care of staff and students and faculty. The best thing to do is to listen to the identified experts. In this case, the who and cdc. And social distancing, closing down public gatherings, and doing these things now and taking them seriously, and doing them for long enough that you know, do not relax the vigilance. Doing them for long enough that dont take good news as a sign that it is time to stop being vigilant. All of the lessons from cholera to influenza, to all Infectious Diseases, suggest that vigilance must go on until rates start to go down consistently in over time. The only way to stop Something Like this is to stop the spread of the contagion. That should be obvious. The only way to do that is to limit contact with one another. To take the advice and directives of Public Health officials, particularly again the cdc and who, seriously, and do what you are told. In 1918 pandemic, it is very clear that the cities in the United States that took early action in shutting down public spaces and kept that action up spaces and kept that action up throughout the fall of 1918 and into the winter of 1919, that is they were consistent and sustained their efforts, they are the cities that have the greatest success with mortality rates during the influenza. 1918 we dont have pharmaceutical interventions available yet. We only have Public Health intervention. So that is the lesson, the single best lesson. Listen to Public Health officials who know what they are talking about. Practice social distancing, and dont rely on a vaccine arriving anytime soon. Susan dr. Christian mcmillan, thank you so much for adding a Historical Perspective to our current pandemic situation. Take you for your time. Christian you are very welcome. All q a programs are available on our website or as a podcast at cspan. Org. [captions Copyright National cable satellite corp. ] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] coming up in an hour, Senate Reporter for the national on the zach cohen congressional efforts to address the pandemic. The former Deputy Assistant secretary for health will discuss the u. S. Response to the spread of the coronavirus. You can join the conversation on facebook and twitter. Azor 47, the nazar 47 es of 47. The motion is not agreed to bring agreed to. Senate failed to move forward on nearly a nearly two 2ldren on a nearly trillion response to the outbreak. Impartial ling calling parts of a slush fund. ,ithout democratic supports republicans failed to get the measure passed and their own rank and file were down in numbers. Ra