 Thank you very much, Andrew. Andrew met a couple of years ago at a conference and had a lot of interest that we shared, including the fact that I was picking his brain, because I'd started working on the 1918 influenza epidemic in Massachusetts. And he is the expert on 1918 flu. So I'd also like to acknowledge another person in the audience, Susan Greenhoff, from the Anthropology Department. For those of you who don't know, Susan, she is a demographer. And that was my training was in biological anthropology and demography. And I have kind of changed paths through the years from historical demographer to historical epidemiologist to medical historian. All these things kind of blur, and you'll see that happening today. But Susan works on contemporary demography, and a large body of her work has been in China, if you don't know, and on the one child policy. But she also brings a theoretical perspective that has strongly influenced my work. And it may not show up in here today, but I owe her a debt. So what I wanted to do today when I briefly emailed back and forth with Andrew was not to give you a deep methodological kind of presentation today. We will have some time for questions about some of the methodologies that we've used on this project. And I'll be using we a lot because it consists of collaborators, graduate students who have gone on and some who are still working on material and so on. So I wanted to give you a sense of, as an anthropologist, as a historical epidemiologist, as a person who's interested in contemporary global health issues, how do I approach this material? And what kinds of questions do we ask? So I'm going to be flipping through a number of different images and some graphs and so on to kind of give you a sense of some different areas I worked on. And I was thinking, I like alliteration anyway sometimes in small doses, but color, canker, rash, and consumption are all things that I've worked on and have some results that have been published as well as some things that I'm just finishing up now. So we'll kind of use those to talk about some of these issues. The what and where of things is always, I think, important, particularly for those of you who are a public health scientist and moving in that direction. I'm really talking about the state of Massachusetts in some cases, and I'll try to be clear about which data sources are coming from which places. Then I have collected data for many, many years, really since I was a graduate student, came out to Massachusetts on a completely different grant and started working in some towns in this part of Massachusetts, which is Franklin and Hampshire counties, and then Boston, of course, would be over here. And then I'm constantly playing those off against state-level processes that are going on at the level of the whole state. And I work on the time period from about 1850 to 1920 because there's this very, very deep history of records in Massachusetts. Some of them very, very good, but it's about 1850 that you historically start to get causes of death that actually start to make some sense to something that we can think of today and that we can more systematically look at in terms of nozology or classification. So I've published biostatistics at the state level. These have been going on for many, many years, as you'll see. The Massachusetts Board of Health Annual Reports, another published source. And sometimes there's other unpublished sources from them. Very specialized medical and sanitary surveys that Boston may be commissioned at a particular point in time when they were having an epidemic or a serious health issue or something. And most of what I'll be talking about on the local level are these data sets here. It's about 15,000 deaths that are collected from three small towns and one small city in that part of Massachusetts. And then we've done family reconstitution in the town of Deerfield, Massachusetts. And for those of you who don't know what family reconstitution is, what you do is you go in and collect births, deaths, and marriages. As you might if you had some published records in a place that you were working and trying to get background data. And then from those births, deaths, and marriages, you computerize them. You create algorithms that will start to bring them together as marriages first, then the children, then the children, then the children of children, and start kind of an almost a genealogical database of these kinds of records. And then you create algorithms to sort of test the quality of them. So we have about 700 reconstituted families of which we have 400 where we follow the children through to the extent possible to the age of 21. So this is this very fine grid. So sometimes what I'm talking about is microepidemiology, where you can ask questions that you can't ask from any kind of aggregated cross-sectional data. You can ask what you're really looking for and weigh our kind of combination of the impacts of fertility and mortality, as well as the kinds of dynamics that happen at the health level within a family. Um, did I already? Oh, this just expands a little bit on the sources because really I'm a scavenger. And in the last several years, I've become more and more interested in playing off as an anthropologist the social, cultural context of the kind of demography, demographic processes or epidemiological processes I'm looking at and trying to put them into some kind of play. Against what is going on in these communities in terms of religious, economic, social dynamics, changes in ethnicity, class, and so on and so forth. And then I found more recently that I'm really drawn to things like even the diaries and account books that farmers wrote and the images that were part of the popular culture just like today. What's the popular culture saying about health and disease at this period and time? Another thing of course that's particular about doing historical epidemiology is that everybody's dead. So that I don't really have to worry about policies or the impacts of the ways in which I look at these questions the way many of you do and consider what are the ramifications of these things. I'm looking at people that are long gone and all I can do is to try to tease out and tell some of their stories and tell some of the stories about the way in which the health experts quote unquote at the time dealt with these. I'm gonna go through these and talk for about, my own tolerance for these kinds of talks is about 40 minutes and I'm gonna try to be in that range and Andrew you could give me a signal when you start to see that I'm approaching that if I'm running a little long. So as Andrew said you've got vital registration was required by the court by the monarchy by England as early as 1659. So you have a huge series of vital registration data not always good. Massachusetts Medical Society created in 1781 and the Massachusetts Board of Health in 1869. Both of these being the oldest continuous running societies and institutional boards in the United States. Now, one of the things that I'm, as Andrew said I'm Professor Emeritus now and one of the things I'm doing is thinking about where I've been with this work and where I'm going with this work because I'm still very actively working on it. But one of the things that anthropologists frequently ask is the question about where do I situate myself in terms of the population that I'm looking at. Whether that be a historical population or whether that be a community in which you're working here in California or in Southeast Asia or wherever your research career takes you. What is my positionality is sometimes called and by doing so you are then asking yourself with these questions about not just well what is my objective in terms of this diarrheal disease or that infection or that particular health problem but you're asking questions that you have to account for yourself in terms of the people you're dealing with in terms of understanding their cultural traditions, understanding the way in which they understand disease and also understanding some of the politics and power relationships that go into both your position in relation to those people you're working with as well as the larger political situation of the state or region you're working. So for historical situations, I have to say very often times try to be aware of am I looking back in time and just trying to tell a good epidemiological story? The kind that we get in medical history very often times where we talk about sort of the progress that's been made with respect to getting control or command over a particular disease. Am I trying to tell a narrative that's just that kind of progressive story? Am I trying to be in that period and understand what is a health researcher doing when they are in the 1890s? What is their sort of cosmology? What is their view of health? What is their understanding of infection? Remember, we don't have a really kind of integrated theory of infectious disease until about, I mean of the germ theory of disease until about the 1870s. So we're going on through this period when we don't even think necessarily the germs or the cause of some of these major diseases that occur during that time period. How do I get back? Well that sort of blew that content a little bit but this is a book that I have completed and will be out in January and in fact, you can even order it today on Amazon.com or University of Massachusetts, perhaps if you like. But as part of that, again, thinking about the kind of culture you're working in. Victorian, in Victorian Massachusetts, this is very stylized. These are images that you could go down to the local general store and buy a lithograph that would have this picture. It's actually really probably more of an English pastoral scene than it is Massachusetts, I would say. But you've got a classic willow and urn pattern which were very symbolic and very common in cemeteries. You've got this woman in Victorian dress mourning in this way and then you could write the names of your deceased family members in this section of the lithograph. What I've been working on in the last few years now is this combination of illness, death, and loss. In other words, very often times as public health people maybe as specialists in whatever discipline we're in, we kind of decouple those. We pull them apart and we're really interested in that this person or this community or this percentage of individuals recover, get better. How did they fare with respect to a certain treatment or intervention, so on and so forth. Life is not like that, of course, for us. We experience an illness. We, if we don't recover from that illness or members of our family or our community pass on and then there's that whole process of loss that involves grieving and reconciliation and so on and so forth. Well, this book really tries to put those three together for this population, particularly this group of people in Western Massachusetts. So we know that how we mourn, how we look at disease, how we do all of these things is very different. I mean, this is a little bit of an extreme example of the difference between maybe the way we had formal ways of mourning men and the way we mourn now. But it makes that point that sometimes we feel like we're in this contemporary setting where we don't have these earlier relationships with infectious disease or relationships with the dying process or the grieving process that we did then. And in some ways, I would want to really question that and even our relationship with infectious disease as you all now know, but there was a time when we really didn't think we had to worry about infectious diseases not that many years ago. Now these also, I'm just showing you a couple of graphics to kind of get you in the space, to get you to thinking about New England at this time period. So this is again, an artist's interpretation of the Connecticut Valley. The communities I'm talking about are right up in this region up in here. And if this was really a clear picture, you could see a couple of little buildings up there and there's even a couple little smokestacks and so on. You see the steamship coming up the river and the train crossing the bridge here. And this is about 1860s. So right about that germ theory period of disease. And this is an area that's thinking that they are modern just as you think you are modern. These people are thinking we have the industrial revolution, we've got this technology, we have this power, we have statist ideas about facts, about the fact that we can name a disease and we can prevent it from happening if we just take a closer look at it. Well here's another image of the same area kind of pinpointing in at exactly the same time. And whereas before you saw a clear open agrarian kind of pastoral environment that's very, very healthy, here you see the reality of the fact that if you go into one of these towns at this time period, look at the smog, the stacks. This is a factory along this river and right over my shoulder here would be tenements or sort of rooming houses going up a steep slope with the waste running right down into this river and the people picking up water from this river to wash their clothes. Very, very shallow wells. The times of circumstances that you might still be able to find in many places in the world today but certainly not in New England. But it just emphasizes that point that those comparisons are not always, I mean, well let's just put it the other way. Let's say they make some sense to look at those sometimes and realize that New England, the United States are really not that far away from many of the situations that you will deal with in health contexts today. So I'm now gonna scan through some of these approaches that I take in the book. Some different medical understandings, we might say, of some of these diseases, notions of risk and causality. And I want you to be thinking also about the fact that we have the same issue that again I assume some of you I'm trying to speak to an audience that I look out and see your age, I see your diversity, I see that you're probably more from public health than anthropology. And I'm trying to point out to you that these issues are so important in many of the contexts that you probably will find yourselves working in and they're extremely important to understanding health outcomes in the past in the United States and particularly in New England. Now let's back out even just one step further real quickly and talk about just very quickly medical history and the way in which most, if you, I was just looking at Andrew's books on his shelf which are at least on one shelf we had a lot of overlapping books and a lot of them are about this sort of big story of medical history. And as I mentioned before that's telling the history of progress and conquering a disease, famous doctors, famous discoverers of a particular infectious organism or what have you. And it's about, as I say here, medical conquests, it's oftentimes the people who tell these stories come out of medicine and they wanna tell that very positive story about how medicine has conquered a disease which as we know also has some problematics. And about important discoveries and therapies. Oops. Well one of those, of course we tell a lot about is European settlement in America and how the indigenous Native American population was decimated by infectious diseases that were brought by Europeans. Those zoonotic diseases that there was no experience with that whole notion of a virgin soil population a population that had never really had been exposed to these diseases so their response to those diseases, no immunities, no long histories with these diseases. And so the Native American population was really, really hurt by this. We kind of sometimes quickly gloss over that. But a very, very common theme in later sort of grand narratives of the United States is the outsiders now that the quite Europeans are the Americans. And in fact, if you look at the historical records that I deal with, Native means not Native American. It means a white person who came over on the sequence of ships that settled in Plymouth and Jamestown and so on. And so here's a cholera, a cholera caricature cartoon from about the 1850s I believe. But this notion that America is a healthy case but we have these waves of immigration. And I know this resonates a lot with UL and California, with the kinds of discourses about immigration today in the United States. And this, I want you also to understand, was going on from day one in New England is that every time an Irish population came in, these were oftentimes people from Europe, Italian populations, French Canadian populations, they would oftentimes thought of this, sometimes called the immigrant menace for the fact that the indigenous population is healthy but those outsiders are bringing in infections and so on. Now the way the book is organized and the way I've been trying to do my work lately is also to deal with the life course. And you all probably know exactly what that is, but this again would be a very common thing, you could go down to the store and buy or put in a buy or a small one that you would find in your family Bible. That would tell you the names of people in your family, when they were born, when they got married and when they died. And that's basically is the life course is watching some of these, especially the reconstituted families now or people go through different stages but also watching the individuals go through infancy, childhood and so on. So the cholera that I'm talking about today, I'll say a minute more about this, but the cholera I'm talking about today is cholera and phantom, which was a very classic classification in the cause of death records in the 19th century. You would know a lot of them as basically weanling diaries or gastrointestinal infections in infants and young children, talking really zero to one and zero to five. So infant mortality and early childhood mortality. Also the pneumonia complex that comes with it. This is a image of a young mother holding her infant and the striking thing about this image for those of you who don't know about it is that the infant is dead and she has lost her child and this is in the time period of some of the earliest photography called the daguerreotype or wet plate photography. And these are very common images that I run across in family records. The only image that they might have of a child would be after that child had passed and they would pose the child with the mother or sometimes they would pose an adult sitting on a couch between relatives kind of propping up the deceased person but then they have a memory, a record of that loss. So infant mortality is huge in New England at this time period. Rates of, in some of the inner cities, 300 per thousand live births, maybe 250 live births would be a common annual average in Boston in the mid 19th century and out of the rural areas, it would be slightly less. And if you open up a newspaper, you see again, commercialization of prescriptions and over-the-counter drugs is nothing new. This is 1898 but I can show you these from 1850 and just imagine being a mother who's being told that if it wasn't for the fact that she just had that one particular extract of wild strawberry, that child might have lived and it's sometimes very emotional to watch the kind of processes that go on in these contexts. For childhood, I'm talking about children that are usually from five, say early adolescence or maybe as young as two at some point and with childhood, the major causes of disease, again, things that you might be familiar with but measles, scarlet fever, diphtheria, chickenpox, not so much chickenpox being fatal but diphtheria, scarlet fever and measles were oftentimes fatal at this time period. Of course there's no inoculation or vaccination and sometimes these are the major killers in a single year. And again, you find in the newspapers commentaries about how this, the population becomes very aware. They hear about an epidemic starting maybe in Boston, maybe it's in Cincinnati or maybe it's in Baltimore and they read their newspaper, their weekly newspaper, these little six page newspapers and they're following these diseases. They say, it's coming our direction and then you see it. Just like you get on the web right now and you look at where's H1N1 now, which schools are letting calling school off and how many kids have it and how many deaths have occurred from it. That same kind of thing in a very slow, slow, slow way is going on with these diseases. And on the lessons I deal primarily with tuberculosis and tuberculosis was a very high cause of death for young women and men in this time period and more so than we might expect. Again, treatments are problematic and I'll go into this but maybe we'll have time in discussion too to go over some of these things that I'll be glossing over as I sort of set up what it is I've been trying to do. And this is a classic image of a, maybe a 16 to 20 year old young woman has contracted TB, has become symptomatic. Keep in mind that in the 19th century in New England and is in many places in the world, the actual exposure to TB and the presence of a response to TB is very, very high even in many populations today. It was probably around 90% plus in some of these populations at this time period. So the difference between being positive and completely asymptomatic means you've really recovered from the exposure and encapsulated the bacillus and you've got no health problems really. But in this case, the disease moves on and so this fact that these young women and men are very disabled at a very early age. Each one of these, by the way I'm looking at is, what I've done is gone through the statistics and sort of independently verified one of the major causes of death for each age group. And these are the ones that consistently hold up in many communities. In adulthood, I really particularly like this image because it's of a knife making, cutlery making factory in a town that I do work in. And you can see here, there's belts all over here, open exposed belts, there's grindstones that are putting up tons of grit. There's petroleum distillates that they use in forming them and you can see how hazy it is and these men lined up together and one false move and you can lose a finger on the eye but sometimes these belts go or a stone explodes or what have you and there's a lot of work related accidents and in addition also, this is when farming starts to get mechanized so you read these stories all the time farmers suddenly working on these fast machines by their standards going from a horse drawn plow to a mechanized tractor and cutting machine, a corn cutting machine say maybe. And then again, violence and war for this age group is always big. Tuberculosis and I do both women of reproductive age and men, there's many fewer women working than men but there are a lot of women working as well in the mills at this time period. All right, so that's kind of the way in which I like to think about the relationship between the life course and the exposure that people have to these various diseases and traumatic incidents at that time. Now, one of the things about looking at a historical situation but I think you would find the same thing if you started looking in a community that has a local population that has its own theories of causalities of disease. You have different traditional notions, you have modern notions, they're coming together. The way in which people treat the disease, I mean I can remember things that my grandmother did are ridiculous but we can probably all tell stories like that that were still part of the healing process and the same, I mean of the treatment process but the same thing can be said about what do we call cholera and what do we call tuberculosis? So that if I go through causes of death for 1850s I might find 10 different kinds of cholera because cholera to a doctor, a physician who was probably pretty poorly trained might mean a very different thing or what a family tells the doctor or the undertaker that their child died of might be cholera but it may have nothing to do with cholera vibrio. So Asiatic cholera was you know because it was the history told us that it was originally came from Asia across Europe over to the United States and so on. Cholera morbis, also sometimes Asiatic cholera sometimes something else, cholera and phantom. So the point here being that keep in mind people who received it who had these conditions and the physicians didn't necessarily name something that was directly correlated to the microorganism that caused the disease. And here I'll just cover a quick example of the reconstitution analysis kind of thing. So what we can do is go into those reconstituted families and this would be much the kind of same thing that maybe somebody would do in Bangladesh where they're trying to look at infant diaries and illness or mortality rates from weaning diaries or whatever and you're trying to look at the family dynamics involved in these households. So the age of marriage, maternal age of each birth order, intervening birth interval length, completed family size and then some kind of wealth indicator of the status of the household in relationship to its wealth. So we get all of these kinds of information out of the original vital records and tax records and so on during the 19th century. So these would be some examples of some of the findings that we might find. This is looking at survivorship of children to 21 years of age given their upper or their lower wealth class. And what that is is it's based on the median wealth and we didn't have enough numbers in the kind of a multivariate model to look at more finer gradations of wealth. So if you just look at upper and lower wealth class and then male or solid, let's see here. Now I'm getting confused here. Oh yeah, male table, a female table and then the total. And what's interesting to look at here is that in the males you can see that if you're in the upper wealth class you actually have a survivorship advantage coming to you over that period of your first years of life that the lower class males don't experience. The females, what's interesting to note here is that they go along pretty close but then they cross over a little bit at approximately age 15. So what's going on there? And then the total wealth class combined males and females. So that's telling you something about the fact that there's a slightly different experience between males and females. And if you look at this graphic, this would be survivorship to age five of these kids. This would be survivorship to age one, the inner bar. Here's the upper and lower for males, the upper and lower for females. And what you notice when you parse it out this way is that there's that male advantage of a higher probability of surviving to age one and age five. Most of it is all infant mortality, incidentally, or very early. But in the females, it actually, in the upper wealth class, the females are actually doing a little less well in survivorship to age five. So, and this is based on over 1,000, about 1,600, almost 2,000 cases. So there's no class advantage for females. So what's going on there? Let us again, something that some of you may relate to in terms of work that you do or know about in contemporary public health. But the households are conferring some advantage to the males over the females. And that could be anything from starting it with female infanticide to differential allocation of resources to males and females. The status that males will achieve at an older age relative to what sons can, what are their prospects for the family compared to daughters and so on. So here again, in 19th century New England, you find something that we certainly know is sometimes present in other places as well. Probability of dying by completed size. This is the upper wealth class and this is the lower wealth class. And I'm not going to go into detail on these or I'll never have time to finish. But so what do you hear is if you had one to two children, three to four children, five to six children and so on. And notice this curve, very, very high infant mortality in the one to two children in the lower wealth class. This is a kind of a classic pattern we can come back to maybe in question and answers. But you can see in the upper wealth class again, there's some advantage to having, these are often times the upper wealth class are farmers who are pretty successful and they control their own food supply basically. They have slightly smaller families at this time period. And you can see the progression of the probability of losing a child going up over the size of the family. That makes perfect sense. The lower wealth class a little bit more problematic. Then maternal age, what's the probability of dying by maternal age? Again, this is upper wealth class. This is maternal age and lower wealth class. Much more dramatic effects that are going on in this pattern than in this pattern. And you see that maternal age is 16 to 23, the first category. And I think this table, this graphic is certainly telling you that younger mothers and many of these would be probably closer to the 16, 17, 18 and the 20, 21, 22. Even with the wealth advantage, there's a higher mortality for young mothers. Something we again, certainly validate with contemporary literature. And then birth, the effects of birth interval. So here's 15 to 18 months, 19 to 22, up to 45 months birth interval. So anything from less than a year to almost four years. And this again is a pattern that we see very often times where the shorter the birth interval between children, the more risk for the infant. And we see this essentially, I want you to be thinking about sort of that in repetition in a household, where you lose a child because of a short interval, death, then you become pregnant again and have a child again within a short interval and death, the kind of sort of sequence that that can produce. And then I'm not sure this is the last one, but it may be the last one for this, this kind of reconstituted family data and looking at, again, primarily weanling diaries. Here, what you have, I meant to scrap, may not be, you can certainly see the pattern, but this is mortality level, high and low. So this is high mortality, low mortality level within a maternal age parameter. So young ages for the maternal age, older age for the maternal age. And what you're seeing here is, again, the kind of interaction that is going on and always behind the, well, we'll just leave it there. We can come back to this on the point. I think the conclusion that I wanted to make about this is what you're seeing when you put these graphics together and put them into a model where you look at, we all know that these variables are highly inter-correlated fertility variables with a mortality outcome. But what we were able to do, kind of parsing those out and then putting it into a multivariate model, is see that these deaths were not happening randomly across, like so I just said a few minutes ago, death infant mortality rates might have been 250 per thousand. And for historical epidemiologists, that's oftentimes as far as they get. The death rate was 250 per thousand. So if you're working in a community, in a health context, you probably become aware quite quickly that not all households have the same death rate of infants. Certain households are at high risk. And the same thing you see here, that the loss of the child in the family is a high predictor of a second child loss or even a third child loss. So what you're seeing is the combination of maternal age and wealth class working together, they both enter significantly to play a role in these what we would call high risk families for those weaning diaries. Everybody gets exposed to the microorganisms maybe, everybody is potentially at risk, but certain households and families are getting much, much greater. So now let's just move to childhood real quickly. We know from a lot of research and literature that there was a huge pandemic of scarlet fever in the second half of the 19th century. This was pandemic meaning everywhere that we have good documentation for. And it had a very, very high mortality rate. It wasn't just that it was a lot of cases, it was a very, very high mortality rate. Massachusetts had thousands of children die in some of these years, sometimes not throughout the state, but in different regions of the state. So again, what we do now with some of this micro data is look at a couple of epidemics that I actually first discovered by the data, not by a newspaper article or something like that. I was looking at the incidents of these rates and started to tease them out and see if I could find high cases. And then I realized it was part of this larger pandemic. But again, canker rash, which I used in the title, could mean all sorts of things. Probably most often when a doctor said a kid had canker rash, they probably meant it had scarlet fever. Scarletina is just a common term. So when I'm going through these records and trying to sort of make meaningful categories on the basis of infectious disease, nozology, or some other basis, I have to figure out what does this mean? And scarlet fever was usually pretty ambiguous by about the 1850s or 60s. It was pretty ambiguous that these were doctors, doctors were getting pretty good at identifying scarlet fever compared to measles or kidney loss, right? And here again, strep pyogenes, which is a streptococcal infection that is really the cause of scarlet fever, found in, again, it was isolated in the 1870s. But keep in mind, so we had the color of, color of the video in the 1870s, this pyogenes in the 1870s, that doesn't mean doctors still know that that pathogen, that particular microorganism is causing the scarlet fever. So the treatments get very, very interesting in terms of how people approach scarlet fever. So I'm gonna just quickly, I'm gonna kind of almost skip over this, except to tell you that what we then did is go into these towns and sort of say, how did the scarlet fever epidemic play out in terms of the health consequences, in terms of the community, in terms of the families that were involved? And I can be quite honest in telling you that sometimes I get very microscopically involved in these things as you start reading about these individuals and you want to know more about how it really played out in particular families. But this is a kind of a classic, this would be much smoother if it was a huge number of cases. This is maybe 300 plus cases of scarlet fever I'm looking at over age. You have virtually no strep infections in little kids. A lot of times it's because of maternal immunities through breastfeeding. Then it starts to spike at age two and then it can stay high oftentimes between about two and 10 years. And then by 10 or 12 years, a lot of kids have developed their own immune systems have become competent and they're more resistant to strep and they may get strep infections but they're not gonna go through the full course of getting scarlet fever and rheumatic fever and so on and so forth. And this was the data that first got me looking for epidemics was I was looking at the cases over the number of years and you can see oh my gosh, here 1859 to 60 and 1867, 68, I believe that was, they were these two really sharp cases of epidemics and then this kind of more low level endemic presence of scarlet fever the rest of the time. The town showed some differing levels of these are deaths and Shelburne Falls was a very small manufacturing town. Again, not a lot of probably poverty in this town, very close to the river, dense but small town. You can show the highest number of cases. You can read these time and time again. You can go to medical textbooks, you can go to newspaper, popular articles in the day that were recommending from others what to do but what you've got so often in these therapies are things which actually increase the risk of the child dying. You have to have a kid with diarrhea and you give them something that makes them throw up more or pervative to make them vomit more or you give them a lot in them or a paraglider or various drugs which will definitely calm the child down but sometimes almost probably to the point of making them unable to physiologically recover. And then we just go through much finer grain analysis so I look at it in near field and I find the kids and I find out the houses so one of the big questions about scarlet fever was was it related to class? Did wealthier households have a better risk of surviving than lower wealth households? And these were some of the kids who died very early in this 1859 epidemic and look at these houses, I mean these are more recent pictures but these are houses of kids who are very, very well off in a very productive farming communities. And then I can plot them on maps so these were those first three deaths and here they are, I didn't even have documentation that these two kids were friends but they live on this street here and then you start hearing about the cases moving down the street and out into the larger community. So it's really possible to do the kind of thing you might well be doing yourselves when you were doing a mapping of an epidemic infection. The question about why did so many children die in that particular epidemic, that pandemic, as I said, there were these big class questions and a lot of kids, usually when you look for an infectious disease mortality rate, you wanna say what is the cost of the economic kinds of underpinning explanations we can look for but in this kind of fever epidemic, a lot of children from households like that died just as well as poor children. And so that starts to raise the question about the variance of a microorganism at a particular point in time. And there's strong arguments now, again even looking at some earlier samples of strep from material that suggests that it was probably a highly virulent evolved strain that was going around the world at that particular time. And just again to remind us, I mean this is an older article but we see these kinds of things regularly of kind of the toxic shocks in the drum or other kinds of streptococcal infections where you get that virulence evolving and in a particular set of circumstances that can cause a very, very high level of mortality even though it's something that we now can intervene with in terms of antibiotics and so on. Okay, just to finish up now, consumption, again the same kind of thing. You're trying to go through these changing disease types and figure out what they mean, which ones can I combine, which ones do I have to keep separate and so on. And the cubicle bacillus gets isolated in the 1880s. So that's that germ theory of disease period. 1870s, 1880s, these microorganisms are showing up in microscopes but doctors are not practicing as if they know about the germ theory. Some even country doctor in Massachusetts might have had a microscope and pulled some spew from an individual that had a chest infection and looked at it under the microscope and seen that cubicle bacillus there. But that kind of clear association of yes, that's a potential cause of disease, that's associated with a set of cascading conditions, why do I see it in some patients and they're healthy. I mean that's the thing about a TV, right? I mean you can find the cubicle bacillus but the person's completely asymptomatic. That really confused physicians to sort of say, wait, does the germ cause the disease or it doesn't cause the disease? Because they had no really good strong epidemiological model from which to infer what's going on. Well, to TV in these communities, what you find is a lot of infection, again, across a number of different economic classes, although there are certain patterns. And the patterns are young adolescents, as I said, young women and men especially and also kind of an ethnic, at least, perceived difference in the sense of the immigrant populations having extremely high consumption and in fact, they didn't have higher rates of consumption. So, higher young women, across class, very classic kind of summary of Massachusetts data done in the late 1890s or in the 1890s and I don't know if you can see this, can people see these? I mean, I'm hoping you can back there. But what's this ensuring is male female differences in Massachusetts between, I think it's about 1850 and 1895. And what you're seeing here is that the female deaths are higher across this whole time period than the male deaths. The tuberculosis we know is not a sex specific cause. What's going on there? And then these were the data in England and in the English data, young women have a higher incidence of consumption death up until here and then it begins to cross over. And this crossover effect, both in terms of time but also in terms of age has been something that has been found in various places in various periods of time. What we found, and I verified this on a number of different cases now of communities and on the state level data. This now, the bottom axis is age. And this is a rate for, I can't remember whether it's 1,000 or 100,000. But what you see here is females again being higher mortality rates up until about age 40. So from age, maybe 10 to age 40. 39, of course, or in that range. Females are dying higher. Then they drop under and the male actually, tuberculosis deaths tend to increase in those working age population individuals. And then they both come down, of course, in old age. So this crossover effect is something I'm working on right now. And also this higher female mortality. And again, if we find this in Europe, in Western Europe and in the United States. Finally, the very interesting, you can find sometimes these specialized reports from places, Boston did a very big survey of the health, the sanitary condition of Boston as the way they were described in health in 1875. And what they were doing was doing a very interesting kind of epidemiological trick. I mean, they're for play, they said, the Irish make up 64% of the population at this point. So huge, they're not just the major immigrant population. Well, wait a minute, I can't remember whether this now maybe it's all born or whether this is 64% of the population. But if 170,000 Irish immigrated in between about 1845 and 1860, and it really was an overwhelming kind of base of population in Boston. But then they said, well, how much are they responsible for of the TV that we observe in the city? They said, well, they're only 64, well, they're 64% of the population, but they account for 76% of the consumption deaths. So what their way of understanding was that, well, Boston is really an healthy city if you just don't count the Irish. It's a way of sort of making a claim about the fact, well, yes, it's those foreigners that are really causing the problem, not our native white Bostonians. So, you know, we know that all these diseases, in fact, every one of them, the Wheeling Diaries, childhood fevers, less so, but certainly the consumption of all very, very important diseases today. It's interesting to take for me at least that historical perspective on what we find and certainly to put them, when I teach this material, to put them in the context of what we talk about now in terms of antibiotic resistance and about new emerging infectious diseases and the same kinds of things we hear about now in terms of immigrants being a threat to the health of our quote, unquote, indigenous population. So, this is an epitaph from a woman who died of tuberculosis at the age of 16. And it's just a reminder to us that we're always talking about individuals here. We're not just talking about populations and samples and statistical analyses. And you go through sometimes and read the diary entries or you read the cemetery epitaphs of these people and you realize how powerful and important this illness and love was in these time periods. So, thank you very much for your patience and... If you'd like to take some questions? Sure, yeah. Hi, I'm going to talk. I was intrigued by the medical value analysis that did the sex differences in the mortality rate of a child, presumably due to the quality of the main causes of the infancy. And I think of differential susceptibility to differential mortality based on infectious disease, based on economics, that is, I think of all maybe they're being exposed differently over the dose of the exposure. There's somehow drinking the water in one region versus the poor gathering of water from one area versus the wealthy in another. Those explanations don't seem to hold in this case. And we also can't know the different treatment of the children because we don't have an effective treatment, exactly, of these infections. So, and so the kind of story we're leaving is that seemingly there is some male preference that wealthy but not poor families are getting, right? And I'm just trying to reconcile that with what I know about the historical improvements in infant mortality for females relative to males. I know most in historical Europe. During this time period, female mortality declines much more dramatically over time than male infant mortality. So the global trend doesn't seem to hold that wealth story. So I just wondered if you could talk a little more about what do you think is going on? Yeah, well, do you want to offer anything? Well, I just, I just presume it's some great constitutional difference, but it's, I don't know if it's so much female infanticide of those poor wealth, it's just giving super preference to that high educated male infant. There's some slight preference for that, maybe in this region that doesn't generalize to larger population on the outside of the Connecticut Valley, but, you know. You know, a very good, really a good question and you constructed the problem very well. The, well, first of all, in the fact that sort of the decline of female mortality, you're right. But, you know, some of the earlier data in Europe also showed that female infant mortality was actually higher than male mortality than it crosses over and then it drops more dramatically and you're right. And the male still stays somewhat higher. And that is a late 19th century phenomenon. What I think, what I think is happening here is that the lower class households that make up that, you know, make up that sort of problematic are probably not feeding differently, investing differently, and those, there could be some statistical just sampling, although, you know, what's a sample in this kind of data, but a sampling difference. Whereas in the upper wealth class, what we have been basically arguing is that there's something that that upper class is doing in terms of differential, not treatment necessarily, but that the boys are just already being nursed better or better fed right after, right at weaning or right after. They're being a little bit better provisioned or a little bit more invested in than the females. And this is a time when women couldn't own property. Women did not have ownership of, I mean, I did not have equal rights over their children. That was starting to change rapidly about that time, but there may have been, they couldn't bode, obviously, in America at that time. So there may have been some of these cell differences. The other thing that some people have pointed out, and this is, I think, follows with the consumption argument, the differences in the consumption as well. Young men were, males at an early age were believed, perceived, and this is in the literature, they were perceived to be more engaged in farm labor and they brought currency, they brought cash into the farm household economy. From even from age nine, they were tending the cows, they were working in the fields of the crops that were sold, and girls didn't work on the farmstead and they take care of the chickens and they're actually doing more work. The girls are actually doing more work as young adolescents than the males. Probably in terms of calorie expenditure, we're kind of in the houses. But those tasks are not regarded as valuable to the household economy. So there's a whole complicated thing going on there that I can't give you on, this is what it is. But I think those are the factors is that as wealth increases, the potential to invest differentially is there. I saw in the newspaper blog that you presented from 1998, the New York Times in the struggle that one of the physicians interviewed said it's probably differences in reporting that make the number of cases seem to go up. And I can't but help thinking historically what would be the difference in reporting, especially with your pieces on socials, momic status, I mean, is there more likely to be reported? Yeah, that's a very good question. Very good question, Mike. That's one of the motivations that I started working in this area for was because these communities are small communities. And when we started, I mean years ago when historical demographers and epidemiologists were looking at the major cities, they knew they had huge levels of under-reporting. And not huge because Massachusetts, as end of reporting goes, it was pretty good, but still significant and you didn't, there were a lot of unknowns. In these communities, it was very, very good registration and they were small enough that you knew like the town clerk was, why did they start getting back in the 1850s that the laws really start punishing the town clerks they don't have, they're fined by missing any records or not performing and so on. And word of mouth had traveled very quickly in some of these communities. So I'm not saying we didn't lose, in fact, at one point, I was thinking on my feet, I can't sort it out, but we certainly struggled with that, I question about what would under-reporting do to this, you know, would parents be less likely to record a female than a male and so on? But it's really a very good question and that's the real weak link sometimes for historical demography is for law places, right? How good are our data? Yeah, anything else? I have one more. Okay. I think they, no, I lost some kind of thought thinking who else is going to answer the question. The, what was the life expect, I mean, is it possible to talk about life expectancy? Yeah. The reason I asked is, I think in the interest of time you went over this slide, but there was one after talking about the workers and the accidents. One about chronic diseases in the elderly and there was a picture of some, and I wonder what were the main concerns, when you survived this business, what were the concerns that you had? Yeah, I didn't have time to do each age group and I didn't even have enough time to do the ones I did, but at least it gives you a sample, but yes, the state even in the 1870s say starts to pick up on the fact that these chronic diseases are becoming, chronic and degenerative diseases are becoming more of a problem in the elderly. It doesn't mean that infectious diseases are not there and still taking their toll. Tuberculosis for a lot of people who we would say, I used to advanced ages, I mean, we could call it old age, but I'm in that age group now, so 60 and above, you don't, you have to be generous to yourself, but there are still a lot of tuberculosis, but they're not good at diagnosing cancers, of course, very good, but there certainly are a lot of them and the health community physicians and the boards of health and so on are really seeing that those are becoming, but when you look at the death, the causes of death for the old aged individuals are the most problematic. They're, you know, because they died a natural death, died of old age, died of constipation of the brain, which was an actual cause of death. We hope that the physician has a sense of humor, we don't know what that is. I actually do know what it is, it's very hard. Yeah, so. Well, thank you, thank you very much. Thank you. Thank you.