Okay. Hello and welcome. Everybody can hear me okay? Great. Welcome. Hopefully everybody is well hydrated and glucose levels are level. I'm Ken Lankin. I'm the enterprise medical director for the Jefferson Occupational Health Network, which is affiliated with Thomas Jefferson University, which is four blocks away from here and encompasses 18 hospitals and 43,000 employees and students in the area. Just prior, I had the fortune of being the associate corporate medical director for JPMorgan Chase, headquartered in New York, and before that was on active duty in the United States Navy as a medical officer for 26 years and got a free trip to Afghanistan, courtesy of the U.S. Army. It was great. All expenses. I loved every minute of it. Thank you, Curtis. No tipping. Meals included. But I want to introduce three other distinguished speakers today. Our second speaker is going to be Verba Moore. And Verba is currently the EHRS medical specialist for the GSC supporting NASA's agency electronic health record system. And she was actually in the Air Force for 22 1⁄2 years. And she began working with NASA, interestingly enough, at Langley, at the Langley Occupational Health Facility, and later on worked as the manager of the multidisciplinary agency for occupational health that supported NASA's office of the chief health and medical officer. Our next speaker will be Dr. M. Gushoff. She goes by Dr. Olga. And she tells us that she is a reformed, she hasn't totally, you can't get it out of your system, but she is a reformed internist. And a pediatrician. And she's worked in primary care, public health, and health preparedness. She's been involved in occupational medicine for the past ten years. And she currently serves as an occupational medicine physician at the occupational health support office, which supports the NASA's office for the chief health and medical officer. So we're kind of outgunned here. We've got two space-oriented occupational health physicians. And then following up, we're going to have Dr. Curtis Cummings. Dr. Cummings is a review officer for federal occupational health, which some of you might know is a division of health and human services. He also had a distinguished career in the Navy beforehand, in the Navy Medical Corps. And he also worked three years with the New Jersey State Department of Public Health. And he's currently an adjunct associate professor at the Drexel University School of Public Health. I'm going to take my phone out so I keep track of the time. How many have been to Philadelphia before? How many is it your first time here? Great. Okay, good. All right, you're going to love it. This is for you. I'm just going to lead off with a little, just kind of an interesting thing, and hopefully a story that you might not have heard. Does everybody know about the Broad Street water pump in England? Well, I'm not going to talk about that because I know you all know that. Okay? And the y'all comes from being from southern Philadelphia. The borderline of what divides Philadelphia is South Street. And I live on South Street, another disclosure. But I live on the southern side of South Street. So therefore, that qualifies us as being in South Philly. If we lived across the street, that would be considered Center City. All right, is this an advance the slide thing? Or is that push like that? What's that? Okay. Technology 101. Yeah, you're doing the laser. Okay, so I don't have any disclosures except for the fact that I love the city. I love Philadelphia. There's a lot to like about it. Philadelphia is an extremely welcoming city, and for a lot of reasons, and historically, and to today's, right up to today's presentation. And I especially want to welcome those who are here for the first time. Most people are familiar with Benjamin Franklin. I would say, probably the most famous, quote unquote, Philadelphian. But what a lot of people don't realize is that he really wasn't from Philadelphia. He was from Boston. And he was running away. He ran away. But he was welcomed in Philadelphia. But off to the right, let me try this right here. That's a very famous painting of him as a young man. This is also, this is real here. This is Head House Square, which is maybe about six blocks away from where you're sitting right now. It's still there. And what he has are some loaves of bread. And that painting was based off of his own memoirs about his trip to Philadelphia. And that's his story, that he came with these loaves of bread and he's sticking to it. My connection here, you've heard of Ben Franklin, Benjamin Franklin. But there's another person, which is this guy, Benjamin Lincoln. Benjamin Franklin was an inventor. This is as possibly, you may have implied, is my grandfather who fled Imperial Russia in 1906. Now what's interesting about this is that a lot of people are very familiar with the Eastern European migration story and people going to Ellis Island in New York. But not everybody went to Ellis Island. Some people came directly to Philadelphia. And there was an immigration port very similar to Ellis Island on Washington Avenue, which is right on the banks of the Delaware. The other thing I wanted to mention to you, there was this weird story in my family that he had invented something. And I really thought that this was an exaggeration of my wishful thinking. And it wasn't after everybody had passed away. I knew my grandfather when he was much older and he had worked as a farmer and a field hand and a lot of kind of industrial kind of work. No college degree or anything like that. And they said he had invented something. And it turns out, thanks to the magic of the internet, that he did in fact invent the hydraulic jack in 1937. And we found the paperwork. It had gone on to a guy named Mr. Kettering. I don't know if anyone knows. That rings a bell. Sloan Kettering. Yeah, he was the chief engineer at General Motors. And basically the letter said, Dear Mr. Lincoln, thank you for your very interesting idea. However, you probably don't understand. You're in the middle of a worldwide global depression and we're not really interested in your idea. But someone else picked it up in the 1960s. So at least it wasn't totally lost. I want to tell you today just briefly a quick story that I hope you have never heard before. Now, many of you may have heard about Valley Forge. We're right here in Philadelphia. And Valley Forge is just up the Schuylkill River. So that's what we're talking about. And what happened is things weren't going well in the Revolutionary War. Not going well for the Americans. Things were really bad. I'll just, in the interest of time, just keep it very short. But there were 12,000 troops and nearly 2,000 died from disease. So that's kind of an old story. And this is true, at least for U.S. forces, that more people died up through Vietnam from disease than from battle injury. What was killing literally the Continental Forces was the disease. And the reason why they were getting disease is because of this. It was very poor sanitary conditions. It was crowding, coughing, people were dying of typhus and dysentery. So enter Friedrich Wilhelm Barron von Steuben. This is the person I'd like you to know about for today. Just one person. Barron von Steuben for short, he was a Prussian military officer. Trying to explain the history of Prussia is a completely separate lecture, and I can't really do that right now. But be that as it may, the Prussians were known for being exceedingly skilled and dedicated to the military. Very much like a modern version of Sparta. It was said that Prussia was an army that had a country attached to it. But the thing about von Steuben is that he was discharged in 1763, if you read about it, as speculative. But if you read on, it was really regarded that he was gay, and that he was discharged for that reason. He became in debt, and somehow encountered our friend Ben Franklin with the loaves of bread in Paris. This is very, very important later on, because Franklin really wanted things to go better, and he just had this idea in his head, hey, maybe this Prussian guy can help us out, because the Prussians are doing really well in Europe. They're good fighters. The only problem was, I kind of put it out of here, so he set him up with Washington. The issue with von Steuben is that he didn't speak English. So how did he communicate? Well, it turned out nobody else spoke German, but there was a guy named Alexander Hamilton, who was Washington's aide at Valley Forge. And Hamilton, does anyone know, like Hamilton, what languages he spoke? It was a lot. He actually spoke, aside from English, he spoke French, Hebrew, and Danish. Another story. But it was because of Hamilton that he was able to communicate with von Steuben. I think being screamed at in German would have some effect on people, but it would help to know what they're actually saying, as well. Von Steuben is really known for, what he did was creating close-order military and drill. Remember that painting and all these ridiculous, everyone hanging around? Von Steuben had the idea of, like, hey, if you put things in rows and orders, I would say the greatest contribution from a public health standpoint was, he asked, like, hey, guys, where's your latrines? Oh, we don't have latrines. We just go wherever we feel like it. So he had that idea to put the latrines up, but that you put them downhill, not up top. And the rates of dysentery and the health status of the entire troop improved dramatically. I'm just going to go over this, but basically, the rest, the Continental Army, I mean, their win-loss record was terrible. It was worse than the flyers. And things went very well. After that, that's a picture of Von Steuben right there. There's a monument to him in Washington, D.C., so any of you get to go, it's right near the White House. You can see Baron Von Steuben, and he eventually became a citizen, and he lived out his days in upstate New York. Now, the other thing, I didn't even really know this until we started the talk, because what we know about Von Steuben was the fact that he's this, like, hard guy, Prussian military officer. How do we know that he was gay? I mean, people don't usually leave, like, certificates talking about their sexuality. But evidently, people weren't allowed to be openly gay, but there was a law at the time that allowed people to, you could adopt, you could adopt another adult. And there are records that Von Steuben, you couldn't have gay marriage, but he actually adopted two other military officers who lived with him and actually inherited what was left of his belongings when he passed away. So, in conclusion, basically, because of Von Steuben, a gay man, he played a giant role in the creation of this country. He also had the idea of having military academies, a standing army. He even had the idea of having a veterans organization. And I would also like you to reflect on the fact, and this is part of the theme of diversity inclusion, it's not just about Von Steuben, but it has to do with Washington and Franklin. They must have known about this story, right? What's up with this Von Steuben guy? Why did he get fired? I think it says a lot about Washington and Franklin. I mean, I know they get painted up as these old, stodgy, English kind of guys, but this is what's so great. They didn't care about that. They cared about what he brought to our military forces. So, with that said, it would also help if I went in the right direction. I probably could use some of Von Steuben's directions. This is also a couple blocks. I hope if somebody has time, this is the middle of Washington Square. I didn't even really know this existed, but there are unknown soldiers buried in Washington Square. And it actually talks about the thousands of people who died of sickness during the Revolutionary War. So, anyway, with that said, together we are better. Thank you so much for coming to Philadelphia. Thank you for being here, and I hope that your welcome is at least as good as it was for Benjamin Franklin, because if Philadelphia wasn't a welcoming city, Ben Franklin would have been in Boston, and we would have lost the war. Okay. I have nothing to disclose. Ramses V was obviously one of the Egyptian dynasties. They believe he died about between the ages of 20 and 29, and six other of his family members also died at the same time. And as you can see from the circle, this is his mummy, and those spots were believed to be smallpox. What's unique about this, maybe one of the first evidence of occupational worker time off, is his mummification was rushed. It wasn't done in the usual fashion. They gave him time off after it with paid leave, believe it or not, and they closed down visits to the Valley of the Kings at that time. And in 1980, they actually did some studies on the skin of the mummy, and it did, in fact, have syphilis in it. So we're going to talk about smallpox, the goat of all killers, infectious diseases. The reason I say that, as of April 12th, WHO had recorded just under 7 million deaths from COVID. The American Museum of Natural History says between 300 and 500 million died after 1900 due to smallpox. So it really, and there's no way to know what the effect it had in antiquity. So you can pretty say that it's the goat killer when it comes to infectious diseases. They believe it appeared around 10,000 BC in Northeastern Africa. It's been written about in several ancient dialogues. And Variola was coined by a Bishop Marius in Avanches, which is in Switzerland right now, excuse me, a Swiss municipality, and he described it during an outbreak. And just for those who know your history about the other pox, syphilis, they call this smallpox to distinguish it from the great pox, which is syphilis. Just a little primer here, because none of us, I don't believe any of us in this room, have seen smallpox. There's two versions, major and minor. Minor doesn't have the fatality. The mortality is only about 1% for minor, 30% for major. You can only distinguish the two by PCR evaluation. And the fact is that there are no animal vectors. That's key to the eradication of it. And the incubation time, for the most part, you're asymptomatic. And there's some say that you may be infectious during the prodromal period, but others say maybe not. Of course, the pathognomonic thing is the rash. Starts in the mouth, works its way out centripetally. And I didn't realize that there really were two forms. There's your standard, and then there's this hemorrhagic version which doesn't give you the pustules, but kind of this coalescence of hemorrhagic bleed under the skin there. Of course, rash progresses from macules to papules, vesicles over four to five days. They become deep. The scabs form about the ninth day, and you remain infectious until the scabs fall off, which could be as much as three weeks. And just as an illustration of, you know, COVID became the problem because of the mobility of humans. You know, our society, we can go from one place to the other in a day on an airplane. It took a little bit longer, but as populations moved around, you can see that it went from being in China and Korea to, you know, the Americas by the 17th century and earlier. Of course, they believe that the explorers brought it with them. So let's talk about the road to eradication. You can't eradicate the disease until you know what it really is. And Abu Bakr Muhammad Ibn Zakaria al-Razi, known as Razi, was actually a pretty Renaissance kind of man, if you want to say before the Renaissance. He was a philosopher, physician, alchemist, and he actually described the difference between smallpox and measles in his book of Smallpox and Measles. He authored a book that was translated into the Libra continents, which actually was considered the most significant medical book in the medieval ages. And I have to give some props to the ladies. Of course, Lady Mary Wortley, she was married to the ambassador of what is now considered Turkey. And she had lost her brother to smallpox, and she herself had also gotten it. Apparently, she had some scarring like smallpox does. And she had had her son inoculated, but her daughter was too young. And what had happened is while she was there in Turkey, she observed that the women had these huts or events where they would actually inoculate people against the smallpox. And she observed this. Apparently, she sent letters back to England about it. And then when she went back to England, she tried to push this through. And of course, because it was women in Turkey doing it, and she was a woman, it was like, you know, folk medicine. A woman. They didn't pay any attention to it. But as is normal, she got some powerful people involved. She had the Princess of Wales, whose, you know, husband was going to be the future king, involving her daughters being vaccinated or at the time inoculated. I have to keep my terms straight here. And then it caught on. And actually, the doctor that had inoculated her son in Turkey was back in England now and is one of the prominent physicians in Turkey at the time. So thanks to her, she's really the one that brought inoculation to England. I'm sure some of you heard of Cotton Mather. He was a Boston minister. And he learned about variolation from Onesimus. Onesimus was his slave that had been given to him by his congregation. And apparently, he asked him, have you had the smallpox? And he said, yes and no. Now, what did that mean? Yes, he had the smallpox because he'd been variolated in his village in West Africa. So he had the local infection, but he did not have the full disease. Well, Cotton Mather passed this idea on to Zebdiel Boylston. He's actually the first physician in the United States at the time, the colonies, to do variolation. And he actually tried it on, first on two slaves, and then he also did it on his two sons. This was not well received. The clergy felt it was divine punishment for sinners. And preventing the disease from taking its course was interfering with God's plans. The Boylston family was actually threatened, and he actually went into hiding for a time. But eventually, he did go to England. He presented his results. And apparently, the mortality rate for those who got naturally occurring disease at the time, and there were quite a number of outbreaks in Boston, was 15%. Those who had been variolated, inoculated, only had about a 2% mortality. So it did make a difference. So let's get back on the road to eradication, taking a detour through the American Revolution. Philadelphia experienced a lot of outbreaks. And as a matter of fact, it was considered endemic at the time of the Revolutionary War. About 300 just come to it in 1774 alone. The possible, it was considered a possible source. You come through Philadelphia, you get smallpox. So they felt it was a part of disseminating smallpox during the Revolutionary period. And even the delegates to the Continental Congress did not want to come to Philadelphia for the meetings. And John Hancock, who was the president at the time, ordered troops to go around Philadelphia, not to come through it. Because as Ken pointed out, you know, there was a lot of illness and disease, and they recognized the impact of this kind of thing on the troop strength. So the inoculation landscape, it's kind of, when I was looking through this, it's kind of, hmm, makes me think of what's going on or went on with COVID vaccination. The New England and the Southern colonies were antivirulators. They did not want to do it. As a matter of fact, if you attempted to do it in Charleston, South Carolina, there's a 500-pound fine for inoculating within two miles of the city. Now, to put this in perspective, 500 pounds could buy 72 horses and 107 cows back in the 1700s. So that's a lot of money to be fined if you're caught doing it. But in other locations, middle colonies, it was less restrictive. They rarely enforced quarantine. They didn't regulate it. And individuals traveled to the middle colonies to actually get inoculated. And part of this they felt because there are people always coming in, immigrants coming in from other countries who already had smallpox. They weren't apparently as concerned about the variolation. And, of course, like anything new, it was a moneymaker. Now, the cost of it was three pounds. And again, three pounds was 30 days wages for skilled tradesmen. So obviously, the poorer middle class, lower middle class really could not afford to do this. In addition to the fact that once you got it, you needed to stay away from people for 30 days, that's 30 days away from work. But the wealthy were able to be inoculated. As a matter of fact, Thomas Jefferson traveled to Philadelphia to get inoculated when he was 23 years old. And when you look at this, there's also a comparison between Abigail Adams and John Adams. When John had his done in 1864, he had to go through these purges with mercury and all sort of medics and things like that. And they did a huge cut in his arm. And he talked about a little bit, joked a little bit about what he went through. But then when his wife came through, they had a new method of doing it, which I'll talk about a little bit, where, you know, she had a small scratch and she continued to go about her business. Now, she probably should have stayed at home because she was potentially infectious. But she didn't suffer the treatment that her husband did. Now, when it comes to the British Army, they inoculated their troops. Now, of course, a lot of them already had it naturally, so they were immune. But they had a policy of inoculating the troops. The Continental Army, you know, George Washington was not in favor because of the issues of being down for 30 days or more to recover, and he just wanted to try isolation. But unfortunately, that did not continue to be successful. So on February 5th, the order was given to start inoculating the troops. And initially, they put them away in a separate area away from the front lines and the troops. But then they decided to move them a little bit closer to where the action was to do their vaccination. And William Shippen was established to put that policy and procedure together. So variolation in 1738, I mentioned it, deep cuts, emetics, purgatives, you know, mercury. And they took material from a smallpox case to use it, and then they isolated it. And then Robert Sutton in 1767 or so came up with a less demanding or more humane, you might say, shallower scratch, less dietary preparations. And then they started taking material from other people who had been inoculated rather than from someone who actually had the disease. Again, both methods, they should isolate themselves. So winding up here. Edward Jenner, everybody's heard of Edward Jenner, the English physician, father of vaccination. But he was not the first to vaccinate using cowpox. As a matter of fact, he was apprenticed to some country surgeons who had noticed that when they used the Sutton method, it failed in individuals who had been infected with cowpox. And apparently, they discussed this at their local medical society, which of course was held at a pub. But he probably heard about this from them as an apprentice. In 1796, he inoculated Phipps as his first case there. And that's where it began. The story of the dairymaid is a myth that was created by his biographer. But as again, you know, the physicians in the country area who observed this, if you didn't write it, make a paper on it, you're not going to get credit for it necessarily. Benjamin Waterhouse was the first physician in the U.S. to actually use the vaccination process. And even though Thomas Jefferson thought that the state of medicine was deplorable, he did support them doing this. And you know that Waterhouse was the founder of Harvard Medical School. So we finally get to the end of smallpox. WHO started in 59. There's some starts and fits. But they finally got it done. And the last case of smallpox was probably due to release in a lab. It was a photographer who was working on a floor above the lab that got infected. Unfortunately, she did die. But then they did declare the world free of smallpox in 1980 and stopped requiring it to be on the international vaccination paper, your yellow form. So smallpox is gone, right? Not really. Smallpox is stored in CDC in Atlanta. And it's also stored in a center in Russia. Those of you who were deployed during the, after the 9-11, you might have gotten your arm shot up with smallpox. They did continue, the military still continued to vaccinate. But then there was this big deal of, you know, smallpox found at a lab in Philadelphia. Well, it turns out it wasn't smallpox, it's vaccinia, the virus that's actually used to create the smallpox vaccine. But it isn't, you need to know that smallpox is still in a couple of labs there. So what are some lessons learned? Vaccination deniers are not new. New medical innovations can be lucrative but cost prohibitive. The social determinants of health, whether you're rich, poor, can afford it, can impact the access to healthcare. And federal support, as I can, Jefferson supporting this, is needed to help facilitate change. What has changed? The medical ethics of clinical trials must be, are improved. I mean, we're not grabbing two people, prisoners and everything off the street to do these. And vaccines don't cause the disease that they are designed to prevent, as did happen unfortunately with the smallpox inoculation. Some individuals, unfortunately, did die. So I'm going to step away and let Olga come up. And hopefully we'll have some time for questions at the end. Which one's forward? The green one? Hello. Having gone through a recent pandemic ourselves, is that really loud? I'm not happy to tell you a report that maybe we haven't come as far as we hoped since the American plague of 1793. I have nothing to disclose. This is Philadelphia, the U.S. capital from 1790 to 1800. And the largest urban center and busiest port in the U.S. In 1793, yellow fever arrived. Famous Puritan Cotton Mather described it as turning yellow and then vomiting and bleeding every way. Known today to be spread by infected mosquitoes, yellow fever was believed to originate in putrefying filth or was contagious. Some thought it had been brought on a ship of French refugees from a slave revolt in San Domingo, which is now Haiti. That it was endemic there. However it arrived, Philadelphians decided that they needed to social distance and avoid shaking hands. They covered their faces with handkerchiefs that were dipped in vinegar or smoked tobacco so they wouldn't breathe in the contaminated air. Most people, and that you can see in the bottom picture, lived within a two and a half square mile area along the Delaware River. This provided Aedes aegypti mosquitoes with water in which to breed and a closely packed population upon which to feast. While no one really knew at that time that mosquitoes caused it, somebody at the time did write, a great many increase of mosquitoes in the city, especially in rainwater tubs where there were millions of the mosquitoes fishing about in the waters with great agility. The earliest cases appeared around Water Street. It's a muddy, narrow lane right along the Delaware River and then you had to climb up steps to an embankment to get to the city. It's been described as the very air confined with stenches owing in part to the quantity of filth and dirt that has suffered to remain on the pavement. Its residents were mostly poor dock workers, sailors and recent immigrants. That also touches on your theme, Verba. August 3rd, on that Saturday a young French sailor at Richard Demme's boarding house on Water Street was ill with a fever. We don't know his name. He didn't really record all that. However, we know that he had some violent seizures and then he died of his fever. Five more people in that same boarding house and two people in a house across the street also died. But the city didn't notice yet. Summer fevers were very common. However, by mid-August, the fever had spread to the wealthier people. After treating a number of cases, some doctors decided on August 19th of the bilious remitting yellow fever. Alexander Hamilton became sick early in the epidemic as does his wife Eliza. They both left for their summer home, but they both recovered. Dolly Todd lost her husband, her infant son, her father and mother-in-law and survived and married President James Madison. Well, he wasn't president when they got married. 20,000 people or half of the population fled, including Thomas Jefferson and George Washington. And just hearing their names over and over in these different talks, it's pretty impressive how many diseases all these people actually survived at the time. It would kill about 5,000 people, which is one-tenth of the Philadelphia population. One-tenth of D.C.'s population today is 70,000 people. And for every death, it is said that 21 people were probably also infected. But at least they didn't die. Benjamin Rush, who we talked about in a previous discussion, he's a prominent 47-year-old Philadelphia physician, civic leader and signer of the Declaration of Independence. He stayed to help treat people. He wrote, dejection sits upon every countenance. Five persons died this morning and five more are expected to die tonight. As most people, they didn't understand yellow fever. His undeniably harsh treatments, bloodletting, mercurial sweating powder, I think mercury was the cure for everything back then, and forced vomiting didn't really curb the disease. And critics said it was fit for a horse. Some of the critics included Alexander Hamilton. He wrote of gentler methods that his own doctor prescribed, taking cold baths, drinking wine and brandy, and eating large amounts of quinine or Peruvian bark. Medical professionals also did not agree on the cause of the disease. Rush suggested that a large cargo of rotting coffee from San Domingo on the dock near Water Street was the origin. And I have a picture, I don't know, how does this work with the thing? Oh, there. So I have a picture right there. This is a University of Pennsylvania professor. He put 50 pounds of rotting coffee out on the street near Water Street. He asked passerbys about the stench and somebody actually said, I feel like I'm going to get yellow fever just from smelling this. Other medical professionals believed that yellow fever was infectious and obviously came from the refugees from Santo Domingo. So this disagreement grew heated and mixed in xenophobia and politics. That's sort of, you know, hasn't changed. The College of Physicians met at the American Philosophical Society's headquarters at Fifth and Walnut, and I have a picture right here that building still exists, issued a report to try to bridge the heated debate and recommended quarantining the city and cleaning the streets. To cleanse the infected air, they began lighting bonfires every night and shot off guns and cannons. And the bonfires actually probably did help to cut down on some of the mosquitoes, interestingly enough. Businesses collapsed. Stores closed. And also of interest, if you want, I have a map. Oops, wrong one. Backwards. Okay. I have a map up here. This is our hotel, and this is where Benjamin Rush lived. And Water Street was just a couple blocks in front of his house is where it all started. Benjamin Rush was an ardent abolitionist. He supported the city's black community to form their own churches as they were segregated from the white ones. However, he also knew that black people possessed a natural immunity to yellow fever. So, happy would it have been for you and much more for us had this observation been verified by our experience, wrote Richard Allen. And he's in the bottom, he's in the top picture with the stamp. He was a co-founder of the African Methodist Episcopal Church and his fellow minister and abolitionist, Absalom Jones. Black Philadelphians responded anyway. There was a call for them to help since they were thought to not succumb to the disease. However, they did wind up dying in droves. Often they were too late. And they said, we found them in various situations, some laying on the floor as bloody as if they had been dipped in it. And others laying on the bed with their clothes as if they had just come in fatigued and laid down to rest. Black men and women acted as nurses, transported the sick and buried corpses at Potter's Field which is present day Washington Square. So, there's a lot of dead bodies if you want to go digging in Washington Square. Let's see. So, within two weeks they also started succumbing to the disease, but Rushdorf believed that blacks probably suffered a lighter disease. And instead of being celebrated for their efforts, black Philadelphians were accused of profiteering. I have a publisher up here from Matthew Carey. He also served on the city's public health committee. He said that even though the black leaders did help, many of the volunteers were really plundering the houses of the sick. Jones and Allen decided to respond with their own pamphlet. And I, oops, that's easy to do Ken. And I have that one here. When the people of color had the sickness and died we were imposed upon. And we were told it was not the prevailing sickness until it became too notorious to be denied. And then we were told that, oh, a few of you died, but not many. Thus, were our services extorted at the peril of our lives. Yet, you accuse us of extorting a little money. By including eyewitness testimony along with detailed financial reports, the two ministers were actually able to force Carey to renege some of his statements. And their pamphlet was the first copyrighted pamphlet written by black authors in our nation's history. And they played a crucial role in combating one of the most serious epidemics of disease in the history of our still young nation. So during the war we were going through a lot and we still continue to have more outbreaks. The sparse and decentralized governing bodies present in Philadelphia, federal, state, and municipal didn't really address the disease. Most federal officials, including President George Washington, departed with providing no resources or directions for countering the fever. The state legislature and Governor Thomas Mifflin also didn't do very much. They refused to create a public health office or grant emergency funds, decided to adjourn and leave the city. On September 14th, so this is a month after the epidemic has been declared, the mayor of Philadelphia called a meeting that created the committee to attend to and alleviate the suffering of the afflicted with the malignant fever prevalent in the city and its vicinity. I think they liked to write things with a lot of words back then. However, it was also called the committee. So Philadelphia now relied on this committee of volunteers to furnish the medical care, bury the dead, and provide relief. As the disease raged, it was realized that a facility was needed. And that's this Bush Hill. It was a house up on this hill right here, which is about a 20-minute walk a little north of here where they had to put them. In the beginning, the dying and the dead were indiscriminately mingled together. And somebody, Matthew Carey, the same gentleman who deposed the African-Americans who helped, said that the odor and other evacuations of the sick are allowed to remain in the most offensive state imaginable. Not the smallest appearance of order or regularity existed. It was, in fact, a great human slaughterhouse where numerous victims were immolated at the altar of intemperance. So going to Bush Hill in the beginning was actually tantamount to a death sentence. The committee inspected Bush Hill also found it appalling. And then on September 16th wrote that Stephen Girard, and that's a picture here, and Peter Helm, I don't have a picture of him, volunteered. They were part of the committee. They actually volunteered to run the hospital. Stephen Girard, he was a French-born, naturalized American citizen. And he was also Philadelphia's wealthiest citizen at the time. Peter Helm was a barrel maker with no notable social or economic stature. However, Girard was convinced that yellow fever was not contagious. And he was willing to work in close contact with patients. Helm, on the other hand, expected never again to return to the city alive. Now remember, this is about a 20-minute walk from here, but it's really considered outside the city at that time. However, the two managers quickly jumped into action. They put gender-matched nurses in each patient room. They gave them a pillow, sheet, and a blanket, and also a plate, a bowl, and eating utensils. Peter Helm repaired pumps to a nearby spring and created a system so that new patients didn't mingle with the patients that were being taken out for burial. He set up an area where coffins could be made, and also converted a barn for nurses to stay. They kept very meticulous records. And usually, there was about 20 to 30 patients arriving every day. In the beginning of September, there was about 60 patients. And by the end of September, it was about 140 patients per day at the hospital. In all, they treated 800 people. Finally, by November 14th, as the colder weather arrived, there were no more patients. Many in Philadelphia were grateful to Stephen Girard for overseeing Bush Hill. And this is a 1793 engraving showing him carrying a fever patient into the stagecoach. This is also a Girard school. He founded a school for orphaned white boys, which is a whole other story in and of itself. And also, if you go in Philadelphia, there is Girard Avenue. So, there's a lot of his legacy that's still left behind in Philadelphia. Finally, in November, the president and the governor decided it was safe to return. They did have a permanent health office established. They instilled more sanitary guidelines, but they relied on volunteers for this enforcement. And then they decided that really what they needed was to create a new water system. Prior to this, residents used to get their water from springs or from public or private wells. Human waste was put in privy pits, usually in the opposite corner of the backyard. And since Philadelphia lots are narrow, for those of you who live here, the water for drinking definitely did mix with the water for disposal. However, and I just have a picture, oops, sorry. And I just have a picture here. They actually didn't put this water works in until the 1800s, but they decided to do this after this outbreak, even though it really didn't have anything to do with smallpox. But they were doing what they could. And in fact, just being able to do a little sanitation makes a big difference. And if you look at it now, it's on the Schuylkill River, just past Boathouse Row. And you can see the water works there. And we still use the water works from the 1800s. So they're doing a good job. So Philadelphians, however, failed at combating yellow fever. It returned to the city eight different times over the next two decades. Only after the Cuban epidemiologist Carlos Finlay and U.S. Army Dr. Walter Reed proved in the final decades of the 19th century that mosquitoes transmitted yellow fever, were we able to actually do anything about it. And that's my talk. I have about eight minutes, but I think we can do this. How many here were near the Bellevue Stratford Hotel in July 1976, raise hands. Not you, Howard, no. Three of us here. I was five blocks away in medical school at Jefferson when this happened. Is it moving? I have nothing to disclose. It was a previously unknown bacterium that caused Legionnaire's disease, which we now know is in a genus of bacteria that were a surprise to everyone as human pathogens. They're almost everywhere, and they can cause trouble almost anywhere. And that's what they did before 1976 and ever since. Previous outbreaks back to at least 1959 were found retrospectively, and Legionella cause ongoing occupational and environmental disease that require ongoing control. Here's a historical photo of the elegant and now infamous hotel on South Broad Street between Walnut and Locust, about four and a half blocks from us here, and five blocks from where I was living then. Jefferson University Hospital was three blocks east. The former Hahnemann University Hospital four blocks north. It looks mostly like this. Now you can go see it. French Renaissance style hotel, opened in 1904, known for its large ballrooms, hosting conventions, business events. And the next three slides I borrowed, and it looks like not everything's coming up. There it comes up. I'll keep clicking. This is from a public domain training slide set from the CDCs. The American Legion's annual state convention was July 21 to 24, look on the left, 1976, in honor of the bicentennial. And within days, a number of them came to emergency departments or distant doctor's offices. Acute onset of fever, chills, headaches, malaise, cough, and muscle aches. Worse, 18 died reportedly from pneumonia. There. From July 26 to August 1st, atypical multifocal pneumonia. Is this the pointer? Okay, I can't find the pointer. Okay, I'll just move along. On the morning of August 2nd, a nurse at the Philadelphia VA called the CDC to report cases of pneumonia among conventioneers. And by that evening, public health officials had 71 additional cases, whose numbers only grew. Epidemiology, cases by date, July and August. It's a common source epidemic pattern. Convention ended on July 24. Cases peaked 25th through the 27th when they'd gone home. Then they'd tail off. The CDC training doesn't emphasize this. And also that, look at the black boxes. Non-conventioneer cases began before the convention and trickled in afterwards. And here's an early age distribution table. I'm sorry about this dark, the darkness. It was sure better on my computer. It focused on the Bellevue, although there were other hotels and they also had cases. By then it was Legionnaire's disease. This focuses on the Bellevue as a possible source of the outbreak because it was a common factor. If you can see what's dark here, sorry. There were trends by age group, older at high risk. Eventual numbers, when you see earlier publications, the numbers are different. Eventually it was 221 cases, 34 deaths. While that went on, the lab studies. They suspected an airborne pathogen, immediately looked for the usual suspects, extensive lab testing, standard cultures, patient specimens already collected, new specimens, the environment, including for evidence of the swine flu, H1N1, whose only actual cases, there were only this many cases, depending on who you ask, four or five cases ever of that outbreak at Fort Dix nearby the previous winter. And within days, usual microbiology, virology, initial environmental surveys found nothing, nothing, and nothing. Now what? They redid it all several times. Nothing. This is a historical photo of the lobby of the Bellevue, where I had been and I've seen CDC presentations of these in bright Kodachrome color. I couldn't find that. These state flags, all 50 states, a real splash of color back then. Some cases who stayed in other hotels got sick, but case control studies showed that this lobby was related to all of them. And not only the lobby, eventually turned out, out onto Broad Street where passers-by were exposed. Initially termed Broad Street pneumonia and brought into the definition later. And for months, no causative agent. It was front page news appearing to be attack on veterans, maybe the swine flu that never happened. Some proposed toxic chemicals that also caused atypical pneumonias. That was wrong. Public discussion was often acrimonious, including among and between government and public health officials. My former supervisor in New Jersey was state epidemiologist here then. I have some inside information, if you want to ask me afterwards about who said what and what he thought of that. The hotel was devastated financially, closed a few months later. It's renovated and open again. And lovely place. Take an eight, nine-minute walk, you can go there. Finally, the breakthrough. On the left, CDC lab scientist Joseph McDade. He revisited previous specimens and cultures that, until then, he and everyone else thought were negative or dead. When they did viral cultures in eggs, what's standard is to put in antibiotics so bacteria don't overwhelm the viral culture. He omitted the antibiotics in the week between Christmas and New Year's Day and found the organism. He later identified human ehrlichiosis and he founded the journal Emerging Infectious Diseases. Quiet superstar. On the right, I looked for images of the hotel cooling towers and air conditioning unit and I couldn't find it. But the CDCs have this specimen on display in their museum in Atlanta, a jug of the contaminated chiller water from that unit that caused the outbreak. Then they tested stored samples from previous outbreaks of unknown pneumonias and found a whole bunch of them. St. Elizabeth's was a bad one. Pontiac, Michigan at the city health department for Pontiac fever. The Odd Fellows Convention at the Bellevue Stratford. Some deaths. Both at that one and in 76. No cases among hotel workers for reasons that still were, still are not known. Pre-existing exposure and low-level immunity, something like that. Briefly, I see what time it is. Legionella, gram-negative unencapsulated bacilli living in water and soil, naturally they infect protozoa. Everywhere that's wet and warm they can be, they affect our phagocytic cells as intracellular parasites. Sources vary on the number and variety of subgroups and species, but LP1 causes nearly all human disease. Exposure via aerosols or aspiration, then inhalation. Person-to-person spread probably doesn't happen or is very rare. Industrial size units cause industrial size outbreaks, but individual cases can happen, such as your own shower head. CDC, ASHRAE, ANSI all have good investigation and control guidelines. Don't do this. If that's your hot tub on the left, disgusting, you're asking for it, keep it clean, like on the right. It's reportable via the NNDSS, National Notifiable Disease Surveillance System. In the 76 outbreak, mortality was 15.4%. And if it's a nosocomial case, higher. You can read this. Two or more cases, that's an outbreak. Staying outside your home, especially in healthcare, more likely. Chronic disease, increased risk, diagnosis, standard. Okay, this is the most recent graphic I found with national data. It's a few years old, but tells a tale. Reported cases are a portion of actual infections. CDC states a true number is some range, 1.8 to 2.7, more than reported. But point is, it's persistent. It's very much out there. It's probably continuing to increase as it has all this century. I'll end with a little bit of irony. After this outbreak, in 1978, the acclaimed former editor of the New England Journal and of Harrison's Internal Medicine Textbook, Dr. Robert Petersdorf wrote in the New England Journal, in an article entitled The Doctor's Dilemma, that the field of infectious diseases was going to go away. He said that the incoming class of infectious disease fellows nationwide, over 300, wouldn't have much to do anymore, except maybe culture each other. This was after this. It was after we already had resistant TB and resistant staph, which have only gotten worse. Since then, we've had E. coli, O157H7, AIDS, MRSA, Ebola, the recurrence this month in Equatorial Guinea of Marburg. There's plenty to do. Okay, we're down to no minutes. But should we take an urgent question? Okay. We'll hang out here. We are out of time. So thank you all for your attention. And see us now, as you wish, and enjoy the rest of your conference. Thank you very much. Thank you very much. Thank you very much. Thank you very much.

occupational health

Ken Lankin

Verba Moore

EHRS medical specialist

NASA

Dr. Olga Gushov

occupational medicine

Dr. Curtis Cummings

review officer

public health