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Mapping Epidemic Diseases

1 in Britain
1.1 Introduction 2

1.2 The Nature of Diseases 2


Disease Recording: General Considerations 2
Disease Recording: British Practice 3
Role of the Office of the Registrar General 5
Changing Geographical Frameworks 5
Data Quality 6
The Public Health Impact of Infectious
Diseases 6
Data Standardisation 8

1.3 The Nature of Epidemics 9


Dening Epidemics 9
Epidemics in World History 9
Shape of Epidemics 9

1.4 Mapping Epidemic Diseases 11


The Nineteenth Century 11
Twentieth Century Mapping 12
Later Maps and Atlases 12
New Developments in Disease Mapping 12

1.5 Atlas Organisation 13


Geographical Parameters of the Study 13
Layout of the Atlas 13
Range of Diseases 14

1.6 Conclusion 14

Figure 1.1 Disease mapping. From the earliest days of the League of Nations Health Committee, which rst met in August
1921, mapping and charting of disease was central. In the very rst issue of Epidemiological Intelligence ( January 13, 1922) the
Introductory Note states the most convenient method of producing charts and maps will be determined by the nature of the
data that may be at the disposal of the Health Section in the future. Figure 1.1 shows part of the Introductory Note stressing
one of the main functions of the Health Committee was effective international exchange of intelligence on epidemic diseases,
part of the contents list of the rst issue, a proportional symbol map of the distribution of dysentery in Eastern Europe and a
choropleth map of smallpox in Europe. Sources: Epidemiological Intelligence, 1, 1922, pp. 3, 5, between pp. 367 (Introductory
Note, contents lists, dysentery); Epidemiological Intelligence, 7, 1923, p. 36 (smallpox).
ATLAS OF EPIDEMIC BRITAIN

fever, diphtheria and whooping cough which eases? What data standardisation issues do we face?

1.1 Introduction retreated but which did not vanish. What role may be played by new and evolving tech-
But the twentieth century decline of epidemic dis- nologies like Geographical Information Systems
eases in Britain was not regular, smooth or uninter- (GIS) and the power of Google EarthTM? The chapter
rupted. So measles, having been on the wane since is concluded by outlining the structure and under-
the 1840s, reasserted its dominance as a leading pinning rationale for the substantive chapters which
A nondescript express in from the South, cause of childhood mortality in England and Wales follow in the remainder of the Atlas.
Crowds round the ticket barrier, a face during the early years of the twentieth century before
To welcome which the mayor has not contrived almost disappearing under the onslaught of mass
Bugles or braid: something about the mouth vaccination from the 1960s only to re-emerge as a
Distracts the stray look with alarm and pity. significant public health threat at the millennium.
Snow is falling. Clutching a little case, For poliomyelitis, there is a similar story. For parents,
He walks out briskly to infect a city
Whose terrible future may have just arrived.
W.H. Auden Gare du Midi (1938)
few infections have scored higher than poliomyelitis
on the dread factor. From the 1920s, poliomyelitis
emerged from the epidemiological background in a
succession of global waves of infection, each of which
1.2 The Nature of
Diseases

Just over a century has passed since the publication outdid its predecessor in the number of children it The term disease literally means dis-ease, the
of Charles Creightons monumental A History of Epi- crippled and killed in Britain. However, from the absence of ease, the opposite of good health.
demics in Britain (Figure 1.2) which provides a singu- 1950s, this picture abruptly changed when preventive Couched in these terms, it is a biomedical defin-
lar account of the history and geography of epidemic vaccines were developed which, by 2000, had ition applied to any sickness, ailment or departure
diseases in the British Isles from Anglo-Saxon times brought the disease to the edge of worldwide eradi- from sound health. Most often it is applied to a spe-
until the end of the nineteenth century epidemics cation. What causes diseases to wax and wane in cific disorder of a specified part of the body ( for
generally caused by what are known as infectious time and space in this fashion is a theme of contem- example, the gall bladder) or to a disorder caused
diseases. In the century which followed the conclu- porary scientific interest. by a specific agent ( for example, the tuberculosis
sion of Creightons account, the epidemic profile of The common belief that infectious diseases had bacillus). Some diseases may be due to external
Britain changed dramatically, and it is the purpose of been defeated by a combination of vaccination, diet causes: physical injury ( for example, trauma),
this Atlas to characterise and illustrate these and general improvements in medical care proved chemical injury ( for example, poisons), or microbi-
changes. In the first half of the century, a gamut of unfounded as the generalised retreat of many epi- ological injury ( for example, by viruses). Others
social, biological, medical and environmental devel- demic diseases in Britain in the first half of the twen- may have internal causes: genetic diseases ( for
opments contributed to the wholesale retreat of tieth century was replaced in the second both by a example, congenital anomalies), developmental
many of the epidemic infections that figured large in resurgence of some familiar foes and by the emer- fatigue ( for example, cardiac arrest), or neoplasms
Creightons History. Such were the changes that, by gence of wholly new agents. The former included ( for example, cancers).
the 1950s, some writers believed the war against vaccine-preventable infections like measles and The absence of health has always been easier to
these epidemics had been won. At mid-century, tuberculosis, both of which re-emerged as serious define than its presence. While a biomedical model
Thomson (1955, p. 106) could report that mortality public health threats. The newly-recognised condi- of health defines diseases in terms of departures of
from the leading infectious diseases was but a tithe tions were sometimes associated with the expansion measurable biological variables from the norm, the
of what it was in Creightons time. Likewise, Stocks of international travel ( for example, new strains of World Health Organizations Charter (World Health
(1950, p. 56) pointed to the extraordinary reduction influenza virus), sometimes with lifestyle changes Organization, 1979) proposes a wider definition of
in infectious disease mortality in the first half of the (HIV/AIDS), sometimes with technical changes health: health is a state of complete physical, social
century decades which witnessed the last signifi- (Legionnaires disease, E. coli, vCJD), and sometimes and mental well-being, and not merely the absence
cant British epidemics of human plague and small- with developments in healthcare provision ( for of disease and infirmity. We shall see the impact of
pox and the disappearance by 1948 of indigenous example, hospital-acquired MRSA and C. difficile). this broader definition manifested later in this sec-
malaria. To this list may be added measles, scarlet It is the mapping and interpretation of the com- tion when we discuss measurement of the public
plex timespace tapestry woven by the uneven health impact of diseases.
retreat of some infectious diseases, the emergence of In this Atlas we have chosen to map just those dis-
new infections and the re-emergence of certain his- eases which are broadly termed infectious diseases
torical plagues in twentieth century Britain which and which, to a lesser or greater extent, have caused
forms the subject matter of this Atlas. It updates outbreaks and epidemics in Britain. All are produced
Creightons magisterial legacy and establishes a twen- by the interactions between micro-organisms such
tieth century benchmark against which the ongoing as bacteria and viruses and the human population,
history of British epidemics can be set. Our aim is to and it is these interactions which produce the mor-
explore the geographical dynamics of these develop- bidity (disease cases) and mortality (disease deaths)
ments through the careful selection of diseases which in space and time upon which this Atlas is founded.
can either be analysed statistically over a century-
long span or which can be mapped in specific geo-
graphical settings. But Britains epidemiological Disease Recording: General
geography has not occurred in spatial isolation. As
Audens poem implies, across geographical areas and
Considerations
Figure 1.2 Charles Creighton (18471927) and A History generations, infectious diseases have been spread by The interactions between the invading agent and the
of Epidemics in Britain. (Left) Charles Creighton, M.D. movement. And so, as well as analysing the British host (the human body) are complex. Figure 1.3 shows
(Right) Title page of volume I of Creightons two-volume
scene, we nest our findings in European and global Evanss (1984) iceberg concept of disease in which
History which covers the history and geography of epidemic
diseases in the British Isles from AD 664 to the end of the contexts to highlight the congruences and the differ- clinical illness forms the upper part of the triangle
nineteenth century. Described in The Lancet (Anonymous, ences between the British epidemiological experi- and death its vertex. Assault by a particular disease-
1894, p. 1543) as a great work great in conception, in ence and that of other countries. causing organism may cause mild symptoms, severe
learning, in industry, in philosophic insight, Creightons Paralleling Chapter 1 in Cliff, et al. (2004), to frame symptoms, or even death. All three states are above
History provides an account of epidemics caused by
the chapters which follow, we begin here by defining the plimsoll line in the sense that they are felt by the
infectious diseases. Creightons subtitle refers to the
eradication of plague but in fact the last enzootic outbreak terms and concepts. What do we mean by a disease patient. Equally the microbiological assault may be
occurred 191018 in East Suffolk (see Section 3.3). Source: and an epidemic? How do we measure and record unnoticed by the human victim (below the plimsoll
(Left) Wellcome Library, London. sickness in Britain? How do we map epidemic dis- line or sub-clinical) and go either unnoticed or be

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CHAPTER 1

Mapping Epidemic Diseases in Britain

Figure 1.3 Iceberg concept of infectious disease. For


many diseases, clinically-apparent illness (above the double
horizontal plimsoll or water line and occupying the upper
part of the triangle) represents only a small proportion of the
hosts response patterns. Unrecognised and inapparent
infections (pecked part of the triangle) are a much larger
part. Responses at the level of the cell (left) and host (right)
are shown. Source: Evans (1984, Figure 2, p. 20).

picked up only in some serological or other study. It


is only the cases above the water line which are likely
to be recorded and thus be mappable. For example,
in poliomyelitis a large proportion of the invasions Figure 1.4 Collecting epidemic records. The sequence of events whereby a clinically-apparent disease event in an individual
(primary level data collection) is eventually recorded in official statistics up to the global level. Routine reactive data collection
are below the water line with the poliovirus only
(left) occurs when a patient presents to a doctor or in hospital and is recorded as a case of some disease. Proactive data
rarely causing the classical symptoms of paralysis. In collection (right) occurs with special surveys or events to investigate a particular health issue. After primary data collection has
measles, severe above-the-line effects are a usual occurred, data make their way into secondary sources like official statistics up to the international level. Source: Cliff, et al.
consequence. (2004, Figure 1.5, p. 4).
The existence of a disease is a necessary but not
sufficient condition for its recording and therefore formally in Chicago in 1893 with the adoption by the ( for example, Sweden) predated England and
mappability. The first requirement is that someone International Statistical Institute of the Bertillon Wales, the majority lagged by several decades.
registers the event. Figure 1.4 shows the reporting Classification of Causes of Death. In 1898, the Ameri- Scotland commenced vital registration from 1854
routes whereby disease mortality and morbidity can Public Health Association recommended the (Registration of Births, Deaths and Marriages
finds its way from the patient level (primary data adoption of the Bertillon classification by the civil (Scotland) Act) and Ireland from 1947. Forms are
collection) via secondary reporting to national (e.g. registrars of Canada, Mexico and the United States, provided for the purpose. Figure 1.6 gives some
in Britain, the Registrar General) to international adding that the classification be revised every 10 representative examples of those used at the pri-
recording agencies like the World Health Organiza- years. The subsequent history of the classification in mary level in Britain during the twentieth century.
tion (WHO). this century, now in its tenth revision, and its adop- Because of its finality, every effort is made to cap-
tion by the Health Organization of the League of ture all deaths and their cause(s).
Standardising Disease Recognition Nations and eventually by the World Health Organi-
The second requirement for consistent mappability is zation is described at length by Israel (1990). The
an agreed clinical definition for each disease. Disease twentieth-century development of the list is illus-
records for the past are often hard to match up with trated in Figure 1.5. MORBIDITY
the specific diseases of today. Nonetheless, the pre-
Mortality recording in Britain predated morbidity by
cise classification of disease has been developing for
several decades. From 1832, however, the great epi-
over three centuries. In Britain, its roots lie in the sta-
tistical study of disease begun in the seventeenth cen-
Disease Recording: British Practice demics of cholera which swirled around the world
fuelled the public health movements in Europe. In
tury with John Graunts analyses of the London Bills of Useful mappability is only generally possible if the Britain, various Acts of Parliament provided powers
Mortality. It continued in the eighteenth century with records of deaths and/or morbidity from a disease aimed at preventing the spread of epidemic, endemic
works by Francis de Lacroix, William Cullen, and the are collected on a sustained, systematic and timely or contagious diseases, culminating in the Public
father of biological classification systems, Linneaus. basis. In this way a picture of temporal and spatial Health Act of 1875. Then, in 1889, provision was made
With the start of the General Register Office of variations in disease patterns can be produced which enabling any urban, rural or port sanitary district to
England and Wales in 1837, attention was focussed on is not possible with one-off recording. Knowledge of make certain infectious diseases notifiable (Infec-
the improvement of disease classifications and on such temporal and spatial variations may in turn tious Diseases Notification Act), although records for
the promotion of international uniformity in their lead to insights into the underlying processes which a few urban areas are available for some decades ear-
use. Israel (1990) has traced the history of the inter- cause the variations. lier. These powers were made mandatory in London
national classification of diseases from that point.
in 1891 and throughout the remainder of England and
The international importance of a statistical classifi-
MORTALITY Wales in 1899. The details for Scotland which began
cation of diseases was so strongly recognised at the
notification in 1887 are broadly similar to England
first International Statistical Congress held in Brus- In England and Wales, registration of deaths dates
and Wales (Ashley, et al., 1991), and those for Ireland
sels in 1853 that the participants assigned to Britains back to 1538 in the reign of Henry VIII when the
are given in Hensey (1979). The reason for making cer-
William Farr in the Office of the Registrar General clergy in every parish were required to keep a
tain infectious diseases notifiable for forecasting
and to Marc dEspine of Geneva the task of preparing record of these events (Benjamin, 1968, p. 43).
and control was incisively summarised at the time
a uniform nomenclature of causes of death applica- Except for a brief period from 1653 to the Restora-
by Tatham (1888, p. 403):
ble to all countries (Israel, 1990, p.43). A compro- tion, Henry VIIIs requirement did not become
mise list of 138 rubrics was agreed at the next Paris statutory until the passage of the Births and Deaths Again and again we have had to complain of the
Congress in 1855. Registration Act, 1836, so that vital registration of importation of infection into Salford [England]
Much revised at subsequent meetings, the Farr- births, marriages and deaths began from 1837. from non-notification outside districts imme-
dEspine list formed a basis for the present Interna- From then on deaths by cause can be tracked at the diately contiguous to our boundaries . . . [E]ven
tional Classification of Diseases (ICD) which began registration district level. While a few countries between towns which possess powers for the

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ATLAS OF EPIDEMIC BRITAIN

Figure 1.5 International Classication of Diseases. (Upper)


Title page from the rst issue of the International
Classication of Diseases, 19013. (A) Decade of discovery
of principal infectious disease agents by taxonomic
division of agents. The switch from bacterial to viral agents
as the twentieth century progressed is evident. (B) Number
of infectious diseases of humans recorded in the A and B
lists of ICD1 to ICD10. The International Classication of
Diseases (ICD) is the standard diagnostic classication for
all general epidemiological and many health management
purposes. It is used to classify diseases and other health
problems recorded on health and vital records including
death certicates and hospital records. The idea of such a
classication is to ensure comparability of data recording
over space and time, thus facilitating the storage and
retrieval of diagnostic information for clinical and
epidemiological purposes. These records also provide the
basis for the compilation of national mortality and
morbidity statistics by country-level surveillance
organisations. The list has gone through 10 versions since
the rst. The latest classication, ICD-10, came into use in
WHO member states from 1994; see http://www.who.int/
classications/icd/en/ for a history. The number of diseases
listed remained around 100 for the rst 65 years of ICDs
existence. In the Ninth and Tenth editions, however, the
number rose sharply from around 350 (Ninth) to over
1,000 (Tenth).

compulsory notification of infectious disease, and the Public Health (Infectious Diseases) Regula- the patient, forthwith send to the proper officer
there exists at present no organization by which tions 1988) states: of the local authority (generally the local Medi-
one sanitary authority may receive timely warn- cal Officer of Health) for that district a certifi-
ing of the presence of infectious disease in the If a registered medical practitioner becomes cate stating:
district of a neighbouring authority. aware, or suspects, that a person whom [s]he is
attending within the district of a local authority a. the name, age and sex of the patient and the
Figure 1.7 shows the dates from which certain infec- is suffering from a notifiable disease or from address of the premises where the patient is;
tious diseases became notifiable in England and food poisoning, [s]he shall, unless [s]he believes, b. the disease or, as the case may be, particu-
Wales and in Ireland. and has reasonable grounds for believing, that lars of the poisoning from which the patient
The present situation. The current law (Section 11(1) some other registered medical practitioner has is, or is suspected to be, suffering and the
of the Public Health (Control of Disease) Act 1984 complied with this sub-section with respect to date, or approximate date, of its onset, and

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Mapping Epidemic Diseases in Britain

Figure 1.6 Registration of deaths in Britain. Sample


forms used at the primary level to record mortality in
England and Wales during the twentieth century. The
upper forms from the 1920s and 1950s show how death by
cause was recorded for return to the Registrar General. The
main and contributory causes as identied in the ICD are
certied. Where insufficient or inaccurate information was
returned, clarication was sought by the Registrar General
(centre left). Accuracy of mortality returns has been a
priority and investigations have been undertaken to assess
this (centre middle). Another potential source of error arises
from the fact that registration often initially occurred in the
district of death rather than of residence. Until recently,
attempts were made to reallocate these to place of
residence (bottom right, upper) so that consistent recording
by residence was the norm throughout much of the
twentieth century. Other deaths could escape the
registration system (e.g. coroners courts and onboard
ships), and attempts were made to capture these (lower left
and right). In the case of ships, a minute was recorded in
the ships log prior to registration. Source: World Health
Organization Library archives.

c. if the premises are a hospital, the day on which Register Office (GRO). The GRO became the Office of for whooping cough to effectively complete for polio-
the patient was admitted, the address of the Population Censuses and Surveys (OPCS) in 1970. myelitis (Benjamin, 1968, p. 171). There have also been
premises from which [s]he came there and Forms on which to make the returns are provided secular changes in reporting completeness. For
whether or not, in the opinion of the person each November by OPCS to the proper officer of each example, in the case of measles, detailed clinical stud-
giving the certificate, the disease or poisoning local authority with instructions for their comple- ies suggest that this disease was generally under-
from which the patient is, or is suspected to tion during the following year (Figure 1.8). All notifi- recorded in the United Kingdom in the pre-vaccination
be, suffering was contracted in hospital. able diseases are reported on these forms with the period prior to 1965, so that reported cases would
exception of leprosy which is reported direct to the need to be multiplied by a correction factor of
Communicable Disease Surveillance Centre (now between 1.5 and 2.0 to give a more realistic estimate of
Role of the Office of the part of the Health Protection Agency) at Colindale. the number of cases. In recent decades, the recording
For much of the twentieth century, the primary of some common diseases has been downgraded as
Registrar General data were amalgamated into (reporting district their incidence and their perceived public health sig-
As Figure 1.4 shows, once the primary data on mor- date disease) format for publication. It is these nificance threat has fallen. In some countries, includ-
tality and morbidity have been recorded, they find aggregated data which form the bedrock of the anal- ing Britain, simple comprehensive secondary-level
their way into the public domain through a variety of yses described in this Atlas. The twentieth-century disease reporting has moved from statutory notifica-
channels. In twentieth-century Britain, this second- publications include the Registrar Generals Weekly tion of all recognised cases to one off sampling and
ary dissemination has been chiefly the responsibility (Quarterly/Annual) Return and their successor publi- surveillance using devices such as sentinel medical
of the Office of the Registrar General. Since the 1920s, cations (e.g. Communicable Disease Report Weekly practices. We discuss work in this area in Section 10.5.
reports of notifications (mortality and morbidity) since 1991) towards the close of the millennium.
have been sent by Registrars of Births, Marriages and Figure 1.9 illustrates some publications.
Deaths, Medical Officers of Health and, more Variations in the relative ease of clinical identifica-
Changing Geographical Frameworks
recently, by proper officers (usually the Medical tion and attack rates mean that the completeness of
Officer for Environmental Health or the Consultant statistical reporting has differed considerably from Even where records are kept, a further mapping
in Communicable Disease Control) to the General disease to disease, ranging from lows of around 20% problem is the changing infrastructure of local

5
ATLAS OF EPIDEMIC BRITAIN

Figure 1.7 Recording of morbidity. Dates on which


recording of morbidity from notiable infectious diseases
became compulsory in parts of the British Isles. Subject to
national approval, local authorities had the power to extend
the list either temporarily or permanently to cover local
situations. Sources: compiled from data in Hensey (1973, pp.
1879) and McCormick (1993).

boundary areas. Figure 1.10 shows a 90-year cal units created artificially from existing adminis- analyses which we describe in this Atlas are
sequence of maps of county level boundary changes trative units. founded upon this philosophy.
in part of eastern England. The traditional county
boundaries of 1912 were reshaped over time to
reflect population growth, a drift of people from
Data Quality The Public Health Impact of
country to towns and political aspirations. Some old The preceding discussion makes clear the fact that Infectious Diseases
urban areas were split (as their populations grew) disease data in Britain are subject to the same limi- The impact of disease on the British population can
and some old rural areas were amalgamated (as tations of patchy recording, missing and inaccu- be assessed in several ways and we look here at three
their populations dwindled). The fishing net by rate observations, misdiagnosis and arbitrary such measures.
which diseases are caught and recorded is rarely sta- collection units as any other of the worlds coun-
ble, posing a continuing puzzle for map makers tries. Notwithstanding the caveats, however, Brit-
MORTALITY
wishing to show local changes over time in a con- ish data remain among the best and most reliable
sistent manner. The mesh of units can be made con- internationally, and to argue that data deficiencies Death is, of course, the ultimate indicator of the
sistent by aggregating to the finest common make analysis inappropriate is a counsel of despair. importance of a disease. But even in Britain, death
framework, but this then requires heroic assump- Instead we need to be aware of the limitations of certificates give only a partial view of the cause of
tions to be made about how to allocate disease data our data, the effect errors can have upon any analy- death despite the recording of primary and contrib-
collected for one framework to a different grid. sis, and wherever possible follow the approach utory causes. Nonetheless they represent the best
Unless otherwise stated, in this Atlas we have used which we have adopted in this Atlas to use robust evidence we have and, as we have seen in Figure 1.6,
the geographical grids in force at the time and have mapping and statistical methods which are com- the Registrar General goes to great lengths to collect
avoided reapportioning disease data to geographi- paratively unaffected by variable data. All of the and codify these data. Figure 1.11 uses a stacked bar

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Mapping Epidemic Diseases in Britain

Figure 1.8 Secondary recording of mortality and


morbidity in the United Kingdom in the twentieth
century. Sample forms for the United Kingdom to record
morbidity and mortality from notiable diseases. Separate
forms are used for the so-called Great Towns as opposed to
boroughs and urban and rural districts. Source: World Health
Organization Library archives.

chart to show the percentage of total deaths MORBIDITY they first contracted the disease (the disease preva-
recorded in England and Wales by ICD chapter at lence). Data availability means that, unless otherwise
Another way of measuring the disease burden is in stated, morbidity is plotted as incidence.
the beginning (1911) and end (1994) of the twentieth
terms of illness (morbidity) rather than death. As
century. At the opening of our time window, the
survival from epidemic diseases improved over the
infectious diseases capable of causing epidemics WEIGHTED MEASURES OF
century, morbidity trends often showed dramatic
(typhus, typhoid and paratyphoid, smallpox, mea-
differences from mortality. Accordingly, wherever MORTALITY AND MORBIDITY
sles, scarlet fever, diphtheria, whooping cough,
possible in this Atlas, when we show time trends for Although counting deaths or cases from a particu-
influenza, cholera, dysentery, tuberculosis and
specific diseases both mortality and morbidity lar cause in a particular year might seem a simple
syphilis) contributed 25% of the burden of mortality
curves are plotted. Morbidity can be measured in dif- and unambiguous way of measuring the burden of
across all age groups. By the millennium, these had
ferent ways. We can (a) count the total number of disease, it avoids a central question. Are all deaths/
fallen to less than 1%, being replaced by cancers
new cases of a particular disease each year or during cases equal? Although this may depend upon your
(26%) and diseases of the circulatory system (44%)
some other interval of time (the disease incidence). religious viewpoint, the theological view might be
as the leading causes of death. Describing and
Or (b) we can count the total people who continue to exactly that all lives and therefore all deaths are
accounting for this massive change is part of the
suffer with a particular disease, regardless of when indeed equal. Let us think about this a little more.
purpose of this Atlas.

7
ATLAS OF EPIDEMIC BRITAIN

This takes into account the year at which a death


occurs as compared with their life expectancy at, say,
birth, as given in the life tables published by most
national population agencies. If an individual dies
before their normal life expectancy, the difference
between date of death and life expectancy in years
represents one measure of YPLL. More complicated
versions of this simple model exist because life
expectancy itself changes with age. Thus, in England
in 2000, a 20-year old male could expect on average
to live for another 55 years (60 for a female) whereas
an 80-year old male could expect to live on average
for another seven years. So under YPLL, the two
deaths would be weighted differently, the younger
death having a weight much higher than the older.
Figure 1.12 shows the years of potential life lost at the
county level in the British Isles from infectious and
parasitic diseases at the millennium.
The effect of measures of this kind is to change the
order of some leading causes of death, all tending to
give greater weight to the infectious diseases (which
especially affect children) and to injuries (which
especially affect young people); where these condi-
tions cause mortality, it is most commonly in the first
two decades of life. YPLL also reduces the relative
importance of heart disease and cancers (which tend
to affect the old). With illness and disability, similar
arguments may be used, giving special weight to dis-
eases which cause a lifetime of disability (so-called
disability-adjusted life years, DALY) rather than a
brief illness. An introduction to the problem is given
in Murray, et al. (2002). Yet other weighting systems
attempt to weight morbidity data by quality of life
measures. But the difficulty with all these approaches
is defining unambiguous and generally accepted sets
of weights.

Data Standardisation
While crude mortality/morbidity rates give a pic-
ture of the geographical pattern of disease in areas
of a country, that picture can be distorted by local
variations in the age/sex composition of the popu-
lation. For example, if a town has a particularly
young population hypothetically say 23 percent
are younger than 15 years and 12 percent are 65
years or older then the crude death rate will be
low and we may also expect the mix of diseases to
be those which affect younger people. On the other
hand, if we take an area with an old population (say
a retirement town), we may expect the crude rates
of death to be much higher and the mix of diseases
Figure 1.9 Secondary reporting of morbidity and mortality by the Office of the Registrar General in twentieth- to be skewed towards those of old age. This intro-
century Britain. The core publications for most of the century are the Registrar Generals Weekly/Quarterly/Annual Return for duces the idea that we need to standardise the data
England and Wales, Scotland and Northern Ireland. Following government reorganisation, these were replaced from 1991 by
in some way, producing standardised mortality/
Communicable Disease Report/Review. In addition to the regular statistical reporting, the results of special surveys and other
health matters of public interest are also published. morbidity ratios (SMRs), to reflect the demographic
composition of the local area if we are going to
make valid inter-area comparisons. Figure 1.13 is a
county-level age standardised map of mortality
We all have to die at some time, and while the simplification and leaves many moral questions among males from infectious and parasitic diseases
death of a child might be seen as a tragedy, that of unanswered. in the British Isles at the millennium. The standard
someone who is very old and perhaps very sick European population (basically the average for
might sometimes be seen as a blessing. In other Years of potential life lost (YPLL) and disability- Europe) has been used as the benchmark. Fre-
words, an argument exists that deaths of the young adjusted life years (DALY) quently, the comparison with the standard popula-
may cut off more potential years of living than For mortality, agencies such as the World Health tion is expressed as a ratio of local:standard
deaths of the old. Or, for morbidity, that some dis- Organization and the US Centers for Disease Control population (sometimes multiplied by 100 to obtain
eases degrade life quality for longer and more and Prevention have been experimenting with statis- a percentage). See Benjamin (1968, pp. 925) for
severely than other diseases. Clearly this is a huge tics which measure years of potential life lost (YPLL). computational details.

8
CHAPTER 1

Mapping Epidemic Diseases in Britain

ify a disease present under similar conditions in a


1912 1949 non-human animal community.
In the sixteenth edition of the standard handbook
of human communicable diseases, Control of Com-
municable Disease Manual, Benenson (1995, p. 535)
defines an epidemic more fully as:

The occurrence in a community or region of


cases of an illness (or an outbreak) clearly in
excess of expectancy. The number of cases indi-
cating presence of an epidemic will vary accord-
ing to the infectious agent, size and type of
population exposed, previous experience or
lack of exposure to the diseases, and time and
place of occurrence; epidemicity is thus relative
to usual frequency of disease in the same area,
among the specified population, at the same
season of the year.

Benensons account goes on to stress that what con-


stitutes an epidemic does not necessarily depend on
large numbers of cases or deaths. A single case of a
communicable disease long absent from a popula-
tion, or the first invasion by a disease not previously
recognised in that area, require immediate reporting
1974 1999 and epidemiological investigation. Two cases of such
a disease associated in time and place are taken to be
sufficient evidence of transmission for an epidemic
to be declared.
Epidemics of communicable disease are of two
main types. A propagated epidemic is one that results
from the chain transmission of some infectious agent.
This may be directly from person to person as in a
measles outbreak, or indirectly via some intermedi-
ate vector (malaria) or a microparasite. In some
cases, indirect transmission may occur via humans
(as in louse-borne epidemic typhus fever, or in a mos-
quitomanmosquito chain with malaria). In others,
the survival of the parasite is independent of man
(thus Yersinia pestis, the cause of plague is continually
propagated through rodents and the infection of man
by an infected flea is in this respect a sideshow).
The second type of epidemic is a common vehicle
epidemic which results from the dissemination of a
causative agent. In this case, the epidemic may result
from a group of people being infected from a com-
mon medium (typically water, milk or food) which
has been contaminated by a disease-causing organ-
Figure 1.10 Instability in spatial records of disease. Changes in the boundaries of counties in part of eastern England in the
twentieth century. Base maps of counties are given at the dates of major revisions to county boundaries. Red lines give
ism. Examples are provided by cholera and typhoid.
boundaries. Boundary changes occur over time by the splitting and amalgamating of districts in response to population
changes. See, for example, the changes made to Yorkshire, Leicestershire and Rutland over the century. The numbered units on
the 1999 map correspond to unitary authorities created on Teesside (Cleveland), in South Yorkshire and the West Midlands.
Epidemics in World History
the Hippocratic corpus, but the section concerned Epic events like the Black Death or the 191819
Spanish influenza pandemic are extreme examples

1.3 The Nature of was mainly a day-to-day account of certain patients


and not an application of the word in its modern from the tens of thousands of historically-recorded
Epidemics sense. In addition to its wider usage in terms of disease outbreaks to which the term epidemic can
public attitudes ( for example, Burkes epidemick of properly be applied. Many are discussed in Cliff, et al.
despair), the word has been used in the English (2009, pp. 45105). For Britain, the standard source
In the title of this Atlas we use the term epidemic language in a medical sense since at least 1603 to prior to the twentieth century is Creightons two-
diseases. We need now to look more closely at this mean an unusually high incidence of a disease as volume A History of Epidemics in Britain (18914).
term and give it greater precision. compared with previous experience, where unusu-
ally high is fixed in time, in space and in the per-
sons afflicted.
Dening Epidemics Shape of Epidemics
Thus the Oxford English Dictionary defines an
What exactly are epidemics? Th e term epidemic epidemic as: a disease prevalent among a people or In a human population, the way in which epidemics
comes from two Greek words: demos meaning community at a special time, and produced by some of infectious diseases occur and are propagated in
people and epi meaning upon or close to. It was special causes generally not present in the affected waves through time and over space is discussed in
used around 500 BC as a title for one major part of locality. The parallel term, epizootic, is used to spec- Cliff, et al. (2004, pp. 811) and is illustrated here in

9
ATLAS OF EPIDEMIC BRITAIN

Figure 1.13 Age-standardised mortality from infectious


and parasitic diseases at the county scale in the British
Isles at the millennium. Although the total burden of
deaths from infectious and parasitic disease was small in the
British Isles at the millennium, as with YPLL in Figure 1.12,
Figure 1.11 Causes of death in England and Wales, 1911 and 1994. The percentage of deaths by ICD chapter at the the map shows especially high rates in Scotland and the
opening and close of the twentieth century. The ordering of key colours corresponds with the bars. Source: constructed London area. The European average by age and sex has been
from data in Charlton and Murphy (1997, Volume 1, Table 4.4, p. 44). Charlton and Murphy s two-volume book, The used as the standard population. Source: redrawn from
Health of Adult Britain 18411994, is an invaluable source of information on recording and trends, primarily from Eurostat Statistical Books (2009, part of Figure 6.1, p. 44).
mortality data.

Figure 1.14. The disease is passed from infected indi-


viduals (infectives) to those at risk (susceptibles). At
the start of an epidemic, the number of infectives is
generally small and the number of susceptibles large;
this balance between infectives and susceptibles
Figure 1.12 Years of potential life lost (YPLL) from reverses over the course of the epidemic. Thus cases
infectious and parasitic diseases in the British Isles at build up over time to a peak. Beyond the peak, the
the millennium. Although the total burden of deaths from number of newly reported cases steadily falls and
infectious and parasitic diseases was small in the British
eventually the epidemic wave passes. This produces
Isles at the millennium, the map shows the greatest
potential losses were in Scotland and the London area. a bell-shaped (usually) single mode curve when cases
The conurbations in South and West Yorkshire, Greater (vertical axis) are plotted against time (horizontal
Manchester, and in the West Midlands also experienced axis) on a graph. The precise shape whether the
comparatively high risks of premature mortality from these build up in cases to the peak is faster/slower than the
diseases as did the Welsh Marches. See Figure 1.10 for
fade out depends upon the size of the input compo-
names. The YPLL is estimated against an age of death of 65.
Source: redrawn from Eurostat Statistical Books (2009, part nent (number of infected people, and the number at
of Figure 6.3, p. 46). risk (susceptible) at the start of the epidemic), and a
third, output, component (rate of recovery from the
disease).
The relationship between the input and output
components has been studied by Kendall (1957). We
can summarise the magnitude of the input compo-
nent by looking at the rate at which new cases are
generated by contact between infected and suscepti-
ble people. We can call this rate a diffusion coeffi-
cient, b. The output or rate of recovery is symbolised
by a recovery coefficient, c. The ratio, c/b defines a
threshold (given by the Greek letter rho, ) in terms
of population size (the critical community size). For
example where c is 0.5 and b is 0.0001, then would
be estimated as 5000.
Figure 1.14A shows a sequence of outbreaks in a
community where the threshold () has a constant

10
CHAPTER 1

Mapping Epidemic Diseases in Britain

Figure 1.15 Changes in the shape of epidemic waves


with distance from the origin of an epidemic, here
hypothesised to be in Essex, East Anglia. Generalised
wave model set within time and space dimensions showing
the shape of the epidemic wave at locations 1, 2 and 3.
Source: Cliff, et al. (2004, Figure 1.13, p. 10).

Figure 1.14 Shape of epidemic waves in time. Kendalls (1957) model of the relationship between the shape of an epidemic
wave and the susceptible population/threshold ratio, S/. (A) Growth of a susceptible population over time showing the effect
of infections introduced into the susceptible population at the black arrows. (B) Three typical Kendall waves for times t1, t2 and
t3 in (A). Source: based on Cliff, et al. (2004, Figure 1.12, p. 10).
1.4 Mapping
Epidemic Diseases

The idea of mapping epidemic diseases in Britain is


value, and it is therefore plotted as a horizontal ulation has grown well above the threshold value as not new and so, in this section, we look back at some
pecked line. Given a constant demographic birth at t3. The resulting epidemic wave is strongly skewed of the predecessors of this Atlas. The approach is
rate, the susceptible population increases and is towards the start, and it is extremely peaked with broadly chronological. For a fuller account, see Cliff,
charted as a diagonal purple line rising over time. many cases concentrated into the modal period. In et al. (2004, pp. 1115) upon which this section is
Three examples of infection introductions are contrast, at time t1, the susceptible population is based.
shown (lower unlabelled black arrows). In the first only slightly above the threshold value. If an out-
two, the susceptible population, S, is smaller than break occurs in this zone, Waveform III will result;
the threshold (S < ) and there are a few secondary the outbreak will have low incidence, will be sym-
cases but no general epidemic. In the third exam- metrical in shape, and have only a modest concen-
The Nineteenth Century
ple of infection introduction, the susceptible popu- tration of cases in the peak period. Waveform III A fillip to mapping was provided by the advent of
lation has grown well beyond the threshold (S >> approximates the Normal curve. Wave II occupies cholera and yellow fever outbreaks in cities on both
); the primary case is followed by many secondar- an intermediate position occurring at t2 and is sides of the Atlantic. Jarcho (1970) lists 29 cholera
ies and a substantial outbreak follows. The effect of included to emphasise that the changing wave- maps published in the 12 years after 1820 following
the outbreak is to reduce the susceptible popula- forms are examples from a continuum. If we relate the emergence of the first great cholera pandemic of
tion below the threshold, as shown by the offset the pattern of Figure 1.14B back to Kendalls original 1817 from India (see Section 3.6 and Cliff and Haggett,
curve in the diagram, causing the epidemic to arguments in Figure 1.14A, then we must assume 1988, p. 5). Most of these maps plotted routes of
die out. that the S/ ratio has changed over space and time. spread, dates, and regions of occurrence. In the fol-
Kendall has investigated the effect of the S/ This could have occurred in three ways: by a reduc- lowing decades sophisticated maps showing the dis-
ratio on the incidence and nature of epidemic tion in the value of S; by an increase in ; or by both tribution of cholera within European cities began to
waves. With a ratio of less than one, a major out- acting in combination. appear. In Britain, John Snows famous map of indi-
break cannot be generated; above one, both the Figure 1.15 illustrates how the shape of an epi- vidual cholera deaths in the Soho area of London
probability of an outbreak and its shape changes demic wave changes with distance from a point appeared in 1854 (Snow, 1855). At a different geo-
with increasing S/ ratio values. To simplify Kend- source. The energy of the wave is dissipated as the graphical scale, Petermann was by 1848 producing
alls arguments, we illustrate in Figure 1.14B the wave swills out to occupy a larger and larger geo- cholera maps of England and Wales attacked by the
waves generated at times t1, t2 and t3 in Figure 1.14A. graphical area, and so it diminishes in intensity and disease. Thus by 1850, medical cartography was
Waveform I is generated when the susceptible pop- right skewness. beginning to be established in Britain.

11
ATLAS OF EPIDEMIC BRITAIN

Twentieth Century Mapping system of squares for urban populations and dia- diseases especially in resource-poor environments.
monds for rural populations (each proportional to the Figure 1.16 shows how the various elements of dis-
In twentieth-century Britain, more and more official at risk population in each area) was utilised. A stylised ease data, display and analytical software can be
reports on epidemic outbreaks were accompanied coastline was added to aid in reading the maps. Howes combined into an integrated system.
by disease distribution maps as the century pro- atlases were followed by more specialised cancer Pioneered by Howe, the use of a demographic
gressed. Percy Stocks, a medical statistician at the atlases ( for example, Gardner, et al., 1983) and atlases rather than an areal base for disease mapping has
General Register Office, was one of the first to try to for other selected diseases (Gardner, et al., 1984). been carried forward in a GIS framework by Dorling
overcome the limitations of the crude death rate in in the health maps which appear in Dorlings New
mapping disease. His map of the regional distribu- Social Atlas of Britain (1995, pp. 136169) and in Shaw,
tion by counties of cancer prevalence in England and Thomas, Smith and Dorlings The Grim Reapers
Wales, 191923, used corrections for differences in
New Developments in Disease
Roadmap (2008). In the former Dorling employed
age, sex and the urban/rural balance. He concluded Mapping maps of local authority wards in Britain (there are
that the mortalities . . . vary over such wide limits The trend towards national atlases of disease started over ten thousand of them). Each ward was plotted
and the counties group themselves into such definite by Howe has continued apace. Howe himself led the as a circle whose area was proportional to its popula-
regions of high and low prevalence, that there can be way with a world atlas of human cancers Global tion. To generate the maps, the centre of each ward
no question that geographical influences are in some Geocancerology: a World Geography of Human Can- was first placed in its correct geographical location.
way concerned (Stocks, 1928, p. 518). More sophisti- cers (1986). Cliff and Haggett produced an Atlas of A computer program was then used to allow the cir-
cated adjustments were included by Stocks and Karn Disease Distributions (1988) with a wide range of dis- cles to be expanded slowly and, if they touched, they
(1931) for both cancers and for tuberculosis. By the eases mapped at different spatial scales. The purpose pushed each other out of the way until their correct
late 1930s, the reports of the British Empire Cancer of the atlas was to provide worked examples of the size was attained. This procedure distorts the shape
Campaign routinely included maps prepared by widening range of analytical methods that could of the map (with large cities occupying more of the
Stocks showing the spatial distribution for England now be applied to epidemiological data. In contrast, map, empty rural areas less), but it is still possible to
and Wales of cancer of various organs in different in their Atlas of AIDS (Smallman-Raynor, et al., 1992), draw county and district boundaries, towns and vil-
age-groups for each sex. the authors sought to catch the first decade of spread lages upon it (Figure 1.17).
of a rapidly expanding world pandemic. A feature of Dorlings map of mortality in England and Wales
the atlas was its heavy reliance on a unique database shows what appear to be areas of especially high
of attested movements of infectives and the use of a and low years of life lost. By making the construc-
Later Maps and Atlases
variety of spatial scales from world maps down to tion of probability maps straightforward, computers
During the Second World War and in its immediate spread within the individual districts of a city ( for can play a role in providing objective assessments of
aftermath, both Germany (Seuchen Atlas) and the example, San Francisco and New York City). what we mean by these terms. In probability map-
United States (American Geographical Society Atlas) The ready availability of powerful computers ping, the possibility that a given location displays
undertook atlas initiatives. These had an impact in now enables large arrays of disease data to be han- unusually high or low levels of some disease is deter-
Britain through the two ancient universities and the dled so that national atlases have grown to become mined by comparing the observed level with the
Royal Geographical Society. At Oxford, E.W. Gilbert continental and global atlases of disease, emanat- value which would be expected if it had arisen by
pursued his historical research on early maps of ing especially from the World Health Organization chance or randomly. Deciding if a map pattern is
death and disease in England (Gilbert, 1958). At Cam- and its regional offices. Linked to GIS software and random or not should be the first step taken before
bridge, J.A. Steers, head of the Geography Depart- the Google EarthTM mapping service, GIS allows launching upon a search for possible explanations
ment, attended the Washington Conference of the sophisticated disease maps to be produced at will. of an observed distribution. We should seek causal
International Geographical Union in 1952 and was GIS is a system for the input, storage, manipulation explanations only for those disease distributions
strongly influenced by the first report there from the and visual output of geographical information. A which have highs and lows that could not have arisen
IGU Medical Geography Commission. On his return, plethora of GIS software packages of varying capa- by chance.
Steers invited Leslie Banks, Professor of Human bilities is available for data processing, analysis and In The Grim Reapers Roadmap, Shaw, et al. (2008)
Ecology within the Cambridge Medical School, to display, ranging from low to high. Lozano-Fuentes, use the same idea of a population cartogram in
give a course of lectures on medical geography in the et al. (2008, pp. 71825) have evaluated the potential which sizes of geographical units are made propor-
Geographical Tripos. of integrated GIS/analytical frameworks to tional to population size rather than spatial area but,
Bankss papers to the Royal Geographical Society strengthen public health capacity and to facilitate to ensure perfect packing of the units, make them
led to the setting up of a medical geography commit- decision-making for the prevention and control of hexagonal rather than circular in shape (Figure 1.18).
tee in 1959, with a medical atlas of Britain as its first
major research project. The publication of the
National Atlas of Disease Mortality in the United King-
dom (Howe, 1963) represented, for the UK, its response
to the international disease atlases noted above.
Using data for the five-year period 1954 to 1958 for
each of 320 administrative units in the UK, it plotted
standardised mortality ratios for thirteen major
causes of death from heart disease to lung cancer.
Unlike some countries, local areas could be used in
Britain since, as noted in Section 1.2, its twentieth-
century death statistics were published by the usual
residence of the deceased. Like Stocks, Howe adjusted
crude mortality ratios to allow for local age, sex, and
degree of urbanisation.
A second edition of the National Atlas (Howe, 1970)
used data from a later five-year period, from 1959 to
1963. It covered an enlarged range of diseases and used
different cartographic techniques. A demographic
(rather than an area) base map was employed to avoid
giving undue prominence to mortality ratios for Figure 1.16 Integrated framework for the visualisation and analysis of geo-referenced disease data. Source: based on
extensive and lightly populated areas of the country. A Lozano-Fuentes, et al. (2008, p. 723).

12
CHAPTER 1

Mapping Epidemic Diseases in Britain

Figure 1.17 Population proportional maps. Diseases


can be mapped using many cartographic devices. In a
conventional map, the size of spatial units is made
proportional to their geographical area. Other graticules
can be used, however. For example, Dorling in his map of
mortality in England and Wales using years of life lost,
1.5 Atlas Organisation

198189, plotted individual wards as circles proportional in


size to their population and shaded according to the average Geographical Parameters of the
years of life lost. The effect is to enlarge on the map those
areas with large populations (e.g. London swells to foetal Study
proportions with closely-packed wards). Conversely lightly
peopled counties such as those of southwest England have The primary geographical focus of this Atlas is Brit-
few dots. The contrast between the inner, poorer areas of ain. However, where they are available, some exam-
London (red, with high average years lost) and the affluent ples are also drawn from the wider British Isles to
suburbs (black, with lower average lives lost) is evident. illustrate points of particular epidemiological inter-
Geographical Information Systems (GISs) make different
est. Figure 1.19 uses a Euler diagram (left) and maps
mapping frameworks comparatively straightforward to
construct and to associate with disease data. Source: Dorling (right) to define the spatial units to which various
(1995, p. 163). geographical names apply:
1. British Isles is the name for the two large islands
and several smaller ones covering England,
Scotland, Wales, Northern Ireland, the Irish
Republic, the Isle of Man, the Channel Islands,
and numerous other smaller islands.
2. (Great) Britain is the name for England, Scotland
and Wales.
3. The United Kingdom (UK) comprises England,
Scotland, Wales and Northern Ireland.
4. Ireland is the largest island to the west of Britain.
The southern part is the Republic of Ireland and
has been an independent country since 1922. The
northern part is Northern Ireland and it is part of
the United Kingdom. Prior to 1922, both parts of
Ireland were known as Eire which was part of the
United Kingdom.
In the chapters which follow, the geographical
units used for analysis are clearly stated.

Layout of the Atlas


This Atlas begins with two general chapters to set
the stage for the detailed work on epidemic Britain
in Chapters 311. In this chapter, we have defined
epidemic diseases and shown how mortality and
morbidity from these conditions is recorded in the
British Isles. The data desiderata to permit disease
mappability have also been discussed. In Chapter
2, a century-long sweep of epidemic mortality in
the countries which comprise the British Isles is
undertaken. We compare British mortality time
series patterns with those of other European coun-
tries to provide an international context for these
islands.
Britains own twentieth-century epidemiological
experience can be conveniently divided into three
phases (Figure 1.20). The first, 190145, is covered
in SECTION I and considers the major infectious
and parasitic diseases which generated much of
British morbidity and mortality in the period
before antibiotics and mass vaccination. While
germ theory had deepened understanding of the
causes of disease from the 1880s, the means of con-
trol and a proper understanding of the bacterial
and viral agents responsible awaited the coming of
Figure 1.18 Mapping frameworks. A conventional geographical framework shows spatial units proportional to their area. antibiotics and the electron microscope respec-
The inset (bottom right) illustrates such a map for Britain at the administrative county level. Extending the population cartogram tively. The great epidemic infections of the first half
idea of Figure 1.17, but this time using population-proportional hexagons rather than circles to ensure perfect packing of the of the century included diseases of childhood ( for
units (inset map, top right), Shaw, et al. (2008) have plotted standardised mortality for 99 categories of diseases in Britain in the example, measles, scarlet fever and whooping
last two decades of the twentieth century. The main map plots one of these, deaths from all respiratory diseases, as
standardised mortality ratios (SMRs) for 1,282 neighbourhoods (each half a parliamentary constituency). The map shows both
cough), as well as unselective killers ( for example,
urban (high SMRs) rural (low SMRs) and north (high) south (low) divides for mortality from respiratory illness. Source: Shaw, tuberculosis, typhoid and influenza). Chapter 3
et al. (2008, map 10, p. 21). completes the story begun by Creighton and covers

13
ATLAS OF EPIDEMIC BRITAIN

chiefly in Section I, and Hope-Simpson and Watson


to Section II, but rather than divide the unique cor-
pus of material arising from general practice, we
have chosen to treat it all here in a single chapter.
Section III, Prospect, comprises a single chapter
and speculates upon the likely future for infectious
diseases in the British Isles in the twenty-first cen-
tury. We first set the policy context for health the
Chief Medical Officer for Englands 2002 national
strategy (Getting Ahead of the Curve) for combat-
ing infectious diseases and the creation of the
Health Protection Agency in 2003. We then discuss
the problems caused by health scares taking, as
part of a wider discussion of epidemics in educa-
tional establishments, the MMR (measles, mumps,
rubella) vaccine farrago as an example, before look-
ing at emergent zoonoses and bird and animal
infections as potential sources for new human
infections. We next consider the possible impact of
priority biological threats to the United Kingdom.
As we write, bioterrorist threats are high and are
likely to remain so for years to come. Finally, the
Atlas concludes with an assessment of geographical
variations in health inequalities and life expectancy
in the British Isles, setting these in the international
contexts of the World Health Organization and the
United Nations health-related Millennium Develop-
ment Goals.

Range of Diseases
An Atlas of this size can only cover some of the sub-
Figure 1.19 Dening the British Isles. Euler diagram and associated maps to dene the names of the geographical units at
the country level which comprise the British Isles. stantial range of recognisable epidemic diseases
which affected Britain in the twentieth century. We
restrict ourselves primarily to human diseases,
the final years of the great plague diseases of his- in declaring infectious diseases to be features of although some which are carried by animals but
tory which so preoccupied Creighton bubonic history. which can affect humans are also discussed. Our
plague, cholera, typhus, malaria and smallpox. SECTION II focuses upon this second phase cov- choice has been dictated by three main considera-
Chapter 4 treats the major childhood infections ering, first, the retreat of some infections which dom- tions: their relative importance in the British burden
diphtheria, measles, streptococcal infections, inated British epidemiological history in the first half of disease as judged by the mortality and morbidity
whooping cough and mumps. These infections of the twentieth century (Chapters 7 and 8); Chapter which may be attributed to them; their economic
consolidated their contributions to Britains mor- 7 treats epidemics caused by bacteria and Chapter 8 and demographic significance to the British Isles as
bidity and mortality during this period. Chapter 5 by viruses. The period from around 1980 illustrates judged by years of potential life lost and disability
discusses the indiscriminate killers influenza Cairnss false dawn. Among the newly emergent dis- adjusted life years; and their mappability. This last
(under the influence), typhoid, and the emerging eases, the obvious example already mentioned is criterion is important because many diseases are so
disease of poliomyelitis. The geographical patterns HIV/AIDS. But there have been many others for rare that data simply do not exist to permit mapping.
of these and other diseases were also shaped by example hospital-acquired, antibiotic-resistant Others are so ubiquitous that they do not display dis-
two world wars, so that Chapter 6 concludes the strains of diseases such as MRSA and water- and tinctive geographical patterns when mapped at the
first phase with a consideration of epidemics on foodborne infections like Legionnaires disease and British scale. For each disease considered, a brief dis-
the home front in wartime. E. coli O157. Chapter 9 deals with a selection of the cussion of its aetiology is provided along with an
A second epidemiological phase began after the epidemics in Britain caused by these agents. The par- annual time series, 19012000, where data are avail-
Second World War. From the middle of the century, ticularly geographical role of increasing travel, popu- able showing the morbidity, mortality and control
many of the epidemic sicknesses of the centurys first lation movements and lifestyle changes in spreading measures ( for example, vaccinations administered)
50 years retreated under the combined onslaught of diseases is illustrated. taken.
vaccination, antibiotics and improvements in stand- A special British strand in the twentieth century
ards of living. By the 1970s, it was fashionable to think history of infectious diseases is the research role of
that the time of infectious and parasitic diseases as general practitioners in recording and interpreting
major causes of British mortality and morbidity was local disease patterns. And so, in Chapter 10, we look
over. Thus the biologist, John Cairns, wrote in 1975 at the contribution of four of the outstanding such
that the western world has virtually eliminated figures James Mackenzie and the Institute of Clini-
death due to infectious disease. But the cheering cal Research, Aberdeen, Will Pickles of Wensleydale,
was premature. Within the decade, a new pandemic
disease, HIV/AIDS, was emerging that killed in the
next two decades as many Britons as did smallpox in
Edgar Hope-Simpson of Cirencester, and G.I. Watson
and the RCGP Epidemic Observation Unit to this
movement. Arising from their work and that of oth-
1.6 Conclusion

all previous years of the twentieth century. The rec- ers, detailed information on the spacetime occur-
ognition of a generation of apparently new diseases rence of a range of infections is available. A selection This chapter has outlined the ways in which a num-
and the re-emergence of others as national health is discussed and mapped in this chapter. We recog- ber of terms and concepts are used in this Atlas
problems confirmed that we needed to be cautious nise that the work of Mackenzie and Pickles belongs what we mean by a disease and an epidemic; how

14
CHAPTER 1

Mapping Epidemic Diseases in Britain

Figure 1.20 Atlas organisation. The 11-chapter sequence of Atlas of Epidemic Britain, arranged on a broadly historical basis. The images illustrate some of the main themes of the Atlas.
Section I deals with the historic plagues, 190145. Tuberculosis was regarded as an intractable infection prior to the advent of modern antibiotics, and the poster from the World Health
Organization c. 1950 captures this historic despair, along with a positive message for the future. Section II, the era of the National Health Service, antibiotics and mass vaccination, examines the
impact of these developments upon Britains epidemic diseases in the second half of the twentieth century along with the recrudescence of some old foes. The small child is suffering from acute
whooping cough, a disease eliminated as a signicant public health threat in the British Isles during this period. Although many infectious diseases disappeared to the back burner as public
health concerns, some like tuberculosis are re-emerging as global health threats. Others, like measles, illustrate what happens when vaccination levels in the population fall as a result of
erroneous health scares. Section III, Prospect, looks forward into the new century. Smallpox still remains the only epidemic disease globally eradicated by vaccination (in 1979). Themes for the
twenty-rst century include prospects for the eradication of other infections; the use of infectious agents for bioterrorism; animal and bird diseases as potential sources of human epidemics;
and health inequalities arising, even in the British Isles, from economic poverty. The bronze statute in the photograph is by the Welsh sculptor, Martin Williams. It is outside the main World
Health Organization building in Geneva. It is a tribute to all the health workers who combined to eradicate smallpox. While it symbolises hope, smallpox virus is constantly cited as a possible
bioterrorist agent. Source: images from World Health Organization archives and by the authors.

mortality and morbidity data are collected, recorded United Kingdom. Although the focus of the Atlas is travel. This flux increasingly acted as the engine for
and disseminated in Britain; what data standard- epidemic diseases in Britain during the twentieth the spread of infections within and between coun-
isation and quality issues must be confronted; how century, Britain was coupled, and increasingly so, tries. To set Britains twentieth century epidemiologi-
epidemic diseases may be mapped and the role into a global framework throughout the century. cal experience in a broader context, Chapter 2
which may be played by new technologies like Geo- Infectious diseases are spread by person-to-person compares the century-long trends of mortality in the
graphical Information Systems (GIS); and what we interactions and these grew dramatically during the countries of Britain with those in the rest of Europe,
mean by geographical terms like Britain and century with the development of mass air passenger and it is to this which we now turn.

15