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This chapter discusses the cholera bacterium, Vibrio cholerae and its toxic viruses. The cholera bacterium causes disease and death when the infection results in a continual watery diarrhea that dehydrates the host. The diarrhea is the immediate consequence of a poisonous substance excreted by the bacterium, namely cholera toxin. However, the cholera bacterium does not carry this toxin by nature. The toxin is coded in the genes of a virus called the cholera toxin phage, or CTXphi.

This chapter notes that children with HIV/AIDS or cancer are very prone to mouth problems, particularly those who are malnourished. One of the most common causes of vomiting in children's palliative care is doctors' prescribing. While GI bleeding is very frightening for all concerned, one must anticipate and prepare for it, but not panic. It is quite rare for a child to bleed to death from a GI bleed. Meanwhile, diarrhoea is very common in children with HIV/AIDS and is the most common cause of illness and death during the first year of life.

This chapter discusses the following: clostridium difficile-associated diarrhoea, gastrointestinal infections, blood-borne viral infections, tuberculosis, respiratory viral infections, respiratory syncytial virus, Legionnaires' disease, meningococcal infections, Varicella zoster virus, viral haemorrhagic fevers, prion disease, and scabies and pediculosis.

The paradox of modern life is that consumers demand government protect them from an ever-greater range of risks, but at the same time complain about ever-greater government control. Reviewing epidemics of foodborne disease in the late 19^th century, Matthew Booker shows how the U.S. government gradually took responsibility for food safety with the 1906 Pure Food and Drug Act. We live longer and healthier lives because of those government regulations. But Americans today are threatened by illnesses like diabetes, high blood pressure, and obesity, calling into question once again what is safe food and who should guarantee it.

Using viral diarrhoea and the rotavirus vaccine as illustration, this chapter introduces the key concepts to be used in the book. Diarrhoea is responsible for the deaths of some 1.5 million children annually, 80% of them in developing countries. Whilst diarrhoeal disease due to inadequate hygiene and water quality can be reduced by sanitary measures, that caused by rotavirus, responsible for the most serious cases, cannot. Safe and effective rotavirus vaccines are available, and in 2007 the World Health organization recommended their introduction into the national immunisation programmes of affected countries. Within 5 or 6 years the vaccine had moved from the laboratories of the multinational pharmaceutical companies which developed it to the bodies of children worldwide. In order to analyse how this happened, the concept of ‘flow’ is introduced. Vaccines, but also information, guidelines, and financial resources, have to flow through the system. This system is conceptualised in terms of a series of interfaces: between global and national levels, national and community levels, and so on. Central to the chapter, and to the book as a whole, is the question of what goes on at these interfaces. The concept of ‘reinterpretation’, taken from anthropology, is introduced. The result is one of a variety of responses, ranging from compliance with the expectations flowing downwards, to resistance. This chapter demonstrates the utility of the concepts of ‘flow’, ‘interface’, and ‘reinterpretation’ for analysing immunisation programmes.

This chapter shows how the built environment of Baltimore and the disease conditions it produced set the ground on which tuberculosis (TB) politics would unfold. The depth of the problem is suggested by comparison of nonwhite and white life expectancies in the United States. The other side of this comparison was the difference between black and white rates of mortality. The pre-1950 disparity in mortality resulted largely from a set of infectious conditions, including TB, whose incidence was known to derive from poor living conditions. Three in particular—typhoid fever, whooping cough, and infant diarrhea and enteritis, all especially sensitive to sanitary conditions—illustrate the point. Typhoid fever is contracted through the consumption of contaminated food and water, emerging most floriferously in places where human excreta are not adequately maintained or treated. Between 1903 and 1923, the disparities between white and black typhoid fever mortality were highest before 1915, although they continued thereafter.

This chapter describes the many ways that pica substances have been used to heal a range of ailments. It begins by discussing some of the physical and chemical features of clay. It then describes clay known as terra sigillata, which was valued by the ancient Greeks and Romans for its healing properties. Pliny, for instance, wrote about how terra sigillata could be used as an antidote to swallowed poisons and snakebites, as a treatment for dysentery, and to reduce inflammation around the eyes. The remainder of the chapter covers the history of clay in Chinese pharmacopeia and how but earth continues to be used by modern medicine as effective treatments for diarrhoea and wound healing.

A 76-year-old woman was admitted to the acute medical unit with a one-week history of diarrhoea. She was opening her bowels four times per day. She had recently started a new medication.

On examination, her temperature was 36.4°C, pulse was 74 beats per minute, and blood pressure was 134/78 mmHg. She had a resting tremor in the right upper limb. Her abdomen was soft, with mild generalized tenderness.

Bradley spent a year investigating the health of rural North Carolinians in the coastal plain and mountains. Disparity between the care available to whites and blacks challenged Bradley’s racial attitudes, especially vis-à-vis midwives and maternal mortality. The bureau published a book-length account of her North Carolina findings that inspired other states to request rural field studies by Bradley.

Ask people which metals are essential for healthy living and I suspect most would say zinc and iron. Some might mention sodium and potassium, although sodium is often regarded as something deleterious to healthy living; and a few people will know that calcium is a metal also, and important. In fact the human body needs fourteen metal elements to function properly. But for every metal that we do need, there is another that our body contains that we could well do without. These metals serve no known purpose, but they come with the food we eat, the water we drink, and the air we breathe and our body absorbs them, mistaking them for more useful elements. As a result we find that the average adult contains measurable amounts of aluminium, barium, cadmium, caesium, lead, silver and strontium. There are also trace amounts of many others, including gold and uranium. Because strontium so closely resembles calcium we absorb a lot of this element, and the average person has about 320 mg in their body, far more than of many of the essential elements. On the other hand the weight of gold in the average person is only 7 mg, worth but a few pence, and the weight of uranium is only 0.07 mg, although turned into pure energy this could drive your car for five kilometres. Our body tends to retain these unwanted intruders either in our skeleton, as in the case of uranium which has a special propensity to bind to phosphate, or in our liver which has proteins that can trap metals like gold. The table below lists the amounts of the essential 14 metals in the average adult—someone who weighs 70 kg (155 pounds). As we would expect, calcium heads the list because, along with phosphate, it is what makes up the bones of our skeleton, which weighs 9 kg on average. Of this, i kg is calcium and 2.5 kg is phosphate. In fact 99% of the body’s calcium and 85% of its phosphate is in the skeleton. Bone also contains water and the protein collagen, plus the elements sodium, potassium, iron, copper and chlorine.

This chapter covers core curriculum topics relating to small intestinal disorders and malabsorption. This includes a discussion of key gut hormones involved in digestion and absorptive processes including with relevance for obesity. Questions on gastrointestinal neurotransmitters and transporters provide education in gut physiology. The protean presentations of several micronutrient deficiencies seen in clinical practice are discussed. Focus is given to the diagnosis, initial management and follow up of patients with coeliac disease and villous atrophy including later-onset complications such as enteropathy-associated T cell lymphoma. Also covered is the investigation of small intestinal motility disorders and the manifestations and management of functional abdominal conditions such as irritable bowel syndrome. Disorders of bile acid recirculation, microbial dysregulation including through acute infections, and key medications causing presentations with diarrhoea are incorporated in this chapter. Additional curriculum material regarding small intestinal disorders will also be covered in the mock examination chapter.

This chapter uses the examples of the transmission of diarrhoea and typhoid via flies and duck eggs to illustrate the ways in which human perceptions of risk can and cannot be changed. Flies were the subject of vigorous public health awareness campaigns in the early twentieth century, despite bacteriologists’ failure to confirm the pathway of transmission in the laboratory, and they are still regarded as a major health hazard in many parts of the globe. By contrast, duck eggs only came to be popularly regarded as a health hazard in Britain very suddenly, as the result of much-publicized hospital outbreaks in 1949 and 1950. The concurrent rapid expansion of the hen egg industry caused this knowledge to be forgotten, yet with the recent re-discovery of duck eggs as a fashionable food item, their role in transmitting food poisoning has been rediscovered.

We have explored, and outline herein, the accumulation of copper in humans, plants, and animals in a remote desert area of southwest Jordan, Wadi Faynan, where mining and smelting activities began about 7000 years ago and effectively ceased 1500 years ago. The archaeological core of the area, Khirbet Faynan, is the ruin of the Roman city of Phaino, one of the major mining and smelting centers of the Roman world. In addition, the Faynan area was one of the most important suppliers of copper to ancient Syria, Mesopotamia, and Egypt (Klein and Hauptmann 1999). Ancient industrial archaeology abounds in the form of adit and shaft mines, ore and metal processing sites, kilns, and spoil and slag heaps (Hauptmann et al. 1992, Hauptmann 2000). The industrial archaeology is closely associated with a complex and extensive irrigated system of fields, which must have been constructed and maintained to feed the workforce in this remote arid area (Barker et al. 1998, 2000). Wadi Faynan is therefore ideally suited to explore the environmental impact of metal production in the past, and its impact, if any, in the modern environment. The study area is located in the hot and very arid Jordanian Desert at the mountain front at the eastern margin of the Wadi Araba, between the Dead Sea and the Gulf of Aqaba. These environmental conditions promote the widespread deflation and redistribution of dusts, which inevitably include metalliferous materials released from eroding spoil and slag heaps and ore processing sites (Gee et al. 1997, Pyatt and Birch 1994). The geology of the region is very complex and of key importance to understanding the consequences of mining and pollution in the region. Copper and locally lead mineralization is present in several rock strata, in particular the Numaya Dolomite Limestone of the Durj Dolomite Shale Formation and the Umm’ Ishrin Sandstone Formation of Middle and Early Cambrian age (Barjous 1992, Bender 1974, Hauptmann 2000, Rabb’a 1992). Adjacent to Khirbet Faynan is a reservoir that was abandoned as a water storage facility before the fifth century BC.

It is convenient to separate those who differ from the general travelling population into easily identifiable categories or special groups. Each of these groups will require advice, medication, or vaccines that are tailored for their specific needs. Thus, the pregnant traveller must be warned of the increased risk of air-travel-related venous thrombosis, the diabetic of the danger of poor glycaemic control, and the young (male) traveller of the risks of casual sex. While there are very few people for whom overseas travel is absolutely contraindicated, common sense should always be heeded.

While our selection of the time period, AD 1850–1990, for the analytical work we undertake in Chapters 3 to 12 is conditioned by the availability of consolidated morbidity and mortality data for both military and civil populations from the middle of the nineteenth century, this time-window gives only the most recent outlook upon an association between war and disease which can be traced back to the great struggles of ancient times. So in the present chapter, in so far as the historical record allows, we review the early history of war epidemics. Our narrative follows a temporal sequence. We consider in turn evidence from antiquity (1500 BC–AD 500) (Sect. 2.2), the Middle Ages (AD 500–1500) (Sect. 2.3), and the modern period (AD 1500–1850) (Sect. 2.4–2.6). To obtain a picture of the geographical distribution of belligerent parties and associated conflicts, 1500 BC–AD 1850, Table 2.1 is based on a subset of the information included in Table 1.4 and gives the number of units engaged in each of the c.2,000 wars and war-like events listed by Kohn (1999). All told, Table 2.1 identifies 2,267 engagements, with the number rising from 365 (antiquity), to 786 (Middle Ages) and 1,116 (modern). As noted in Section 1.2.3, the Old World and Europe especially dominate the geographical record; entry of the New World awaited European colonization in the modern period and the beginning of a written record for the Americas and Oceania. As a marker of recorded conflicts, Table 2.1 defines the broad geographical limits to an historical review of war-related epidemics. A review of all the wars that underpin the tabulation is outside the compass of this book. As noted in Section 1.4, relevant information is simply not available for the majority of early wars while, even for relatively recent conflicts, the nature of the disease(s) that beset military and civil populations continues to defy confident retrospective diagnosis. Inevitably, language barriers offer a further limit to our coverage. But within these constraints it is possible to sample from the available evidence and to obtain some idea of the magnitude and scope of war epidemics prior to AD 1850.

In this chapter, we examine the time trends that have occurred in the causes of morbidity and mortality in civil populations over the last century and a half. Particular attention is paid to the period since 1900 when international comparative data become readily available. We begin with two case studies—of Australia, and England and Wales—to establish the main trends affecting the advanced economies over this period. Next, using data collected by Alderson (1981), we extend our analysis to 31 countries to give global coverage. We look first at the statistical evidence of change. It is shown that mortality and morbidity from all causes have declined. Since 1850, it is the infectious diseases which have witnessed the most spectacular falls in their contribution to total mortality and morbidity. Within the general decline, however, sharp upturns in both mortality and morbidity from infectious diseases occur during times of war. In the second half of the chapter, we examine some of the factors which lie behind the declines. Notwithstanding the general falls, in recent years there has been a revolution of interest in infectious diseases arising from a sharp resurgence of both old and new diseases. The former include drug-resistant strains of tuberculosis and the latter HIV (human immunodeficiency virus). The disease setting is also evolving with environmental change and increased human interaction. And so the chapter is concluded with an assessment of the potential significance of infectious diseases in the present century in times of peace and war. In Australia, notifiable diseases data are collected by states and territories under their public health legislation; collection has taken place on a regular basis since 1917. The legislation has required medical practitioners and some other classes of people to notify health authorities of the number of cases recorded of certain communicable and other diseases. The resulting data were published in the Medical Journal of Australia from 1917 to 1922, Health, 1924 to 1939, and in the Commonwealth Year Book since 1945. Additionally, the Commonwealth Department of Health and its successors have published an annual compilation of notifiable diseases data in the Department’s Annual Report.

In the previous chapter, we looked at the main trends in morbidity and mortality in civil populations since 1850. In this chapter our focus shifts to the military. An invaluable recent source of information on this topic is Lancaster (1990: 314–40) who gives a disease-by-disease account of morbidity and mortality among soldiers from the seventeenth century. Until the twentieth century, soldiers were lucky to survive military medicine. Basic treatments included the cauterizing of wounds and the removal of limbs to prevent gangrene. The biggest early advances in military medicine came when doctors started to wash their hands. The role of Florence Nightingale in transforming the military hospitals during the Crimean War (1853–6), and her broader role in improving the welfare of the British Army, is legendary. Yet, notwithstanding the gigantic losses directly attributable to battle, up to World War I, most deaths in war among soldiers were caused by epidemic diseases like dysentery, enteric fever, cholera, typhus, plague, and simple infections like measles—the traditional killers encountered in civil populations. And, as with civil populations, the real advances in controlling these infections came with the development of antibiotics and vaccination after 1945. In this chapter, we begin by looking at mortality trends in a number of theatres of war between 1859 and 1914 using data from Curtin (1989). As a specific illustration of the role of one simple infectious disease, measles, as a cause of mortality in military camps during this period, we take the American Civil War (1861–5). By the end of World War I in 1918, the role of many infectious diseases as causes of military mortality and morbidity had changed from lethal to nuisance value. This shift is shown through an examination of the role of measles in World War I. After 1945, the use of antibiotics and the generalized availability of vaccination against most of the common infectious diseases ensured that the historic infectious diseases waned in their impact on military populations just as they did in civil populations. Again we use measles and the American army as examples to show these declining effects.