The Grantville Gazette - Vol 3 Part 23

"The public health situation has been frightening and in some ways, shocking, to us. Public health measures for us have been so interwoven into our lives that we no longer noticed many of them. We took for granted that our water would be safe to drink, our air clean to breathe and that our food wouldn't make us sick. Children are taught the basics of handwas.h.i.+ng when they are toilet trained. No one has to specify that the reason for was.h.i.+ng your hands after going to the bathroom is to avoid spreading certain diseases.It's part of the knowledge we absorb as small children, unquestioned and just there. It's considered rude to sneeze or cough without covering one's mouth and nose. The reason isn't openly stated, that the person who sneezes or coughs without covering their mouth and nose could spread airborne diseases to other people. It's automatic, part of everyday life. Then, suddenly, we've found ourselves fighting an invisible war, a war we thought largely won, against communicable diseases. That is, diseases like measles and smallpox that can be spread among a population. Many of those diseases were controlled or eradicated in our time. Vaccination had been around for several centuries. School childrenwere required to be vaccinated before entering school. Before the measles vaccine was developed in 1963, there were millions of cases every year in theU.S. By the time children were six, more than half had had the measles and ninety percent had the measles by the time they were fifteen. After the vaccination programs began, the number of cases dropped by ninety-eight percent. What was once a common disease becamerare. While many of the public health supports that we took for granted are gone now, much of the knowledge remains and we are putting those supports back into place just as quickly as we can. I'd like to talk with you today about how public health developed, how we got to where we were and where we are moving toward in the future. As you learn about these measures, you could become soldiers in an invisible war against diseases that have been the scourge of humankind from time immemorial.

"Public health efforts focus on measures that prevent illness or injury, track disease outbreaks, and promote life and maximum functionality in groups of people. I'd like to talk with you today about historic developments in public health history and how those have led to changes in public health practice. I'll be focusing on three areas primarily: epidemiology, public health measures and vaccination. Obviously, this will be a brief introduction to what can be a very complex subject.

"Epidemiology is a cornerstone of public health. Epidemiology gives us a way to study how factors which affect health and illness are distributed in a given community or population. Epidemiology is really a form of research and uses many of the same methods as research. The epidemiologist collects a variety of data from many sources in order to identify at risk populations and to prevent or ameliorate the spread of disease and illness and promote health."

So far no one looked lost. She turned on the computer she'd borrowed from Hayes and pulled up the first slide. "Hippocrates was the first known epidemiologist. In fact, Hippocrates was far more accurate in his perceptions about public health and the spread of communicable diseases than about his medical treatments. He developed a number of principles of epidemiology that are still important. Hippocrates gave very accurate descriptions of diseases in his practice. He also wrote about natural factors such as water supplies that are important to consider in public health. He stressed that clinicians should be observant and should consider lifestyle factors such as activity in treating illnesses. He noticed that certain disease occurred at certain places or times of year. We'll talk more about some of these things as cla.s.s progresses today."

Beulah paused for a sip of water and let the students catch up a bit on their notes. She hoped that hearing a familiar name and that he had contributed relevant, accurate information to public health would rea.s.sure her audience that all they knew didn't have to be relearned. Some but not all of it had later been proven inaccurate. Hayes had found copies of Hippocrates' Epidemics I and Epidemics II that were being translated. She planned to use some of it in the developing curriculum. Not only was some of it still relevant, but use of some "cla.s.sics" added legitimacy to the things they were teaching and were still relevant. She was acutely aware that in the long term, there was more involved here than just the university atJena . She also wanted to make the point that they all stood as it were, "on the shoulders of giants." Knowledge had been created, lost, accepted, ignored and tested in various ways, moving forward in fits and starts. Such was the nature of scientific advances.

"Did you all have a chance to attend the sanitation committee meetings?"

Most of those present nodded. James had commented that there hadn't been so many people at the committee meeting last week for over a year.We take the risk of infection too lightly. We're too used to antibiotics and clean streets and an immunized population. So we don't pay attention to them.

Despite all the preparation we've been trying to do, most of our people still have, at most, an intellectual understanding of an epidemic. Even the oldest of us, who ought to remember ouryounger years, aren't immune to that att.i.tude. She shared the fears of James and the others. It was only a matter of time until they were hit here in Grantville. How bad it would be depended in part on how prepared their neighbors were.There's never enough time to get everything done. There are too few of us, spread too thin. We should be having programs like this all over the USE. At least this is being videotaped. I've got to talk with James and the others on the sanitation committee about spreading this information out. We need to put together a basic primer and recommendations for prompt action.

She'd given lectures like this so many times that part of her had gone on autopilot while she talked about how to identify potential problems or disease outbreaks. The cla.s.sic example she'd given was John Snow's work identifying the cholera epidemic in 1850sLondon . The initial outbreak in the early 1830s had caused at least sixty thousand deaths inGreat Britain . Snow's investigations of the 1849 and 1854 epidemics had occurred years after the first outbreak. She saw the way the students' attention sharpened when she pointed out that the epidemiological approach he'd taken to identify geographic cl.u.s.ters of outbreaks had helped identify the water source as a culprit before the cholera germ was identified. She emphasized his use of epidemiological data such as mortality rates, too. He'd spotted the crucial fact that, among other things, the source of drinking water had changed but the population had stayed the same.

Those with the better water source were twenty times less likely to die from cholera. He'd done door-to-door validation of water source to get an accurate rate, a typical public health approach to collecting data. The result was that they were able to take appropriate public health measures and control the contaminated drinking water sources. She thought that the students leaning forward a bit in their chairs got the point that you needed knowledge, not just technology to address these problems. Public health and spreading knowledge were two types of invisible war. They weren't fought in the open but the effects could be profound and even more lasting. Kunz and Willi were both nodding thoughtfully in separate parts of the room. Kunz had a particularly intense look on his face.And if they thought that example was pointed, wait till I bring upFlorenceNightingale.

With an effort she pulled herself back to the matter at hand and went on to talk about the work of Koch and Pasteur in discovering microorganisms and how to set criteria to determine the role of the microorganism in a given outbreak. "In order to transmit an infectious disease, you need three things: a vulnerable host, an agent and an environment that can result in an infection. I'd like to take each one at a time. Host factors may be things that can be changed or things that indicate the public health professional should pay particular attention to that group in certain situations."

Beulah moved onto a discussion of pa.s.sive and active immunity and immunization. Active immunity to a particular disease was acquired through immunization or a previous infection with the microorganism that caused the disease. Pa.s.sive immunity was a bit more difficult to explain. Maternal antibodies and gamma-globulin prophylaxis weren't as easy to understand but she thought they were getting it. She noted another student perk up when she talked about the idea of herd immunity. If at least eighty percent of a community was vaccinated, it was more difficult for communicable diseases to find a vulnerable host. The example she used was of the development of smallpox vaccine using cowpox by Jenner. She was careful to point out how long some form of vaccination had actually been around and what Jenner had done that was different and why what he did was so effective. The drops in death rate were impressive statistics.

From there, it was a fairly easy step to talk about personal hygiene and cleanliness before she moved onto the agent of disease part of the lecture. "Are you all familiar with childbed fever? During the 1840s, many women died of childbed fever. Often, the child became ill and died as well. A doctor named Semmelweis conducted a cla.s.sic epidemiological study of what caused the fevers. He noticed that in the two clinics he was director of, one had higher rates of death than the other. The mothers were ill during the birth or up to thirty-six hours later and then quickly died in the clinic with the high mortality rates. He observed that the problem seemed to start during the examination of the mother during dilation." Shewent on to discuss the data he'd collected and a.n.a.lyzed and the controlled experiments he'd conducted to try to determine the cause of the deaths.

"He realized that the deaths were caused when the medical students came to the hospital from the death house after performing autopsies and conducted pelvic examinations on the laboring mothers. The doctors' hands carried germs from the dead bodies to the mothers because they didn't wash their hands.

The traditional Hippocratic view of disease was still held and, initially, his findings weren't accepted. He was successful however in inst.i.tuting handwas.h.i.+ng by every nurse or doctor entering the ward. At first, he thought it would be enough just when entering the ward. Later he realized that it was necessary to wash between each examination. Something as simple as consistent handwas.h.i.+ng dropped the mortality rate by ninety percent in just six years. I know you've seen how often we wash our hands in the hospital and clinics here. It is a very simple but very effective way to stop the spread of infection. It's quick, cheap and anyone can learn to do it.

"The presence of infectious agents is another concern I'd like to touch on. One of your handouts gave common infectious agents, which we also callpathogens, that are found on or in the body and that are found in the USE."

One of the students waved his hand. "Yes?"

"Excuse me, Frau Professorin, but if these pathogens are in and on the body and all around us, why aren't we all sick all the time?"

Beulah beamed at him. "An excellent question Mr...?"

"Georg Holtz." His voice sounded a little more confident.

"Well, Mr. Holtz, you've raised a very important issue about pathogens. That has to do with part of the agent, namely the vector, as well as how strong the pathogen is. The vector is the way the pathogen gets to the person in a way to do harm. The vector may be biological, such as a person or animal that has the disease, or it can be mechanical. A mechanical vector can be something like a contaminated surgical instrument or piece of clothing." She very carefully didn't notice them stiffening. She remembered how she and all the students she'd met had reacted when they came face to face with some of this. As she recalled, she hadn't been the only one who'd suddenly wanted a shower with lots of hot water and soap.

A truly evil thought encroached.Well, it's all for the greater good. It certainly made an impression on other students and it's fairly easy to do. The lab is going to love this one.

"As a matter of fact, if you're interested, I'll talk to the lab folks for you. They can show you how to culture some of those organisms we live with all the time on our hair, skin, clothing and so on. Most of the time, we call those organisms benign. Even benign microorganisms can be nasty under the right circ.u.mstances. Let me give you an example you've probably seen in practice. A person with a wound has an open area that the germs that normally are on your skin, such as the staphylococcal cla.s.s, can get into.

If the person had an intact skin, the microorganism couldn't get into them to cause an infection. The host was vulnerable, the microbe was there and it had a way to get in."

She finished what she had to say about agents of disease and went on to control measures such as quarantines. The students seemed surprised that the practice of quarantines had begun in the fourteenth century and that she still considered it a relevant measure of infection control.

When she talked about the role of disasters such as floods or war in creating conditions that promoted the spread of disease, she saw that they were fitting what she was saying into their own experiences. Waras a topic led her to Florence Nightingale and the Crimean war. She talked about howFlorence had used epidemiology and statistics as well as astute political and other lobbying to improve conditions and reduce mortality and morbidity of the soldiers and later, of people inEngland . Making the point that when she'd arrived in 1854 in theCrimea , she'd immediately worked to improve the conditions for the ill soldiers by organizing measures such as kitchens, laundries and a central supply department. The end result was that in ten days, the death rate dropped from thirty-eight percent to two percent. Mentioning that she was a nurse near the end didn't hurt either. Beulah fully intended to discuss Clara Barton, the U.S. Civil War and the founding of the Red Cross later in her lecture.

"The methods Nightingale and others have used rely on incidence, prevalence and relative risk ratios."

She went to the board and put the formulas up with discussions of each, how it was calculated and what it meant. That naturally led her to a brief mention of statistics such as infant mortality that gave important clues to a population's health.

"But that is really beyond the scope of our talk today. I'd like to talk some more about modes of transmission of disease and then we'll talk about ways to break that chain of environment, agent and host determinates leading to infection. Biological modes of transmission are physical contact such as spitting or touching, s.e.xual contact such as intercourse, and airborne contact such as dust or droplet nuclei. Those modes of transmission are direct or airborne. Indirect transmission results from mechanical transmission.

Books, coins, toilets, soiled dressings, food and many other things can be a reservoir for an infectious agent. For the last hour today, I'd like to talk about ways to interrupt the transmission vector, to strengthen potential hosts and to reduce risks from the environment."

During the next hour, she covered everything from adequate sewage disposal to handwas.h.i.+ng. The work of Joseph Lister and the use of antiseptic techniques and carbolic acid solution fit in here. She also brought up Thomas Syndenham, who was only nine years old at the present time. She made an effort not to stress too much that he used observation and other techniques to diagnose different diseases and avoided Galen's approaches. Syndenham's work cla.s.sifying fevers inLondon during the 1660s and 1670s and how he treated the different cla.s.sifications went against the Hippocratic and Galenic approaches. For which he took considerable flak. His treatments were effective, however, even if he hadn't understood what was causing the fevers. She also made a point of talking about the criticism and threats he endured.

He persevered despite that and influenced an up and coming generation of physicians with his use of empirical techniques.

She gave them additional resources to read on all the areas she'd introduced and hoped it would be enough to get them started. Hopefully, they'd take the ideas back toJena . "If any of you have specific areas of interest in public health, please see me. I'll try to set up an experience for you so that you can learn more in a clinical setting and I can probably point you to more references. Thank you for your attention today. Do you have any other questions before we adjourn?"

5.

"May we join you, Frau Professorin?" Georg sounded a little hesitant but eager.

"The Leahy garden is always better for company. Please Georg, Kunz, have a seat." "We wanted to thank you for showing us around the lab and setting up the culturing experience after the lecture yesterday." Kunz sat next to her on a bench and grinned at her. "We really enjoyed it. Georg and I are very interested in aspects of public health and would like to talk with you more about books to study and a clinical experience in public health."

"With you if we can," Georg blurted and then blushed right up to his straw-olored hair. "I'm particularly interested in microbiology."

"While I am interested in the methods of disease surveillance you spoke of," said Kunz. "We were on our way to check on the microbial growth but when we saw you here, we thought we'd take the opportunity to ask."

The smile she gave them both was slightly blinding. "I'd love to. I'll make up a list of materials for you. I can even lend you my personal texts if you'd like in some cases. Most of them have been copied already.

I'll check and see what's at the printers right now."

"You're all certainly keeping the printers inJena busy." Kunz grinned back at her. She couldn't help but contrast that with the att.i.tude a few months ago and took heart.

"Please excuse me, Frau Professorin, but in the lab, they said that there would be growth within a day.

I'd like to go check the petri dishes before things get too busy there."

"Have fun. Kunz and I will set up a time to meet and talk some more."

She and Kunz grinned after the tall young man as he dove for the door.

6.

"What are you doing here?"

Georg nodded politely. "I am one of the medical students fromJena . My name is Geo-"

"I know you're one of theJena students. I asked what you're doing here in thelab? "

Georg straightened to his full height. "I have permission to be here. I was checking the growth of the cultures we took yesterday."

Mara stared at the young man standing a few feet away. She couldn't believe he was arguing with her this way.Little know-nothing. "There won't really be anything to see if you just took the cultures yesterday. I don't know why anyone is letting you do cultures in here anyway. It's a waste of our resources to be using materials that way."

"Frau Professorin MacDonald didn't think so. She called it a good learning experience. I and the other students found it most interesting."

"We only have so many supplies. They should be used for patients or for our students." Mara heard thebelligerence in her tone but didn't care. She was sick of everyone trying to make them happy. She'd already figured out she wasn't going to be one of those asked to be in the MD program atJena . She should be. G.o.d knew she'd earned it and she was certainly smart enough. She'd even volunteered for the education committee. It was all going to be people's petswho got in, especially Beulah's pets. She'd heard someone talking with Mary Pat in the hall yesterday, asking if she was going to apply to the MD program. The other nurse thought Mary Pat would be great. Mary Pat had laughed and said she wasn't interested, she liked nursing too much. Hearing one of Beulah's pets dismiss what she herself wanted had just frosted the cake.She should be in that program.She should be getting special attention.But no. Beulah was sponsoring Fritz and now it looked like she was going to have one of theJena students, too.

"I am one of the students," Georg replied in evident confusion.

That was more than she needed to hear. All thoughts of running a pregnancy test before her s.h.i.+ft started and anyone else was around went flying out of her head. Theinjustice of it, the slights were more than her temper could stand. "Well, you are sort of a student. Not that any of you'll be worth much for a long time. We'll have to spend a lot of time and effort just getting you up to speed on things any junior high student would know.Some people may think you'll be useful teaching a.s.sistants but I'm not one of them.

We'd be much better off starting from scratch with our own people."

Georg's attempt to interrupt went unheeded. "You're nothing but a bunch of parasites. You'll take and take but you sure won't give much back. You don't know enough. Your ideas about everything are from the dark ages. There's no way you'll be able to catch up on hundreds of years of knowledge in a few years, much less a matter of weeks."

"How dare you say such athing! " Georg's voice was rising toward a yell and echoed oddly in the lab.

"We arenot parasites. The others would not be spending so much time with us if they didn't think we could learn. More than that, we are not some sort of ignorant fools who..."

Even Mara knew she'd gone too far. With an effort that left tears in her eyes, she stopped herself from saying any more. She spun away from him and slammed out of the lab.

7.

"Hi Kunz, Georg.Are you all right Georg?" Beulah asked in concern. Georg and Kunz had just come into the conservatory as she was about to leave, and looked upset.

"Fraulein Beulah. No, I do not think I am but I will be fine."

Beulah tried again. She thought she had an idea of what was wrong. Young people had tender egos about such things, sometimes, so she proceeded rather obliquely. "Did you just come from the lab?"

"Yes. I had permission to be there." His tone was both defensive and angry. He looked pale. "I was just checking the samples."

"An excellent idea.Did somebody say you couldn't be in the lab or look at the samples?" "Not exactly."

"What did happen?Exactly." Beulah noticed that Kunz was getting red blotches in his face and clenching his fists. Something was really off here.

"I can handle it."

"I have no doubt of that but since I was the one who suggested the lab experiment, I feel a little responsible. Humor me, okay? What happened?"

"One of the nurses felt that I should not be in the lab."

Kunz jumped in. "She did far more than just tell him that he shouldn't be in the lab. She also felt that our presence was a waste of time and told him that in the rudest way. There is no excuse for such behavior."

Beulah was adding one and one and coming up with...Mara. She had a pretty good idea what Mara had been doing in the lab since she was the one who'd told Mara to have a pregnancy test. Beulah had seen lots and lots of pregnant women in her career and Mara definitely had the look. She'd like to be able to blame Mara's behavior on hormones but the hormones had probably just made her less subtle in her attack methods. "Let me guess.About this tall?" Shehelp up her hand to around five feet and a bit. "

Strawberry blonde, big blue eyes, tanned, looksharmless?"

At Georg's nod she gritted her teeth and said one word."Mara." This certainly put her in an interesting position. Starr and Mara were sisters-in-law. She needed to go to Starr about the behavior of one of her staff. It was going be awkward for Starr but she would handle it. In the meantime, Beulah got damage control duty.Lovely. "Help me up please, Georg. We'll all get something from the cafeteria and then go to my office to talk. I'm upset at Mara, not at you. I just want a little privacy."

Georg and Kunz were largely silent after that except for an offer by Georg to carry her coffee mug. She hated being glad of that offer. The cold weather wasn't doing her joints any good and she'd had to cut back on the willow bark tea. The tea and stress was turning her stomach sour and she was starting to get bruises at the slightest touch. She'd been able to hide them with long-sleeved sweaters or s.h.i.+rts and since she almost never wore dresses, no one had noticed the bruises. Delayed blood clotting times were one of the side effects of the tea.So, less tea.Which didn't leave her much for the pain unless she wanted her mental state interfered with by some of Stoner's crops of marijuana or poppy. She couldn't afford that right now. A break in the tea would give her body a chance to recover. It would be weeks though before her clotting times were close to normal again. She was also trying more stress management techniques.So far so good.Except for the pain.

Beulah nodded toward the small table in her office. She used it for meetings sometimes or when she needed to spread her work out. She didn't want to be sitting behind the desk with Georg in front of it like an errant schoolboy. The walk had helped her calm down a little and given her some s.p.a.ce to think. "Can you tell me what happened, please?"

By the time Georg had finished the description of what had just happened downstairs, Beulah was ready to do Mara a mischief in a dark alley. Kunz would probably help by holding Mara still for it. The description rang too true to some of the things she'd seen Mara do, but she'd never gone this far over the line before. She'd been tripping over little bits of poison strewn by Mara and a few others over the last month. This was the last straw.I don't care if it is her hormones, we do not need this kind of c.r.a.p.

Specifically, she didn't need to be doing more damage control right now. Now, how did she avoid undermining one of the few senior nurses they had but support Georg while one of theJenafaculty waswatching and not looking at all friendly? She had no doubt that this would spread among the Jenaites at the speed only good gossip can obtain. Einstein should have made gossip an exception to the travel at the speed of light stuff.

"What do you intend to do about this woman?" demanded Kunz.

"I'll speak with Starr first. Mara is one of her staff. Second, I'll speak with Mara personally. I know I'm not the DON anymore but Georg is one of our students and that should give me a say in how this is handled. It won't happen again if I have anything to say about it. I'm really sorry Georg. If Mara had pulled anything like this in an up-time hospital, she'd have been out the door so fast she'd have left skid marks on the linoleum." Beulah sighed. "As it is, because we don't have enough staff, we can't do what I'd like which is fire her. Between Starr and me, we'll come up with something... suitable.One thing for sure. This won't happen again to you or any of the other students. If you or any of the other students get so much as one whiff of att.i.tude from anyone, come right to me."

Just wait till I get my hands on little Miss Twit. Maybe I'd better watch some WWF reruns first.

8.

Beulah peeked into Garnet's hospital room. Garnet was sitting up in bed, awake. Beulah didn't like the way she looked or was breathing at all.This is what happened when people pushed themselves this hard for so long. She'd just got the call after Kunz and Georg left her office. Garnet had just been admitted to the medical ward. She hadn't been able to get to see Garnet for another few hours, which was probably just as well. She had other things to take care of including meeting with Starr, finding the treat she'd brought and that didn't even touch what she had to get through before today had started going downhill. The meeting with Mara at the end of the s.h.i.+ft today was just going to finish up a lousy day with a lousy mess. Garnet, however, didn't need to know or see any of that. She needed to get well.

"Come on in. I'm not contagious. It's just pneumonia."