For the Medical Record - Randy Packard Interview
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Mia Levenson: Welcome back to For the Medical Record, a podcast from Johns Hopkins University Center For the Medical Humanities and Social Medicine. We are your hosts, Mia Levenson.

Richard Del Rio: And I'm Richard Del Rio.

Mia Levenson: Today we have with us Randall Packard, Professor Emeritus in the History of Medicine at Johns Hopkins, here today to talk about his new book, "Fevered Cities: A History of Dengue Fever Epidemics".

Richard Del Rio: Well, I, I'll just say that I'm very excited to have this conversation with Professor Packard today because, um, you know, we're gonna have this discussion about a disease that is very widespread, but most people don't know much about. It's one of the world's foremost neglected tropical diseases. Dengue Fever has four different subtypes. Each of those subtypes have their own genetic [00:01:00] varieties, and it's proven to be a very serious public health challenge. And today we're gonna talk about a book that looks at dengue across centuries from the 18th century to the 21st in eight different sites. There's a saying that if you have seen one dengue epidemic, you've only seen one dengue epidemic, because of all the variabilities to approaching it. So I'm really excited to talk about the contents of this book.

Mia Levenson: Hi Randy, how are you doing? Can I call you Randy? Is that okay?

Randy: That's okay. Yeah, absolutely. I'm fine. How are you guys?

Mia Levenson: Good. So Randy, can you tell us a little bit about what brought you to write about Dengue Fever?

Randy: Yeah. Well, in 2007, I published a book on the history of malaria. Uh, it was, uh, "The Making of a Tropical Disease: A Short History of Malaria". And so I needed another project. I actually began thinking about it before then. In 2007, I [00:02:00] also went to Rio de Janeiro for a conference, and Rio turns out to be one of the hotspots for dengue infections globally. It probably has more annual cases year than almost any other city. And actually the year after I was there, they had a massive epidemic in Rio. So I was interested in that.

I also had a friend who had worked in the South Pacific years ago and had come across Dengue. He was an infectious disease doc, and he said, "this is an interesting case, you should look at." And also because it's an emerging illness. This was a time when there are a number of things that were emerging in terms of diseases, he said It may not be a great thing now, but it's a wave and it's gonna be great. So get into the bottom floor now before it actually crests. And he was right about that.

Because when I started writing it, hardly anyone had heard about dengue, who wasn't involved in, you know, tropical disease research or, or [00:03:00] lived in areas where dengue was, was prevalent. Now there are articles in the paper, not frequently, but you know, frequently enough that talk about the, the epidemic spread of the disease across the globe. So the timing was that.

I also was interested in dengue because while I was a vector-borne disease, it was in many ways different from malaria. is a kind of chronic rural disease that, that exists in endemic levels in, in many parts of the world, that has peaks and valleys, but it's mostly a rural phenomena. Dengue on the other hand, occurs in explosive epidemics in urban settings. So it was a very diff, I mean, it occurs in rural areas as well, but, predominantly, the big epidemics occur in urban spaces, and that was interesting because it's, it's, it's a different phenomena to study a, a time limited epidemic as opposed to talking about an [00:04:00] endemic disease, which exists at, you know, for long periods of time.

So those things all sort of interested me and so I started dabbling in it. mean dabbling, but just sort of, because I was doing other things and teaching at Hopkins, I was just started looking at Dengue. And I looked at, first of all, I looked at, uh, new Delhi and Singapore, um, in part because they were both sort of major Commercial world-class cities that, were both, exposed to and suffering from dengue epidemics, but were very different in terms of the nature of the cities and the nature of the responses. And I also then came across Benjamin Rush's description of a 1780 epidemic of recurrent remittance fever in Philadelphia. And that was a, a disease which most specialists in dengue who look back at that time argue that it was dengue [00:05:00] fever. Now, I wrote about that and I gave the Garrison Lecture at the American Association of the History of Medicine in 2013, I believe. and made the case in that article about that lecture that it could have been dengue, but also made the case that it's really difficult to know because at that period of time, the whole understanding of what a disease was, the ideas seventeens 18th century medical ideas were so different from 21st century medical ideas that it's very difficult to use that kind of data to actually, you know, absolutely nailed this as dengue. Nonetheless, it was good enough for me. So I used that as the first chapter of the book because allows allowed me to actually up a longer narrative historical change and understandings of the disease going from the 18th century to the 21st century.

And maybe I'll stop there 'cause I'm rambling a lot right now.

Richard Del Rio: [00:06:00] it's not a problem. I think it's a great description because from the vantage point of historian, there's a probably a good number of our listeners who are maybe working on, uh, manuscripts for thesises or dissertations or books. Could you speak to the process of putting this book together? I mean, you talk about very di very distant spaces. You're building off of a lecture you gave in 2013. How much time and how many miles and, and what was the collection of materials, especially I imagine you working on this during COVID.

Randy: That's a good question. As I said, I mentioned I started it in 2007. It was published this year, right. So, you know, almost 20 years later, you know, we're talking. And it was partly because I got into it and two years after I got into it, I decided I was gonna put it aside and work on a history of global health, which I did. And that was published in 2017. And that took a lot longer than I thought it was.

Um, and then, um, [00:07:00] after that I got back into it, started giving some talks on the material, I, the material I'd collected. But then in 2019 I went into a sort of stage retirement from Hopkins, moved to Atlanta that took a lot of time. I was doing part-time teaching on, on the online program that year. And then I retired in 2020 and COVID came along. COVID actually, it probably, it probably contributed a lot to the completion of this book because I was sitting here, what am I gonna do? I had, I had a, what am I gonna do moment, both because I was retiring, but also because of COVID. So anyway, that sort of explains the link it took to do it. It wasn't just that it was so hard to do, it was just lots of interruptions and, and, and, you know, stallings that occurred.

So in thinking about how to write this book, I didn't want it to be a [00:08:00] "History of Malaria 2," you know, "The Making of Tropical Disease 2." That book was similarly global in terms of its geography, in terms of the, the time span. It was even longer. It was going like 30 million, 30,000 BC to the present, you know, so, but there was a central theme in that book, which was that the history of malaria has been very much determined by social and economic situations and contexts , and social and economic determinants of the disease were very serious and, and played a big role in both the spread of the disease, how it affects different societies, and how it's been eliminated in some areas and not in others .

Anyway, so I wanted to tell that story for Dengue, but that's not the only story I wanted to tell, in part because I had been working at the, in the a Department of the History of Medicine, and in the History of Science at Hopkins. I had become [00:09:00] much more interested the details of medical science and how people did scientific research, how they came about conclusions in science and medical research.

And so because I was looking at dengue over a long period of time, and from a period of the 18th century was dengue was a, physiological phenomena in which it wasn't a, it wasn't a disease that was caused by something other than, it was an ailment that people had either be because of behavior, because of what they were consuming or because of the weather. But it, it was, it certainly wasn't an ontological disease caused by a virus or anything else. Right. So. That was a starting point. And so how you get to that, to the 1920s where medical researchers in the Philippines are able to sort of nail down that it's a virus or what they call a virus. I don't think they, they never really saw it, but what they was a done a filterable virus, but they could look, they [00:10:00] couldn't, they, it was so small they couldn't, it couldn't get through the finest filters.

Right. Um, and that it was being transmitted by the Aedes aegypti mosquito. I mean, the research that was done on Dengue in the Philippines was very much like the research that was done in Cuba for yellow fever by the, the US military, and you had so-called volunteers who were infected or bitten by mosquitoes that, then transmitted the disease. Anyway, etc. But the point is you're going from this, on this, this physiological disease to a vector, vector-borne disease, and so I wanna tell that story and then how it evolves after that time and how more and more knowledge becomes the story is really one of people thinking they know what it is. And then before you know it, it all falls apart because there's new things discovered.

Or in the case of, um, the chapter on Bangkok, you have where you had this massive epidemic of [00:11:00] hemorrhagic fever, dengue hemorrhagic fever as it turned out to be, but they didn't know it was dengue at the time. So how did they figure out what it was? How did they figure out why it was occurring at that, in that place at that time where dengue had occurred but had not produced these kinds of symptoms at any great extent anywhere else?

Anyway, so story two. Again, rambling. Story two was tracing the medical history, the discovery, the the history of changing understanding of the disease. And then the third story I wanted to tell was I wanted to really go from global to local, and I wanted to be able to focus on what it meant to be in a city that was being hit by a dengue epidemic. How did people understand the epidemic? How did they respond to it? And how did this differ as you move from city to city to city? In the middle four chapters of the, I mean, I have eight, uh, eight cities, but the middle four cities are basically about describing the variation that occurs in different [00:12:00] places and how that variation is shaped by the local culture, local economics, local social forms, and so forth.

So how do you tell all three of those stories? How do you talk about the broad social economic determinants affecting the distribution of dengue and then dig down into the work of virologists and epidemiologists and entomologists. And so the only way I could figure it was to go back to what I started with and I say, I'll just, let's, let's do it city by city. Now choosing the cities was, I took some time thinking about that. In part, the cities were chosen, some of them because they were where different understandings of the disease occurred. So in the beginning of the book you have Philadelphia, then you go to the the Philippines and the early work of US military medical researcher and then to Bangkok where you have all this research that goes into, understanding why dengue hemorrhagic fever is [00:13:00] occurring. Some of the cities are basically chosen because they showed different forms of the, of the epidemic. They just, and somewhere, I mean Cuba was really interesting for a whole bunch of reasons when I was at the, uh, the book launch, I don't know if you were at the book launch, but one of a new graduate student stood up and she's from Puerto Rico and she had, why didn't you do San Juan? And it was a great question because I actually had a lot of research on San Juan. Um, and the answer was that I actually had a friend who has worked in Dengue for a long time, worked at the CDC down there, and, and he is also a historian. I say, well, he's gonna write that book. I don't know if he ever will. But anyway, so I laid off, but also, many, how many islands in the Caribbean could I actually include in the book of this length? And Cuba was compelling in part because it was the first place. In the Western hemisphere where there was an outbreak of dengue hemorrhagic fever, it was also compelling because it was Cuba and it was, Cuba had with its amazing medical system early [00:14:00] on, and how they actually, Cuba was the only country to actually sustain control of dengue, that is prevent dengue from occurring over an extended period of time. Basically from 1981 to 1996, there were no outbreaks of Dengue.

One of the lessons that comes through with this book is that once dengue and, and the Aedes aegypti, You know, settle into a city, it's almost impossible to get rid of them. None of these cities have been there. I mean, Singapore, for god's sakes, the best, most advanced medical system and public health system has been unable to un, you know, to root it out. So the Cuban story was really interesting because of that. and then at the second part of that, yes in 1996 and 1997, they have a major outbreak and explaining why that happened is really interesting. But also it's another one of those cases where it's not only that dengue outbreaks differ from city to city as you move across the [00:15:00] globe, but they can differ in one place over a period of time. 'cause the way they responded in 1981 was drastically different from the way they responded in 1996. And as I argue it, it was that way because Cuba was a very different place in 1981 than it was in 1996. Using cities as the sort of building block was the way I thought was the best to do all three stories and to tie them together. And once I made that decision, it was just a question of doing each of these.

Now the, the, the, the COVID virus comes into play here because I couldn't travel. And I had wanted to go to some of these places and to, know, if not, do research at least sort of be there, if you will. but that was impossible. So everything was done at a distance. I had lots of help from people who were specialists in the cities or the countries that I, that I chose, but I [00:16:00] felt somehow that I wasn't actually there, but was unable to travel to these places.

So that sort of describes the, the process by which I thought about how to put it together. And once I'd figured that out, it was just a question of doing one, one city after the other. The only thing that was different is that the end of the book, I decided I just didn't wanna do two more stories, what I wanted to do was talk about the future in a way. And the future is, is, you know, one future is the sort of biotechnical future, and that's the one that has gotten the most attention, and that is the development of vaccines, the development of genetically modified mosquitoes. And so I have two when I look, go back to the Philippines to talk about the early experience with dengue vaccine, Dengvaxia, then back to Rio de Janeiro to talk about efforts to test two kinds of [00:17:00] mosquitoes. One that's infected with wolbachia, which is a bacteria, which prevents mosquitoes from transmitting dengue. And the other is the genetically modified mosquitoes, which essentially kill off Aedes aegypti mosquitoes. So the book is three parts. The first part really is the early development of the disease. Second is the variation of, of how Dengue develops in different cities. And the third part is the efforts to develop bio technical responses to the disease.

Mia Levenson: Randy, can you describe for us briefly what Dengue Fever does to a person?

Randy: Yeah, well, a significant portion of people who are infected with dengue have no symptoms. There's a lot of asymptomatic cases, but there are also a lot of people who come down with what is referred to like classic dengue symptoms. So it begins with aches and pains. Retroorbital, pain in the eye, various parts of the body aching, fever, malaise. And this will last for a [00:18:00] number of days. Seven, 11 days. The US military used to figure that would their, their troops would be out for two weeks, right?

And then after that, you get this extended period of just tiredness and malaise extends, and it varies from individual to individual. And so all 'em tall two weeks and, and anyone who has had the disease will say they had the worst headaches that they've ever had in their lives, right?

That that's the one symptom that just is, everyone repeats, but, but it's the aches and pain and it's why, you know, in the 18th century it was referred to as break bone fever, so that's what you can look forward to or not.

Richard Del Rio: I've only been here at Hopkins, uh, for one year, and in this one year I've learned so much about mosquitoes.

Randy: Mm-hmm.

Richard Del Rio: Um, in fact, those, those, the latter part of the book is kind of my first, my personal favorite, but, but there's a lot of ground to cover before we get there. You present [00:19:00] this disease that's not only a problem of socioeconomic conditions, which is why the, the Cuba examples, excellent example, because they have a totally different economic system. And not just as a, as a technological issue, but also as kind of political, cultural issue. , You know, dengue means something when, when, when you are a booster for a city or when you live in a certain urban space and you hear an outbreak of dengue, it means something. Could you elaborate on that aspect of it as well? 'Cause that, I think that's also an important part of the story that you capture.

Randy: Yeah, I mean, one of the things that was different about dengue from malaria was the presence of stigma attached to the disease. And this surprised me. Again, because I was coming from malaria, didn't think that both, particularly middle class residents of cities, or even upper class residents of cities, felt that being infected with dengue was a sign [00:20:00] of their failure to maintain clean households. And in the case of, of India, their failure to achieve middle, really achieve middle class status.

The other side of that was that cities, who are trying to, or aspiring to become great global cities are embarrassed by the existence of a, a tropical disease associated with poverty that they can't get rid of. So you have this, as I say, stigma attached to the disease, which has consequences in terms of how cities try to, they try their best to get rid of the disease, but they also try to, deflect attention from the fact that there is the disease.

There are middle class people who don't wanna cooperate with the efforts to control the disease because they see this as intrusive into their lives. And also, how can we have dengue? We are, living in a, you know, clean, [00:21:00] well kept household. So, I think that was an important part of the story and, and a part that distinguishes it from other vector-born diseases. I'm just trying to think of exceptions to that. There might be. There may be. Um, but if you even think, you know, yellow fever, um, malaria, there's probably some of it with Zika. Um, was a very different kind of disease because of its the effects it had. but anyway, I thought that was, I thought that was interesting and I thought it was a, a distinguishing characteristic of dengue epidemics.

Mia Levenson: Something that you talked about during your book launch at Bird in Hand the other week, you mentioned for this book, you really wanted to take the science seriously. Right? And you've talked already a little bit about the different technologies that are getting [00:22:00] introduced, the genetically modified mosquitoes, and stuff like that.

So I was wondering, can you elaborate on sort of what you meant by saying that for this book, you, you wanna take the science seriously?

Randy: Um, I guess it's a, it's relative to what I did with the malaria book, which yeah, the science took seriously, but I didn't at any point sort of dig down into how they knew what they knew. know, we talk about Ross, when we talk about Grassi and they discover this and that and the other thing. But I didn't pay much attention to the actual research that they were involved in.. And so really wanted to do that. And again, it's, it's part of being, having been at Hopkins, I mean, it's, it's a, I have this sort, I said, I think I said this at the, at the book launch, that I didn't come to this position or to what I'm doing from having been trained in the history of medicine. I had a PhD in African history from the University of Wisconsin. I did [00:23:00] very, you know, sort of basic African history teaching and research for a long time until I, you know, got onto thinking I wanted to write a history of tuberculosis in South Africa. I went and did that, and then basically that was in the eighties. And from that point on, all my research was basically medical research.

Most of it was faced, in, in Africa. But having not been trained in the history of medicine, I hadn't been trained to think very critically about the processes of medical investigation. The way my colleagues think about it or thought about it when I arrived there. And it's not, it's the history of medicine and the history of technology in science technology.

So this was fairly, fairly central, talking about the context of research, the process of research. And how research is done and what, what forces shape research were all things that I became really interested in while I was at Hopkins. And so I said, well, [00:24:00] I really wanna, I, I really need to put this in the book. And so, you know, I did that and it was, it took a lot of work. You know, I, I, I, I took an online virology course, well, I, during the pandemic, all sorts of things just to try to be able to get on top of that. and it was, it was interesting, and I think I said this at the, the book talk that chapter three on hemorrhagic fever in Bangkok. ,Which was the most difficult chapter to reach because I got the furthest into the weeds of the, of the biomedical research that occurred. I also had a lot of good material from that. I had a, I had a medical student who was working with me went to the US Military Medical Archives, in Bethesda at Walter Reed and collected a whole bunch of stuff. So I had a lot of primary data on the research. And I wrote a draft of the chapter and I sent it off to [00:25:00] Mari Webel at Penn who was working on neglected Tropical Diseases. And she wrote back and she says, well, where's Randy? And what she meant was, where is my larger vision in talking about the social determinants of disease and all this kind of stuff? And she was right. I had just gone so far into it that I'd sort of lost that.

So I went back to the chapter and I sort of pulled back a bit, and as I did that, it suddenly dawned on me that my, my subjects, my, the researchers I was writing about were lost in the weeds in a sense they were so focused on the virus, on blood samples, on, you know. saving lives really, that they never stop for the most part, and not, this is not true for everyone to think about the larger context. And I mean, the question they were asking the two questions was, why is this, why is Dengue causing this kind of severe illness here? And now. Right. And that's [00:26:00] not a question you can answer simply, or you can, but there, there's a very reductionist that, you know, well, it's a, uh, it's a mutating virus. But in the end, they didn't really accept that they, they developed a different understanding of what was causing dengue hemorrhagic fever, which was based on people having been infected serially by multiple subtypes. But what they didn't talk about was the context that made that possible. That Bangkok, between 1950 and 1970 went through this massive social and economic transformation, was building up the economy and migrant workers coming in. You had the US military moving into Bangkok or into Thailand as part of the buildup in Vietnam. whole set of things were happening that were allowing for the buildup of conditions which encouraged the breeding of Aedes aegypti Mosquito. And at the same [00:27:00] time, were introducing multiple strains of the virus into the country. So there was, you know, I didn't, I never said that in the book as so many words that, that these guys were lost in the weeds. but in a way they were. But some of them actually did think about, and I point out that some of the people that were looking at Dengue hemorrhagic fever, Actually step back or at least acknowledge that there were things going on that may have been shaping the context in which it was going on.

Anyway, that's what I meant by going digging deep into the science.

Richard Del Rio: I would like to revisit the issue of how you went about selecting cities. Because I think while African descendant peoples are certainly in the story, especially talking about brazil, it seems geographically settings in Africa are absent from, from the book. Is there a reason for the choice?

Randy: Yeah. Um, it's because it's changing a [00:28:00] bit now, but dengue is present in many parts of Africa. It's probably severely under-reported, it's difficult to diagnose clinically and then you need certain technology in order to do it accurately. and there are a number of other viruses and more serious diseases so it sort of gets lost in the wash. But also there are no, with one exception that I know of in the period up till, you know, the early 20th century, no big explosive urban epidemics of dengue. The one that occurs is in Durban in the 19, I think, twenties or something like that.

The dengue that's occurring in Africa doesn't fit the model that's occurring the rest of the world. I probably could have said more about that. And there were periods of time where I was saying, gee, I really need to do something on Africa. And I mentioned it here and there, but it [00:29:00] just didn't seem to fit into the pattern that I was seeing in which I was describing for, you know, the rest of the world.

I suppose by the time I got to the dengue book, I'd sort of gone fairly far from Africa, um, having, you know, while I was involved in African studies stuff at Hopkins, my last research in Africa was in the 1990s, early 1990s. So it's sort of like, you know, I had, I'd gone away from that and become, I'd become more global. Right.

Mia Levenson: Well, in speaking to this sort of like. This, this, book is almost like a magnum opus for your, like, life's work. You know, so much of like the central thesis of this book and of so much of your work as a whole is about needing to rethink these structures of global health and what we mean when we talk about global health.

And reading your book, it's hard not to like constantly be thinking in the back of your head about how all these structures, um or many of these structures are now [00:30:00] being defunded or just simply canceled outright.

And so, you know, looking at this idea of fevered cities, what do you see as the future of fevered cities? What do you see as the future of global health?

Randy: Well, I'm not very optimistic.

Um,

Mia Levenson: which is fair.

Randy: yeah, I mean, I don't know anyone involved in global health that is optimistic. Um, you know, I'm, I, I may have mentioned this at Brien hand. I, I am thinking of a second edition of the Global global health book or getting pressed to do a second edition and have a new final chapter, which is, you know, the Death of Global Health or something like that. The central tension within the history of global health as described in my book, "the History of Global Health," is between a sort of broad based social economic perspective of health and the need for [00:31:00] broad-based healthcare right on one hand. And on the other hand, a vision, which is basically we need to find quick fixes to solve these problems.

We use vaccines or what have you, that there's this tension between a bio technological solution and a a more broad-based social economic sort of solution to the problem. And these two visions exist over time in the history of global health. Oscillated back between those two visions as sort of dominant in the history of global health for the last 20 years, at least it, you know, the biotechnical vision has been the one that's been dominating and almost all the research money goes into finding new bio technologies and applying new technologies to deal with health problems. Right. And the efforts to deal with the broader social determinants of health, or build basic health systems, has received much less attention. Right?

So now we get [00:32:00] to, you know, Trump 2.2 and all the money for all this, for global health is drying up. But what that really means is all the money that's been going into bio technical solutions to global health problems is disappearing. So what that does is two things. One, is it, it's gonna reveal the failure of global health over the last a hundred years to really address the basic causes of ill health or to, or the basic causes of health. And the fact that countries across the globe have become dependent on the availability of technologies to keep their populations healthy. And once that money goes away, once the vaccines go away, once all this stuff goes away, you're gonna see how, you know, sort of bankrupt. It's been in terms of actually making huge forward movements in terms of the health of populations.

And we don't know how long that's gonna last. Is this not gonna [00:33:00] reverse? But the other thing that's gonna happen in terms of dengue is that I'm guessing, and I don't know, you know, I was talking this, um. Who was it? He was at the meeting, Steve. Anyway, who works at the CDC? To what extent the research is already drying up. I mean, the problem with dengue is that barring, you know, getting rid of slums, let's say, you're trying to find ways to eliminate the breeding of betas, Egyptian mosquitoes. If you can eliminate the breeding of Aus Egyptian mosquitoes, you don't have any dengue. Right? And people have been trying to do this for years, decades. And yet really difficult to do. And it was the failure of these early efforts to actually eliminate Aedes aegypti mosquito that has put so much emphasis on trying to develop genetically modified mosquitoes and vaccines.

If those things [00:34:00] aren't gonna be available, then you're either gonna have to go back to, to sort of rethink your model of what it takes to get rid of dengue in a city, or you're gonna have to learn to live with dengue, which is also a, you know, a possibility. We live with the flu, and, but, you're not gonna be able to get rid of it short of finding ways to fundamentally change the, the, the urban landscapes so that you have clean water. You don't have people with all sorts of bottles and jugs full of water that they're providing breeding sites. But I don't know what that's, if that's gonna happen or not, but that's also, you know, on a broader scale in terms of reassessing global health, it's, it's it, this, I mean the, the Dengue case is sort of a microcosm of the larger problem is that we're now left with all of these health problems, many of which have social and economic determinants, which have not been addressed. And you don't have the technologies to fight them. So what [00:35:00] are you gonna do? I mean, you, really is sort of going back to an earlier age, what we're talking about, in terms of the tools we have to, to prevent disease. Now that may be overstating it. And in my more optimistic moments, I, I try to think of this as a really bad, dark age that will eventually end. and it will end when, you know, we're having major outbreaks of measles in Philadelphia. then, you know. You know, people will begin to realize maybe we made a wrong turn here. But I don't, I don't, uh, I think, I think there's gonna be, it is gonna be, you know, tough going for a while.

Richard Del Rio: That that tension in finding tools health challenges was something that, something that struck me on your second chapter on the City of Manila. because it seems like the issue there was there was vaccine hesitancy, and. [00:36:00]

Randy: In the last chapter so the

Richard Del Rio: In the last chapter with

Randy: two last.

Richard Del Rio: valent, uh, vaccine for Dengue, um, what I find interesting is that, you know, it's very, it's very hard for biotech to overcome vaccine hesitancy. And it would seem that the other side of that coin would be the kind of the socioeconomic conditions that can help prevent disease. What do you think the lessons that we learned from this contemporary moment, the history of, of that tension between socioeconomic conditions and biotechnological solutions, can we address this issue of vaccine hesitancy, which the United States that that issue is now reverberating through the halls of power.

Randy: I mean, the vaccine hesitancy in Manila came as a result of the failing of Dengvaxia and the, and the, the threat it represented to, you know, a million children who were were vaccinated. [00:37:00] Um, And I don't, I haven't followed up on the Philippines, so I don't know what's happened with that subsequently.

But. what we're facing now is something very different from what happened in Manila. We're dealing a fa a, the loss of faith in a vaccine without any evidence, right, without anything an adverse really having happened, except for a few people who have a lot of influence, who believe that something happened. But the data from every source I know doesn't support that vaccines have these adverse effects. Or if they do, they're minuscule compare. It's always, you know, and even with the, the, with the dengue vaccine, because the dengue vaccines, the best of 'em now still have , you know, problems.

But you're always weighing it, you know, well, there may be so much percentage of those who are vaccinated that may have an adverse effect. But you're saving another million lives. You [00:38:00] know, there's this kind of balancing act that, that, that is being sort of lost sight of, for those people who are worried about a couple. You know, I mean, it's not, it's not that it's insignificant that there are adverse effects, there's also adverse effects about doing nothing and not vaccinating people, and they're actually much greater than the adverse effects that you're getting from, from, the group that might be having an effect of the vaccine itself.

So I think that it's, it's gonna be a real problem. it already is a real problem. I mean, I'm trying to figure out where I'm gonna get my COVID vaccine. And in Georgia, you know, it, it seems like a moving target because last week none of the CVS we're going to give anyone a, a vaccine because they didn't know what was gonna be covered, what wasn't gonna be covered. Now they seem to be saying, well, we might do it for people over 60. I mean, I don't know what's gonna be. The good news is that the, the medical people say that it would probably the best time is to wait till the end of September and [00:39:00] October anyway, and hopefully something will be resolved. it's a mess. It's a real mess. And you know what Florida's doing is just absolutely obscene. And, you know, I don't know how I, I, I just, I don't know what you can even think about that if it's, you're dealing in a state that has not only a large chi children population, a huge population of elderly who are gonna be ex, you know, running up against children who haven't been vaccinated and are coming down with mumps and measles and God knows what else. I mean, it's gonna be a medical disaster down there, if nothing el if this isn't changed, but you know. So I, I, I, I don't have much else to say about that. It's just an awful situation.

Mia Levenson: I've been really loving this conversation, in general. Just I, the book is just such a, a great read, and obviously connects so much to what is just happening in today and like in the news and what we're reading about. And I, I don't wanna end it on that bummer note, but, but I also wanna [00:40:00] be cognizant of, of time.

So the last thing we can end it on is just to say like, you know. If someone comes along and picks up this book, whether they're, you know, within the medical humanities or they're a historian of medicine or they're just someone interested in the history of dengue, what is the big takeaway that you want readers to, to take from, from this book?

Randy: Well, A) that dengue is an emerging problem that is only gonna get worse, that while we don't know much about it now sitting here in Atlanta, it could be a problem. I mean, people forget that the Aedes aegypti mosquito was causing epidemics in Philadelphia in the 18th century. You know, we were different sort of climatic things, but that the real issue about dengue is the mosquito. The virus is here and the virus comes in every day. this one, you don't wanna be, you know, supporting the anti-immigration [00:41:00] people. But there are a lot of people coming to this country who I'm sure have been infected with Dengue. And Dengue is hugely endemic in Puerto Rico, and there's lots of people coming. I mean, it's just the virus is here, right?

What we don't have is a significant population of Aedes aegypti mosquitoes. And so far our public health system has been able to keep that under control, but I don't know how long that's gonna last. I mean, we have people living in air conditioned settings, but we have an awful growing population of people who are living on the streets. we have a lot of people who are living in less than ideal conditions where breeding of mosquitoes could easily begin to happen. Especially if the, you know, the funding for public health, you know, gets worse than it already is. So to look at it now and say, well, you don't have dengue here now. I mean, yeah, global warming, it could be really nasty, very fast. And I think people need [00:42:00] to recognize that this isn't something that's going to be some sort of curiosity from the tropics. This is a real potential threat.

And the second thing, and it's the way I end this book, is that, you know, this is a, like other books I've written, this is another example of disease which really cannot be brought under control, at least for anything we have now with whatever we have now without some substantial efforts to improve the living conditions of people living in cities. I mean, when it hits Rio, when it hits Dehli, when it hits Singapore, everyone is at risk. Mosquitoes can move from one place to another. but it's, it's a disease which, is particularly propagated by adverse social and economic conditions. And when those conditions are ignored, it appears that all the efforts in the world aren't able [00:43:00] to eliminate them the disease. So I guess those are the two messages I would, I would wanna leave.

Richard Del Rio: The title of Randall Packard's book is "Fevered Cities: A History of Dengue Epidemics." A clearly written book, very informative, and my favorite thing is it's very well organized. So

whether you have 10 minutes or 10 days to read it, you'll get an answer to your question.

Thank you for spending your time with us Professor Packard.

Randy: Thank you very much. I enjoyed it.

Mia Levenson: Randy, this was such a great conversation, thank you.

Mia Levenson: