Infectious Diseases – Dr Richard Meech

Jim Newbigin: It’s 8th November 2022 and our speaker tonight is Dr Richard Meech.

Joyce Barry: Richard is as good as anyone in our area to talk about infectious diseases. Richard is a New Zealander; he was born in New Plymouth, lived some junior years in Westport and landed up in Lower Hutt ultimately, where he did his main schooling. Then Otago University, and I think at university he had his first inkling of being interested in [cough] infection, per se. He had a stint in Cleveland in America as a student and it sparked his interest again, and then he went to St George’s Hospital in London and did his specialist. [Specialty] He also trained as a specialist physician in Wellington Hospital. So a great background; returned to New Zealand 1977 [coughing] and has worked twenty-five years for the Hawke’s Bay District Health Board; retired for seven years now, with his family here.

Now the timing led to Richard[‘s] long history associated with the AIDS [Acquired Immunodeficiency Syndrome] and HIV [Human Immunodeficiency Virus] pandemic as it hit the world. He became an advisor to the New Zealand Ministry of Health about this new disease; he also served as a consultant to the World Health Organisation, and he’s chaired the Ministry of Health’s AIDS Medical and Technical Advisory Committee. He deservedly has been awarded the Order of New Zealand Medal for his contribution to public health, and it’s a great pleasure to welcome him tonight. Richard, welcome.

[Applause]

Richard Meech: Thank you, Joyce.

‘In 1492 Columbus sailed the ocean blue’; sails away with three ships, the ‘Santa Maria’, the ‘Nina’ [coughing] and the ‘Pinta’, and he returned on 15th March 1493. Managed to sink the ‘Santa Maria’ running aground on a reef, and they used it as target practice from the other two ships to impress the natives – as an aside.

When he came back he arrived first in Lisbon, and he spent a week there before sailing on to Barcelona, and a physician by the name of Diaz examined two crew members. He was on board the ‘Pinta’, and that was comprised of forty-four crew members and six natives that they were bringing back. He mentioned all of this in a treatise that he wrote in 1539 when he described what he called the ‘serpentine disease of Diaz’. Now this very, very rapidly spread across Barcelona, then Spain, and it was described by the German humanist [Joseph] Grünpeck in 1494 as ‘a disease so cruel, so distressing, so appalling that until now nothing more terrible or disgusting has ever been known on this earth’. Now this truly was a new disease; there is no record of this disease in the ancient Roman or Greek medical literature, there’s no history of this in Chinese medical literature nor in the Arabian medical literature. It was a disease that was characterised by fevers and sweats, severe muscle, bone and joint aches and pains, a nasty rash that covered the entire body and often resulted in ulcers around the mucus membranes, nose, mouth, eyes, genitalia; in fact often associated with the rotting of the tip of the nose, and artificial nose prostheses was [were] quite a feature of those particular times.

This is the history of how it spread in Italy and France, 1494; 1495 it’s in Germany, British Isles in 1497; over to India, Hungary and Russia, and by the early 1500s it was over in Japan. And everyone called it everyone else’s disease. Here they called it the Spanish disease; here they called it the French disease, [chuckles] and everyone blamed everyone else for this new disease. Johannes Glickman who was actually a mathematician, noted that any Spaniard who was unchaste in Hispaniola caught [coughing, inaudible] … He was the first one who recognised that there was a sexually transmitted infection here, but it was so florid it was also transmitted by non-sexual means as well. This disease became known as the ‘impedimenta of the armies’. In those days when the army marched there was a large baggage train. There were many women in the baggage train, and women became infected with this disease and [cough] transmitted it to the soldiers.

Charles VIII of France had been invited by Pope Innocent VIII to enter into Italy and take over Naples because Ferdinand of Naples had not been paying taxes for some years. And so in September 1494, just one year after Columbus arrives back, he invades Italy with an army of twenty-five thousand which [who] were mainly mercenaries, and they were gathered from all over the world. They advanced down through Italy with no opposition at all; they arrived in Rome and they spent a month of idleness and debauchery. They then marched on to Naples which they took without any fighting because Naples only had an army of about a thousand, and occupied Naples. Again, idleness and depravity was the main pastime of these soldiers.

In the meantime the other Italian states realised that they were in difficulty because we now had the King of France entrenched down in Naples. And so the League of Venice was formed between unarmed Venice and Florence, and they armed themselves and mobilised. And Charles, realising that this was a force that he was going to have to march through to return to France, was not very keen to head home. He did so in July of that year and met the League and they battled at [?Fornovo?] … which I guess on paper you’d say that he won because the League lost four thousand troops and Charles only lost one thousand troops. But unfortunately the reason that there was this discrepancy was that most of the League soldiers were actually trying to nab the baggage train and all the loot that Charles had accumulated. And the end result is that all the booty was captured and Charles returns to France impoverished. The army after this, scattered, and as we said it was a mercenary army gathered from all over the world, and as it [they] spread back to their home countries it [they] took this new disease with them, which then proceeded to spread like wild fire across Europe.

It was only 1530, so we’re only thirty-five years or so after Columbus arrived back that a Viennese physician and poet by the name of Girolamo Fracastoro wrote a poem: ‘Syphilis Sive Morbus Gallicus’, which is ‘Syphilis and [or] the French Disease’ (translation). He wrote this poem about a shepherd who made an offering to the Goddess Aphrodite on a hill that belongs to Apollo, who was very angered by this whole process and split Syphilis with this condition that he described in beautiful Italian first. He is by the way, ranked in the top one hundred Roman poets, and it’s an amazing poem. Syphilis was the shepherd’s name, and that is how syphilis acquired it’s name internationally.

So why are we talking about this today? Well this is a condition that in 2015, WHO [World Health Organisation] figures are that 48.4 million cases are infected; six million cases new a year. It causes over a hundred thousand deaths per annum, and between 2013 and [20]17 there was a seventy-two percent increase in cases of syphilis in the United States, and congenital syphilis which had virtually disappeared from their scene, had started to recur. It is a condition for which we have a cure, penicillin – very simple, highly effective. It’s only [coughing] transmitted human to human. And the reason that we see this escalation is believed to be due to the failure, if you like, of safe sex programmes. As our treatment for HIV and AIDS has improved considerably there’s no longer the fear that used to drive a lot of the behaviour, and because it’s no longer fashionable to use condoms, then we’re seeing these increases not only in the United States but right across the world.

And I think it’s important to pause here and just say, well, we’re dealing with a virus that’s come from an animal source; we’ve got marginal treatments for it. What about this condition? We’ve had treatments for a long time; we still can’t manage this. The pandemic of syphilis was characterised wherever it touched countries by fear panic, hysteria, blaming … always blaming the other people, or another race, or another group somehow or other … scapegoating, false rumours, false theories [sneeze] – fake news we call it now – and quackery. And if you look at that list, and say, well, what have we experienced in the last couple of years? What did President Trump … how many of these could we tick that he’s actually contributed to? Certainly quackery and false news, and blaming people; he’s always calling it ‘the China virus’. Does it achieve anything? Has it achieved anything in the history of infectious diseases? [Cough] The answer is ‘No’. So we’ve been around a long time but we haven’t come very far in understanding how to deal with this.

Now back in 1976 I was doing my training in infectious diseases in St George’s Hospital in London, and I was sitting there reading all of this history of syphilis. And I remember, sort of in a lull, daydreaming and thinking, ‘What would it be like to face up to a disease that was brand new, like syphilis? Not known in any other body of literature, for which we have no treatment? How would we manage today?’ Well, in 1981 – that’s only five years from those musing thoughts – the Morbidity [and] Mortality Weekly Report (MMWR) that comes out weekly in the United States, first described a series of cases of immune deficiency in young men that initially was known as GRID (Gay Related Immune Disease), and we now know as AIDS. HIV was identified in 1985, and we’ve had effective treatment since the mid 1990s and we know that potent drugs are very effective; we have effective tools in being able to monitor what’s happening in patients; we can measure their viral load and we drive that down so it becomes undetectable. We monitor how that benefits the immune system by doing the so-called CD4 counts; we’ve got good handles on this condition and we know that if we control viral replication we prevent completely the emergence of resistance. The problem is that treatment can be lifelong because this virus writes itself into the human genome, and whenever you stop treatment then within a few weeks viral load, which you may not have seen for some years, will suddenly zoom back up and the whole cycle starts again.

So it’s very expensive, and it costs about $18-20,000 a year to treat a patient, and when you’re advising Pharmac and sitting with Pharmac they have grave concerns, because every year the number of people who’re being treated is going up. We hardly ever have people dying of AIDS these days so this has reached a category of a chronic manageable viral condition [mobile phone] that we have excellent treatment for. WHO estimates that there are eighty-four million people [who] have been infected with HIV; over forty million people have died, and at the end of 2021 there are round thirty-eight million people living with HIV – that is point two percent [.2%] of adults in the fifteen to forty-nine year old age group. And of course the big problem area in the world remains Africa, where one in twenty-five adults are [is] infected with HIV and the cost of treating this for an African health care [?] is actually horrendous.

So we have epidemics and we have pandemics – what’s the difference? An epidemic is a localised outbreak of an infectious disease … measles, meningococcal disease. You can have a bad flurry of cases locally or in a country, but a pandemic crosses international borders, it crosses continents, becomes world-wide, there are substantial numbers – that doesn’t have to be defined in any particular number as far as WHO is concerned – and there is limited community spread. What’s the importance of declaring a pandemic? And the answer is that when a pandemic is declared every country has to develop their own rules and regulations as to how they are going to deal with this, and all those international trade agreements that you have formulated and agreed upon – this is what we will do and how we’ll go about it – become null and void while a pandemic rages. It’s each country looking after itself, and we’ve seen classic examples of that.

Pandemics are part of the fabric of humankind; there are mass graves dating back to 5,000BC [before Christ] in China where entire small cities and villages have died off and they’ve all been buried in a mass grave; there’s no trauma there. There is a certain amount of infectious disease archaeology where you can go back, and particularly if you can get teeth out of these skulls, you can determine that a particular organism has caused the outbreak of the infection. So pandemics have existed for a long, long time.

The number one pandemic of course, is plague. This is a bacterial infection that’s due to an organism called Yersinia pestis; it is carried by fleas on rats. The fleas bite humans, they have blood meal and they tend to vomit when they’re getting full, and it’s the regurgitation of that blood [speaking in background] contaminating the [?] that transmits the organism to the human. The oldest case? Over 5000BC from a skull in Latvia, again using the technology I mentioned of examining the teeth, and particularly the dental pulp. There was a major plague in Constantinople in 541 – you can see it raged for about eight years. There were up to ten thousand deaths a day and over the course of this forty percent of the population died of plague. In England there were cycles [cough] of plague every two to five years from 1360 to 1480, and by the mid 1370s the population had been reduced by about fifty percent. There was no treatment for plague.

Black Death occurred in repeated cycles throughout the Middle Ages in Europe where it’s estimated at least a hundred million and possibly as high as two hundred million people died. Entire villages were emptied. It actually resulted in the end of serfdom because it became so expensive to employ people to work the fields in labour, but it was actually a positive spin-off of the black death. There was an [coughing] interesting story here about plucked chickens. A bubo, which is an enlarged lymph node in often the groin or the armpit, would be about the size of [coughing] an egg and possibly up to the size of an apple, and it would be lanced by the surgeons of the day. And you would apply a plucked chicken against this discharging wound. Now the reason they pluck the chicken is that you remove the feathers and you have little bleeding points in the chicken, and the chicken would obviously get infected and die, and that was thought to be ‘draining the humours’. Understand that [chuckles] right throughout this time there was no understanding of infectious diseases. They were thought to be miasmas, [air pollution] or humours, [Theory of Four Humours] or [noxious] vapours, or something to do with the alignment of the stars. There was no concept of bacteria at all. The chicken eventually would survive, and that’s because your immune system has got on top of the infection, but in the understanding of people at the time they would say, “Hah! The chicken has drained all of the badness out of the host”. So actually what was in their mind a treatment for the condition was actually just a marker of what was actually going on within the host, as far as viable organisms.

[Showing slides] This was a saying that was very much promoted at the time when there was a case of plague recognised in your village or your town or your city, “Go far, go fast and stay long.” This is a physician of the time carrying the stick which was required by law that if you were treating patients you had to carry a stick like this. This *beak here was filled full of herbs, often rosemary or lavender. They had little eye pieces here, and so they were able to move around, [with] gloves and feet covered; they’re actually pretty well covered as far as dealing with an infectious organism was concerned.

In London there was an outbreak, 1665 through to 1666. In 1665 there were a hundred thousand deaths, twenty percent of the population in one year, due to plague. The Great Fire of London destroyed forty percent of the city, and of course many of the rats were destroyed and it slowed or stopped the outbreak in London. It still didn’t stop what was going on outside of London but it certainly had a major impact. The advantage as far as London was concerned was rebuilding the city – the streets were much wider, there was a chance to address the sewerage because up to that stage most houses would’ve been three to four storeys high, and the chamber pot would just be emptied out the window, and the person emptying the chamber pot would call out, “Gardez-l’eau” (Beware of the water), [quiet chuckles] warning that they were emptying the [coughing] chamber pot, and out the window it would go. There were mounds of [background heavy traffic] household rubbish just out in the street randomly, including all of the meat and proteins and so forth from the kitchen, that was discarded there. It was a hey-day for the rat, so at least the fire of London enabled a cleaner city to be laid out with wider streets, and it also enabled planning to start addressing clean water supplies, sewerage management and rubbish disposal. And at the end of the day these are the issues that are critical if you’re going to come to grips with an outbreak of plague.

There are still odd cases of plague going on in the world, roughly two thousand cases get reported a year to World Health. There was an outbreak a couple of years ago in Congo where they had fifty-six cases, and regularly in the United States, particularly in the western half of the United States they will have somewhere between five up to twenty cases reported to CDC [Centre for Disease Control] a year. This is a bacterial infection; it is sensitive to antibiotics and we have ways of managing it now that they didn’t have. But these were the big lessons that the presence of plague in civilisation has taught us.

The number two infection is smallpox. This is a viral disease too, very old nature. It has killed at least five hundred million people over it’s history. The first recorded [coughing] cases of the Antonine Plague were in Rome, 165-180AD, and these were soldiers [coughing] who had been involved in the Parthian campaign out on the eastern borders of Rome at that time, returning home. And for about fifteen years there was a rather horrendous mortality within Rome of five million Romans dying ultimately, over the course of this plague; one in four people who became infected died of smallpox. You’ll see that very shortly afterwards, a matter of about seventy years, there was another major plague, the Cyprian, that occurred in Rome with [cough] five thousand deaths per day of smallpox, and the combined impact of these two pandemics was that it probably contributed significantly to the destabilisation of the Roman Empire.

Now we started talking about a disease from the New World coming to the Old World – well, tit for tat, we sent a disease from the Old World out to the New World. 1521, so [cough] we’re talking only about twenty-five years after Columbus discovered the Americas, smallpox toppled the Aztec Empire. Cortés and six hundred troops had invaded what we now know as Mexico; they were confronted by the Aztec warriors and they were [coughing] severely beaten, and about a third of the troops were killed. And they sat there waiting for the final attack to occur, and it never occurred. What they found when they entered the cities, the houses and stockades were full of heads and corpses; it was the same in the streets and ports. One could not walk without treading on the bodies and heads of the dead Indians. The stench was so horrible that no-one could endure it.

And you can see that a mere ten years further [on], Pizarro, with a hundred and sixty-eight soldiers, has victory over the Inca Empire due to smallpox. The story there was that a sailor had introduced smallpox a couple of years before this really small force of soldiers arrived on the scene again. When they were confronted by the army which was disorganised by fear and civil rebellion, all bought about by smallpox, this rather small force was able to triumph over the Inca Empire. So both the Aztecs and Inca Empires were really ceased by the impact of smallpox being introduced from without. Similar sorts of figures in the population of North America as well, where vast tracts of the population were killed by smallpox, measles and influenza.

And one of the things that we see in infectious diseases is that where a group of people have not experienced what we consider as the common childhood illnesses, that the initial impact of these viruses on those populations can be quite devastating. I remember that when I was a registrar in Wellington the hospital employed between twenty and thirty Sri Lankan housemen and registrars, and they were hit by chickenpox. And I saw more cases of chickenpox amongst my colleagues there as housemen than I saw in the rest of my professional life. They were severely ill with myocarditis, overwhelming pneumonia … terrible presentations, and when we talked to them they knew nothing at all about chickenpox – not a disease that occurs in Sri Lanka.

Smallpox … over three hundred million deaths [cough] occurred in the twentieth century alone due to this virus. Now [Edward] Jenner was a general practitioner in the UK, [United Kingdom] and he made an observation that dairy maids developed cowpox on their fingers, and never developed smallpox when there were outbreaks of smallpox, so he ended up vaccinating his own children and they survived through epidemics or outbreaks without any problems. And the notion that – this is again before there was any knowledge of bacteria or viruses – this was a simple observation that you could use this to prevent smallpox. This was the first case for vaccination, and ‘vacca’ comes from the Latin word for cow. WHO declared smallpox eradicated locally in 1980; one of the triumphs of modern public health.

Currently it’s the number one biological warfare weapon in the world. And when the Berlin wall fell down and Russia was opened up, it became obvious that they had hundreds and hundreds of kilos of freeze-dried smallpox virus stored as biological weapons. They had developed techniques to spread this through missiles that would produce little cluster bombs that would pop open at a certain level and produce a whole lot of little bomblets that would spread over a wide area. They would drop down to another level and those bomblets would all explode and spread the virus. And this had been tested and it hadn’t worked very well.

For the last decade or so while WHO was quietly working to eradicate smallpox there were a number of clusters in Pakistan and Afghanistan which were particularly vicious, and the Russians were in there collecting all those viruses to act as their number one [cough] biological weapon. Such is man!

You’ll recognise that we now have a [an] issue with monkeypox virus, which is not likely to be a major international problem [children’s voices] but monkeypox was controlled through smallpox vaccination. When there was an outbreak of monkeypox everyone thought, ‘Well, we’ll go back to all of the stored supplies of vaccine for smallpox.’ And they were woefully inadequate. What does that mean? It means that the world is highly susceptible to smallpox once again. Have we finished with it? Doubt it.

The number three virus is the one that we are more familiar with – influenza. First described by Hippocrates in 412BC, and we are all familiar with the Spanish flu … [19]18-19 … where half a billion were infected worldwide, and there was [were] at least fifty million deaths, and some estimates have put that nearer a hundred million deaths. We talk about this language of H&N when we talk about influenza. H stands for Haemagglutinin, which are like little sort of crochet hooks that stick out on the surface of the virus and they latch on to the host cell. And Neuraminidase is an enzyme that is produced and the neuraminidase receptors are more like little mushrooms that are poking out here. And there are up to fifteen variants on the H, and nine variants on N, so there’s [there’re] quite a few strains of influenza virus.

We call this the big shape-shifter of the viral world. This is an RNA virus and when it enters into the cell it’s highly promiscuous as far as its genes are concerned; it swaps them like crazy. It will pick up whatever genes are loose around the cells, and particularly if there’s a co-infection with an other strain of virus; then it’ll swap genes there quite happily. One virus goes in, and about ten hours’ time somewhere between a hundred thousand and a million viruses will come out. With measles, they are exactly like what went in; with influenza there will be something like two hundred and fifty variants of the virus that come out. It’s a big job for the immune system; many of those will be dud virus, but it’s a very impressive virus when it gets going. It killed more in twenty-five weeks back in the 1918 epidemic than they’d managed to kill in twenty-five years.

You can see here how we see these numbers H&N change if we look at different outbreaks of virus. H1N1 was the big 1918 strain, so whenever this one pops us World Health gets very concerned about things. Most of these viruses will come from the aquatic birds, particularly up in Asian countries, Pakistan right across to China. The virus that comes out of these may not infect humans at all, and there are outbreaks of H1N1 where birds die but humans don’t get infected because we have different receptors from birds. When we talk about receptors, think about a lock and a key – you have to have the correct receptor on the surface of the virus plugging into the keyhole that’s on the surface of the cell. If they match exactly, then bingo! You’ve got viral entry into the cell. But if they are different then the virus cannot get into the cell. So some strains of H1N1 do not infect humans at all. In birds H1N1 tends to affect the gut of the bird and so they get a lot of faecal spread of virus. And then between spring through to summer there is a migration across Asia and Europe and down into Africa of aquatic birds, and then when we get late in the season they migrate back again. And on that course they’re flying over pig farms, and the pig is the big mixing bowl between avian strains of virus and humans because the pigs’ receptors will accept both the avian strains of virus and also human strains of virus. And so you see these are bird ones here, and then we suddenly find a couple of swine flu pops up, and these are going to be strains that have been passaged through pigs; have come from birds but passaged through pigs and now affect humans.

So we have two things occurring with influenza. We have seasonal flu which is where we get an antigenic drift; so you get an H3N2 virus and for about five or ten years it will just drift with subtle changes occurring all along the line, every strain a bit different from what’s happened before.

This virus is, I like to think of, in a hurry. It makes a lot of copying errors along the line and those errors are not picked up by the virus. Now coronavirus that we’ve experienced, is actually what we call a proof-reading frame, and what that means – it doesn’t look at the spell checking before it releases the virus, so that what comes out is pretty much what’s gone in. Mutations are low with the virus that’s got a proof- reading frame. Influenza lacks a proof-reading frame, so it just produces a scatter of viruses.

We have over a hundred laboratories that WHO funds worldwide that are constantly isolating viruses from all around the world. But particularly, southern hemisphere watches what goes on in the northern hemisphere because we know [cough] that if there is an outbreak of a virus that is undergoing drift, and if it occurs up there, we will cop that six months later down here. And so we would regularly look at … say we have to predict what we want in our vaccine strains of virus … we look at what we’ve experienced in this last year, we look at what’s happened in the northern hemisphere, and then we reach a decision that’s going to cover most of those strains, and particularly anything that’s been active in the opposite hemisphere. That is what happens with antigenic drift.

But then every now and they we get anti-genic shift, which is where an H3N2 virus [coughing] suddenly becomes an H1N1. And this is completely unpredictable; random; occurs anytime between fifteen and thirty years, and then we’ll just have six months’ notice that things are changing dramatically and we have to get a vaccine up and running in that time. So this is the problem with antigenic shift, is these viruses that spread by aquatic birds, faeces, migration patterns that cover a large chunk of the world. And of course where the birds that are flying long distances and get hungry like to find a lot of food that’s lying around and not particularly well managed, it’s often around pigsties, and hence [coughing] we get this mixing between bird and pig. This by and large works pretty well except when we get an antigenic shift. Vaccine is available yearly but it has limited efficacy; but on the other hand if you keep having your yearly vaccine it has a cumulative benefit against the current strains that’re undergoing antigenic shift. We also have antivirals that are effective against influenza. So it would [coughing] be a slightly different thing if we ever got a 1918 virus – I shouldn’t say ‘if’ – when we get another virus that’s undergone a major antigenic shift and the government has bulk supplies of [?] purchased moderately regularly.

The fourth one I just want to comment on in pandemics really is cholera. This is a bacterial infection; it’s water-born. It’s killed tens of millions of people. As you can see here an outbreak in 1817 … seven years … fifteen million people on the sub-continent died, and another outbreak here over quite a long period of time, twenty-three million people. This is all about safe and clean water supplies and sewerage management and of course whenever we get into natural disasters, floods, earthquakes, then we get a certain probability that you’re going to get mixing of sewerage with water supplies. And always you hear, “Authorities are worried about an outbreak of cholera”, and yes it will happen.

So where does that leave us at the moment? Well, look at one thing – as I said, pandemics are part of the fabric of humanity; they will happen again. There was a think tank that WHO did about three or four years ago looking at potential viruses, and the discussion came around that there were eight hundred and fifty thousand roughly, viruses [cough] that infect viruses in [cough] birds and mammals, and you can’t really predict what’s going to happen there. Deforestation has increased the contact of man with animals in the wild, and that’s contributing to outbreaks of conditions like Ebola, and also Covid-19. A hundred years ago the world population was two billion; currently – these are WHO figures as of end of October – seven point eight [7.8] billion people. We’ve had almost a four-fold increase in the world’s population in the last hundred years.

Everyday facilities as we’ve experienced are just not suitable in pandemics. Some thirty years ago our hospitals were staffed for about an eighty-five percent occupancy, and we knew that if we kept beds at that level and staffing at that level, that we would be in crisis on about three days a year. Treasury in it’s wisdom insisted that the occupancy be driven up to ninety-five to ninety-eight percent, which means that hospitals, as you are familiar with now, are in crisis for between two and four months every year. They have absolutely no flexibility to accommodate an outbreak epidemic or pandemic. Covid-19 is really the baby brother of the viruses we’ve been talking about; I have said many times that I think it was a good run-in … a trial run of what we would need to do if we really came in contact with one of these other viruses – which is a question of when, and not if. Mortality rate overall is really quite low with coronavirus, hence the sorts of the figures I’ve been talking about before. I think we have to really stand back after this whole business has fizzled out, look very critically at how we plan hospitals, and plan our management and approach to epidemics in future. Thank you. [Applause, DELETED]

Joyce: Wasn’t that great? [Chuckle] Quite depressing, [chuckles] but thank you. Questions please?

Question: Could you run over that plucking of the feather again, thanks? [Laughter]

Richard: You got a chicken and you plucked its feathers out of its … usually it’s tail. That produced little microscopic bleeding points and it would be applied against a bubo … the lymph node that would be draining pus. Now the pus would contain viable bacteria; the chicken would die. And under the understanding at the time, which was that most of this was due to a miasma … a vapour, and that there were bad vapours in the body and the chicken was drawing out decay, which was considered a treatment. As an indicator that your immune system mightn’t be [several members of audience talking, inaudible] … you would end up with this [?] pus that was draining, and the chicken would survive. And so it was a marker of your immune function, not the treatment. That’s what happens when you have theories that are inappropriate, because you don’t understand … [talking, inaudible].

Joyce: Briefly, can you just imagine what those epidemiologists went through standing listening to Trump? [Chuckles] I’m surprised that they stayed sitting or standing.

Richard: I have immense respect for Tony Fauci; I have followed him right through the whole AIDS … he comes from an immunology background and right at the start of the whole AIDS scenario he was the prime lecturer on ‘How is the immune system dealing with this’. He’s incredibly clear thinking, he’s very articulate, and extraordinarily level-headed, and I was absolutely disgusted with the way that Trump treated him, ignored all the advice, and blabbed on about some spurious treatments. [Chuckles]

Joyce: I think also, what people didn’t realise with Fauci is that he was in security the whole time. His family had to shift and they were all given individual security, such was [were] the death threats that occurred.

Richard, thank you so much. Richard has a high interest in just the artistic aesthetics of life as well, and he just told me that he has traced the art of pandemics, which outstripped the knowledge, really. Thank you, Richard, on behalf of Landmarks, the most fabulous talk; a lot of preparation for that, Richard; thank you very much.