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At the intersection of medical geography and disease ecology: Mirko Grmek, Jacques May and the concept of pathocenosis

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History has learnt much from science over the past two centuries, almost as much as science has learnt from history. But it is surely salutary to see science itself as a cultural construction and to remember the extent to which our views, like those articulated by people in the past, are inescapably the product of the world-view of a particular age, society, class and gender (Arnold 1996, p. 189).

Abstract

Environmental historians are not sufficiently aware of the extent to which mid twentieth-century thinkers turned to medical geography—originally a nineteenth-century area of study—in order to think through ideas of ecology, environment, and historical reasoning. This article outlines how the French–Croatian Mirko D. Grmek (Krapina, 1924–Paris, 2000), a major thinker of his generation in the history of medicine, used those ideas in his studies of historical epidemiology. During the 1960s, Grmek attempted to provide, in the context of the Annales School’s research program under the leadership of Fernand Braudel, a new theoretical framework for a world history of disease. Its development was inspired by several sources, most notably the French–American Jacques M. May (Paris 1896–Tunisia, 1975), who was then pioneering an opening up of medical geography and movement towards the concept of disease ecology. The cornerstone of Grmek’s “synthetic approach” to the field was the notion of “pathocenosis”. The diverse uses of this notion in the course of time—from his early agenda focused on a longue durée history of diseases in Western Antiquity to his last, relating to the new epidemiological threat of (re)emerging infectious diseases, specifically HIV/aids—enables us firstly, to note how concepts of ecology sat uneasily alongside those of medical geography; secondly, to assess the reach and limits of his theoretical contribution to historical epidemiology; and thirdly, to understand better the uneven fortunes of his concept of pathocenosis at the end of the twentieth and beginning of the twenty-first centuries.

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Notes

  1. The traces of evolutionism in pathocenosis through the influences exerted by Theobald Smith (1859–1934) and Charles Nicolle (1866–1936) have been recently analysed in depth by Méthot (2016).

  2. Italian edition: Grmek (1993–1998), 3 vols.; French edition: Grmek (1995–1999), 3 vols. The fourth and last volume was published posthumously (Fantini and Lambrichs 2014) and only in French.

  3. Grmek referenced Hirsch (1860–1864, 2 vols.; 2nd ed.: 1881-1886, 3 vols.) and Sigerist (1933, 1951).

  4. In addition, most of the contents of this second article in Annales was advanced, without footnotes, in the proceedings of the 21st International Congress of the History of Medicine held in Siena. On this occasion, Grmek chose to make his neologism (“la pathocénose”) explicit in the subtitle (Grmek 1968).

  5. “La tendence actuelle est de transformer la pathologie et l’épidémiologie géographiques en une ‘écologie des maladies humanes’ inserée dans le cadre mondial” (Grmek 1963, p. 1091).

  6. In 1963, Grmek referred to two works by Jacques M. May, namely the paper “History, definition and problems of Medical Geography: a general review” (1952), and the monograph The Ecology of Human Disease (May 1958) (Grmek 1963: 1090–1091). In 1969a, Grmek again referred to the same monograph by May in addition to the later Studies in Disease Ecology (New York, Hafner, 1961) (Grmek 1969a, p. 1475).

  7. May quoted this monograph using the first volume of its second edition (Sorre 1947). The new edition was complemented by two further volumes, volume II published in two parts in 1948 and 1950, and volume III published in 1952.

  8. The other three papers were given by Douglas H.K. Lee on physiological climatology, Arthur Geddes on malaria in the late nineteenth-century Mediterranean, and Maximilien Sorre on cartography and human ecology. The four works appear to have only circulated among the Congress delegates. Twenty-six years after, they were reproduced in 1978 in the journal Social Science and Medicine, 12D, 207–250. They were preceded by an introduction by A.T.A. Learmonth (pp. 207–209).

  9. “Our approach to medical geography can be summarized as ‘the study of the distribution of manifested and potential diseases over the earth’s surface and of factors which contribute to disease (pathogens) followed by the study of the correlations which may exist between these and the environmental factors (geogens)’” (May 1952, reproduced in May 1978, pp. 211–212).

  10. On May’s medical geography and its disciplinary context, see also Valenčius 2000, particularly at p. 22.

  11. The only two bibliographical references to Pavlovsky I have come across in May’s works are to the former’s handbook of human parasitology in Russian (Moscow-Leningrad, 1948, 2 vols.) with regard to his reporting on the frequent occurrence of brucellosis in the Turkmenian Republic, notably among wild animals and mainly rodents (May 1958, p. 74, 302); and to his monograph, also in Russian, on parasitology of the Far East (Leningrad 1947), with regard to one of the mosquito species involved in malaria in Asiatic Russia (May 1961, p. 184, 545).

  12. Interestingly, in his publications May does not appear to have mentioned the work of MacFarlane Burnet; and his only reference to René Dubos is a few quotations from some articles included in a collective volume edited by the latter with James G. Hirsch, on bacterial and mycotic infections in man (Dubos and Hirsch 1948).

  13. At this point, Grmek extended his criticisms to the whole tradition of history and geography of diseases, from August Hirsch (1860–1864, 1881–1886), Corradi (Corradi 1865–1880), Creighton (1891–1894), and Sticker (1908–1912), to the recently published monographs by Ackerknecht (1963) and Henschen (1966).

  14. A collective volume on the concept has been recently published (Coste et al. 2016).

  15. I will quote this article through Pierre-Olivier Méthot’s English translation (Grmek 2019, pp. 31–40).

  16. Interestingly, Grmek appears to have been reluctant to take on Sigerist’s socio-cultural approach to the history of medicine in teaching medical undergraduates (Grmek 1969a, p. 50).

  17. "It consists of a system with precise structural properties that should be studied so as to determine its nosological parameters in qualitative and quantitative terms" (Grmek 1989b, p. 3).

  18. In 1968, Grmek had first used the phrase “dominant diseases” (maladies dominantes), but he did it to merely refer to “a small number of very frequent diseases” in contrast to “a very great number of rare diseases (maladies rares)” (Grmek 1968, p. 688).

  19. This is not the place to deal at length with these questions, but I cannot hide my amazement at how far Grmek took his speculations about pathocenotic relationships with regard to the two last examples, typhoid and lung cancer: “their antagonism results only from the fact that the first characterizes the pathocenosis of a society with primitive hygiene, while the second dominates the pathocenosis of a technologically developed society” (Grmek 1969b, p. 1480; Grmek 2019, pp. 37–38).

  20. Grmek quoted Preston’s paper “The commonness and rarity of species” (Preston 1948). In the early 1960s Preston published in the same journal two more major papers on the same topic, namely “Time and space and the variation of species” (1960), and “The canonical distribution of commonness and rarity” (1962a, b).

  21. “The relation between the number of species and the number of individuals in a random sample of an animal population” is the title of this important work, which actually includes three different papers, each signed by each of the coauthors (Fisher et al. 1943).

  22. “The distribution of diseases as per their frequency seems to correspond to an interference between the simple logarithmic series and the normal log series" (Grmek 1969b, p. 1481; Grmek 2019, p. 38; my italics). Three years before, at the 1966 London conference, Grmek claimed that he had studied “some morbidity statistics using this method”, and found that “there are either log normal distributions, or log series, or combinations of these two” (Grmek 1969a, pp. 119–120).

  23. Two monographs by Dubos are referred to, namely Bacterial and Mycotic Infections of Man (1948) and The White Plague: Tuberculosis, Man and Society (1952). References to Smith entirely disappeared in Grmek’s further monographs on diseases in the ancient world and on HIV/AIDS, while Dubos continued to be referred to in both monographs through his popular The White Plague (Grmek 1989b, pp. 205, 409; 1990a, p. 160, 233) in addition to two new references, namely Dubos’ informative speech “The evolution of infectious diseases in the course of history” (1958) (Grmek 1989b, pp. 13, 359) and his chapter “Infection into disease” in the edited volume Life and disease (Dubos 1963) (Grmek 1990a, p. 159, 233).

  24. Grmek’s earlier views on the relationships between diseases and demographic movements had been rather more generic than deterministic: “In this global historical vision, diseases take on prime significance as mass phenomena affecting economics, demography and social behavior” (Grmek 1989b, p. 16).

  25. In his speech on the occasion of the tribute to Braudel, Grmek had referred to “the microbial unification of the Mediterranean” and placed it during the first centuries of our era (Grmek 1989a, p. 20). In a later article, he summarised the history of the pathocenotic ruptures in the Mediterranean world as follows: “Des ruptures fondamentales de la pathocénose se sont produites dans le monde méditerranéen au néolithique, aux temps héroïques de la Grèce, à l’époque de l’expansion romaine, puis lors des grandes migrations du Moyen Âge et à la suite de la découverte du Nouveau Monde. Le XXe siècle a connu la plus profonde rupture pathocénotique de toute l’histoire de l’humanité” (Grmek and Sournia 1999, p. 273).

  26. “Nous nous contenterons ici de mentionner seulement quelques événements historiques qui ont entrainé des changements profonds de la pathocènose en Europe" (Grmek 1968, p. 688).

  27. McNeill’s monograph had been definitely quoted in Grmek’s previous book on diseases in the ancient world, with regard to what he qualified as two less abrupt pathocenotic ruptures, namely one happening in the 5th century BC as a result of Greek cities’ colonial expansion, and another at the end of Hellenistic times and during Roman times having resulted from “the microbial interchanges with the pools of Far East and Afrique” (Grmek 1989b, pp. 91–92, 381).

  28. For Grmek’s specific attention to different theories about the origin (Africa versus America) and spread of AIDS agents, see Grmek 1990a, pp. 141–155; 1990b, pp. 235–256; Grmek 1995a, b, c, pp. 253–273.

  29. On the problems inherent in viewing biology and medicine as merely “technical historical tools”—a major methodological feature in the Annales’ approach—, Toby Gelfand acutely noted the following: “Beyond the epistemological pitfalls of plugging modern sciences into fragmentary data from mediaeval and early modern sources, there was a failure to appreciate a crucial distinction between medicine in history and the history of medicine and the difficulties of applying the first without understanding the second” (Gelfand 1987, p. 23).

  30. I have found no trace of the announced article in the extensive “Bibliographie choisie” of Grmek, printed at the beginning of the collective mélanges volume in his honour, prepared and edited by Danielle Gourevitch (1992).

  31. “La distribution des maladies [à une pathocénose en état d’équilibre] en fonction de leur fréquence semble correspondre à une interférence entre la série logarithmique simple et la série log normale. Notons à ce propos que la série logarithmique normale caractérise la dispersion aléatoire des phénomènes en progression géométrique, comme la courbe de Gauss l’exprime pour les phénomènes en série arithmétique" (Grmek 1983, pp. 14–17; quotation at p. 16: my italics).

  32. “La notion de pathocénose est encore peu connue et il est difficile de prévoir sa valeur pragmatique et ses limitations" (Grmek 1983, p. 17); "But the concept of pathocoenosis is still in its infancy, and no one can yet predict its practical value or its limitations" (Grmek 1989b, p. 4).

  33. “La pathocénose, dans son état d’équilibre qui n’est vraiment sensible que dans une population relativement fermée et dans une situation écologique stable, présente une structure mathématique régulière correspondant à l’interférence des distributions linéaire, logarithmique et log normale. La série log normale exprime la probabilité de la distribution des variations dont les classes sont caractérisées par une progression géométrique (comme la courbe de Gauss exprime la probabilité de la distribution des variations en progression arithmétique)" (Grmek 1990b, p. 261, my italics).

  34. An eight-line paragraph close to the end of the article with a bibliographical reference to his 1969 article was all that Grmek had to say there about pathocenosis: “Examining the interaction between diseases is critical to understanding the suppression as well as the emergence of pathological conditions. To this end, the notion of pathocenosis can help us not only to gain a better understanding of the relationships between certain pairs of diseases (e.g. between leprosy and tuberculosis, and between tuberculosis and AIDS), but also, and above all, to better grasp the natural laws governing the relationships between diseases in a given population at a given historical moment” (Grmek 2019, p. 53; cf. Grmek 1993a, p. 296).

  35. “La répartition globale des morbidités particulières tend vers un état d’équilibre qui peut être exprimé par des expressions mathématiques relativement simples (avec la prédominance de la distribution logarithmique normale)." (Grmek 1995a, p. 12, my italics).

  36. "Les maladies qui frappent une population déterminée pendant une période historique donnée constituent un ensemble appelé pathocénose. Il s’agit d’un ensemble structuré dans lequel la répartition des fréquences de diverses maladies présente certaines caractéristiques mathématiques. Ainsi, dans toute pathocénose historique, existe un petit nombre de maladies très fréquentes, à morbidité extrêmement élevée, et un grand nombre de maladies relativement rares" (Grmek and Sournia 1999, pp. 271–272).

  37. “La pathocénose est une structure dynamique tendant vers une condition idéale et qui ne peut être saisie par une formule mathématique simple. Dans l’état d’équilibre vers lequel tend chaque pathocénose, la distribution des fréquences correspond à une superposition de la droite et de la courbe qui s’appelle la normale logarithmique” (Grmek 2001, p. 30; my italics).

  38. See my italics in the relevant quotations at notes 22, 31, 33 and 35.

  39. See particularly the chapters “Les maladies dominantes au xxe siècle” by Joël Coste (pp. 259–278), “Géographie, santé et pathocénose" by Gérard Salem, Stéphane Rican and Zoé Vaillant (pp. 279–289), and "Les maladies émergentes" by Bernardino Fantini (pp. 291–309). More occasional mentions of Grmek’s pathocenosis are included in Gérard Lambert’s “Génétique médicale: de l’exception à la règle" (at p. 52), and Fabio Zampieri’s "Médecine et darwinisme: aperçu historique" (at p. 90).

  40. The works in this special issue dealing more or less extensively with Grmek’s pathocenosis are “The pathocenosis moment: Mirko Grmek, the Annales and the vagaries of the Longue Durée” by Colin Jones (pp. 5–11), “The dialectics of understanding: on genres and the use of debate in medical history” by Frank Huisman (pp. 13–40), “History of disease and the Longue Durée” (pp. 41–56), and “The Galenic plague: a breakdown of the Imperial pathocenosis. Pathocenosis and Longue Durée” by Danielle Gourevitch (pp. 57–69).

  41. In contrast, as mentioned above (p. 13 and note 26), Grmek referred to McNeill’s popular monograph Plagues and Peoples (New York 1976) in the two books he devoted to diseases in the ancient world (1989) and to HIV/AIDS (1990), and he even appears to have been inspired by it in his enumeration of the major pathocenotic ruptures in the history of the Western world. As to Crosby, Grmek referred to him only at his monograph on the diseases in the ancient world, specifically through Crosby’s short newsletter “Favism in Sardinia” (1956; see Grmek 1989b, pp. 228, 414), a work irrelevant to our purpose here.

  42. For Grmek’s remarks on the reasons why medical geography had been discredited since the end of the nineteenth century, see Grmek 1963, p. 1085.

  43. According to Oppong and Huddleston (2014), in the 1960 s, disease ecology moved “away from an organismal emphasis to one centered on relations and functions of systems”, so that “the connection to the natural environment was lost and the ‘environment’ considered in disease ecology became primarily a social one” (ibidem, pp. 1–2). From the 1970 s, disease ecology came to mean “multivariate complexity”, to the point that by the mid-1990 s disease spread was considered to be influenced by interactions among such varying factors as “culture, society, behavior, topography, vegetation, climate, vector, and pathogen ecology” (ibidem, p. 2). Moreover, although traditional disease ecology continues to ignore the role of socio-political factors in disease dynamics, many recent studies, particularly those focused on emerging diseases and on the effects of climate change and globalization, are overcoming these limitations by looking to understand the relationship between disease, humans and their environment through interdisciplinary approaches (ibidem, pp. 3–5).

  44. "Today, a major part of the enigma seems resolved: the current AIDS pandemic was released when a series of circumstances coincided, facilitating the transmission of the highly virulent strains of an old virus, namely sexual contacts of a quantitatively new type (organized homosexual promiscuity, greater liberty in amorous behavior, mixing of diverse populations, travel that significantly expanded the choice of sexual partners); transfusion of blood and blood products; and rupture in the pathocenosis, particularly the great fallout in the incidence of other infectious diseases. Most of these events are quite recent cultural artifacts” (Grmek 1990a, p. 158; 1990b, p. 260).

  45. Grmek 1995b, pp. 272–273. IOM’s views (1992 and 2003) on the causative factors involved in EIDs have been taken into account in a review article on the concept of “emergent disease” by Méthot and Fantini (2014, pp. 223–226).

  46. Grmek 1995b, p. 271: “In 1969, I defined and named the concept of pathocenosis according to which the frequencies of diseases obey certain rules and can be studied using mathematical models”.

  47. Grmek merely referred to a brief magazine article by Tenner, who would later publish a monograph on the question of the unintended consequences of new or modified technologies (Tenner 1997).

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Acknowledgements

I am indebted to José Chabas (Universitat Pompeu Fabra, Barcelona, Spain), Sandra Guevara (CEHIC-Universitat Autònoma de Barcelona, Spain), Pierre-Olivier Méthot (Université Laval, Quebec, Canada), Annie Oakes (Palma de Mallorca, Spain), and Frédéric Vagneron (University of Zürich) for their advice and material assistance; to the participants of the Grmek Memorial Conferences held in London (2005), Geneva (2008) and Dubrovnik (2010), and to the London Conference on disease ecology (2016), for their comments, criticisms and suggestions; and to the anonymous referees and the editors for their comments, criticisms and suggestions.

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Arrizabalaga, J. At the intersection of medical geography and disease ecology: Mirko Grmek, Jacques May and the concept of pathocenosis. HPLS 40, 71 (2018). https://doi.org/10.1007/s40656-018-0236-8

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