This Podcast Will Kill You - Ep 21 Measles: The Worst Souvenir

Episode Date: March 5, 2019

You’ve seen the recent headlines and heard the news reports, but they’re only part of this deadly virus’s story. This week we’re covering the rest. We take you on a one-of-a-kind tour of measles, exploring how this vaccine-preventable virus can wriggle its way into your cells and cause short-term misery and long-term damage. Then we trace the history of this notorious killer from its bovine beginnings to the devastation it wreaked on unexposed populations. The tour ends with a look at measles by the numbers around the world today. If you take home one souvenir from this tour, let it be gratitude for vaccines! See omnystudio.com/listener for privacy information.

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With leading networking and connectivity, advanced cybersecurity and expert partnership, Comcast Business is powering the engine of modern business, powering possibilities. Restrictions apply. It begins with a rigor, followed by heats and chills during the first day. On the second day, there's fever with intense malaise, thirst, loss of appetite, white tongue, not actually dry, slight cough, heaviness of the head and eyes, and constant drowsiness. In most cases, a humor distills from the nose and eyes, the effusion or suffusion of tears being the most certain sign of sickening for measles, more certain indeed than the exanthum.

The child sneezes as if it has taken cold, the eyelids swell, there may be vomiting, more usually there are loose green stools, and, and there is excessive fretfulness. On the fourth or fifth day, small red maculae, like flea bites, begin to appear on the forehead and the rest of the face, which coalesce as they continue to come out in increasing numbers so as to form racimo's clusters. These maculae will be found by the touch to be slightly elevated,

although they seem level to the eye. On the trunk and limbs to which they gradually extend, they are not elevated. About the sixth day, the macular, begin to roughen and scale from the face downwards, and by the eighth day are scarcely discernible anywhere. On the ninth day, the whole body is as if dusted with bran. The common people say that the spots had, quote, turned inwards, by which they mean that if it had been smallpox, they would have remained out longer and have proceeded to separation or maturation. The rash, having thus gone in, there is an access of fever, attenuated with laborers,

breathing and cough, the latter being so incessant as to keep the children from sleep, day, or night. Aw. Wot, want. That's awful. It's not great. No, but that sounds really miserable. Yes, so that was from Sindenham's account of London measles epidemic that happened all

the way back in 1670. But it could be an account of what's... going on today. It really could. It actually was very similar in a lot of ways to things that I read in my textbooks about describing measles. Including the common people part? Maybe not that part. The common people. Hi, I'm Aaron Welsh. And I'm Aaron Olman Updike. And this is, this podcast will kill you. And we're obviously talking about measles if you haven't caught the hint yet. A lot of you asked for it. And we've been wanting to do it. So, Here it is.

Yeah. Thanks for asking everyone. This one is, there's a sense of urgency here, though, which is very real. Yeah. Why is that, Erin? Well, I mean, spoilers. There's measles going on, right? In the world today.

So much measles today. There's a lot that's happening. And I think this is a really interesting one to cover because it deals with a lot of different issues that we have sort of skirted. it around or skirted past maybe touched on very briefly here and there in terms of vaccination, in terms of how to view historical epidemics in the light of today. Yeah. Measles is really one that's going to bring it all home. So I'm excited.

Me too. It's going to be fun. Yeah. So speaking of fun, I think it's quarantine time. Absolutely. And what are we drinking today? Today we're drinking a rash decision. thus named because for the characteristic measles rash and the poor decision making of some people to not vaccinate their children

wop-wap yep yeah we said it okay so what's in this drink that we're drinking well we've got vodka we've got grenadine we've got ginger lique or ginger ale up to you. We've got lime juice and lingen berries. Oh yeah, if you're in Finland. Otherwise, cherries. If you're not in Finland, where lingon berries are so abundant.

Whatever small red berry to mimic the spots of the mees. Yeah. And as always, we'll post the full recipe for this quarantini along with our placebo Rita, our non-alcoholic version, on our website. as well as all of our social medias, this podcast will kill you on Instagram and Facebook and

TPWKY on Twitter. And also, someone has started a subreddit called TPWKY, which is really thrilling. And we have seen the quarantine is posted there. So whoever is doing that, thank you very much. And you should know that Aaron Welsh checks it all the time and loves it and is thrilled. I'm a lurker. Yeah. Okay. So, measles.

Measles. Should we talk about it? I think that's why we're here. All right. We're going to do that right after this break. Dinner shows up every night, whether you're prepared for it or not. And with Blue Apron, you won't need to panic order takeout again. Blue Apron meals are designed by chefs and arrive with pre-portioned ingredients, so there's no meal planning and no extra grocery trip. There, assemble and bake meals take about five minutes of hands.

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relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands caused by constant hand washing and harsh conditions. Working Hands creates a protective layer on the skin that locks in moisture. It's non-greasy, unscented, and absorbs quickly. A little goes a long way. Moisturization that lasts up to 48 hours. It's made for people whose hands take a beating at work, from health care and food service to salon, lab, and caregiving environments. It's been relied on for decades by people who wash their hands constantly or work in harsh conditions because it actually works. O'Keefs is my hand cream of choice in these dry Colorado winters, when it feels like my skin is always on the verge of cracking.

It keeps them soft and smooth, no matter how harsh it is outside. We're offering our listeners 15% off their first order of O'Keefs. Just visit O'Keef's Company.com slash this podcast and code this podcast at checkout. A timeless wardrobe starts with pieces that are built well from the beginning. From the fabrics to the fit, everything needs to last beyond one season. And that's how Quince approaches design. Quince has all the staples covered, from 100% organic cotton sweaters to premium denim made with stretch for all-day comfort and luxe cotton cashmere blends, perfect for the changing seasons.

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now available in Canada, too. That's Q-U-I-N-C-E dot com slash this podcast to get free shipping and 365-day returns. Quince.com slash this podcast. All right, measles. Before I dive into the biology of measles, I want for everyone to know that we are going to be doing an entire episode focused on vaccines, where we'll talk about the history of vaccine development. Well, when I say we, I mean Aaron Welsh. I don't do that. I'll talk about how vaccines actually work in your body to give you immunity. and then we'll talk more generally about the status of vaccination across the U.S. and the globe. Today, we're talking about one disease, measles, that's often a large part of the conversation about vaccines,

and we'll talk about why that is. But I'm not going to talk super broadly about vaccines because I do want to give measles the attention that it deserves specifically, if that makes sense. Makes sense to me. Yeah. So stay tuned, people. Yeah, but we will talk about vaccines because vaccines are an important part of the measles story. Yes. Okay, so, measles. First of all, it's a virus. It's an RNA virus, which usually I say that means it's scarier than DNA viruses because they mutate and they're hard to target.

But actually, it turns out measles has like very low antigenic diversity. So it hasn't changed over its history with humans. We got lucky. Yeah. Very. So that means that the vaccines that we developed way back when are still effective against the wild circulating virus today. So that's like the best news I have for you about measles downhill from here. Oh, cool.

Yeah. Gotta start off on a high, you know. Okay. So when you get infected with measles, the incubation period, which again is that period from when you first get infected until you start showing symptoms, lasts between 10 and 14 days. Okay. Okay. However, you become infectious up to five days before those symptoms start.

You know, those are the deadly ones. Those are the ones. They really are. It's a very, very big deal. And we've talked about it before with flu and things like that. But in the case of measles, the fact that you're infectious before you have any symptoms is an even bigger deal because the are not of measles, which again is the number of secondary infections that a single infected individual will cause if the entire population is

susceptible. For measles, that number is between 13 and 18. Yep. It's the highest one that we know, right? is the highest one we know. Yeah. And what this essentially means is that for every single person who's infected, on average, 90% of the people they come in contact with who are susceptible will become infected with measles.

That's a horrifying statistic. Exactly. Yeah. I mean, if you think about smallpox and how massive of outbreak smallpox was able to cause, the R knot of smallpox is between five and seven. And people are terrified of things like Ebola or SARS. And the R-Nots of those are like less than two for Ebola or between two and three for SARS. Yeah.

And yet, measles is this thing that infects almost everyone who comes into contact with an infected individual. Do you remember what the R not is of the virus that's in contagion? I don't remember what it actually is. I remember her listing. I don't know if they ever actually said it because she just was like, we need to figure out what the R not is. But I don't remember. Yeah. We'll have to look it up.

I remember her writing on the board, measles, 14. Yeah. I think she wrote polio on there too, which was like six or seven. Yeah. Anyways. Okay. let's get worse. Okay, so measles is transmitted, airborne, not just in respiratory droplets, but actually airborne. I told you it gets worse. So what that means is that measles can stay

the virus, infectious measles viral particles can stay suspended and alive and infectious in the forking air for up to two hours after an infected person. And so, you know, person leaves the room. Wait a second. So it's sort of like, you know how pig pen in peanuts, when he's got that cloud of dust around him? So if he were a measles kid, it would just be a cloud of measles that would stay in the room two hours after he left. Yeah, that's the thing. It stays in the room. And so what happens when there's, okay, we have had some measles cases here in Champaign. And every time there's a new case, public health sends out an alert. And they give you a list of all the places that this person was during the time that they were infectious, along with the

times that they were there. And those times include a two-hour window after that person left, because the room itself remains infectious. Good gracious. My God. Okay. All right. Let me summarize the things we've learned so far. Measles is a virus that if I have it, before I even know I'm sick for five full days, I can be walking around, breathing, coughing into a room. And once I leave that room, for two hours, people can walk into it and become infected by the air which contains my measles. And if those people are susceptible, meaning if they're unvaccinated, 90% of them will become infected. And then for four to five days after my symptoms resolve, I'm still infectious.

Oh, wow. Yep. I'm just wondering the total amount of time that an individual is infectious. The total amount of time is probably a good two weeks. Okay. So, okay, so let's talk about the symptoms. It starts, as the name of our future spin-off podcast, would suggest, with a fever. And in this case, with measles, we're talking about a really high fever, often up to 104.

Oh, 104 Fahrenheit, 40 degrees Celsius. So the virus invades your bronchials first. Your bronchials are the tubes in your lungs where the air goes. It infects the epithelial cells, which we've talked about a lot in this podcast because a lot of viruses infect those epithelial cells, which are the cells that line your bronchials. And so that's why the first set of symptoms that you see after fever are respiratory symptoms, a cough, runny nose. You can get conjunctivitis if it moves up into your eye. And then within two to three days of after symptoms begin, you'll often get something called, I believe it's coplic.

It might be coplic. Oh, yeah. Coplic spots. Yeah. I read about the dude. Yeah. Oh, cool. So these are these small white spots in your mouth.

And while these spots don't appear in every single case, they are a very common manifestation. and there's pretty much nothing else that causes these particular types of spots. So they're what we call, you're going to learn how to talk like a doctor, pathognomic for a disease. Pathognomic, it's a really fun word. It basically means that it's a specific symptom that is very specifically characteristic and indicative of a particular disease. So once you see this symptom, Coplec spots,

you can say that kid has measles. Can you spell that? P-A-T-H-O-G-N-O-Monic. Huh. Pathan-Monic. It's a weird word, yeah. But so other examples, we've actually talked about some other diseases that have pathonomonic findings. Ricewater stool is pathonomonic for what disease?

So it's like a dead giveaway of cholera. Exactly. Yeah, it's like dead giveaway. It's like there's nothing else. There's no other diseases that you would see this symptom in. essentially. So anyways, that's your vocab word for the day. I love it. So after those coplick spots, in another few days, you'll break out in a rash. And this is the classic measles rash. It's often called the bucket of paint rash. That's how I learned it in class. Can you explain to me

what that means? Because you suggested that as a drink name. It's like if someone took a bucket of paint and spilled it over your head. Okay. Because the rash starts up at your hair line. And then it slowly works its way down across your face, over your trunk, onto your arms. So it's literally like if you took a bucket of paint, like the Gatorade buckets after a football game or something, and you dumped it on top and now you have Gatorade dripping down your face. Okay. So it's like the trajectory of where it's going to pass through. Not that you look like a bucket of paint has been dropped on you. Well, it also is that the rash becomes confluent.

And so it does pretty much cover your whole body. So it starts out as individual spots, but then those spots kind of merge together. So it does, I mean, it doesn't actually look like paint because it's your skin, but, you know, doctors. But that does help me visualize what this, what this looks like. Yeah. Oh, good. I'm glad. And so that rash, that rash is mostly caused actually by your immune system, killing cells that are infected with the virus. So not caused by the virus itself necessarily. Okay. Now, in most cases, this rash is kind of one of the final symptoms. After a few days of this rash, both the rash and the fever will start to subside and you'll recover in most cases.

But not everyone will recover. For every 1,000 people infected with measles, one or two will die. And at least one will develop acute encephalitis, which is an infection of your brain, that can cause permanent brain damage. You can also get a lot of secondary bacterial infections like pneumonia. which is pretty common after a measles infection because of the damage that measles does to your respiratory tract. Right. But, and this part is a really big deal, measles also causes suppression of your immune system

in general. And not just while you're infected, but for weeks or months after infection, after you recover, if you recover, you're immunocompromised, which, means you're more susceptible to infection from other pathogens. And not yet done, it gets even more serious than that because recent data has shown that infection with the measles virus destroys your immunologic memory. What? So yes, this is the part I was hoping you didn't know because it's so terrifying. So it destroys. It destroys. your immune system's capacity for memory.

And our immune system is essentially built on the fact that we have cells that live for a really long time and provide us with defenses against things we've already been exposed to. That's what immunologic memory is. Measles wipe that out. So anything that you had been previously exposed to and should be able to fight off, you can't. It's like you had never been exposed. Oh my God. Okay. First question. Okay, I have two questions. Okay. The first one is that you said that it destroys the capacity. So does that mean that if you get infected, let's say with something again, then you will not develop protective antibodies to that? You could continue to get reinfected with that? So I, that's a really good question. I don't know if it, it transiently suppresses your immune system overall. And then it wipes out all of your memorandum. cells. But I believe after the period of immune suppression, so like after a few weeks or months, you would be able to then mount an immune response, but it's just that it would have,

it would be like mounting an immune response all over again, like you had never been exposed. But once that, once you had been re-exposed to whatever it was, then subsequently, if you were exposed, that you can still build memory. It's just sort of, it wipes out. It's basically clears that your hard drive. Yeah, starts you back at zero. And you add stuff again. Okay. Yeah. Second question. Yeah. How? Great question. There is a paper on that, but it was getting very in-depth, technically, on the like, this is how these immune blah, blah, blahs, and I couldn't deal with it. So I'll link to that paper. Okay. Yeah. And the other thing is I don't think that it's entirely clear. This is a pretty recent paper. We didn't realize just, we knew about the short-term suppression of your immune. system. We didn't know until very recently, and the way that we actually found this out is looking at long-term data trends of mortality rates. So I don't think that it's entirely clear. There's mouse models

that show that it's possible for measles to wipe out those cells, but it's not 100% clear how the heck measles is so powerful and destroys your immune system so much. That's amazing. It's, oh my gosh. So measles infection is not just, it can kill you by killing you outright. It's also associated with short-term increases in opportunistic infection and long-term, I'm talking years, increased mortality rates due to non-measles disease. This is something that makes a lot of sense in light of vaccination. because what we know is that vaccination with the measles vaccine not only protects you from measles, but at a population level, it decreases mortality from non-measles diseases for years after vaccination. And the reason that that is what's happening with vaccination is because of how strong the effect of infection with measles is on your immune system.

It just destroys it. I think that the long and short of it is that being vaccinated against measles and getting measles naturally and then gaining immunity to it are not the same thing in any respect whatsoever. Exactly. Being naturally infected will lead you to have adverse health outcomes, probably ones that you won't even realize. Vaccinated protects you. Exactly.

They're not even comparable because that's something that I think a lot of people, you know, it's like, oh, well, why can't I just let my kid get the chicken. instead of, you know, giving him the chickenpox vaccine or whatever. And in this case, especially with measles, that is not the case. Vaccination protects you not just from measles, but it protects your immune system. An infection with measles wipes your immune system out. So it's amazing. So remarkable.

I had no idea. I'm glad. It was really fun to get to tell you. Yeah. Yeah, so that is, that's measles. That's the virus. That's how it makes you sick. So, that's all I've got, Aaron. Okay. So how did we get here? How did we learn how to fight this sucker? It's a good story. Cool. Shall we take a quick break? Let's do it. But for real, because I'm going to get a quarantini. Anyone who works long hours knows the routine. Wash, sanitize, repeat. By the end of the day, your hands

feel like they've been through something. That's why O'Keefe's working hands hand cream is such a relief. It's a concentrated hand cream that is specifically designed to relieve extremely dry, cracked hands caused by constant hand washing and harsh conditions. Working hands creates a protective layer on the skin that locks in moisture. It's non-greasy, unscented, and absorbs quickly. A little goes a long way. Moisturization that lasts up to 48 hours. It's made for people whose hands take a beating at work, from health care and food service to salon, lab, and caregiving environments. It's been relied on for decades by people who wash their hands constantly or work in harsh conditions because it actually works. O'Keefs is my hand cream of choice in these dry Colorado

winters when it feels like my skin is always on the verge of cracking. It keeps them soft and smooth, no matter how harsh it is outside. We're offering our listeners 15% off their first order of O'Keefs. Just visit o'keefscompan.com slash this podcast and code this podcast at checkout. On eBay, every find has a story. Like if you're looking for a vintage band tea. Not just a tea.

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I think we should call it Doctor. Connecting homeowners with skilled pros for over 30 years. Angie, the one you trust to find the ones you trust. Find pros for all your home projects at Angie.com. The measles virus probably came from something like bovine rinder pest. Oh! Future episode. Someday.

Or canine distemper virus. But archaeological evidence isn't really clear on that, so we don't really know exactly where it came from. Okay, but what do we know? Well, we know that the measles virus would have needed a pretty large population density with a sufficient influx of susceptible people in order for it to be sustained. Makes sense. It's a crowd disease. Yeah. But saying pretty large population density isn't exactly me being precise.

So let's get some precision here, Aaron. I mean, that's my middle name. Not at all. Okay. But there is some pretty cool math here, actually. All right, so some researchers calculated that the virus has to move to a new host at least 26 times a year if it's going to survive in a population. Interesting. That makes sense if it's two-week disease.

Yeah. Yeah. At a bare minimum, there needs to be 26 susceptible people in a population every year for measles to persist. Okay. But there are a lot of butts. But then those people would have to be in close or frequent enough contact for transmission. And then, you know, once infected and hopefully recovered, you were immune. So new susceptibles had to come in from somewhere, either being born, whatever. Basically, while in theory you only need 26 new hosts, but in practice, you need a whole lot more. So the real, the more reasonable estimate was calculated to actually be, A population, this includes both susceptibles and immune, of 250,000 people. Wow, that's a huge jump up. And so that's for maintenance to keep the virus around. Right.

Because otherwise, I mean, of course, the virus could get into a population and sweep through it, no problem, of any size. Right. But this is for these cyclic outbreaks to happen. Yeah. But yeah, that is a pretty big size. So then when and where did people start to even form settlements that big? Yeah. The authors of this measles book that I read, which, by the way, has a million cool maps and figures so full of information.

Holy cow. So many. They did so much work on it. Anyway, so they started looking through archaeological records to make a list of possible places where, A, there would be enough people. And B, there would also be agriculture and exposure to domesticated animals, because that's That's probably where the virus came from. And so then they came up with a list and dates for these so-called urban nuclear areas, most of which were in the fertile crescent, but some were also in Central and South America and West Africa.

But the most likely place where measles was first established was in Sumeria in the Tigris and Euphrates River Valley, around 3,000 BCE. Wow. So it's old. That's a long time ago. Five thousand years. Yeah. Okay. Cool. So. Done.

There we go. Established. And that's the history. We've got measles. Okay, but still we're there. Measles, Sumeria, 3,000 BCE. Okay. But it wasn't there for long, or at least it wasn't only there for very long. Measles did what diseases do. Spread. The virus spread north to southern Europe, the rest of the Middle East, and East East East. India, China, and Japan, where early writings indicate it was there by like 300 or 800 AD.

Wow. As for Africa, measles didn't seem to establish there the way it did in Europe and Asia, possibly because of lower population density. I don't know. Possibly because of physical or landscape barriers making pathogen exchange not super frequent. Or possibly it was there and we just don't know about it because there aren't as many written records. Okay. I don't know. Distinguishing between measles and smallpox and historical text is really quite tricky.

That makes sense. Yeah, I mean, physicians didn't often, or at least at various points, didn't make a distinction between the two. But that would change in the Middle Ages when measles really came into its own. It's like, I need to distinguish myself. Listen, I'm my own person. I'm my own person. Measles going through its teenage years. Yeah, I mean, that sideswept bangs and the heavy eyeliner top and bottom. I can't. This is hitting too close to home. Yeah, I know, right, right?

Okay. All right, so by the middle ages, which let's say the 5th to 15th century, measles was fully established throughout the old world. I mean, it was there. If the population center was big enough, it was there. Although I wonder, I read this as a little side note to myself, I wonder how the black death, the bubonic plague in the 14th century, how that disrupted the measles epidemic pattern.

Oh, it probably just, it screws everything up as we saw, as we've seen. I just want to know. I didn't look it up, though. Okay. Anyway, so during the Middle Ages is when physicians started to recognize and describe measles as a disease, although the term measles, for instance, was used to refer to to the lesions from leprosy. And so it's not fully clear when it switched from being used interchangeably to being

reserved just from measles alone. Okay. But the earliest reference that we can say for sure is talking about measles is from the physician Razzis, which was Latinized from, I'm going to try to pronounce this. Do it. Abu Bakar Muhammad Ibn Zakaria al-Razi. So he was from close to where Tehran is today. Okay.

Not only was he one of the first people to suggest that a fever might be your body's natural defense against a disease in like the year 900. Wow. He also wrote a whole treatise on how measles and smallpox were different things and how to tell them apart. Cool. Also in 900. Wow. Super cool. That's awesome.

All right. So now all of that was just me laying the groundwork for getting to the real part of the story, which is 1,500. hundreds onward. Okay. So by 1500, which is the end of the Middle Ages, measles was established in pretty much all parts of the old world. But how much of it was actually impacting populations? As we've talked about, if you want to trace historical patterns of disease, you have to rely

on some pretty iffy records. One of these, which is absolutely fascinating, I came across, is the London Bills of Mortality, which I think was started to keep track of play. plague outbreaks. Oh. But now they're a goldmine, not just for, like, statistics and looking back words in time, but also for ridiculous names for diseases. For instance, in 1665, which was a plague year, 397 people died of, quote, rising of the lights,

which had to do with lungs, possibly croup. Okay. 86 people died of King's Evil, which. is tuberculosis, scrofula. Because they got it from the king. Well, this was the whole royal touch era. Right. The king didn't cure them.

Yeah. And five died of distracted. Distracted driving. It happens early. That horse and buggy. When were buggies invented? Okay. Anyway, but you should look into it.

It's fascinating. And you'll also see some recognizable ones on there, you know, scurvy, leprosy, smallpox. and so on. And even though these records are incomplete and not super reliable, they can help to paint a picture of some of the disease trends, especially year to year. In London, there were measles deaths every year from 1676 to the mid-1800s, which shows that the disease was fully endemic. Yeah. But if you look at the yearly trends, you can also see that there were some years with a lot of cases and some with just a few. And the interval between these outbreaks got short.

shorter and shorter as time went on, and the deaths due to measles also grew, probably because population was growing, probably because crowded conditions, nutrition, et cetera, et cetera. And measles was also not just variable year to year, but also throughout the year. So it was a very seasonal disease. You knew that it was springtime in Europe when measles was on the rise, and then smallpox would follow in its footsteps in the fall. and some researchers have suggested that the measles epidemic in the spring weakened the population and led to a super intense smallpox epidemic in the fall.

Oh my God, are you serious? Yeah. Oh, dude. Yeah. Oh, it's really, yeah. Oh, my gosh. I love it. Flabbergasted.

Good work. Thanks. So this seasonality of measles was viewed. as evidence that the origin was my asthma. Bad air. Of course. But a few people said, no, no, it's infected clothing or other agents or the air.

And, you know, but measles would shown to be contagious conclusively by someone with probably only the best intentions. The Scottish physician, Francis Holm, had heard about Turkish physicians inoculating against smallpox. And I thought, no, I bet I can do that with measles. First, he tried to get some pus-like material from the rash and bumps of his volunteers,

but I guess there wasn't really... It's a pretty flat rash. It's not really a pussy situation. So he's like, I'll just go for the blood. The blood's fine. So he sliced open the most measly section of measles. The most measly. It's awful.

And then he soaked... Put some cotton balls in there to soak up the blood? No. And then he sliced it. open the arms of 12 children and put those blood-soaked cotton balls. Oh, my God. This guy. What on earth? Well, he, um, 10 of the 12 came down with measles. Shocking. But he was like, oh, no, it's much milder. It's, it's super mild. I don't know for sure whether it was milder, but they didn't die. And he viewed his experiment as a success. I'm sure he did.

It was debated amongst his peers. So, okay. But let's go back to some of these measles outbreaks, though, because, you know, I say, oh, an outbreak happened there and an epidemic happened here, you know, but what numbers really am I talking about? For instance, the great Glasgow epidemic of 1808 led to 787 measles deaths, most of which were children, out of a population of around 100,000 people. Oh my gosh. Which, you know, compared to some of the other diseases that we've talked about, looks like a relatively small mortality rate. But measles did still kill. Yeah. When he was 73 years old, Louis the 14th lost his son, his grandson, and his great-grandson, all within 11 months of each other to measles. Whoa.

So his sole surviving great-grandson would succeed him at the age of five. Whoa. So I don't claim to know anything about French history, but a quick Wikipedia skim tells me that Louis the 15th, which is the five-year-old who didn't die of measles, was one of the longest reigning monarch. and also the one whose excessive spending helped to lead to the collapse of the government and the French Revolution, and thus his grandson being beheaded. So, measles.

So pretty much we have measles to thank for the French Revolution. I just wanted someone to write an alternate history book on an org TV show of what would have happened if measles didn't wipe out so much of the French royal line. Wow. Also, I didn't know that Louis XIV lived to be so old. 73. That's old. Yeah. Back then.

Well, he lived, I think, a few years beyond that as well. Wow. That's just when he lost everyone. That sucks, by the way, for them. Yeah. But in general, measles was viewed in Europe as a moderately deadly disease that killed mostly children. But let's remember a couple of things about that. First, there are many other diseases going on at the same time that had horrific mortality rates like plague, smallpox, tuberculosis.

etc. that may have overshadowed measles deaths and second these are populations that have some history of exposure to measles. But what happens when measles gets into a population that has never experienced it before? Can you tell us? I think I'm about to. Excellent. So let's go to the new world for another round of Colombian exchange. Oh no. Guess how many people die? So you know those quaint measles mortality rates of like three to five percent, seven percent, whatever? Or even lower these days? Oh, yeah, way lower. Well, those are going to seem ridiculous to what I will tell you about the new world.

So Caribbean islands and Central American regions were the first hit by measles and other diseases brought over from Europe. And Cuba, for instance, may have lost up to two thousand. of its entire population due to measles in 1529. Oh. Two-thirds. That's my plague status. Yeah. Jesus.

I had no idea. I didn't either. Measles was the leading cause of death in many of these places, competing with smallpox, typhus, mumps, influenza, et cetera, et cetera. Wow. Yeah. I mean, the history of, of measles in the new world reads pretty much like you would expect it to. Just a horrific tragedy.

The conquistador Francisco Pizarro brings it to Nicaragua and then to Peru as he's on his mission to destroy the Incan Empire. And then from there, it just sort of spreads all throughout South America, completely unimpeded by anyone or anything. And it also moves north, all within the span of a century or so from when Columbus landed. But it's not like it swept through killing an enormous chunk of various populations and then disappearing. It became endemic in many of these regions with more major epidemics happening at irregular intervals, killing thousands regularly. So mortality rates, they ranged from 60% at the beginning, then 50, then 25, then 16, You know, sort of slowing down or creeping down a bit over time.

Right. As the immune population built up. Right. And obviously it's hard to separate out the effects of measles and smallpox and all these other diseases that were going on at the same time. But measles took a much larger toll than I knew. Yeah. It did. Yeah.

So measles and smallpox are considered to be the two big killers. of Native American populations of the new world with only smallpox outranking measles and the number of deaths caused. Wow. And measles was also an epidemic disease and European settlements in North and Central America, primarily affecting children, but also every now and then getting its grip on a larger proportion of the population. And it seemed for some reason like measles was more severe in the colonies than it was back in Europe. And our good friend, Cotton Mather. You remember him?

Why does that name sound familiar? Smallpox. Oh, I have such a hard time airing with the names and the dates and things. Cotton Mather. We lost our minds over it. I believe you. I'm pretty sure it was smallpox. Anyway.

Well, poor Cotton lost his wife, three children, and his maid to measles in a span of two weeks. Two, oof. Mm-hmm. He has a bunch of, I found an article. that had his diary entries during this time, and it's really heartbreaking. Yeah. So he noticed this big difference. He was like, why is it so deadly here?

Back in Europe, you know, this is seen as a routine illness. And probably it had to do with the lower population density, maybe a larger susceptible population was built up. But yeah. Also, I wanted to shout out a listener named Meredith, who sent us an email, who had some fun cotton-mathered tidbits, such as the fact that he may have been an instigator of the Salem Witch Trials, and his father's first name was Increase. Just fantastic.

Oh, I remember that. Okay. Over the years from 1840 to the early 1900s, the world's population grew tremendously, so almost doubled. And during this time, we see a lot of measles epidemics of two. kinds, so the typical cyclic measles outbreaks in endemic countries, and the epidemic devastation in naive populations. Broadly, urbanization increased, as did transportation, and as did our understanding of how measles spreads. Okay, so this dude named Peter Ludwig Panum, who is the measles guy.

Okay. He really set the groundwork for what we understand about measles, or at least what we did going into the 20th century. How measles moves through a population. And so he developed all this information when he was tracking an epidemic in the Faroe Islands in 1846. So in 1846, in the Farrow Islands, there were 7,782 people living there. Of those, 6,000 became infected by measles. Whoa. So that's 77 percent. Okay. became infected, because the population was isolated. They had never had measles. So this dude,

Panam, went to the Faroe Islands to watch the spread of the disease, making observations such as incubation period, classic symptoms, the time when someone is most infectious, so on. And he also noticed that all age groups seemed to be impacted, which wasn't normally the case. So he was like, oh, this could be because the population has never experienced it before. and so on. So it was a pretty big conclusion to draw back then, and it made a big impact in terms of understanding future outbreaks and how they differed among different populations. So the final big impact of his report on this epidemic was his complete dismissal of my asthma as the way it spread. He was like, no measles is clearly contagious, and the only way to prevent someone from getting infected is to isolate

the infectious person. It's the only way. As for mortality rates due to measles, they did drop over time. But again, looking just at death due to measles infection during the epidemic is only going to show you the tip of the iceberg. Because of all of these things that we talked about, immunocompromise, this immune system forgetfulness. Not really forgetfulness. Descimation, really. Yeah. So major cities like London and Glasgow would see a few thousand cases of measles every year with a few hundred deaths. Iceland experienced some intense epidemics, for instance. To quote an Icelandic surgeon during the 1846 epidemic, it would be easier to count the people who escape the disease than to count those who were affected by it, for it spared very few.

Wow. So similar was Hawaii who lost one-fifth of its population over the decade between 1850 and 1860. Whoa. Uh-huh. But also even in places where measles was supposedly endemic, like in the U.S., measles could still cause a huge problem. During the American Civil War, over the course of that, over 204,000 troops were killed on the battlefields due to, you know, fighting. but over twice that number died of disease. Not measles alone, but just disease. Camp measles was one of them. So camp measles seemed to be more severe than regular measles. Weird.

Yeah, and had much deadlier complications. So you probably wouldn't die directly from measles, but you'd probably die from how it had weakened you. and sort of in more foreshadowing of this whole thing, some surgeons during the war said that they thought the bulk of all serious illnesses, nine out of ten cases during the Civil War, were traceable to measles. Wow. All right.

If you've ever learned the term virgin soil epidemic in a biology or public health class, never heard that term? No. Virgin soil epidemic? No, I haven't. It's basically like naive population epidemic. Oh, okay, all right. Yeah.

But, okay, if you've heard either of those terms, it was probably in association with the Fiji measles epidemic of 1875, which destroyed close to a quarter of the entire population of that country. Let's track the sequence of events. In September 1874, the most prominent chief of Fiji, King Kakobao, signs over Fiji to be under British rule. obviously this was a big deal politically and many discussions had to follow so that people could figure out how things were going to fall out basically how things were going to work after Fiji became part of the British Empire. So King Kakabal, along with a couple of his sons, went to Australia to chat with the governor of Sydney.

While there, Kakabal picked up measles. But he recovered before getting back on the ship. But his sons didn't. So their illnesses weren't detected until they were well on their way back to Fiji. And the doctor on the ship was like, okay, you guys are sick. You're going in an isolation room. But when the HMS Daito arrived at the Fijian capital on January 12th, 1875, no yellow quarantine flag was flown and no notice of measles was made. Oh, no.

Over the next 10 days after the ship got back, about 69 high up political people from all over Fiji and other nearby islands came to Kakabah's house. And other political gatherings were taking place to discuss what it meant that the kingdom of Fiji was no longer. So everyone after this goes their separate ways back to wherever they had come from. Oh, no. Bringing measles back as a souvenir unexpectedly. The worst souvenir. Within a couple of weeks, nearly all of those 69 chiefs would be dead. And the epidemic would be unstoppable.

Cases exploded. It just tore through. Oh, my God. I mean, it was enormously high mortality, which was probably exacerbated by the breakdown of infrastructure and any medical attention as there just weren't people around to do it. It was also a really bad year weather-wise with lots of hurricanes, which meant ruined crops and starvation, or at the very least, poor nutrition, which makes measles more deadly. Vitamin A deficiency, really bad. Very bad. So for two months, the epidemic raged, and the rest of the outside world had no idea because all of the harbors were closed to isolate the islands to not allow any more cases in or any more cases out.

So at the end of those two months, the world was like, how many people died? How many? In a population of around 150,000 people estimated, 40,000. 40,000 died of measles. No one, virtually no one was spared. And a quarter of the population died. Oh, my God. Mm-hmm.

I had no idea how absolutely devastating measles has been. Me neither. Yeah. I'm so glad we're doing this episode. Me too. On that note of the Fiji epidemic, I came across this incredible paper by Dr. David Morin's about this epidemic and also reexamining it in light of today, in today's political climate, in today's educational system.

It was just a really eloquent, wonderful read, and we will definitely link to that. Moving on. In the first half of the 20th century, measles was endemic nearly everywhere, at least in all places with the population large enough to sustain it, and it had its fun during both World Wars. Of course.

But fortunately, the reign of measles was coming to an end, or at least that's the illusion. Okay. Although the mortality rate due to measles had dropped quite a bit in the 20th century, it was still killing children, so it was still a big priority for vaccine development. Enter John Enders. So he's the reason I suggested the quarantining name Ender's fame, which would have been so good, just slightly too obscure.

Yes, quite obscure. Maybe we can make a t-shirt. Oh, my God, Ender's fame. Ender's fame with the design of the Ender's Game Book. Yeah, 100%. But I've mentioned him at least once before on the podcast, I think in the context of polio. Because he's the super famous phirologist who, among other things, isolated the polio virus, which allowed people to make a vaccine, Salcan Sabin, and won Enders the Nobel Prize in 1954.

Okay, that does sound vaguely familiar. Okay. But in that same year, so in 1954, he and another scientist named TC Peebles isolated the measles virus from an 11-year-old boy. And having this virus that they could finally isolate, they could then measure it to see how much virus was present in a particular culture, which made standardization really possible. So anyway, vaccine was just around the corner. Cool. So within six years, they had a vaccine they could test. Wow.

Which they did on... Uh-oh. 1,500 developmentally delayed children in New York City. Oh, dear. And 4,000 children in Nigeria. Oh, God. It's like we just never managed to get it right, do we? Oh, dear.

But what I can tell, those vaccine trials worked. Oh, thank God, but... Fortunately. It's not that much solace. I know, I know. And mass vaccination campaign started shortly after in 1963. So in the first two years of the campaign, over 10 million doses were given to kids in the U.S. But that wasn't enough.

And the vaccination effort wasn't equal in all places. So for instance, rural and inner city areas had lower rates of vaccination. So new initiatives were planned. The target was to get at least 90 to 95 percent of the population vaccinated, because that was the only way to actually break the cycle of outbreaks. Yeah. The year before the vaccine was introduced, there were over 481,000 cases of measles in the U.S. Within four years, that number had dropped by more than half, and by 1968, there were only 22,200 cases in the U.S.

That's amazing. Bananas. But then tragedy struck because all of the campaign funds for the U.S. measles were diverted for the Rubella vaccine and vaccination rates for measles dropped. And as a result, they tripled a few years later. Oh. The case is tripled. Interesting.

But anyway. I bet I know how they fix that problem, though. MMR? Yeah. They just put it together. I mean, you just put it in the same vaccine. Well, when I read that sentence, I was like, but wait a second. Weren't they the same vaccine?

Yeah. I want to quickly shout out some of the measurable possible. positive impacts of the measles vaccine in the first 18 years of its implementation. Okay, so cases averted between 1963 and 1981, an estimated 48.4 million cases. Wow. And over, in almost 5,000 lives saved. Is this in the U.S. alone? Mm-hmm.

Yeah. Oh, wow. And the net benefits achieved in terms of monetary things, 4.5 roughly billion. dollars saved. Yeah. Yeah. Wow. International vaccination campaigns were started by the WHO in 1974, and they were operated

on basically a shoestring budget. Shocking. But they did get the job, well, they didn't get the job done necessarily, but they did really a lot of good work. And vaccination rates were high in some areas geographically variable due to logistical and other reasons. But all in all, measles cases, complications, and deaths went down, and many researchers said that there was no reason to believe that eradication is impossible. Which brings us appropriately to the current status of measles and the dumpster fire slash poop parade slash catastrophe.

You say poop parade? Yeah. That's going on today. So tell me. Tell me what is happening with measles today. Okay. All right. We'll take a quick break.

So measles was eliminated from the U.S. in the year 2000. What, Aaron? There's hundreds of cases going on right now, and it's 2019. You're right. You took the words right from my mouth. So elimination means that for more than 12 months, there can't be any continuous disease transmission. Elimination does not mean eradication. It does not mean that there are zero cases.

It just means there's not sustained transmission. Okay. So most of the cases of measles that we see in the U.S. begin as imported cases. So someone traveling who's unvaccinated comes back to the U.S. or something like that, most of the time. However, that wouldn't be an issue if the entire population was immune. But that's not the case because we have outbreaks.

So basically, every time that you see more than three cases in any one place that are linked in the U.S., it's considered an outbreak. Three cases makes an outbreak. I'm fairly sure that at some point in the last 19 years, they considered a single case an outbreak, but I could be wrong about that. So let's talk about how many cases we've seen in the U.S. The first 10 years after elimination were going pretty great. Since 2010, not so much. We've had several years of much, much higher than normal cases. In 2011, there were 220 cases.

In 2013, 187. In 2014, we hit an over 20-year high with 667 across 23 different outbreaks. Yeah, 2014. A huge amount of those outbreaks or a huge amount of those cases, I think, like 380 cases, were in one outbreak alone. Where was that outbreak? The 2014, there was 383 cases primarily among unvaccinated Amish communities in Ohio.

And then we get to 2015, probably the most infamous outbreak in recent days in the U.S., because that's the Disneyland outbreak. Oh, yeah. So in 2015, there were 188 cases that year in total. 147 of them happened from the Disneyland outbreak. Oh my gosh. There's your 14. There's your R not of 14. Right. Exactly. We had 86 cases in 2016, 120 in 2017, 3702 last year. But so far, as of February 14th, 2019, we have already had 127 confirmed cases. And actually, I can tell you, we can up that to 129 because two more cases have been reported in Champaign, Illinois, that aren't yet up to date on the CDC website. So the CDC

website, as of February 14th, says there have been five outbreaks so far. But now we know there have been six because there are four confirmed cases in Champaign, which makes an outbreak. So that means that we are on track to have a banner year for measles in the U.S. Definitely. So the thing is that we can say that these are happening, these outbreaks are happening because of declining vaccination rates. So if you look at the U.S. as a whole, the MMR vaccine rates are actually steady at about 91%. However, that's not true across the entire country. There are pockets of the country where vaccination rates are much lower and where vaccination rates are declining. Additionally, over the past, I think, three years, there have been declines in, the number or the percentage of new kindergartners entering with vaccine exemptions,

personal vaccine exemptions. So that means you have more kids going into the public school system who are not vaccinated. Right. So, yeah. So obviously, people who are becoming infected with measles are those whose parents choose to not have them vaccinated, who choose not to be vaccinated, and those who cannot be vaccinated or those who don't have access. Yeah. The ones who, for health reasons, cannot be vaccinated, do we have any sort of measurable idea of how much they are being impacted by these outbreaks, whether, what proportion they constitute, you know, because presumably these people are immunocompromised or might be in a way

where they cannot be vaccinated against measles. they get measles, it makes everything worse. Yeah. Yeah, no, that's a really good question. I don't know. Like, I can tell you for sure that the vast, vast, vast majority of cases in measles outbreaks happen to unvaccinated individuals. So it's not like you got vaccinated and the vaccine just didn't work very well.

It's actually a very effective vaccine. It's not 100% effective, but it is pretty effective. So there are not stats that I can find on why those individuals are not vaccinated. whether it's because of immunocompromise or personal exemption, religious exemption, or lack of access. Okay. So let's zoom out a little bit and we'll talk about the world and I'll also address a little bit more about this idea of why some people can't get vaccinated because it's an important part of the story. Right. Worldwide measles is still a huge, huge problem.

It's a little difficult to get really great numbers just like it is for most diseases. It's estimated that only about 10% of measles cases are actually reported. Wow, that's very low. It's very low. It's surprisingly low. But the measles rebella initiative, which is a collaboration between the CDC, the WHO, the United Nations, UNICEF, and the American Red Cross. They have this big initiative where their goal is to eliminate measles from five out of the six WHO regions by 12. 2020. That's one year away, by the way.

Oh, okay. Yeah, they're not going to hit their goals and they know it, but they're trying. But they estimate that while in 2017, there were 173,000 cases reported worldwide. It's estimated that 7 million people were infected with measles in 2016, for example. I'm sorry. Yeah. Seven million? Seven million.

But only the ones that were reported were at 170,000? It was, yeah. That was in 2017. So it was a little bit higher in 2016. Oh, my God. And so it's estimated that 90,000 children a year die from measles. Again, these are estimated numbers, not actual numbers of deaths that we know are confirmed. But that's like 246 children a day. It's major.

90,000 preventable deaths. Yeah, we're talking about 90,000 human lives that are lost to a disease that we have the ability to prevent. It's horrifying. That we have the ability to eradicate. Yeah. Yeah, we do. Because we didn't mention this, but like smallpox, which we did eradicate, measles is a disease of only humans. There's no animal reservoirs to worry about. So if we can eradicate it from the human population, we eradicate it, period. It's a great target for eradication. But so let's talk about the vaccine. So in terms of measles, the first thing I can tell you

is that the MMR vaccine is safe. It's very safe. The rates of adverse events are extremely, extremely low, and the vast majority of those adverse events are things like fever and excessive crying. Compared to death and encephalitis, which is not that uncommon for infection with measles, along with wiping out your entire immune system, the MMR vaccine is worlds and worlds safer. Right. It's also very effective. It's not 100% effective, but one dose of the MMR vaccine is about 93% effective against measles. And two doses, which is what's recommended in the U.S. and in the World Health Organization would like to have everyone vaccinated with two doses, it's 97% effective. So that means that 97% of people will have immunity to measles after

two vaccinations. So because of that, because it's not 100% effective and because of just how contagious measles is, ideally you have to have very, very high. high vaccination coverage, 95% to interrupt transmission. Yeah. And that is a huge challenge. And that's kind of the challenge behind why we haven't seen as much decrease in me. We've seen a huge decrease in measles. Don't get me wrong.

But they have a hard road in front of them for a number of reasons. Number one. So the MMR vaccine, which again is measles, mumps, and rebella. So it covers three different diseases. diseases, but this is a live attenuated vaccine. So what that means is that it's an actual virus. It's three actual viruses. They're a modified strain of the virus that can replicate just like a real virus would, but they do not cause disease. They basically grow these viruses in cell culture until they lose their virulence or their potency. So,

In some ways, that makes for a better vaccine because your body responds to it in a way that's more akin to a real infection. But one of the challenges with a live virus vaccine is that, number one, it has to be kept cold because it's a live virus. So when you're trying to go all over the globe, you might not always have access to a refrigerator. So that's challenge number one. Number two, you have to give this vaccine via injection, which means you need trained healthcare workers to actually administer that, vaccine and you have to jab a needle into a tiny baby human and usually they don't like that. So that's stressful both for the caregiver and for the infant. Number three, when the baby is born, when a baby is born, they get antibodies from their mom. And their immune system itself is super immature. It's

basically non-existent. Babies are like, they're just kind of useless. So you can't give a tiny baby human, a live virus vaccine, because A, those maternal antibodies that are floating around in their blood will just destroy that virus, assuming that the mother has been either exposed or vaccinated to that virus. And B, the baby wouldn't be able to mount a proper immune response anyways. So you can't give the MMR vaccine to babies until ideally they're at least 12 to 15 months old. But in some cases, when there's outbreaks going on, they'll give the MMR vaccine to babies as young as six months, but then they're going to need a third vaccine because we don't actually think it's that effective at six months. It's kind of one of those better than nothings if there's an

outbreak going on. Yeah, which is tricky that you need that double dose and to time it right. So if you're part of the WHO mounting this campaign for vaccination, you can't just go to a place and vaccinate. You have to be at a place and vaccinate for long periods of time. Yep. And also, because it's attenuated vaccine and not a killed vaccine, people like you, you said who are immunocompromised can't get this vaccine because in those populations, it can cause more serious adverse effects. So what that means is that you are always going to have some percentage of the population who cannot get vaccinated because of an immunocompromise. And you're always going to have a certain percentage of the population that's under 12 months, so they can't get vaccinated either.

So in order to hit that 95%, you kind of have to vaccinate everyone who's capable of getting vaccinated. Right. And like you said, the fifth point is that you have to give two of these. I mean, giving one is protecting 93% of the population. So that's pretty good, but 97 is better. Oh, yeah. Right. So yeah, it's really challenging. And so I want to give credit where credit is due. The measles and rubella initiative has given vaccination to over two billion children since they started in 2001. And worldwide global vaccination rates are increasing, actually, across the globe if you just take a very broad view of it. That's not true everywhere. There's a lot of places where vaccination rates are declining.

There are a couple of really big measles outbreaks going on right now outside the U.S. as well. So in the Philippines, there have been, in the last two months from January to February of 2019, over 11,000 confirmed cases. Oh, my God. And 189 deaths. What? And in Madagascar right now, there's an outbreak that's been going on since September that the last number I saw from the WHO said over 68,000 cases. And they're estimating 900 deaths. There's at least 38,000.

68,000. 68000. And in Madagascar, where a plague epidemic had just ravaged the entire population. Yes. Yep. And I should say, too, that in recent analyses from the CDC, the vast majority of children in the U.S. who are unvaccinated are also uninsured or underinsured. So we have a big problem with access in this country as well. I think it's sometimes easy to just blame it on, you know, the Disneyland outbreak. Oh, it's these rich people who are choosing not to vaccinate. But it's not just that in this country or in any country. It's also an access. issue and an education issue and a miseducation issue. Yeah. So it's a double whammy. We have gotten and would probably continue to get a load of questions. We're from people living in certain foci of outbreaks right now. So Seattle, Vancouver, New York, yeah. And then now

we have one here where I am. People who are vaccinated, people whose kids are vaccinated, whether there's any concern that they need to have for their own personal safety or the safety of their children. Basically, if you got two MMR vaccines, you are 97% sure that you're immune. Yeah, and babies, like I said, in places where there is an active outbreak going on, you can get the vaccine for those children as young as six months. What a fun so, guys. Well, it's very relevant and much more deadly. I know. I really didn't know that it, you know, because the number you have always seen now is like one to two per thousand. That's what it tends to be in current times.

Not. It killed a quarter of the population of Fiji. Good God. Sources. Okay. So I mostly relied on a book called measles and historical geography of a major human viral disease by Andrew Cliff, Peter Haggett, and Matthew Swindon. Malman Rainer. I mentioned this earlier, but an article by David Morins called Measles in Fiji 1875, Thoughts on the History of Emerging Infectious Diseases, and also the Cambridge World History of Human Disease, edited by Kenneth Kippel. Excellent. I had several good articles. This one on non-medical exemptions is by. Main author is Jacqueline Olive, and then the also science article. On all of the articles and books we will always post along with links whenever we can on our website.

This podcast will kill you.com. You can find all of our sources from every single episode there. And somebody on Twitter also was making like a, what do you call it, like citation friendly source list too on some like bibliography website that I didn't know existed. So I'll find that and post a link to it somewhere too. Great. Yeah. Thank you all for listening. Thanks for requesting this. This was a really interesting one for us to get to research, and I think it was, it's very timely and relevant, unfortunately. Yeah. Thank you to Bloodmobile for providing the music for this episode and all of our episodes. We love it. And that's all of our thank yous. Okay. Well, in that case, wash your hands. You filthy animals. And get vaccinated.

Please. Why have we asked our contractor we found on Angie.com to be kids' legal guardian? Because he took such good care when redoing our basement that we knew we could trust him to care for our kids, all eight of them. Should something happen to us? Are you my dad now? No, sorry, I do

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