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

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.

1 Introduction

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 about ecology, environment, and historical reasoning. This article outlines how a major thinker of his generation in the history of medicine, the French–Croatian Mirko D. Grmek (Krapina, 1924–Paris, 2000), used those ideas to develop his views on historical epidemiology. In the 1960s Grmek attempted to provide the world history of diseases with a theoretical framework, with his notion of “pathocenosis” (pathocénose) as the cornerstone of a new and ambitious “synthetic approach” to the field. During the 1980s, he applied his views to two historical points in Western civilization, namely diseases in the ancient Greek world, and the new pandemic of HIV/aids.

In this article, I will first analyse Grmek’s theoretical proposals for the history of “collective diseases” in the context of the Annales School’s longue durée historical research program under the leadership of Fernand Braudel (Braudel 1958). Secondly, I will examine Grmek’s sources of inspiration,¹ specifically the work of the French-American physician Jacques M. May (Paris 1896–Tunisia, 1975) who pioneered disease ecology starting from medical geography. Finally, I will explore Grmek’s diverse uses of pathocenosis through the years—from his early agenda focused on a longue durée history of “dominant diseases” (maladies dominantes) to his last, regarding the new epidemiological threat of (re)emerging infectious diseases—in order to address a triple aim: first, to note how concepts of ecology rested 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. Understanding Grmek’s views may help to show where the field of medical geography was going, and what ideas it was wrestling with during the post-World War II decades and into the closing years of the twentieth century.

2 Grmek and Fernand Braudel’s Annales School

During the 1960s, under the leadership of Fernand Braudel (1902–1985), who had succeeded Lucien Fevbre (1878–1956) as its director in 1956, the Annales School pursued the development of its understanding of history as the science of the past. Braudel successfully pushed the School to extend its systematic and sustained longue durée historical enquiry into the bio-medical aspects of history, so that biology and medical specialties like epidemiology, pathology and haematology were also incorporated into its analytical framework. The purpose was “to provide more powerful explanations of demographic and especially epidemiological patterns”, one of the major ways through which Braudel aimed to develop his well-known longue durée paradigm. This paradigm gave priority to long-term historical structures over events, and to populations shaped by these rather static structures, which were mostly beyond their immediate understanding or control. Thus little historical room was left for individual actors or small communities (Gelfand 1987, pp. 21–23). This is not surprising as Braudel’s “scientific history” emphasized the controlling role of large-scale impersonal structures (ecological, biological, demographical, economic, social, technological) acting on wide geo-historical areas, at the expense of any conscious human agency (Iggers 1985, pp. 175–205; McNeill 1986, pp. 199–226; Arnold 1996, pp. 39–45); Burke 2015, pp. 36–72). Braudel had given an open invitation to historians and non-historians to contribute to this research programme, aiming for new perspectives from the widest variety of social, human and bio-medical sciences.

Mirko D. Grmek met Braudel on the occasion of a two-month research stay in Paris in April–May 1960. He was there thanks to a CNRS research grant, shortly before he would be appointed as the first director of the recently founded Institute for the History of Mathematical, Natural and Medical Sciences, as well as Professor of History of Medicine at the University of Zagreb. Previously, Grmek had been actively involved in the Resistance against Nazi Germany during the Second World War, and had studied medicine in Zagreb (1946–1951). It was then that he began to devote his time to medical history research. In 1953 he was appointed head of the newly created department of history of medicine within the Institute of Medical Research at the Yugoslavian Academy of Science (Lambrichs 2001, pp. 91–127). During the summer of 1961 Grmek returned to Paris to work on and classify the manuscripts of Claude Bernard (1813–1878) at the Collège de France. In 1963 he took up residence in Paris having received another CNRS grant to continue working mostly on the Bernard manuscripts; this was highly relevant work, because the centenary of the publication of his Introduction à l’étude de la médicine expérimentale (Paris 1865) was approaching (Lambrichs 2001, pp. 127–135).

At all events, Grmek appears to have gradually become involved in Braudel’s ambitious research programme through the 1960s. His situation in Paris must have become more stable when he was appointed in October 1963 as attaché de recherches au CNRS under the direction of Braudel, and before the end of that year when he published in the Annales the article “Géographie médicale et histoire des civilisations”, in which he gave a historical review of medical geography and its relevance to the Braudelian history of civilisations (Grmek 1963). Five years later, Grmek published –with Braudel’s encouragement and again in Annales– his programmatic article on the history of diseases, “Préliminaires d’une étude historique des maladies” (Grmek 1969a; Lambrichs 2001, pp. 125–126, 133, 144). During the 1960s and subsequent decades Grmek appears to have been aiming to bridge the gap between historians and bioscientists at the Annales School by offering his expertise to help throw some light on the biomedical dimensions of the history of civilisations. Not surprisingly then, the two speeches he gave at the conference held at Châteauvallon (Toulon-Ollioules, France) in October 1985 to pay tribute to Braudel shortly before the latter’s death, dealt with “L’homme biologique en Méditerranée” and “Biologie et longue durée” (Grmek 1989a, pp. 19–24, 90–93). Grmek stated there that,

We will only be able to elucidate the respective role of the biological and human factors through a close collaboration between historians and biologists, with an absolute respect for historical facts. (Grmek 1989a: 24)

According to Grmek, Braudel’s longue durée was the history of permanent features in a specific civilisation. These features could not be reduced to their purely sociological aspects because “the history of the ‘social facts’ is associated with that of the ideas through the history of mentalities”. Grmek also questioned any “narrow social determinism of ‘pure’ or ‘hard’ sciences”, and asserted the value of both psychological (i.e., “the ‘genius’ of the ‘great scientists’”) and epistemological explanations (Grmek 1993b, pp. xxiii–xxiv). His interest in these issues was reflected in many historical studies, mostly nineteenth-century French physiology and its “founding father” Claude Bernard (Gourevitch 1992). However, his major contributions, both theoretical and practical, to the Braudelian Annales deal with the history of disease –l’étude historique des maladies, in his own words. Early in his career, he did some work on the history of the relationships between individual genius and disease (mostly madness; Grmek 1962), but soon his attention in the field came to be mostly focused on the history of collective diseases.

The two articles mentioned above, which Grmek published during the 1960s, are the most notable examples of his concern to provide the history of collective diseases with a historiographical and theoretical framework (Grmek 1963, 1969a, 1969b). Later, in the 1980s, he dealt with specific cases of diseases at the two historical ends of Western civilisation, namely one major study of diseases in the ancient Greek and Roman world, and another on HIV/AIDS (Grmek 1989a, b, 1990a). Moreover, Grmek’s interest in the history of disease continued until the end of his days, as revealed by the structure and contents of the ambitious four-volume project Histoire de la pensée médicale en Occident,² as well as other works he published during the 1980s and 1990s.

3 From medical geography to disease ecology: the work and influence of Jacques M. May

The historical review of medical geography that Grmek presented in his earliest long article in the Annales stressed the need for a dynamic, historico-geographical perspective of disease that investigated the setting, migration, regional characteristics, and disappearance of diseases, in line with the thinking of August Hirsch (1817–1894) and above all Henry Sigerist (1891–1957).³ Here Grmek only dealt with a couple of the issues, mainly intended for those “historians wanting to familiarise themselves with a complex of factors most commonly neglected in historical narratives” (Grmek 1963, p. 1073). To him, medical geography played an essential role in better understanding the history of civilisations. This was very much in agreement with the historiographical views held by Braudel whose géohistoire—the method applied to his history of the Mediterranean world in the time of Philip II—had been accused of geographical determinism (Braudel 1949; Symcox 2010, pp. 36–39). Thus, Grmek emphasised the close and complex interrelations between geographical factors of every kind (physical, biological and social) and epidemiology, as well as their utility in providing explanations for many historical events (Grmek 1963).

By 1969, when Grmek published the programmatic, second article at Annales (Grmek 1969a),⁴ he appears to have been persuaded that the rising discipline of medical ecology could supply a more powerful framework to study past diseases than medical geography. Certainly, 6 years earlier, Grmek had already claimed that the “current tendency” in the field was towards the transformation of “geographical pathology and epidemiology” into an “ecology of human diseases” on a worldwide scale.⁵ But only now did he appear to have become entirely aware of the essential novelty of medical ecology as opposed to medical geography, as well as of the greater potential of this new integrative approach as a basis for the theoretical framework he aimed to construct.

Above all, it was the works of Jacques M. May (Paris 1896–Tunisia, 1975) that Grmek associated with the new tendency. He introduced him as one of its leaders and May appears to have been a major inspirational source and cause of his change of mind.⁶

3.1 The work of Jacques M. May (1896–1975)

But, who was Jacques M. May? Born in Paris, where he took his medical degree in 1925, May had received training in tropical medicine before entering the French colonial service as chief surgeon during the 1930s and 1940s—first, in Indochina (1932–1940), then in Guadeloupe, French West Indies (1940–1947) (May 1949). Among other positions, May was chief surgeon at the French mission hospital in Bangkok (1932–1936), professor of surgery at the Hanoi University Medical School (1936–1940), and physician to the royal palace in Siam. In 1947, he moved to the United States where 1 year later he was appointed as head of the Medical Geography Section in the American Geographical Society (AGS). May was then commissioned by the powerful professional association of US geographers—founded in New York in 1851—to compile a monumental global Atlas of Diseases (May 1951–1955). Allegedly, May’s “studies of the human response to surgery” in French Indochina, Siam, Central Africa and the Caribbean led to his later interest in medical geography (May 1950, p. 9; see also Brown and Moon 2004). In turn, he “alerted geographers to the possibilities of studying the relationship between health and environments” (Valenčius 2000, p. 21–22). Furthermore, as with other scientists of his generation, May’s practical experience of tropical medicine was highly influential in his pioneering work as a disease ecologist (Anderson 2004, p. 58).

In a seminal paper published in 1950, May stated that disease was “a multiple phenomenon which occurs only if various factors coincide in time and in space” so that focus of interest of physicians should “encompass the relationship between the various factors of this complex and their respective geographical environments”. After considering the “pathological factors” involved in the composition of a “pathological complex” as well as the “geographical factors” determining its “evolution and behaviour”, May proposed to define medical geography as the study of the relationships between the pathological factors (“pathogens”) and the geographical factors (“geogens”), among other factors which he did not list (May 1950, pp. 9–10). The notion of “pathogenic complexes” (complexes pathogènes) had originally been formulated by the biological and human geographer Maximilien Sorre (1880–1962) in 1933, as also noted by Grmek in his 1963 article (Grmek 1963, pp. 1086–1087). Acknowledging his debt to Sorre in a private letter in early May 1949 (Simon 2016, p. 267), May took his “fruitful idea” as the starting point of his disease ecology programme from 1950 by referring to his monograph Les fondements biologiques de la géographie humaine. Essai d’une écologie de l’homme (Sorre 1943).⁷ A pupil of the geographer Paul Vidal de la Blache (1845–1918), Sorre appears to also have influenced Fernand Braudel, who devoted a long review to the same monograph soon after it was published in the middle of the Second World War (Braudel 1944).

At the 17th International Congress of the International Geographical Union held in Washington in 1952, a four-paper panel was organised by the “Commission on Medical Geography of Health and Disease”. May opened the proceedings giving a general review of medical geography, its history, definition and problems (May 1952, in May 1978).⁸ He then refined his previous definition of medical geography, assigning to it the study of worldwide distribution of “manifested and potential diseases”, and reducing the types of factors involved to those contributing to disease—the pathogens—, and the “environmental factors”—or geogens—rather than his former “geographical factors”.⁹ It is thus not surprising that he approved of the Commission’s proposal to replace the phrase “medical geography” with that of “ecology of health and disease”. To him, the new terminology had the advantages of stressing not only that it was “primarily a study of environmental factors”, but also that the “environment of health” and the “environment of disease” were inseparable. Moreover, he stressed that the progress of medical knowledge in the post-Pasteurian era was arousing “a renewed interest in environment” because it had become clear that “the organisms themselves were closely related to the milieu” (May 1952, in May 1978, p. 212). In sum, May’s disease ecology meant the construction of a new intellectual space for medical geography. It reconfigured its relationship with tropical medicine by returning to the “environmentalist view of disease causation”—which had been abandoned by tropical medicine due to the impact of germ theory—as the “context within which pathological disease processes occur” (Brown and Moon 2004, pp. 751–752, 759).¹⁰

May’s innovative views were set out at length in his book The Ecology of Human Disease (May 1958, pp. 1–34). He further worked out and summarised these views in an article published two years later (May 1960, pp. 789–794), whose contents, with some limited changes, became the “foreword” of May’s next book Studies in Disease Ecology (May 1961, pp. xv–xx). In the first book, he defined “medical ecology” as “the study of the ‘home’ of disease, both within the individual organism and in the larger environment” (May 1958, p. 1). May’s definition strongly evokes that of “oschag”—the ‘hearth’ or ‘fireplace’ of disease—given by the Soviet parasitologist and epidemiologist Yevgeny Pavlovsky (1884–1965) and other remarkable Soviet scientists who during the 1920s and 1930s developed the “natural focus” or “natural nidus” theory–practice framework for transmissible diseases (Jones and Amramina 2018, p. 48). Yet, I have been unable to find any quotation by May associating his views to Pavlovsky.¹¹

Both of these volumes being focused on “transmissible diseases”, May presented them as part of a three volume project dealing with “some of the most important transmissible, degenerative, and behavioral diseases”. He claimed that in the past these types of studies had been given different names like epidemiology, medical geography, medical ecology, and natural history of disease, all of them having applied more or less directly similar “philosophy, methods, and facts” (May 1958, p. 2). In spite of their titles, both books were published as the first two volumes of a “Studies in Medical Geography” series, under the auspices of the AGS. May left the AGS in 1960, and the third volume of his planned trilogy never appeared. Instead, from 1961 to 1974, he published—partly in collaboration with Irma S. Jarcho and May’s wife Donna McLellan– no less than six country-by-country surveys on The Ecology of Malnutrition in different parts of the world within the same series, this time funded by the United States Army. Indeed, May’s increasing connection to the US military led to his appointment in 1962 as chief medical education adviser to the US Operation Missions in Vietnam (Brown and Moon 2004, p. 751, 761).

To May, disease was an “alteration of living cells or tissues that jeopardizes their survival in their environment” (May 1960, p. 789). It could “never occur without the combination of three orders of factors converging in time and space”: First, three “stimuli from the environment”—“physical”, “biological” and “emotional”; second, three “responses from a host”—“degenerative diseases”, “transmissible diseases”, and “behavioral disorders”—with respect to which May also stressed the relevance of the “genetic make-up of the host” and the “role played in the evolutionary processes by these genetic susceptibilities”; and third, “the conglomeration of thoughts and traits” termed “culture”, which he defined as the “sum total of the concepts and techniques used by individuals or populations to control the environment in which they live” (May 1960, pp. 790–792). According to May’s views of disease ecology, disease was “a biological expression of maladjustment” to its environment. He stressed that the idea of the “adjustment of man to the world around him” was crucial to physicians (May 1960, p. 789), and that this could not be “understood without an ecological study in depth”. Thus, he concluded that “the credo of physicians for many generations”—“one ill, one pill, one bill”—should be replaced by something giving an “equal importance to the three approaches: the environment, the host, and the culture” (May 1960, p. 794).¹²

For the rest, May’s first volume was devoted to the ecology of a number of individual communicable diseases—namely cholera, brucellosis, poliomyelitis, tuberculosis, leprosy, bacillary dysentery, salmonellosis, amoebiasis, yaws, nematode infections, scarlet fever, measles and trachoma—in which he applied, more or less extensively, the principles he had previously expounded (May 1958, pp. 35–298). Accordingly, each transmissible disease appears to the observer as a “complex” including different numbers of factors, namely two (agent and host), three (agent, host, and vector), or four (agent, host, vector, and intermediate host or reservoir); and all the “elements of the complex have their own ecological requirements” (May 1958, p. xxiii). While May appears to have written all the chapters of the first volume, except for the twentieth and last one on trachoma, in the second he wrote only two of the fourteen chapters, namely those on malaria and African trypanosomiasis (May 1961, pp. 161–260).

3.2 Grmek's response to and development of May's ideas

Grmek referred to May in both of his 1960s articles though in different contexts. In the first article, published in 1963, Grmek defined medical geography as “a science of conjunction that emphasises at once medicine and geography” (Grmek 1963, pp. 1072–1073) and, having claimed that it was “a discipline still in the making”, he took the genealogy of this venerable branch of knowledge back to the origins of the Western medical tradition, specifically the Hippocratic work On Airs, Waters, and Places, and set out the historical landmarks of the discipline up to his time. He gave an overview of the most outstanding contributions to medical geography from France, Germany, Britain, Italy, Russia and the United States, and related their increased interest in the discipline to the demands of colonial expansion and the development of more rapid means of communication. He chose to stress those approaches that were more sensitive to history, that had a higher integrative power, and/or that tended toward the ideal of an interpretative science (science d’interprétation) by looking for cause-effect relationships between geographical and physio-pathological phenomena (Grmek 1963, pp. 1073–1091). In a second and shorter section, he focused on the economic repercussions of diseases, and on the many-faceted historical interdependence between disease and civilisation, in consonance with the studies of C.E.A. Winslow (1951) and Sigerist (1943). He illustrated the allegedly close historical relationships between epidemiology and medical geography from the case of the historical relevance of diseases’ endemicity and migration, by using historical examples of the outstanding diseases (malaria, syphilis, smallpox, yellow fever, and typhus, mostly) that had influenced the economic and political history of humankind (Grmek 1963, pp. 1091–1096).

Grmek concluded his first article by claiming that the historical development of human epidemics could not be explained merely in terms of interaction between “the microorganism (the ‘cause’) and the man (the ‘ground’)” with no attention to the “conditions of the environment”. He also reminded the Annales readers that contemporary epidemiologists were reconsidering “historical and geographical factors in their widest sense” as life determinants for both the man and the microorganism. He stressed that history and geography were useful for epidemiology and on the other hand, epidemiology could supply useful explanations for many historical events as well. Finally, he anticipated, in the light of the most recent medical advances, the geographical and historical relevance of non-contagious diseases, even though most of them—the nutritional ones being the single exception—were less studied up to then. Thus, he foresaw that a systematic work of medical geography in the service of history would soon be available (Grmek 1963, pp. 1096–1097).

Grmek also followed the connexion between medical geography and major biomedical movements all over the world. He referred to the activities of allied international professional associations, particularly the Société internationale de Pathologie géographique from 1929, and the AGS after the Second World War with specific mention of the AGS’s series “Studies in Medical Geography” led by May. Grmek presented him as the editor of the AGS’s already mentioned Atlas of Diseases (May 1951–1955), and the exponent of the methodology used to draw its charts (Grmek 1963, p. 1090). But, most significantly, he identified May with a current tendency to “transform geographical pathology and epidemiology into an ‘ecology of human diseases’” (Grmek 1963, p. 1091).

In the second article published 6 years later, Grmek criticised the fact that the history of disease had been so far written almost exclusively in an “analytic” way, i.e. by examining separately how each condition developed through time,¹³ so that those features involving mutual influences among different diseases had remained in the shade. And he claimed that it was time to supplement the analytic approach, characteristic of disease geography, with a “synthetic” one looking at the “interconnection between diseases”, by paying attention to a “tendency to integrate all the morbid phenomena at any specific time and place”. Complaining that “historians seem not to have drawn the full lesson”, Grmek forcefully reiterated his claim that this tendency was spreading fast through most recent studies of “disease ecology” (écologie des maladies). And he explicitly associated it to “J.M. May and others”, referring to May’s above mentioned books Ecology of Human Disease (1958) and Studies in Disease Ecology (1961) (Grmek 1969a, pp. 1475–1476).

4 Pathocenosis in the history of civilisations

The cornerstone of Grmek’s new synthetic approach to the history of diseases was a concept of his invention, namely that of pathocenosis (pathocénose).¹⁴ He officially introduced it in the second of his two articles in the Annales (Grmek 1969a, b), though he had advanced its contents at the International Congress of History of Medicine held in Siena a year before (Grmek 1968, 1969b).¹⁵ He had also outlined his idea on the occasion of the conference “Medicine and culture” at the Wellcome Institute of the History of Medicine, London, in late September 1966 (though its proceedings were not published until 1969; see Grmek 1969a, pp. 48–50, 119–120). There, following a realistic approach closely related to historical epidemiology, he distinguished between writing about the “intellectual conquest of single diseases” (i.e., “the intellectual elaboration of observational data”) and the “real conquest of diseases” (i.e., “the real morbidity of the population”). And he made the point that there was not yet available a “natural history of diseases” that took into account the “very complicated interplay and biological evolution of diseases”, but only “one-sided and analytical” studies of morbidity, which he qualified as “quite unreal and unhistorical”. Grmek was convinced that historians could make an important contribution to overcoming these limitations, though “an appropriate study” would require them to bear in mind a mixture of epistemic, nosological and ecological questions, including the confusion between clinical symptoms and nosological entities, “collusion between single diseases”, and different interplays between seed and soil, individual and community, disease and social conditions (Grmek 1969a, p. 49).¹⁶

In another discussion at the same conference, Grmek stressed the difficulties in studying, “by statistical methods” and “as a whole”, the connections between diseases, and “the cultural, social, and economic factors”. He claimed that this new, synthetic approach was feasible if “all diseases appearing in a spatio-temporal connection”—what he proposed to call pathocenosis—were considered as a whole, and “some mathematical laws in the actual distribution and incidence of the diseases in a society” were found. To him these laws were analogous to those related to the mathematical “problem of the distribution of the zoological species in function of the number of living specimens of each species” (Grmek 1969a, pp. 119–120).

In the 1969 article, Grmek developed the notion of pathocenosis by analogy to the old ecological concept of biocenosis (biocénose) (Grmek 1969b, p. 1481; Grmek 2019, p. 38) which Karl Möbius had coined in his study of oyster beds (1877) in reference to what was later called “biotic community” (Jahn 1990, p. 351; Labeyrie 1996, pp. 302–303). Not incidentally, the article was published just as the idea of ecology was starting to enter popular awareness on a worldwide scale (Worster 1985, p. 341).

Grmek defined his notion of “pathocenosis” through three propositions. First, it was the “ensemble of pathological states present in a specific population at a given moment in space and time”. Secondly, the “frequency and overall distribution of each disease depend[ed], in addition to endogenous and ecological factors, on the frequency and the distribution of all the other diseases”. And thirdly, it “tend[ed] toward a state of equilibrium expressable in relatively simple mathematical terms; that equilibrium is especially perceptible under stable ecological conditions” (Grmek 1968, p. 682; 1969b, p. 1476; 1989b, p. 3).

This “ensemble of pathological states” included not only infectious diseases, but also hereditary, degenerative, and others. In his book on diseases in the ancient world, Grmek emphasized its systemic character—at all events in consonance with the consolidation of disease ecology at the time.¹⁷ There, he also maintained that “each pathocoenosis must have a small number of common diseases and a great number of rare ones” (Grmek 1989b: 4). Years later, in 1999, Grmek gave the name “dominant diseases” (maladies dominantes) to those most frequent and serious conditions in demographical and life quality terms for a given population, in contrast to “recessive diseases” (maladies récessives) given to the rare ones—a rather obvious borrowing from Mendelian genetics’ “dominant” and “recessive” characteristics that even became the title of a new work (Grmek and Sournia 1999, mostly pp. 271–272).¹⁸

Again by analogy to the ways different living beings can relate to each other, Grmek contemplated three forms of interrelation between two diseases belonging to the same pathocenosis, namely symbiosis, antagonism or, most frequently, indifference to each other. And he set out possible examples of symbiotic diseases (wear or degenerative diseases in a technologically advanced society, several hereditary syndromes, “secondary illnesses” acquired at the individual level because of previous suffering from another, and so on) as well as of antagonistic ones (malaria and tertiary syphilis, treponematoses from the Old and the New World, leprosy and plague, leprosy and tuberculosis, for example). He claimed that two diseases could antagonise each other not only by opposition between microorganisms, but also because of “a conflict between the particular genetic state of a human organism and the germ of a given disease” (e.g., malaria and sickle-cell anaemia), or even as the indirect result of a “very complicated sequence of the most diverse causes” (e.g., dysentery and coronary occlusion, typhoid fever and lung cancer) (Grmek 1968, pp. 682–685; 1969b, pp. 1476–1481).¹⁹

Grmek claimed that the relationships among diseases were much more complex in practice than in theory so that solutions should be sought empirically. Admitting that the “notions and methods of modern ecology” were a major inspiration for him, he approached pathocenosis from the perspective of quantitative ecology as embodied by the work of the English-American ornithologist Frank W. Preston (1896–1989) and the English entomologist C. B. Williams (1889–1981). Grmek quoted a major paper on the mathematical characteristics of ecological rarity and commonness that Preston had published in Ecology, the journal of the Ecological Society of America, in 1948,²⁰ and Williams’ Patterns in the balance of nature and related problems in quantitative ecology (London–New York, 1964), a still valuable overview of statistical ecology. From his entomological research Williams had already noted in 1937 that logarithmic patterns were widespread in nature. This idea was later developed in a key work in community ecology, co-authored by himself, the statistician and geneticist R. A. Fisher (1890–1962), and the naturalist A. S. Corbet (1896–1948),²¹ as well as in the works of other ecologists like Preston.

Grmek extrapolated Williams’ and Preston’s conclusions on the relevance of logarithmic patterns, to the distribution of diseases, claiming that in mathematical terms, “the study of the distribution of diseases by frequency poses a problem that corresponds to that of the distribution of animal and vegetable species determined by the number of living individuals in a biocenosis” (Grmek 1968, pp. 685–686; 1969b, p. 1481).

While recognising that his “numerical analysis of diseases in human groups of relatively stable states of pathocenosis” was still at a preliminary stage, Grmek expected to “find certain regularities in distribution and perhaps genuine laws of equilibrium”. And he proposed that the “distribution of diseases as per their frequency seems to correspond to an interference between the simple logarithmic series and the normal log series”, apparently on the basis of a morbidity statistics article by the Austrian-English statistician Gustav Herdan (1897–1968) as well as of his “own limited analysis”.²²

To Grmek, the concept of pathocenosis was instrumental for studying not only the synchronic relations among diseases at a precise historical moment, but also the diachronic changes in these disease ensembles—what he called “dynamics of pathocenosis” (dynamique de la pathocénose)—to the point where the idea has been mostly (if not exclusively) applied to historical epidemiology (Grmek 1968, p. 682; 1969b, p. 1476). Grmek pointed to three major obstacles in the “quantitative analysis of pathocenosis” that could become “insurmountable” in dealing with past societies; namely, the “ambiguity of all definitions of morbid species”, the “practical difficulties of a correct diagnosis”, and the “impossibility of a complete inventory of sick individuals”. These obstacles, however, would not prevent the study of at least “some principal tendencies” and “some essential characteristics” of former pathocenoses. He drew the attention of medical historians to the two major stages he distinguished in any pathocenosis, namely its periods of equilibrium (périodes de l’équilibre) and those of upheaval (périodes de bouleversement)—somewhat similarly to Thomas S. Kuhn’s influential ideas on the dynamics of “scientific revolutions” (Grmek 1968, pp. 686–688; 1969b, p. 1481, 1483).

In 1969 Grmek seemed particularly concerned to explain why conditions that had been historically so predominant over a period of time, such as leprosy or plague, could come to what he called a “‘spontaneous’ end” (arrêt “spontané”). For this purpose, he turned to two groups of immunity hypotheses (by no means mutually exclusive), namely that of “the creation of a state of equilibrium between the host and the pathological agent”—by “protection” (prémunition) after an acute infection has become chronic, or by “immunological resistance which diminishes the clinical reaction while at the same time blocking proliferation of the parasitic micro-organism”; and secondly, the hypothesis of “an antagonistic activity between diverse microorganisms” as in the case of the phenomena known as antibiosis (Grmek 1969b, p. 1477; Grmek 2019, pp. 34–35). It was the only place in this article where Grmek referred to the US epidemiologist and pathologist Theobald Smith (1859–1934) and to the French–US microbiologist and environmentalist René J. Dubos (1901–1982). Smith was briefly mentioned as an “illustrious microbiologist” who had anticipated the hypothesis of the natural tendency towards a mutual tolerance between host and pathogen, while Dubos was presented as having used this hypothesis to explain the historical evolution of such scourges as tuberculosis, some gastro-intestinal infections and toxoplasmosis.²³

Grmek applied his notion of pathocenosis to specific historical cases in two monographs. In the first, he aimed to study the distribution of diseases in the ancient Greek world (Grmek 1983, 1989b). In this way, he mostly drew on one pathocenosis dimension—space rather than change over time—and his main evidence came from paleopathology. In the second monograph, however, he aimed through the emergence of HIV/aids (Grmek 1990a, b) to account for a pathocenotic breakdown so that evidence of ecological factors became much more relevant. Let us briefly examine Grmek’s uses of pathocenosis in both works.

In his monograph on diseases in the ancient world, Grmek substantially refined his notion claiming that the pathocenosis of a given historical moment depends on the previous distribution of diseases in its population, and is determined by an extremely complex interaction between four other variables. These variables were the geographical setting, the presence of pathogens and their hosts in that setting, the associated gene pools, and the social life of its inhabitants (Grmek 1989b, p. 8). He claimed that during the last millennia biological laws have experienced no change, and the properties of human bodies only scarcely so, while diseases usually undergo changes in their frequency and clinical symptoms as well as in some of their epidemiological features. He pointed out, however, that these changes mostly involve two kinds of diseases, infectious and those deriving from an environment modified as a result of human action. And he claimed that while infectious diseases had dominated the pathocenosis in the past, environmental diseases were having an unrivalled impact on human health in the present world (Grmek 1989b, pp. 8–14).

In his later monograph, using the case of HIV/aids, Grmek accounted for the rise of new scourges as a result of major pathocenotic breakdowns, by linking them with “demographic upheavals” (bouleversements démographiques) that selectively struck in “some more fragile groups” (Grmek 1990a, p. 159; 1990b, p. 261).²⁴ He went on to claim that the Western world had undergone four major historical ruptures in its pathocenotic equilibrium, namely,

in the Neolithic, with the shift to a sedentary lifestyle; in the High Middle Ages, with the migrations of the Asian peoples; in the Renaissance, with the discovery of America; and, finally, in our epoch, with the worldwide unification of the pool of pathogens and the spectacular decline of most infectious diseases (Grmek 1990a, p. 159; 1990b, pp. 261–262).²⁵

Grmek had in fact already advanced a number of “historical events that had implied profound changes of pathocenosis in Europe” at the end of his 1968 paper at the Siena congress.²⁶ However, in the 1969 programmatic article, he made no reference to these events at all, presumably because he had decided to postpone their discussion to an announced future article, which in fact he would never write. Thus, the statement from 1990 quoted above may be the first time Grmek enumerated four different pathocenotic ruptures in the history of the Western world. Unfortunately, he did not give any references to support such a forceful statement though it may have been inspired by William H. McNeill’s Plagues and Peoples (McNeill 1976) referred to in the book’s bibliography.²⁷ As to the notion of “microbial unification”, it had first been formulated by Emanuel Le Roy Ladurie (1973), and Grmek had already used it in a speech in tribute to Braudel, referring to an alleged microbial unification of the Mediterranean achieved around the first centuries of our era (Grmek 1989a, p. 20).

At all events, in 1998 Grmek still subscribed to the first part of his 1983 claim about the predominance of different individual infectious diseases in the past—“malaria … in the ancient pathocenoses at the Mediterranean world, leprosy in the medieval pathocenoses, and tuberculosis in last-century European pathocenoses” (Grmek 2001, p. 30). Yet, we might wonder whether the spread, from the early 1980s, of the HIV/aids pandemic and other (re-)emerging infectious diseases had modified his views about the predominance of environmental diseases in present times.

Grmek explained the emergence of the HIV/aids pandemic as a result of “a concatenation of causes both biological and social”. Arguing from genetic evidence, he claimed that the new human pandemic had remained undetected from the 1970s to 1981, and that its pathogen—the human immunodeficiency virus (HIV)—might have already existed throughout the world for centuries, “scattered and manifest only at a low level, in sporadic cases and mini-epidemics invisible to medicine before 1980” (Grmek 1990a, p. 155; 1990b, p. 256).²⁸ His idea was that until the end of the 1970s the development of HIV/aids had been hindered by other disease conditions whose disappearance had led to a pathocenotic breakdown, disrupting the ecological equilibrium among pathogens, so that the virulent HIV strains were able to proliferate (Grmek 1990a, pp. 158–161; 1990b, pp. 260–264). Furthermore, a series of social changes characterising the second half of the twentieth century like the mingling of populations, the multiplication of modern means of rapid transport, and the “liberalization of morals, notably among homosexuals”, had caused a huge population to be exposed to HIV, and the generalization of blood transfusion and the use of intravenous drugs had also opened up new paths of transmission for the virus (Grmek 1990a, p. 156; 1990b, pp. 257–258; 2001, pp. 31–33).

5 Pathocenosis: a notion on the wane?

As noted earlier, enthusiastically following the new developments in disease ecology, in 1969 Grmek attempted to explain by means of pathocenosis the variable disease distribution in different past and present societies (their epidemiological patterns), the laws (in terms of symbiotic, antagonistic, or indifferent mutual relationships) governing the interconnections between the diverse dominant diseases, and the processes of crisis and change in different pathocenotic equilibria. Furthermore, in accordance with population dynamics studies—a fashionable research area in the 1960s, not least as a result of the general model formulated by F.J. Richards (1959)—, Grmek set out to quantify the distribution of diseases in any past pathocenosis, using an algebraic function that he defined as “an interference between the simple logarithmic series and the normal log series” (Grmek 1969a, p. 1481).

Extrapolating to every pathocenosis, from the laws governing the distribution of animal and vegetal species in a given ecosystem, does not seem to have initially caused Grmek major theoretical difficulties, among other reasons because he tended to consider disease as a primarily biological and ecological phenomenon. Indeed, his nosological views continued to be remarkably ontological in 1969: he dealt with disease labels as natural kinds, thus displaying great confidence (widespread among medical historians of his generation) in the capabilities of modern bio-medical science as a technical historical tool to retrospectively identify past human diseases.²⁹ Needless to say, this generational self-confidence contributed greatly to the fulfilment of Braudel’s expectations just as he was launching his “scientific history” programme.

However, it cannot have taken Grmek too long to realise the huge dimensions and almost insurmountable limits of the research programme on the history of diseases that he aimed to undertake. In his 1969 programmatic article, Grmek had announced a forthcoming article to develop further the notion of pathocenosis in order to show future historians of diseases what he considered as one of their major tasks, namely “to establish the various types of pathocenotic equilibrium, and to study the factors that can hinder, and finally provoke, the rupture of this equilibrium” (Grmek 1969a, p. 1483). The announced article was never published.³⁰ Certainly, Grmek continued to refer to pathocenosis in the 1980s and 1990s, but his emphasis on the notion gradually decreased through the years, not least because he appears to have become increasingly critical of seeing diseases in an ontological way as well as sceptical of any mathematical representation of the notion. Let us briefly explore how Grmek’s views of both issues evolved.

On the one hand, at the beginning of his 1980s monograph on diseases in the ancient world, he stated that disease labels were “explanatory models of reality and not constituent elements of it”, and that he recognised that retrospective diagnosis is a “difficult and fragile” exercise. Yet, he reduced the complexities of this practice simply by stating that it was always hypothetical character and referring to the shifts in the meaning of medical terms referring to disease conditions, particularly when the word remained while the concept changed (Grmek 1989b, pp. 1–2, 6–8). Beyond this declaration of principles, his views about disease continued to be remarkably realistic throughout the monograph, which is full of learned discussions establishing retrospectively the identity of ailments described in ancient texts—mostly, albeit not exclusively, medical—according to the categories of current medical nosology. One after the other, Grmek examined a long list of “dominant diseases” (syphilis, leprosy, tuberculosis, favism, thalassemia, malaria, fevers, purulent inflammations, and so on) whose identities, with considerable confidence, he unveiled mostly from ancient written sources with the help of a wealth of paleo-pathological, paleo-demographical, and medical-history studies. By way of example, in dealing with the case of syphilis, he offered a valuable synthesis of the different theories about the origin and global dissemination of human treponematoses and its osteo-archeologic remains (Grmek 1989b, pp. 134–141). Furthermore, he went on to show his preference for the hypothesis of a mutation of the American Treponema pallidum as the pathogen responsible for venereal syphilis once it was introduced into Europe by Columbus’s sailors (Grmek 1989b, pp. 141–144). Last but not least, he identified, more or less confidently, in ancient medical and literary sources, the following conditions: gonorrhoea, vaginitis by Trichomonas vaginalis and Candida albicans, the disease of Adamantiades-Behçet, and tuberculosis from clinical signs such as spermatorrhea and leukorrhea; and such disparate ailments of external sex organs as genital herpes simplex, lymphogranuloma venereum, condyloma or genital warts, tuberculous chancre, chancroid, and the cancers of penis, vulva and uterus (Grmek 1989b, pp. 144–151).

In addition to all this, Grmek maintained a substantial part of his former considerations on pathocenosis in his monograph on diseases in the ancient world, including his 1969 hypothesis about its mathematical representation whose definition he kept in the same literal terms.³¹ Yet, at the same time he pointed out that the “notion of pathocenosis” was still “scarcely known” so that it was “difficult to foresee its pragmatic value and limitations”.³² Furthermore, he admitted the impossibility of applying any “true mathematical analysis to the diseases of peoples as ancient as those that are the subject of this book” on the basis that “data on such distant pathological events are quantifiable only in a uselessly hypothetical and approximate way” (Grmek 1983, p. 16; 1989b, p. 4). More significantly, in the English translation of the book Grmek—who took advantage of this translation “to revise and correct his original” (Grmek 1989b, p. ix)—chose to clearly soften the previous terms of his former definition of the mathematical structure of pathocenosis by claiming that it “corresponds to the conjunction of several kinds of distribution but with a preponderance of the log normal type, which therefore gives its character to the whole” (Grmek 1989b: 4).

Grmek made fewer and more concise references to pathocenosis in later works like his monograph on HIV/aids (Grmek 1990a, pp. 158–161; 1990b, pp. 260–264);³³ two journal articles on the emergence of diseases: one for a special issue of History and Philosophy of Life Sciences focusing on this very topic (Grmek 1993a, 2018, pp. 41–54)³⁴ and another for História, Ciências, Saúde—Manguinhos (Grmek 1995a, pp. 11–12)³⁵; and a co-authored chapter with Jean-Charles Sournia on “dominant diseases” in nineteenth century medicine for the monumental history of Western medical thought that he was editing (Grmek and Sournia 1999, pp. 271–274).³⁶ In all of these works, references to pathocenosis were in passing and, except for the case of his history of aids, without any mathematical apparatus. Finally, in the section devoted to pathocenosis in his memoirs (Grmek 2001, pp. 29–33), though still claiming that the state of pathocenotic equilibrium adjusts to a “log-normal distribution”, he finished, quite casually, recognising that the notion was “a dynamic structure verging to an ideal condition, and impossible to grasp by means of a simple mathematical formula”.³⁷

This scepticism about a mathematical representation of pathocenosis put an end to a series of substantial changes Grmek had been introducing over the period. In 1969, and still later in his book on ancient diseases of 1983, he represented the notion as an “interference between the simple logarithmic series and the normal log series”. However, in the book on HIV-aids (1990), pathocenosis was represented as an “interference of linear, logarithmic and log normal distributions”; in 1995, as “relatively simple mathematical expressions (with the predominance of the normal logarithmic distribution)”; and, finally, in 2001 [1998], as a “superposition of the straight line and the curve called normal logarithmic”.³⁸

It might be useful to note, first, that a normal distribution, also known as a Gaussian distribution (though first “discovered” by Abraham de Moivre in 1733 and developed by Pierre-Simon Laplace in 1812) is symmetric in relation to a central axis that is bell-shaped and most frequently used to describe natural phenomena; while a logarithmic distribution, also known as log-series distribution, is much more complex and less frequent than the normal one. It was first used by the English statistician and biologist Ronald Fisher in 1943 to describe relative species abundance patterns, and has no central symmetry. Secondly, a normal logarithmic distribution results from combining the two types. And thirdly, the concepts of “interference” between two distributions and of “superposition” of two curves are not applicable to the analysis of mathematical or statistical functions. To sum up, without denying that statistical analysis can be usefully applied for studying the distribution of diseases in any population, Grmek appears to have mastered neither statistics nor its terminology, and spoke of the issue from hearsay and with no little stretching of the imagination.

Let us now examine the fortunes of Grmek’s notion of pathocenosis. To the best of my knowledge, it appears to have had a very limited circulation, scarcely beyond his circle of closest pupils. Indeed, historians, even those under the direct influence of the Annales school, paid scant attention to the notion during the last decades of the twentieth century. Among the few exceptions are Jean-Noël Biraben’s long chapter on diseases in ancient and medieval Europe for the first volume of Grmek’s edited history of Western medical thought, which was structured around the concept of pathocenosis (Biraben 1993), and Peregrine Horden’s introductory article to his edited special issue for Social History of Medicine on medical practice around the year 1000, where he discussed the concept as well as the limitations of the tenth- and eleventh-century historical sources to reconstruct contemporary pathocenosis (Horden 2000, pp. 205–208, 211–212). For the rest, until the year 2000, references to Grmek’s notion were few in number, and rather generic or irrelevant in their content.

I will give just a couple of significant examples to illustrate my claim. First, of the thirty contributions to the collective volume Maladie et maladies. Histoire et conceptualisation in Grmek’s honour (Gourevitch 1992), only one short and rambling article (with neither notes nor bibliography) deals with pathocenosis (Niaussat 1992) while, in the rest of the volume it does not appear to be mentioned at all. Secondly, in the special issue of History and Philosophy of Life Sciences with the papers presented at the Conference on “Emerging Infectious Diseases: Historical Perspectives” held at Annecy in April 1992, presided by the Nobel Prize winner Joshua Lederberg, and attended by the distinguished virologist Frank Fenner, only Alfred Perrenoud and Grmek himself referred to pathocenosis, both of them generically and in passing (Perrenoud 1993, p. 310; Grmek 1993a, b, c, p. 296).

In contrast, pathocenosis has received greater and renewed attention since Grmek’s death in 2000. On the one hand, it was discussed by five of the twenty-four contributors to the posthumous fourth and last volume of Grmek’s editorial project Histoire de la pensée médicale en Occident which was eventually published in 2014 under the direction of Fantini and Lambrichs (2014).³⁹ On the other hand, it was paid still more attention in two publications resulting from a series of meetings held in different parts of Europe to pay tribute to Grmek. The earlier came from a memorial conference on the longue durée in the history of science and medicine held at the Wellcome Trust Centre for the History of Medicine at UCL, London, in 2003, and was published as a special issue of the journal History and Philosophy of Life Sciences two years later, in which four of the six contributions dealt more or less extensively with pathocenosis (Grmek Memorial Symposium 2005).⁴⁰ The later one is a recently published collective volume, mostly including a selection of papers presented at three successive conferences held at the Abbey of Ardenne (near Caen) 2005, Geneva 2008, and Dubrovnik 2010), which focuses on the genealogy and the new historical applications of Grmek’s pathocenosis from Antiquity to nowadays. Its editors have chosen to show how the notion has been “received, used and discussed by researchers from different disciplines during the decade after its creator passed away”, and to claim its allegedly “intact usefulness both innovative and heuristic for the historical science of diseases and allied disciplines at the beginning of the twenty-first century” (Coste et al. 2016, pp. 7–8).

6 Some final considerations

Having said this, why did Grmek’s pathocenosis concept decline during the last 3 decades of the twentieth century? Answering this question is not easy. Yet, I will attempt to supply some thoughts about it from different perspectives.

On the one side, Colin Jones has claimed that Grmek’s pathocenosis was trapped between three historiographical shifts. First, soon after the 1969 “pathocenosis momentum”, the “total history” research agendas of the Annales School moved, under the leadership of Emmanuel Le Roy Ladurie, towards an orientation that was totally different from Braudel’s, as a result of which the original sense of his notion of longue durée shifted from geographical substrata to mental structures (Jones 2005, p. 8). Secondly, the major shift from the late 1970s, towards the new cultural and social history of disease (social constructivism, linguistic trends, and so on) hardly favoured concepts grounded in “realistic” theoretical soil like pathocenosis. Finally, from the early 1970s other outstanding scholars, also basing their work on rather deterministic biological views about the history of disease, notably the North Americans Crosby (1972) and McNeill (1976, 1986), used analogous concepts in their “grand narratives” about the global expansion of infectious diseases without mentioning Grmek’s pathocenosis at all.⁴¹

One wonders also to what extent the neglect of Grmek’s work could be due to the fact that Anglo-American historians of the mid and late twentieth century who might have been interested in Grmek’s ideas, tended neither to read French well nor to follow the literature in French, so that they were only able to read those bigger pieces that had been translated into English. In fact, part of the story may also be interpreted as the transition from French historians as leaders in the field of history, to English-writing historians based in the US and Britain. During the 1960s and 1970s great challenges to conventional historical narratives were convulsing the field in the US. The new approaches were exciting and liberating but also somewhat inward-turning. US historians in that period were looking back onto their own history, and much less outwards to other traditions. That may have also shaped their lack of interest in a physician writing about somewhat fusty-sounding ecological concepts—even though Grmek was in fact perceptively presenting many insights as to where medical ecology was headed!

Moreover, pathocenosis would surely have experienced difficulties that were similar to those of disease ecology, in consolidating its position in the biomedical world. For example, for Warwick Anderson, usually considered along with Mendelsohn (1998) as representing the starting point in the historiography of disease ecology, only since the 1980s have “changes in the natural and conceptual environments” provided “a larger niche for ecological reasoning in medical science” so that “‘mainstream’ biomedical science” began to recognise that disease might be “the outcome of dynamic processes in a global ecosystem”, not only in the developing world but “even in Europe and North America” (Anderson 2004, p. 59). HIV/aids was highly instrumental in this respect and, of course, Grmek was soon aware of the relevance of the new epidemic’s emergence. Yet, by that time, his 1969 notion of pathocenosis appears to have become rather outdated and quite clearly insufficient to explain the complexities regarding the outbreak and dissemination of HIV/AIDS. Incidentally, Anderson referred to Grmek (1963) along with Charles-Edward Amory Winslow (1943) as historians of epidemic diseases who had earlier criticised the fact that so much more attention had been paid at the time to the biology of the pathogens than to the influence of milieu. However, Anderson only referred to Grmek’s 1963 article, and situated Grmek`s views of the “milieu” in the sphere of medical geography, without having assessed the extent of the shift towards an environmental perspective in his 1969 article (Anderson 2004, pp. 40–42).⁴²

Furthermore, Grmek appears to have been both informed of and receptive to disease ecology developments when he formulated the notion of pathocenosis in 1969. Yet, most of the quoted works that influenced him had been published in the 1950s, during the early days of disease ecology and before it became a growing interdisciplinary field.⁴³ And he does not seem to have kept up to date in this respect. By way of example, around 1990 Grmek stressed the impact of some causal factors (sexual contacts of a quantitatively new type, transfusion of blood and blood products, and rupture in the pathocenosis) on the origins of HIV/AIDS,⁴⁴ at the expense of others of a more demographic, socio-economic, and political nature, which could be considered equally relevant. Certainly, the impact of two of these factors (the sexual and the technological) has been recently revived by Pepin (2011) so that Grmek’s views might well be considered ahead of his time. Some scholars pointed out, however, that his views on the origins of HIV/AIDS fitted a rather traditional “infectious disease [ecology] paradigm of equilibrium disturbed and paradise lost” that fed on “millenarian tendencies of the late twentieth century” (Fee and Krieger 1993, pp. 463–464). More specifically, Steven F. Kruger criticised Grmek’s reading of AIDS as ecological disaster as depending “on a view of the sexual acts involved in HIV transmission as a certain unnatural interruption to natural balance, with ‘the homosexual community’ constructed as ‘the ideal « culture medium » in which, as though in a laboratory experiment, the virus could multiply during its critical phase’” (Kruger 1996, p. 256; Grmek 1990a, pp. 170, 196–197; 1990b, pp. 278–279, 318–319).

We must remember that Grmek’s book on HIV/AIDS was first published in 1989, 3 years before the Institute of Medicine (IOM) of the U.S. National Academies published its earliest report on emerging infections (Lederberg et al. 1992). There, six major “causative factors”, usually in combination, were enumerated as crucial to the consideration of HIV/AIDS and other (re)emerging infectious diseases, namely, human demographics and behaviour, industry and technology, economic development and land use, international travel and commerce, microbial adaptation and change, and the breakdown of public health measures (Lederberg et al. 1992, pp. 47–112). The 1992 IOM list was revised and supplemented in 2003 with seven additional causative factors, namely, human susceptibility to infection, climate and weather, changing ecosystems, poverty and social inequality, war and famine, lack of political will, and intent to harm (Smolinski et al. 2003, pp. 53–135). In the additional list, the prestigious IOM was finally taking on board two of the most remarkable recent developments in disease ecology, namely social and economic determinants of infectious disease, and environmental risks.

By that time, very regrettably, Grmek had already died. However, to the best of my knowledge, the IOM’s early views were not mentioned in any of his works on HIV/AIDS or emerging infectious diseases published in the 1990s.⁴⁵ In an article on the origin of virulent strains of HIV/AIDS viruses (Grmek 1995b), along with a passing reference to pathocenosis,⁴⁶ he continued to point to the contribution of “changes in social behaviour” to the appearance of the new pandemic. Yet, he particularly blamed “technological progress” for being an unintentional cause of the emergence of HIV/AIDS, and echoed Edward Tenner’s “revenge effect” theory as a suitable framework to interpret such a paradoxical circumstance (Grmek 1995b, pp. 272–273).⁴⁷