1 00:00:02,120 --> 00:00:05,119 Speaker 1: Shingles is a disease that has been around for thousands 2 00:00:05,200 --> 00:00:08,720 Speaker 1: of years. It affects millions of people every year, but 3 00:00:08,920 --> 00:00:12,400 Speaker 1: as recently as the middle of the twentieth century, scientists 4 00:00:12,560 --> 00:00:16,560 Speaker 1: didn't really know how the disease worked. It was clear 5 00:00:16,600 --> 00:00:21,200 Speaker 1: that shingles and chicken pox were related. People sometimes got 6 00:00:21,400 --> 00:00:25,400 Speaker 1: chicken pox from people with shingles, but the clarity ended there. 7 00:00:26,160 --> 00:00:29,320 Speaker 1: How were the diseases related. Were they caused by different 8 00:00:29,400 --> 00:00:32,640 Speaker 1: viruses or the same virus. Could you get shingles from 9 00:00:32,640 --> 00:00:36,319 Speaker 1: someone with chicken pox? Nobody knew. But by the mid 10 00:00:36,400 --> 00:00:39,800 Speaker 1: nineteen sixties, scientists had figured out what was going on. 11 00:00:40,240 --> 00:00:42,320 Speaker 1: And one of the people who did the most to 12 00:00:42,320 --> 00:00:45,239 Speaker 1: figure it out was not some high powered researcher at 13 00:00:45,240 --> 00:00:48,600 Speaker 1: a prestigious university. It was a family doctor in a 14 00:00:48,640 --> 00:00:54,240 Speaker 1: small British town. His name was Edgar Hope Simpson. I'm 15 00:00:54,320 --> 00:00:57,640 Speaker 1: Jacob Goldstein and this is Incubation, a show about viruses. 16 00:01:06,160 --> 00:01:08,160 Speaker 1: In the second half of the show, we'll talk about 17 00:01:08,200 --> 00:01:12,000 Speaker 1: the most common symptom of shingles, pain and we'll talk 18 00:01:12,040 --> 00:01:15,000 Speaker 1: about the surprising methods that some doctors are using to 19 00:01:15,040 --> 00:01:18,360 Speaker 1: try and alleviate that pain. In this part of the show. 20 00:01:18,560 --> 00:01:21,360 Speaker 1: We're going to talk about Edgar Hope Simpson, that family 21 00:01:21,400 --> 00:01:24,800 Speaker 1: doctor who helped solve the mystery of shingles. I talked 22 00:01:24,800 --> 00:01:28,760 Speaker 1: about Hope Simpson with Anne Arvin. Anne's retired now, but 23 00:01:28,880 --> 00:01:32,640 Speaker 1: she spent decades as a clinician and a microbiologist at Stanford. 24 00:01:33,080 --> 00:01:37,240 Speaker 1: She studied the Vericella zoster virus, the virus that causes shingles. 25 00:01:37,720 --> 00:01:40,720 Speaker 2: Edgar Hope Simpson, as you just said, was a GP 26 00:01:41,600 --> 00:01:47,600 Speaker 2: who was very interested, as many practitioners are, in trying 27 00:01:47,640 --> 00:01:52,960 Speaker 2: to solve unresolved issues in medicine. And his practice was 28 00:01:53,320 --> 00:01:56,680 Speaker 2: largely older people, and he was seeing a lot of 29 00:01:57,480 --> 00:02:02,240 Speaker 2: shingles relatively speaking, but he was also seeing kids with 30 00:02:02,360 --> 00:02:07,000 Speaker 2: chicken pox. It was really easy to see that one 31 00:02:07,080 --> 00:02:10,120 Speaker 2: kid with chicken pox would give it to fifteen other kids. 32 00:02:10,320 --> 00:02:13,840 Speaker 2: They would get chicken pox. That was easy to observe, 33 00:02:14,280 --> 00:02:18,000 Speaker 2: Uh huh. It was a lot more difficult to nail 34 00:02:18,120 --> 00:02:23,760 Speaker 2: down the question of what about shingles and does exposure 35 00:02:23,919 --> 00:02:30,000 Speaker 2: of a child to shingles really result in chicken pox 36 00:02:30,320 --> 00:02:33,239 Speaker 2: or is that just coincidence proximity? 37 00:02:34,040 --> 00:02:34,560 Speaker 1: Huh? 38 00:02:34,600 --> 00:02:36,760 Speaker 2: And so that was his question. 39 00:02:37,800 --> 00:02:42,600 Speaker 1: There's this moment, I guess in the nineteen forties when 40 00:02:42,840 --> 00:02:47,600 Speaker 1: Edgar Hope Simpson reads in a British medical journal just 41 00:02:47,639 --> 00:02:50,880 Speaker 1: a case report, just a letter from a doctor on 42 00:02:50,919 --> 00:02:57,600 Speaker 1: this remote Shetland island called Yell. Tell me about Edgar 43 00:02:57,639 --> 00:03:00,679 Speaker 1: Hope Simpson and this island of Yell and this sort 44 00:03:00,760 --> 00:03:06,600 Speaker 1: of quest to understand the relationship between chicken pox and shingles. 45 00:03:07,040 --> 00:03:10,520 Speaker 2: Yes, so why did he jump on the boat or 46 00:03:10,560 --> 00:03:14,040 Speaker 2: train or boat and train or whatever to go practically 47 00:03:14,080 --> 00:03:17,120 Speaker 2: a day and a half to get from where he 48 00:03:17,280 --> 00:03:20,560 Speaker 2: was in sort of southern England up to this remote 49 00:03:20,600 --> 00:03:23,640 Speaker 2: island in the Shetland Islands in the North Sea. Why 50 00:03:23,720 --> 00:03:24,600 Speaker 2: did you do that? 51 00:03:24,880 --> 00:03:27,239 Speaker 1: It was going to go on summer vacation. And he's like, no, 52 00:03:27,320 --> 00:03:29,040 Speaker 1: I'm not going to go on summer vacation. I'm going 53 00:03:29,080 --> 00:03:30,359 Speaker 1: to go investigate this. 54 00:03:30,360 --> 00:03:36,520 Speaker 2: Outbreak because the letter that he read said there was 55 00:03:36,560 --> 00:03:40,320 Speaker 2: a school teacher who had shingles and there was an 56 00:03:40,440 --> 00:03:43,840 Speaker 2: outbreak of chicken pox in her class. 57 00:03:45,000 --> 00:03:49,760 Speaker 1: In nineteen forty six, Hope Simpson reads this letter in 58 00:03:49,800 --> 00:03:53,119 Speaker 1: the medical journal about the school teacher case in Yell, 59 00:03:53,840 --> 00:03:56,520 Speaker 1: and then Hope Simpson reaches out to the local doctor 60 00:03:56,560 --> 00:03:58,960 Speaker 1: who wrote about the case and they stay in touch 61 00:03:58,960 --> 00:04:03,400 Speaker 1: they're corresponding with each other. Eventually, Hope Simpson learns that 62 00:04:03,440 --> 00:04:06,680 Speaker 1: there is another outbreak on the island. There's something like 63 00:04:06,760 --> 00:04:10,080 Speaker 1: one hundred chicken pox cases that seem to have come 64 00:04:10,120 --> 00:04:12,240 Speaker 1: from a single case of shingles. 65 00:04:13,280 --> 00:04:18,240 Speaker 2: When he heard about this crofter who had shingles and 66 00:04:18,279 --> 00:04:23,320 Speaker 2: whose five children then had chicken pox, he thought, this 67 00:04:23,520 --> 00:04:26,520 Speaker 2: is an irresistible opportunity. I will go up there and 68 00:04:26,600 --> 00:04:30,880 Speaker 2: I will actually see this outbreak unfold in real time 69 00:04:31,520 --> 00:04:37,239 Speaker 2: from this shingles case. And so undoubtedly the shingles case 70 00:04:37,520 --> 00:04:41,960 Speaker 2: did lead to chicken pox in that family. The question 71 00:04:42,279 --> 00:04:46,240 Speaker 2: was could he then trace a further outbreak. 72 00:04:46,920 --> 00:04:50,240 Speaker 1: I mean, I guess there's something about a remote island 73 00:04:50,360 --> 00:04:53,560 Speaker 1: that's actually a perfect place to test the hypothesis, right 74 00:04:53,560 --> 00:04:56,800 Speaker 1: because unlike in you know, twentieth century England, people are 75 00:04:56,839 --> 00:04:58,919 Speaker 1: taking trains, people are coming and going, this was like 76 00:04:59,120 --> 00:05:03,039 Speaker 1: truly a remote people are like crofters which I don't 77 00:05:03,040 --> 00:05:06,279 Speaker 1: even know they're farmers or they're raising sheep or something. 78 00:05:06,400 --> 00:05:09,240 Speaker 1: Right Like, it's it's very out there. So he goes 79 00:05:09,279 --> 00:05:13,599 Speaker 1: out there and I mean it's amazing, Like what he's 80 00:05:13,600 --> 00:05:18,559 Speaker 1: doing is contact tracing basically. Right, there's here, he wrote 81 00:05:18,560 --> 00:05:21,240 Speaker 1: this reminiscence that I just want to read because I 82 00:05:21,240 --> 00:05:24,560 Speaker 1: love just a paragraph of it. There's this moment when 83 00:05:24,720 --> 00:05:27,960 Speaker 1: like they're trying to track down one case and he says, 84 00:05:29,520 --> 00:05:31,200 Speaker 1: the team, which is just like him and two other 85 00:05:31,240 --> 00:05:34,480 Speaker 1: people walked from mid Yell to the south shore of 86 00:05:34,560 --> 00:05:37,200 Speaker 1: the vau Vae is apparently a Shetland word for a 87 00:05:37,240 --> 00:05:42,919 Speaker 1: little cove or something road themselves across. He means ourselves 88 00:05:43,000 --> 00:05:46,000 Speaker 1: rode themselves across to north of Vo and walked for 89 00:05:46,160 --> 00:05:50,040 Speaker 1: several miles across the heather to the home of K six. 90 00:05:51,200 --> 00:05:54,640 Speaker 1: And then he was hoping this one particular connection was 91 00:05:54,720 --> 00:05:58,920 Speaker 1: going to answer everything, and he writes, alas no, because 92 00:05:58,960 --> 00:06:00,920 Speaker 1: this girl who was going to tie it all together 93 00:06:00,960 --> 00:06:03,159 Speaker 1: for it was not in fact at this other place. 94 00:06:03,200 --> 00:06:06,560 Speaker 1: So anyways, it's a great story. 95 00:06:07,839 --> 00:06:10,919 Speaker 2: I love that. I love that description too, And I 96 00:06:11,000 --> 00:06:13,880 Speaker 2: had to look up what is a voe? So I'm 97 00:06:13,920 --> 00:06:17,159 Speaker 2: sad that we now know a voe is a bay, 98 00:06:17,240 --> 00:06:20,320 Speaker 2: a small bay. I can tell you that kind of 99 00:06:20,400 --> 00:06:24,120 Speaker 2: vs V Barricela's osterro virus research. That is not how 100 00:06:24,200 --> 00:06:29,479 Speaker 2: we do it now, but it looked kind of interesting 101 00:06:29,760 --> 00:06:30,800 Speaker 2: to be able to do that. 102 00:06:31,120 --> 00:06:33,600 Speaker 1: You never you never wrote, did you? How much rowing 103 00:06:33,760 --> 00:06:35,160 Speaker 1: did you do in your research? 104 00:06:35,279 --> 00:06:40,680 Speaker 2: Absolutely not so. Anyway, he was trying to see whether 105 00:06:40,720 --> 00:06:45,359 Speaker 2: he could get a second, a reproducible finding, so to speak, 106 00:06:45,480 --> 00:06:50,800 Speaker 2: because he heard that the person in the other location 107 00:06:51,360 --> 00:06:55,279 Speaker 2: had shingles, and then he thought, well, there's going to 108 00:06:55,279 --> 00:07:00,359 Speaker 2: be maybe another traceable cluster of cases. So back to 109 00:07:00,440 --> 00:07:04,760 Speaker 2: your question about why islands, islands are really important in 110 00:07:04,839 --> 00:07:09,640 Speaker 2: epidemiology of infectious diseases, and so the reason is because 111 00:07:09,680 --> 00:07:16,360 Speaker 2: the populations are tiny and in that particular geography, as 112 00:07:16,400 --> 00:07:19,320 Speaker 2: you just said, you row your boat, you walk three 113 00:07:19,400 --> 00:07:22,760 Speaker 2: miles or ten miles or whatever, there's a lot less 114 00:07:22,960 --> 00:07:27,880 Speaker 2: contact in a very rural situation. So you can have 115 00:07:28,040 --> 00:07:32,840 Speaker 2: the situation in epidemiologic terms where there's a fair number 116 00:07:32,880 --> 00:07:37,920 Speaker 2: of susceptibles and you can actually then take the so 117 00:07:38,040 --> 00:07:42,560 Speaker 2: called index case and you can map literally house to 118 00:07:42,680 --> 00:07:44,680 Speaker 2: house the cases. 119 00:07:45,240 --> 00:07:48,679 Speaker 1: Yeah, but then I think he sort of dug further 120 00:07:48,760 --> 00:07:52,480 Speaker 1: and figured out more connections, right, and it did suggest, 121 00:07:52,520 --> 00:07:56,160 Speaker 1: although it wasn't conclusive, well, that it's the same virus 122 00:07:56,240 --> 00:07:59,880 Speaker 1: and that you can catch chicken pox from someone with ching. 123 00:08:00,280 --> 00:08:05,840 Speaker 2: Right, he went a great distance, so to speak, towards 124 00:08:06,080 --> 00:08:08,200 Speaker 2: actually proving that hypothesis. 125 00:08:08,360 --> 00:08:10,559 Speaker 1: I picture him with like a wall, like a map, 126 00:08:10,600 --> 00:08:14,120 Speaker 1: but with like pushpins that maybe like red yarn, you know, 127 00:08:14,240 --> 00:08:16,400 Speaker 1: like a like in a detective show or something. 128 00:08:16,480 --> 00:08:23,440 Speaker 2: Sure, well, epidemiology is basically a detective story most of 129 00:08:23,480 --> 00:08:26,960 Speaker 2: the time. So yes, I think that's exactly what he did. 130 00:08:27,000 --> 00:08:31,040 Speaker 2: They went around house to house, took records and ask people. 131 00:08:31,640 --> 00:08:36,679 Speaker 1: Yeah, so this is like a very colorful and you know, 132 00:08:37,760 --> 00:08:40,800 Speaker 1: kind of low key heroic thing he's doing to try 133 00:08:40,800 --> 00:08:44,400 Speaker 1: and learn something for the benefit of humanity. But he 134 00:08:44,600 --> 00:08:50,120 Speaker 1: is doing this longer term study based on his practice 135 00:08:50,360 --> 00:08:55,199 Speaker 1: right where he's closely tracking all of the chicken pox 136 00:08:55,280 --> 00:08:59,199 Speaker 1: cases and all of the shingles cases over many, many years, 137 00:08:59,800 --> 00:09:03,520 Speaker 1: and he winds up giving a lecture, publishing a paper 138 00:09:03,559 --> 00:09:06,120 Speaker 1: that is the summation of that work, and he does 139 00:09:06,200 --> 00:09:09,320 Speaker 1: wind up solving this mystery. Tell me about that paper. 140 00:09:10,000 --> 00:09:13,960 Speaker 2: That paper is about his long term study. And he 141 00:09:14,040 --> 00:09:18,640 Speaker 2: apparently studied everyone in his practice who got shingles. So 142 00:09:18,760 --> 00:09:21,679 Speaker 2: not only did he make the diagnosis, he made a 143 00:09:21,840 --> 00:09:25,439 Speaker 2: chart of each person and marked on this chart here's 144 00:09:25,480 --> 00:09:28,920 Speaker 2: where this person lesions were, this is where the other 145 00:09:29,000 --> 00:09:33,160 Speaker 2: person's lesions were. And so he had an enormous set 146 00:09:33,280 --> 00:09:39,120 Speaker 2: of data on where the shingles rash appears on people's bodies, 147 00:09:39,559 --> 00:09:42,240 Speaker 2: and he also had all of the chicken pox data. 148 00:09:42,760 --> 00:09:46,080 Speaker 2: And what he was able to conclude is it's a 149 00:09:46,200 --> 00:09:53,080 Speaker 2: one way traffic. Shingles causes vericella. Vericella does not cause jingles, right, 150 00:09:54,440 --> 00:09:59,880 Speaker 2: chicken pox. Yeah, So that was his finding, his fundamental observation. 151 00:10:00,080 --> 00:10:03,960 Speaker 2: And it's a one way traffic. So that means where 152 00:10:04,000 --> 00:10:07,880 Speaker 2: does the virus come from when you've got shingles? 153 00:10:08,240 --> 00:10:10,720 Speaker 1: Uh huh. It doesn't come from someone with chicken pox, 154 00:10:10,840 --> 00:10:13,240 Speaker 1: and it doesn't come from someone with shingles, right. 155 00:10:13,760 --> 00:10:16,480 Speaker 2: That's also what he observed. And so he had all 156 00:10:16,520 --> 00:10:20,440 Speaker 2: this massive data sets of people who had shingles and 157 00:10:20,480 --> 00:10:24,080 Speaker 2: were in close contact with somebody or several other somebodies 158 00:10:24,360 --> 00:10:27,680 Speaker 2: and they didn't get shingles, but if there were kids around, 159 00:10:27,880 --> 00:10:31,000 Speaker 2: they got chicken pox, but not vice versa. 160 00:10:32,000 --> 00:10:36,480 Speaker 1: So from that beautiful data set he can show clinically 161 00:10:36,520 --> 00:10:40,760 Speaker 1: what's happening. And from this clinical finding, he presents in 162 00:10:40,800 --> 00:10:44,720 Speaker 1: this paper a hypothesis of what's going on at the 163 00:10:44,760 --> 00:10:46,920 Speaker 1: micro level, at the cellular scale. 164 00:10:46,960 --> 00:10:50,920 Speaker 2: What does he hypothesize the hypothesis is what we now 165 00:10:51,240 --> 00:10:55,880 Speaker 2: know to call latency. That is, when you have chicken pox. 166 00:10:56,040 --> 00:11:00,880 Speaker 2: In the course of your chicken pox episode, the virus 167 00:11:00,920 --> 00:11:04,320 Speaker 2: you can imagine, is in those little boxes all over. 168 00:11:05,080 --> 00:11:09,600 Speaker 2: And what is also in the skin Right next to 169 00:11:09,679 --> 00:11:13,000 Speaker 2: where those boxes are, which are full of virus, there 170 00:11:13,000 --> 00:11:19,040 Speaker 2: are nerve endings. And so the virus has created a 171 00:11:20,320 --> 00:11:26,920 Speaker 2: great scheme for persisting by taking not just the opportunity 172 00:11:26,920 --> 00:11:30,760 Speaker 2: to form skin lesions, but to go backwards up the 173 00:11:30,800 --> 00:11:35,400 Speaker 2: nerve axons to the nerve cell body, which is in 174 00:11:35,600 --> 00:11:39,040 Speaker 2: what's called sensory ganglia, all up and down the spinal 175 00:11:39,120 --> 00:11:45,359 Speaker 2: cord and cervical spine and face. But developing the hypothesis 176 00:11:45,400 --> 00:11:49,320 Speaker 2: of how the virus got to the sensory ganglia, he 177 00:11:49,600 --> 00:11:56,160 Speaker 2: outlined what he called suppositions. I like the phrase suppositions. 178 00:11:56,559 --> 00:11:59,800 Speaker 1: There's a nice humility to it, right, I don't know, 179 00:12:00,080 --> 00:12:01,120 Speaker 1: but let's suppose. 180 00:12:01,880 --> 00:12:07,679 Speaker 2: Yeah. So he created a set of suppositions that have 181 00:12:08,720 --> 00:12:14,080 Speaker 2: subsequently been found right. But also because they were suppositions, 182 00:12:14,320 --> 00:12:16,000 Speaker 2: a number of them were not right. 183 00:12:16,640 --> 00:12:17,680 Speaker 1: What did he get wrong? 184 00:12:18,440 --> 00:12:21,880 Speaker 2: Well, for starters, he thought chicken pox was a pox virus, 185 00:12:22,400 --> 00:12:26,720 Speaker 2: which it isn't. It's a herpes virus related to herpes 186 00:12:26,720 --> 00:12:28,360 Speaker 2: simplex type one and type two. 187 00:12:29,240 --> 00:12:33,160 Speaker 1: Let's talk for a minute about just herpes viruses, and 188 00:12:33,200 --> 00:12:37,120 Speaker 1: in particular the persistence, right the fact that they have 189 00:12:37,320 --> 00:12:40,680 Speaker 1: this from the point of view of virus clever, from 190 00:12:40,679 --> 00:12:44,079 Speaker 1: the point of view of a human host, insidious quality 191 00:12:44,640 --> 00:12:48,040 Speaker 1: of hanging around forever. Tell me more about that. 192 00:12:49,120 --> 00:12:53,120 Speaker 2: First of all, these viruses are ancient, and they sort 193 00:12:53,120 --> 00:12:58,080 Speaker 2: of evolved into different subgroups over millions of years. And 194 00:12:58,120 --> 00:13:01,959 Speaker 2: if you look at every specie, they all have their 195 00:13:02,000 --> 00:13:05,280 Speaker 2: herpes viruses too. It's not just us. You have a 196 00:13:05,320 --> 00:13:08,360 Speaker 2: guinea pig, that guinea pig has guinea pig herpyes virus. 197 00:13:09,880 --> 00:13:14,440 Speaker 2: So it is. It is a story that encompasses the 198 00:13:14,600 --> 00:13:19,800 Speaker 2: entire family of viruses. And what we know is that 199 00:13:20,240 --> 00:13:23,880 Speaker 2: for the most part. The other thing the virus as 200 00:13:23,960 --> 00:13:27,400 Speaker 2: agent has to keep in mind is don't make the 201 00:13:27,440 --> 00:13:33,319 Speaker 2: person too sick, right, accommodate if you can, just don't 202 00:13:33,360 --> 00:13:37,520 Speaker 2: even cause any symptoms at all. Just arrange to be 203 00:13:38,559 --> 00:13:42,959 Speaker 2: periodically showing up at a mucosal surface. In fact, a 204 00:13:43,080 --> 00:13:47,360 Speaker 2: few cells, dump a few virus particles into the saliva 205 00:13:47,600 --> 00:13:50,360 Speaker 2: or whatever, and so be it. 206 00:13:50,800 --> 00:13:55,359 Speaker 1: Everybody's happy. Everybody's happy, right, problem. 207 00:13:55,120 --> 00:13:58,640 Speaker 2: No problem, so in fact, you know, chicken pox is 208 00:13:58,640 --> 00:14:02,239 Speaker 2: a bit unusual in the It does typically cause symptoms, 209 00:14:02,520 --> 00:14:06,640 Speaker 2: but very very mild. When it's not mild, it is 210 00:14:07,000 --> 00:14:11,120 Speaker 2: potentially lethal. And so that's why all of us in 211 00:14:11,160 --> 00:14:14,880 Speaker 2: the field work so hard to develop vaccines, vaccine for 212 00:14:15,000 --> 00:14:17,120 Speaker 2: chicken pox and vaccine for shingles. 213 00:14:17,559 --> 00:14:21,880 Speaker 1: So when you look back at Hope Simpson's work, what 214 00:14:22,400 --> 00:14:23,080 Speaker 1: do you make of it? 215 00:14:24,120 --> 00:14:27,520 Speaker 2: Well, I think it's pretty straightforward for me to say 216 00:14:27,560 --> 00:14:32,320 Speaker 2: why I and my colleagues so much admired the work 217 00:14:32,360 --> 00:14:35,680 Speaker 2: that he did and the suppositions that he came up 218 00:14:35,720 --> 00:14:42,600 Speaker 2: with because he was looking from an evolutionary perspective. He 219 00:14:42,880 --> 00:14:50,200 Speaker 2: was asking why does this happen? And what he proposed, 220 00:14:50,440 --> 00:14:55,680 Speaker 2: which is definitely true, is that the virus gives itself 221 00:14:55,720 --> 00:14:59,560 Speaker 2: a kind of second chance to spread. So, if you 222 00:14:59,640 --> 00:15:02,760 Speaker 2: look at it from an evolutionary perspective, and you're thinking 223 00:15:02,840 --> 00:15:05,920 Speaker 2: from the point of view of the virus, how to 224 00:15:05,960 --> 00:15:11,640 Speaker 2: sustain your life if you will, your life cycle in 225 00:15:11,760 --> 00:15:16,320 Speaker 2: a community is as important as how to sustain it 226 00:15:16,800 --> 00:15:22,000 Speaker 2: in one person. And so you have to imagine a 227 00:15:22,080 --> 00:15:27,200 Speaker 2: rural community if chicken pox isn't reintroduced as a kid 228 00:15:27,240 --> 00:15:31,000 Speaker 2: with chicken pox showing up from somewhere. That is it 229 00:15:31,160 --> 00:15:36,720 Speaker 2: for the virus unless unless there's another way for it 230 00:15:36,840 --> 00:15:40,640 Speaker 2: to introduce itself again, so to speak. And that is 231 00:15:40,680 --> 00:15:44,720 Speaker 2: where the Shingles think. So that is why his work 232 00:15:45,200 --> 00:15:49,760 Speaker 2: in Yale was really important. He was actually showing that 233 00:15:50,200 --> 00:15:54,280 Speaker 2: life cycle as it rolls out in a community. 234 00:15:54,840 --> 00:15:57,920 Speaker 1: Yeah, like the virus as agent. Right, it's giving the 235 00:15:58,040 --> 00:16:01,720 Speaker 1: virus agency. 236 00:16:00,640 --> 00:16:02,960 Speaker 2: Which we know not to do. But it's so. 237 00:16:03,000 --> 00:16:05,640 Speaker 1: Tempting, I mean, whatever that's a word. I mean, I 238 00:16:05,640 --> 00:16:08,760 Speaker 1: think there's a non anthropomorphic way, Like, I don't care 239 00:16:08,800 --> 00:16:11,680 Speaker 1: what anybody says, it's clever that the virus is doing that. 240 00:16:11,840 --> 00:16:13,240 Speaker 1: It's very clever. 241 00:16:13,520 --> 00:16:18,240 Speaker 2: Certainly my point of view. Yeah, So it's an evolutionary 242 00:16:18,320 --> 00:16:22,240 Speaker 2: strategy of the virus. That's one reason why this work 243 00:16:22,960 --> 00:16:27,200 Speaker 2: is important. And the other reason, I think is back 244 00:16:27,200 --> 00:16:31,880 Speaker 2: to the suppositions. He did not assume that the story 245 00:16:32,120 --> 00:16:36,760 Speaker 2: was fully understood, and that was that he knew and 246 00:16:36,880 --> 00:16:39,920 Speaker 2: identified the gaps. So there's a way in which you 247 00:16:39,920 --> 00:16:42,400 Speaker 2: can say we've been filling in the gaps that he 248 00:16:42,520 --> 00:16:45,320 Speaker 2: placed out there as suppositions. 249 00:16:45,720 --> 00:16:50,680 Speaker 1: I think there's something also really elegant, maybe even romantic, 250 00:16:50,720 --> 00:16:56,280 Speaker 1: if I'm being honest about the family doctor, the general 251 00:16:56,320 --> 00:17:01,160 Speaker 1: practitioner as epidemiologist. You know, he's he's there every day 252 00:17:01,200 --> 00:17:04,360 Speaker 1: treating patients. And the thing that he did, I mean 253 00:17:04,400 --> 00:17:06,480 Speaker 1: besides going to yell, which is very dramatic, but the 254 00:17:06,560 --> 00:17:09,320 Speaker 1: less dramatic but maybe ultimately more important thing that he 255 00:17:09,400 --> 00:17:13,520 Speaker 1: did is keep this meticulous data as you say, about 256 00:17:13,840 --> 00:17:16,919 Speaker 1: where the where the rashes are and what the household 257 00:17:16,960 --> 00:17:21,159 Speaker 1: connections are. I mean that transforms his work from you know, 258 00:17:21,240 --> 00:17:25,840 Speaker 1: helping individuals to like making this significant breakthrough in human 259 00:17:25,920 --> 00:17:28,119 Speaker 1: knowledge exactly. 260 00:17:28,400 --> 00:17:32,280 Speaker 2: And picking picking a question. I mean, there's always a 261 00:17:32,400 --> 00:17:36,800 Speaker 2: science of great challenge is pick a question where you 262 00:17:36,920 --> 00:17:40,720 Speaker 2: can really gather some data that's going to lead somewhere. 263 00:17:41,760 --> 00:17:46,520 Speaker 2: That's as much of a contribution as a researcher as 264 00:17:46,600 --> 00:17:49,520 Speaker 2: actually finding answers to some of those questions. 265 00:17:53,760 --> 00:17:55,760 Speaker 1: Thank you for your time. It was great to talk 266 00:17:55,760 --> 00:18:01,760 Speaker 1: with you. You too, And Trevin is a retired clinician 267 00:18:01,800 --> 00:18:05,399 Speaker 1: and microbiologist at Stanford. In a minute, I'll talk with 268 00:18:05,520 --> 00:18:08,320 Speaker 1: a physician and researcher who was a friend of the 269 00:18:08,400 --> 00:18:11,600 Speaker 1: late Edgar Hope Simpson and who has spent decades studying 270 00:18:11,600 --> 00:18:12,840 Speaker 1: shingles and pain. 271 00:18:26,560 --> 00:18:30,760 Speaker 3: Anyone who has done any work on shingles. Probably the 272 00:18:30,840 --> 00:18:34,120 Speaker 3: first name they will come across is Edgar Hope Simpson. 273 00:18:34,840 --> 00:18:36,479 Speaker 1: Is it true that you knew him? 274 00:18:36,640 --> 00:18:40,360 Speaker 3: Oh? Yes, I can't tell you precisely when, but I'll 275 00:18:40,359 --> 00:18:40,880 Speaker 3: tell you how. 276 00:18:41,560 --> 00:18:45,560 Speaker 1: Robert Johnson is a physician who spent decades treating shingle's patients. 277 00:18:45,880 --> 00:18:48,120 Speaker 1: He no longer has a clinical practice, but he still 278 00:18:48,200 --> 00:18:50,480 Speaker 1: does research at the University of Bristol. 279 00:18:50,800 --> 00:18:53,880 Speaker 3: It was about nineteen ninety four. There were a group 280 00:18:53,920 --> 00:18:57,080 Speaker 3: of us who were going to be presenting in a 281 00:18:57,119 --> 00:19:03,040 Speaker 3: symposium and somebody said, is Simpson still alive? And I said, 282 00:19:03,040 --> 00:19:05,400 Speaker 3: I have no idea. Let's have a look and telephone directory. 283 00:19:05,640 --> 00:19:08,640 Speaker 3: So we looked up and there was Hope sinstance siahen sister. 284 00:19:09,040 --> 00:19:11,119 Speaker 3: So we phoned him. I think it was about eight 285 00:19:11,119 --> 00:19:15,000 Speaker 3: o'clock one evening, and there was a fairly brusque answer. 286 00:19:15,000 --> 00:19:19,080 Speaker 3: I Hope Simpson here, I said, is that doctor Egger 287 00:19:19,119 --> 00:19:22,399 Speaker 3: Hope Simpson? He said yes, And I said, could I 288 00:19:22,440 --> 00:19:24,880 Speaker 3: ask you? Are you still interested in shingles? 289 00:19:25,400 --> 00:19:25,800 Speaker 1: Oh? 290 00:19:25,920 --> 00:19:29,280 Speaker 3: Yes, he said, And that was the start of it. 291 00:19:29,760 --> 00:19:33,119 Speaker 3: And he was brilliant. He was the most humble man 292 00:19:33,200 --> 00:19:38,240 Speaker 3: you can imagine, an enormous breadth of knowledge. Everyone had 293 00:19:38,280 --> 00:19:42,720 Speaker 3: stories about him, both from the medical point of view, 294 00:19:43,080 --> 00:19:46,640 Speaker 3: as a friend and in particular as a general practitioner. 295 00:19:46,720 --> 00:19:51,280 Speaker 3: He was clearly extremely caring, and they told me that 296 00:19:51,920 --> 00:19:55,679 Speaker 3: he'd be known to ski in the winter out to 297 00:19:55,760 --> 00:19:59,800 Speaker 3: a patient for an emergency call. He was obviously a 298 00:19:59,840 --> 00:20:01,840 Speaker 3: very dedicated a character. 299 00:20:03,000 --> 00:20:07,320 Speaker 1: So I want to talk about shingles as a disease 300 00:20:07,359 --> 00:20:11,879 Speaker 1: and about your work with shingles. What happens in the 301 00:20:11,920 --> 00:20:13,840 Speaker 1: body when you get shingles. 302 00:20:14,520 --> 00:20:18,920 Speaker 3: What happens is that the virus, which has been dormant 303 00:20:19,280 --> 00:20:22,560 Speaker 3: in nerve tissue near to the spinal cord and near 304 00:20:22,600 --> 00:20:27,240 Speaker 3: to the certain areas of the brain, has found itself 305 00:20:27,280 --> 00:20:32,520 Speaker 3: able to reactivate without getting an immune response adequate to 306 00:20:32,640 --> 00:20:36,800 Speaker 3: prevent its spread. And then the virus replicates it, It 307 00:20:37,000 --> 00:20:41,399 Speaker 3: increases its numbers, it multiplies and spreads along the peripheral 308 00:20:41,440 --> 00:20:44,639 Speaker 3: nerve that runs from the area where it was latent 309 00:20:45,160 --> 00:20:48,440 Speaker 3: and eventually reaches the skin, where you get the typical 310 00:20:48,760 --> 00:20:50,440 Speaker 3: rash of shingles. 311 00:20:51,160 --> 00:20:56,000 Speaker 1: So I had chicken pucks decades ago, and right now 312 00:20:56,800 --> 00:20:59,520 Speaker 1: inside my nerve cells inside my body, there is that 313 00:20:59,600 --> 00:21:05,359 Speaker 1: virus still just hanging out weeding more or less and 314 00:21:05,400 --> 00:21:07,520 Speaker 1: if there is some moment when my immune system is 315 00:21:07,560 --> 00:21:11,480 Speaker 1: compromised in some set of factors, a line I will 316 00:21:11,480 --> 00:21:12,160 Speaker 1: get shingles. 317 00:21:12,520 --> 00:21:16,639 Speaker 3: Yes, you're absolutely right. In a lifetime, about thirty percent 318 00:21:16,640 --> 00:21:19,280 Speaker 3: of us will get shingles, and if one lives into 319 00:21:19,280 --> 00:21:22,320 Speaker 3: one's eighties, which these days is very common, it's about 320 00:21:22,320 --> 00:21:24,520 Speaker 3: a fifty percent chance of getting shingles. 321 00:21:25,240 --> 00:21:27,639 Speaker 1: Tell me more about the symptoms of having shingles. What 322 00:21:27,720 --> 00:21:28,960 Speaker 1: is it like to have shingles? 323 00:21:29,480 --> 00:21:34,119 Speaker 3: Very frequently one has several days of pain or tingling sensation, 324 00:21:34,560 --> 00:21:38,120 Speaker 3: maybe feeling a little bit unwell, but then the rash 325 00:21:38,119 --> 00:21:45,160 Speaker 3: appears and the diagnosis becomes clear. Almost always, the acute disease, 326 00:21:45,320 --> 00:21:49,199 Speaker 3: the first three or four weeks is painful, and it 327 00:21:49,240 --> 00:21:53,840 Speaker 3: can be extremely painful. In some people, the lucky ones, 328 00:21:54,359 --> 00:21:57,359 Speaker 3: the rash the pain over a period of ten days 329 00:21:57,359 --> 00:22:00,320 Speaker 3: to three weeks disappear. There's often a little bit of 330 00:22:00,359 --> 00:22:04,480 Speaker 3: scarring and that's the end of it. But in others 331 00:22:04,680 --> 00:22:09,080 Speaker 3: that's not the case. The pain persists. It can be intermittent, 332 00:22:09,280 --> 00:22:13,560 Speaker 3: but it can go on for weeks, months, or even years, 333 00:22:14,440 --> 00:22:19,359 Speaker 3: and when it reaches three months from the rash appearance, 334 00:22:19,520 --> 00:22:21,760 Speaker 3: we call it post Pettit euralgia. 335 00:22:21,880 --> 00:22:25,480 Speaker 1: So post herpetic neuralgia is the technical term, the term 336 00:22:25,520 --> 00:22:29,960 Speaker 1: of art for basically long term pain after you have shingles. 337 00:22:30,680 --> 00:22:32,800 Speaker 1: You can sort of unpack it right, post her petic 338 00:22:32,880 --> 00:22:37,800 Speaker 1: after herpes and neuralgia is a pain from from the nerves, 339 00:22:37,880 --> 00:22:41,400 Speaker 1: right from the nerve, absolutely, and it seems like that 340 00:22:41,560 --> 00:22:44,000 Speaker 1: is I mean, shingles is the thing you don't want. 341 00:22:44,200 --> 00:22:47,280 Speaker 1: Post herpetic neuralgia, long term pain from shingles is the 342 00:22:47,320 --> 00:22:50,080 Speaker 1: thing you really don't want, right, So let's talk some 343 00:22:50,119 --> 00:22:53,080 Speaker 1: more about that. I know you're working on that. What 344 00:22:53,280 --> 00:22:56,199 Speaker 1: is the mechanism of post her petic neuralgia. Why is 345 00:22:56,240 --> 00:22:58,200 Speaker 1: it that some people get it and some people don't. 346 00:23:00,480 --> 00:23:03,560 Speaker 3: I'd say I don't know, but I will try and 347 00:23:03,600 --> 00:23:08,800 Speaker 3: give you a full answer without waffling too much. There 348 00:23:08,920 --> 00:23:14,919 Speaker 3: is definite damage to nerve tissue, nerve fibers right from 349 00:23:15,119 --> 00:23:19,719 Speaker 3: the skin to the spinal cord and indeed within the 350 00:23:19,720 --> 00:23:24,919 Speaker 3: spinal cord. But the problem starts with the clinical side, 351 00:23:24,960 --> 00:23:28,440 Speaker 3: because there is no single pain syndrome of post de 352 00:23:28,520 --> 00:23:32,080 Speaker 3: pendant euralgia. You can have numbness, or you can have 353 00:23:32,280 --> 00:23:36,800 Speaker 3: a severely increased sensitivities to touch. You can have a 354 00:23:36,920 --> 00:23:40,720 Speaker 3: reduction in sensitivity to heat and cold, or you can 355 00:23:40,760 --> 00:23:44,359 Speaker 3: have an increase. You can have a continuous burning pain, 356 00:23:45,320 --> 00:23:50,880 Speaker 3: you can have severe intermittent lancinating, page shooting, electric shock 357 00:23:51,080 --> 00:23:54,800 Speaker 3: like pains, And if you take that forward to months 358 00:23:54,920 --> 00:23:57,960 Speaker 3: and years, you can see what it can do to 359 00:23:58,000 --> 00:23:58,479 Speaker 3: a patient. 360 00:23:59,240 --> 00:24:02,920 Speaker 1: Let's talk about eatment and prevention, right, Okay, what can 361 00:24:02,960 --> 00:24:05,480 Speaker 1: you do to avoid getting shingles in. 362 00:24:05,480 --> 00:24:10,560 Speaker 3: The first place? Don't have chicken pox, And the only 363 00:24:10,640 --> 00:24:13,560 Speaker 3: way you can be fairly confident in not having chicken 364 00:24:13,600 --> 00:24:16,760 Speaker 3: pox is to be vaccinated against it, which in the 365 00:24:16,840 --> 00:24:21,200 Speaker 3: States you have done pretty routinely since nineteen ninety five. 366 00:24:21,920 --> 00:24:24,280 Speaker 3: But it's going to be some years before we see 367 00:24:24,320 --> 00:24:28,520 Speaker 3: any marked effect on that in shingles because those people 368 00:24:28,560 --> 00:24:32,200 Speaker 3: are still, relatively speaking young as far as the age 369 00:24:32,200 --> 00:24:36,920 Speaker 3: for getting shingles is concerned. So vaccination against chicken pox 370 00:24:37,000 --> 00:24:41,960 Speaker 3: is one, the next one is vaccination against shingles. 371 00:24:42,720 --> 00:24:47,760 Speaker 1: If you are not fortunate enough to prevent shingles, what 372 00:24:48,000 --> 00:24:53,119 Speaker 1: is the treatment both for the initial disease and for 373 00:24:53,240 --> 00:24:54,800 Speaker 1: post herpetic neuroalgia. 374 00:24:55,240 --> 00:25:01,199 Speaker 3: Right, Well, one may have a capacity to actually even 375 00:25:01,240 --> 00:25:04,760 Speaker 3: when shingles has started prevent post to pedant euralgea. It's 376 00:25:04,800 --> 00:25:09,359 Speaker 3: a bit uncertain. Anti virals we hoped would have a 377 00:25:09,400 --> 00:25:13,320 Speaker 3: massive effect on that. And the anti viral drugs are 378 00:25:13,359 --> 00:25:18,400 Speaker 3: remarkable for treating the acute symptoms and any serious disease, 379 00:25:18,960 --> 00:25:22,119 Speaker 3: But how much they influence development of post to pedant 380 00:25:22,119 --> 00:25:25,600 Speaker 3: euralgia's always remained a bit of a gray area. It's 381 00:25:25,920 --> 00:25:29,520 Speaker 3: very hard to see why they wouldn't. But if they do, 382 00:25:30,119 --> 00:25:33,960 Speaker 3: it hasn't reduced the incidence of post pedant euralgia overall 383 00:25:34,080 --> 00:25:34,560 Speaker 3: very much. 384 00:25:34,760 --> 00:25:36,400 Speaker 1: If they work, we can't see it. 385 00:25:37,080 --> 00:25:41,400 Speaker 3: Well, that's sort of how it is. Yes, Having said that, 386 00:25:41,560 --> 00:25:45,840 Speaker 3: I wouldn't want to underplay the value of the antiviral drugs. 387 00:25:46,040 --> 00:25:49,080 Speaker 3: My personal view is that almost everybody who gets shingles 388 00:25:49,080 --> 00:25:50,200 Speaker 3: should receive them. 389 00:25:50,560 --> 00:25:53,520 Speaker 1: I know you're working now on a study looking at 390 00:25:53,560 --> 00:25:56,960 Speaker 1: it at another way of treating shingle's patients with lasting pain. 391 00:25:57,600 --> 00:25:58,320 Speaker 1: Tell me about that. 392 00:25:58,840 --> 00:26:03,720 Speaker 3: We're now looking. In England, we have a study based 393 00:26:03,760 --> 00:26:09,280 Speaker 3: on Bristol looking at amitriptlen that was originally an antidepressant drug, 394 00:26:09,640 --> 00:26:13,199 Speaker 3: but in very low doses it has an effect on 395 00:26:13,280 --> 00:26:19,680 Speaker 3: europathic pain. And another neurologist called David Bouscher from Liverpool 396 00:26:19,720 --> 00:26:23,320 Speaker 3: in England had published a study all three decades ago, 397 00:26:23,359 --> 00:26:30,000 Speaker 3: perhaps basically showing that probably low dose ami triptlen given 398 00:26:30,800 --> 00:26:34,600 Speaker 3: early in the course of jingles reduced the incidents of 399 00:26:34,880 --> 00:26:40,880 Speaker 3: post dependant eualgia dramatically. David Bouscher was a character and 400 00:26:41,240 --> 00:26:45,920 Speaker 3: he did push the case of herpes oster extremely well 401 00:26:46,320 --> 00:26:50,480 Speaker 3: as far as people getting interested in research in it. 402 00:26:50,480 --> 00:26:54,959 Speaker 3: It was a very interesting paper and very indicative that 403 00:26:55,040 --> 00:26:59,000 Speaker 3: further research was needed, but it didn't prove the case. 404 00:27:00,560 --> 00:27:05,520 Speaker 1: This is a very odd the decades or antidepressant yes, 405 00:27:05,680 --> 00:27:10,080 Speaker 1: or drug that was developed as an antidepressant, yes, why 406 00:27:11,240 --> 00:27:14,119 Speaker 1: why might it help reduce postropedic neuralgia. 407 00:27:14,880 --> 00:27:19,640 Speaker 3: Well, again it's not fully understood, but it does have 408 00:27:19,760 --> 00:27:26,400 Speaker 3: certain effects which can affect transmission of impulses within nerves 409 00:27:26,520 --> 00:27:33,439 Speaker 3: and excitability of damaged nerve tissue, possibly effects within the 410 00:27:33,440 --> 00:27:39,960 Speaker 3: spinal cord at inhibition of pain from impulses which traveled 411 00:27:40,080 --> 00:27:43,639 Speaker 3: down from the brain out towards the spinal cord and 412 00:27:43,680 --> 00:27:48,119 Speaker 3: the peripheral nerves. There are all sorts of possible mechanisms, 413 00:27:48,200 --> 00:27:50,399 Speaker 3: but I think it would be wrong with me to 414 00:27:50,440 --> 00:27:51,600 Speaker 3: say we know the answer. 415 00:27:52,480 --> 00:27:54,360 Speaker 1: I want to talk about pain a little bit more 416 00:27:54,560 --> 00:27:57,760 Speaker 1: more broadly. And you know, when you mentioned an antidepressant 417 00:27:58,680 --> 00:28:01,040 Speaker 1: as a treatment for pain, there's one universe where there 418 00:28:01,080 --> 00:28:04,280 Speaker 1: is some very direct mechanism in the peripheral nervous system. 419 00:28:05,160 --> 00:28:07,760 Speaker 1: I mean, there is also a universe where pain is 420 00:28:07,840 --> 00:28:11,439 Speaker 1: related to our psychological state. And as a doctor who 421 00:28:11,480 --> 00:28:14,760 Speaker 1: has treated pain a lot, I'm curious about your view 422 00:28:14,840 --> 00:28:18,440 Speaker 1: on that. More generally, on pain, you know, as part 423 00:28:18,520 --> 00:28:24,040 Speaker 1: of this broader complex of well of a person psychological state. Oh. 424 00:28:24,119 --> 00:28:30,840 Speaker 3: Absolutely, pain is biopsychosocial. There's a pathology, the biobit, there's 425 00:28:30,920 --> 00:28:34,760 Speaker 3: the psychology, and there's the social the environment that we 426 00:28:34,880 --> 00:28:39,320 Speaker 3: live in, and all these things play a part in 427 00:28:39,520 --> 00:28:42,480 Speaker 3: pain and how we respond to it. And you know, 428 00:28:43,120 --> 00:28:45,800 Speaker 3: just go back to Hope Simpson for a second. When 429 00:28:45,880 --> 00:28:50,320 Speaker 3: Hope Simpson talked about management of patients in general practice 430 00:28:50,480 --> 00:28:54,200 Speaker 3: with shingles, he said the main thing was to care 431 00:28:54,320 --> 00:28:57,520 Speaker 3: for the patient, to take an interest in the patient, 432 00:28:57,760 --> 00:29:01,560 Speaker 3: to follow the patient up, to encourage them. And this 433 00:29:01,720 --> 00:29:06,000 Speaker 3: is so true. My wife and I started a herpesoster 434 00:29:06,080 --> 00:29:09,959 Speaker 3: clinic here in Bristol or many years ago now, and 435 00:29:10,000 --> 00:29:13,480 Speaker 3: we saw mainly post a petit euralgia patients, but we 436 00:29:13,480 --> 00:29:17,440 Speaker 3: were very happy to see acute patients that general practitioners 437 00:29:17,480 --> 00:29:21,600 Speaker 3: referred us who had unusual features or severe pain, or 438 00:29:21,600 --> 00:29:28,200 Speaker 3: were particularly distressed. And it was really the persistence and 439 00:29:28,280 --> 00:29:31,680 Speaker 3: the interest shown in the patients which made a huge 440 00:29:31,720 --> 00:29:36,400 Speaker 3: difference to their progress. The treatments we had available were 441 00:29:36,400 --> 00:29:40,280 Speaker 3: pretty limited, and you just had to persevere. We worked 442 00:29:40,280 --> 00:29:43,400 Speaker 3: through the treatments with them, We discussed the treatments with them, 443 00:29:43,960 --> 00:29:48,320 Speaker 3: and I think it makes a world of difference how 444 00:29:48,360 --> 00:29:52,160 Speaker 3: you treat the patient overall. And one of the things 445 00:29:52,280 --> 00:29:55,720 Speaker 3: that is essential is to encourage them to get back 446 00:29:55,880 --> 00:30:01,160 Speaker 3: to social interactions, to go out and meet people, not 447 00:30:01,320 --> 00:30:04,000 Speaker 3: to hide away nursing the pain. 448 00:30:05,040 --> 00:30:06,720 Speaker 1: Why Why is that so important? 449 00:30:07,640 --> 00:30:12,680 Speaker 3: Because pain is multifactorial, and if you can address one 450 00:30:13,040 --> 00:30:17,440 Speaker 3: or more of the bio psychosocial elements, you're going to 451 00:30:17,480 --> 00:30:20,560 Speaker 3: get improvement. Well, the bio we weren't so good on, 452 00:30:21,320 --> 00:30:24,080 Speaker 3: although we did have drugs and we did have other treatments. 453 00:30:24,560 --> 00:30:28,440 Speaker 3: The psycho, I don't know much about that, but the social, yes, 454 00:30:28,840 --> 00:30:36,000 Speaker 3: you could definitely influence that. Encouragement and taking a concern 455 00:30:36,040 --> 00:30:37,880 Speaker 3: about the patient's problem is essential. 456 00:30:41,160 --> 00:30:43,160 Speaker 1: It was really lovely to talk with you. I thank 457 00:30:43,200 --> 00:30:45,040 Speaker 1: you for being so generous with your time. Thank you, 458 00:30:45,200 --> 00:30:49,880 Speaker 1: Andrew Knowledge, Thank you very much. Robert Johnson is a 459 00:30:49,920 --> 00:30:53,560 Speaker 1: researcher at the University of Bristol. Thanks to both my 460 00:30:53,640 --> 00:30:57,600 Speaker 1: guests today, Anne Arvin and Robert Johnson. By the way, 461 00:30:57,800 --> 00:31:00,080 Speaker 1: last week's show, in case you missed it was all 462 00:31:00,120 --> 00:31:03,320 Speaker 1: so about a herpes virus. That show was about the 463 00:31:03,320 --> 00:31:08,120 Speaker 1: epstein bar virus EBV, which also has some very insidious 464 00:31:08,320 --> 00:31:13,000 Speaker 1: long term effects. Next week on the show, the HIV 465 00:31:13,080 --> 00:31:15,840 Speaker 1: epidemic that changed the world and the scientists who are 466 00:31:15,920 --> 00:31:21,360 Speaker 1: racing to understand it. We have something, We have something. 467 00:31:23,120 --> 00:31:26,280 Speaker 1: Incubation is a co production of Pushkin Industries and Ruby 468 00:31:26,320 --> 00:31:30,720 Speaker 1: Studio at iHeartMedia. It's produced by Kate Ferby and Brittany Cronin. 469 00:31:31,080 --> 00:31:34,040 Speaker 1: The show is edited by Lacey Roberts. It's mastered by 470 00:31:34,080 --> 00:31:38,640 Speaker 1: Sarah Bruguier, fact checking by Joseph Friedman. Our executive producers 471 00:31:38,680 --> 00:31:42,240 Speaker 1: are Lacey Roberts and Matt Romono. I'm Jacob Goldstein. Thanks 472 00:31:42,280 --> 00:31:42,800 Speaker 1: for listening.