What we now call Covid-19 appeared as a new disease in China in late 2019. It rapidly spread worldwide as a pandemic with countries struggling to manage it, and to prevent their health services being overwhelmed while simultaneously keeping their economies functioning. Before considering some of the issues around this, I though that an historical perspective would help to understand how and why “we are where we now are”.
Leprosy is one of mankind’s oldest scourges. It’s mentioned in the Book of Leviticus which was compiled several centuries before Christ. The causative organism, a relative of the tubercle bacillus, was first recognised by the Norwegian Gerhard Armauer Hansen in 1873. The disease causes a patchy rash and peripheral nerve damage resulting in unrecognised injuries and disability. It’s curable with antibiotics today.
In the Middle Ages, lepers were ostracised and many found refuge in leper colonies; those run by monks dedicated to St Lazarus, the patron saint of lepers, were called Lazar houses. They often cared for other indigents. Other lepers wandered from place to place seeking alms; they warned of their approach by ringing a bell and crying, “Unclean, unclean”. In Leviticus chapter 13 we read:
45 And the leper in whom the plague is, his clothes shall be rent, and his head bare, and he shall put a covering upon his upper lip, and shall cry, Unclean, unclean.
46 All the days wherein the plague shall be in him he shall be defiled; he is unclean: he shall dwell alone; without the camp shall his habitation be.
Leprosy is still stigmatised today; the preferred name for the affliction is now Hansen’s disease.
Bubonic plague is the commonest form of the plague. Fleas bite infected rats, and then humans. After such a flea bite, the local lymph glands, typically in the groin, become swollen as buboes and may become necrotic; this is commonly followed by gangrene of the extremities. The word ‘bubo’ derives from the Greek for ‘thigh’. Septicaemic plague and pneumonic plague are less common than bubonic plague and can be spread from human to human. The overall mortality without treatment is between 30% and 90%.
There have been three major global pandemics of plague. The first, the Plague of Justinian, in the 6th century CE caused around 25 million deaths. It recurred episodically over the next two centuries; a total of about 50 million people died.
The second pandemic is much better known; it was the Black Death which ravaged Europe, Asia (where it began) and northern Africa in the 14th century. It killed at least one-third of the European population then, and perhaps over 100 million people world-wide. It too returned episodically. One of the last episodes was in London in 1665, the year before the Great Fire.
The black rat was susceptible to infection by plague, but was gradually supplanted throughout Europe after the Black Death by the larger, disease-resistant, brown rat. After the Great Fire, London’s houses were rebuilt in brick; this too many have helped in the eradication of the disease.
A German illustration of a plague doctor — “Dr Beaky from Rome”
In the subsequent outbreaks of the Black Death, Plague Doctors would tend to the sick. These men, not necessarily medically qualified, wore black gowns and a strange mask like a beak. Rather like a nosegay, this contained aromatic herbs such as lavender which were thought to counter the evil air or miasma which was then believed to be the source of the disease. The eyes were made of glass. The hat signified the profession, and the stick was used as a pointer, to remove clothes, and to take the pulse — all achieved without touching the patient. Unsurprisingly, the people were terrified by such an apparition, signifying as it did the imminence of death.
During the Black Death, from 1377, the city state of Ragusa, modern Dubrovnik, required newcomers to spend 30 days on nearby islands before they could enter. Later the Venetian authorities lengthened this period to 40 days — quarantino — from which the word quarantine derives. Whether the 40 days was akin to Jesus’s 40 days in the desert, or the Lent observance, or whether there was some understanding of the incubation period of the disease is unclear. This quarantine was compulsory and involuntary, and was very effective at reducing the local transmission of plague. People were kept in repurposed lazarets or lazarettos; the Venetian original was specially built on a nearby small island. Such isolation stations became widespread at ports.
There was an outbreak of plague in the Derbyshire village of Eyam in 1665. The villagers discussed this with the local rector and a puritan minister. They voluntarily decided to isolate themselves to prevent the plague spreading to the neighbourhood; they marked the boundary of the village with stones, and arranged for supplies to be sent. Payment was made with coins soaked in vinegar. At least 270 villagers died, but the plague did not spread.
The third global plague pandemic began in China and India in the late 19th century. It spread worldwide through shipping networks to the western seaboard of the USA and beyond. It still persists today in small pockets. About 10 million people in India died. The Ukrainian Waldemar Haffkine developed an early vaccine against plague in Bombay in the late 1890s. Though only partially effective, four million people were inoculated within a few years.
The Swiss physician Alexandre Yersin, after qualifying at Lausanne, studied further in Germany and at Louis Pasteur’s research laboratory in Paris. He took French citizenship, and went to French Indochina to practice. He was sent to investigate the plague in Hong Kong in 1894. There he identified (or co-identified) the bacterium responsible for plague. It was subsequently named after him: Yersinia pestis. He was a co-founder of the Medical University of Hanoi, and its first director.
Smallpox is caused by one of two virus variants, Variola major and Variola minor, a less common and less severe form. It is a member of the pox family of viruses. It only infects humans and is very contagious. It is characterised by an eruption of vesicles, particularly on the face; these fill with matter, fester and can burst. Around 30% of those infected die; and a similar number have severe, deep, and disfiguring residual facial scarring or pocks, from which the disease gets its name. (The great pox is syphilis.) Smallpox is estimated to have killed at least 350 million people altogether.
The Chinese devised the procedure of variolation. In this a small quantity of matter is taken from a pustule of a smallpox sufferer on the tenth day, placed on the skin of a patient and inoculated into the skin by scratching. It was believed that the tenth-day matter would produce only a mild illness, and indeed this usually happened. It was known that once a person had recovered from an infection with smallpox they could not catch it a second time; they were immune.
News of this travelled to Constantinople, the capital of the Ottoman Empire. There, Lady Mary Wortley Montagu, whose husband was ambassador to the Sublime Porte, saw the procedure, and wrote back to England about it. On her return to England in 1718, she was an enthusiastic promoter of variolation; it was taken up at Court, and soon after in America. Unhappily, variolation usually had a 3% mortality. Johnnie Notions, a self-taught practitioner in Shetland, achieved local fame using a variolation technique of his own devising; he weakened or attenuated the pus by subjecting it to peat smoke, then burying it with camphor for several years. Reputedly, he had a zero mortality.
Edward Jenner was a physician in rural Gloucestershire. He was told, according to the story, by a milkmaid that as she had had cowpox she could not get smallpox. This seems to have been common knowledge among country folk at the time. Jenner studied cowpox carefully, for there was often confusion between it and similar infections.
On 14 May 1796 he inoculated eight-year-old James Phipps, his gardener’s son, with pus from Sarah Nelmes, a cowpox sufferer. Sarah had caught the disease from Blossom the cow. The boy had a mild illness. Jenner, in an ethically dubious experiment, later inoculated James with pus from a smallpox patient; nothing happened. He repeated this; again nothing happened, convincing Jenner that the boy was now immune. Jenner called his method vaccination after ‘vacca’, the Latin for ‘cow’. He reported this and subsequent findings to the Royal Society; there was no enthusiasm at first, vaccination only slowly receiving general acceptance.
Variolation was made illegal in the UK by an Act of Parliament in 1840; it also recommended vaccination. In a further series of Acts, starting in 1853, vaccination was made compulsory for young infants.
The National Anti-Vaccination League was founded in Britain in 1866, though its origins were in earlier, smaller organisations. Their campaigning was based on such themes as:
— individual liberties and the role of the state,
— individual and collective rights,
— bodily integrity,
— the “natural order” of things, and
— the idea of putting “foreign matter” from cows into people.
There were class issues too, as well as the cost of vaccination for the poor. Lily Loat was secretary of the organisation from 1909 until her death in 1958.
There was a further parliamentary Act in 1898 which modified the previous Acts; it gave a conditional exemption for conscientious objectors, the first time this term appeared in UK law. Previously, there had been penalties for non-compliance; these were removed.
The World Health Organisation (WHO), in an attempt to eradicate smallpox, organised a global campaign of surveillance, containment, and vaccination in the second half of the 20th century. The last natural case of smallpox was diagnosed in Maow Maalin, a cook in Somalia, on 26 October 1977; he survived. (Janet Parker, a medical photographer at the University of Birmingham, contracted the disease in unclear circumstances from the laboratory where smallpox was kept for research. She died on 11 September 1978, the last known person to die of the disease.)
The global eradication of smallpox was declared in 1979, and endorsed by the WHO on 8 May 1980. It’s estimated that Jenner’s vaccination saved the lives of at least 500 million people.
Florence Nightingale recorded the effects of her regime in Scutari, particularly the improvements in sanitation and reduction of mortality from disease. She presented the results statistically and in graphical form. She was the first female member of the Royal Statistical Society.
John Snow famously traced an 1854 outbreak of cholera in London’s Soho to contaminated water from the pump in Broad Street; this was one of first examples of epidemiology. While a skeptic of the miasma theory of disease, the germ theory, an idea from the 17th century and earlier, had not been fully developed or accepted.
Mary Mallon was born in Cookstown in 1869 and emigrated to America when she was 15. She worked as a cook in New York between 1900 and 1907; seven of the eight families contracted typhoid. She was arrested and quarantined in 1907; she was found to be an asymptomatic carrier of the disease. She rarely washed her hands, not unusual at a time when the germ theory of disease wasn’t fully accepted. She refused to have her gallbladder removed. She was released in 1910, later returning to work as a cook. After further outbreaks of typhoid, “Typhoid Mary” was quarantined from 1915 to her death in 1938. At post-mortem typhoid bacilli were said to have been found in her gallbladder.
The British Isles were kept free of endemic rabies by a policy of quarantining imported dogs and similar animals for six months. This was changed in 2000 to a pet-passport scheme indicating rabies vaccination.
Quarantine, strictly speaking, means compulsory isolation, but it’s often used as a catch-all to include a cordon sanitaire, the restriction of peoples’ movements into and out of a defined epidemic area; and voluntary or protective sequestration. The usual term today is lockdown. We call the Biblical management of lepers self-isolation today. Dr Beaky’s strange costume has been replaced by PPE (personal protective equipment) and hazmat suits. PPE includes masks, vizors, gowns, gloves, and sometimes hoods. Specially fitted-out wards have been built and repurposed; we don’t call them lazarets but Nightingale Hospitals. Frequent hand washing is a modern idea.
Strictly, vaccination means inoculation only against smallpox, but is widely used as a synonym for inoculation, how the procedure is done, and immunisation, the aim of the procedure.
Two inevitable consequences of the fear and uncertainty that an outbreak of disease creates are the development of Conspiracy Theories and misrepresentations; and the peddling by quacks of nostrums, “patent medicines”, and fake cures all of which are either useless, dangerous or even fatal.
In Part 2 I’ll look at some contemporary perspectives on the management of Covid-19, together with Conspiracy Theories and vaccine hesitancy or “anti-vaxx”.
My thanks to SeaanUiNeill for his help during the drafting of this blogpost.
Defoe, Daniel; A Journal of the Plague Year, London, 1722
Tuchman, Barbara W; A Distant Mirror: The Calamitous 14th Century, London, Macmillan, 1979
Robert Campbell is a retired surgeon.