Epidemics and Society: From the Black Death to the Present, by Frank M. Snowden
Super interesting book by a historian of medicine at Yale. Recommended in general to anyone interested in history, large-scale societal changes, medicine, or infectious diseases, and also recommended to anyone frustrated with COVID-19 responses over the last 18 months and looking for context.
The book is copyright 2019, and includes an additional preface from 2020 addressing COVID-19. I write this in the second half of 2021 as our nation experiences the fourth wave of COVID. From the preface: “Like all pandemics, COVID-19 is not an accidental or random event. Epidemics afflict societies through the specific vulnerabilities people have created by their relationships with the environment, other species, and each other. Microbes that ignite pandemics are those whose evolution has adapted them to fill the ecological niches that we have prepared.” In the case of COVID, we—humanity—created the epidemic because of habitat destruction, increased contact with wildlife, rapid international travel, and underfunding of public health infrastructure. “Nobel laureate Joshua Lederberg famously argued that, in the contest between humans and microbes, the only defense humans possess is their wits. One could add to Lederberg’s formulation our capacity to collaborate—if we so choose.” Alas, many people in our world and our country lack both wits and the willingness to collaborate.
Dr. Snowden looks at major epidemics over the last millennia, when/where/why they occurred and how they resolved, and explores how society responds to them—both formalized and informal responses, including public health developments, riots, scapegoating, inspiration for arts and literature, the sanitary movement, etc. Infectious diseases have changed wars and the course of history. He also summarizes the advancements of medicine from the supernatural causes (divine theory: illness is a punishment sent by an angry god; demonic theory: demons cause illness through their evil influence) to humoral theory (disease occurs because of an imbalance of the four humors within your body) to the Paris School of Medicine (hospital-based learning for physicians and students, with physical exams correlated with autopsy findings) to germ theory (infectious diseases are caused by microbes, not “miasma” or bad air).
Epidemics covered:
Bubonic plague (Yersinia). There have been three major epidemics, the Plague of Justinian (5th-7th centuries), the Black Death (13th-15th centuries), and modern plague (1870’s to present). Black Death significantly impacted total population numbers for centuries, economy, religion, art, and development of public health measures. Societal responses in particular to the Black Death included flight (rapidly evacuating from places with outbreaks, thus spreading infection), scapegoating (blaming the plague on Jews and prostitutes), and religiosity (Saint Sebastian and Saint Roch were worshipped as plague saints). The plague also prompted the first institutional public health measures: “The first antiplague measure was the establishment of an institutional framework of officials capable of taking extraordinary action to defend the community throughout an emergency. Created under specially drafted ‘plague regulations,’ the new authorities were termed ‘health magistrates.’ They exercised full legislative, judicial, and executive powers in all matters relating to public health under the ancient precept salus populi suprema lex esto (the health of the people is the highest law).” Modern plague exists still today, maintained in wild rodent populations and causing regular outbreaks.
Smallpox. Smallpox killed approximately half a million Europeans every year throughout the 18th century. Smallpox was endemic, considered “normal,” so did not induce hysteria, riots, and scapegoating as plague did. When smallpox was introduced to indigenous populations in the Americas, it wiped out entire populations. The indigenous population of Hispaniola fell from 1 million to 15 thousand after Columbus, easily enabling colonization. So many indigenous people died that it prompted importing labor from elsewhere: “disease was an important contributing factor in the development of slavery in the Americas and the establishment of the infamous Middle Passage.” In the formal public health realm, smallpox led to the invention of vaccination—and, alas, the first antivaxxers (“the antivaccination movement in both Europe and the United States became one of the largest popular movements of the 19th century”).
Cholera (Vibrio). The first cholera epidemic was in 1817, and was followed by six more pandemics. The cholera organism relies on human movement, and it wasn’t able to establish pandemics until the modern era of global travel. “Cholera thrived on such features of early industrial development as chaotic and unplanned urbanization, rapid demographic growth, crowded slums with inadequate and insecure water supplies, substandard housing, an inadequate diet, ubiquitous filth, and the absence of sewers.”
Tuberculosis (Mycobacterium). TB is interesting because its epidemic lasted across the time of the discovery of germ theory; before germ theory, it was thought to be an inherent illness that increased a person’s intelligence, beauty, and creativity (Keats), but after germ theory it was seen to be contagious and evil, and patients were shunned.
Malaria (Plasmodium). Malaria continues to be a major problem today, with half a million deaths per year despite good prevention and treatment options.
Poliomyelitis. Polio was historically a cause of infant mortality, but with improved sanitation around the early 20thcentury, people reached adulthood without having been exposed, and new epidemics were seen in affluent teens and adults. After widespread vaccination in developed countries, the epidemic shifted to the impoverished, ethnic minorities, and religious groups that opposed vaccination.
HIV/AIDS. Snowden compares the epidemic in South Africa (a disease of the general population spread by heterosexual sex and worsened by the legacy of apartheid) to the epidemic in the US (a focal disease of white gay men spread by homosexual sex and leading to stigmatization). In both cases, disinformation played a significant role in spreading disease.
Emerging and reemerging diseases. Ebola, dengue, cholera, antibiotic-resistant bacteria, and SARS all demonstrate the global lack of preparedness to deal with epidemics—as we’ve seen with COVID. “To survive the challenge of epidemic disease, humanity must adopt an internationalist perspective that acknowledges our inescapable interconnectedness.”
Societal effects of epidemics discussed:
Scapegoating (blaming a group of people for the disease) and conspiracy theories:
- · Black Death was blamed on Jews, prostitutes, foreigners, witches, lepers, beggars—people were stoned, lynched, and burned at the stake.
- · Cholera’s symptoms progress very rapidly, causing explosive diarrhea and death within hours, which led people to believe it was a poison rather than an infection. People in the slums noted that health officials, clergy, and doctors didn’t fall ill when they came into the slums (because they weren’t eating and drinking and sleeping there) and thought they were deliberately introducing the disease. This led to riots in hospitals to “rescue” patients, and attacks against doctors and stretcher-bearers.
- · During an outbreak of plague in 1894 in Hong Kong, there were “desperate rumors that the colonial government of ‘foreign devils’ was spreading plague as a means to rid itself of the poor while harvesting their body parts for experimentation and allowing ‘barbarian’ soldiers to take women away to satisfy their ‘sordid intentions.’” In Bombay (Mumbai) in 1896, a rumor told that plague “was a poison administered by the British to solve the twin problems of overpopulation and poverty. A further theory alleged that Queen Victoria’s intention was to sacrifice Indian bodies to placate the god of plague, thereby preserving Britain, not India, from divine wrath.”
- · The global attempt to eradicate polio has run into some problems in the 21st century. “In Kano [Nigeria], Muslim leaders, suspicious of Western intentions after the launching of war in Afghanistan and Iraq, preached that Sabin’s doses were not a public health measure at all. The vaccine, they warned, formed part of a sinister plot to sterilize Muslim children with a reproductive poison.”
Formal public health developments:
- · Plague: Venice invented quarantine (quaranta = forty), where incoming ships and their cargo, crew, and passengers, were isolated for 40 days and decontaminated. Austria maintained an overland sanitary cordon, a permanent line of troops and forts that protected much of Europe for over a century.
- · Smallpox: Dr. Edward Jenner’s cowpox-derived vaccine, which eventually enabled eradication of smallpox, and which also led to other vaccine development including rabies and polio.
- · Cholera: city planning, sanitation, and public waterworks.
- · Tuberculosis: many formal sanitaria were established, where patients lived for months in a healthful environment, along with local community “dispensaries,” which offered free diagnostics and treatments and education of family members.
- · Malaria: efforts in Sardinia showed that multi-faceted prevention is key, with medications and mosquito-spraying being ineffective without also reversing environmental degradation, educating people, increasing the standard of living, and improving nutrition.
- · Polio: two vaccines were developed, Salk’s inactivated injectable vaccine in 1955, and Sabin’s modified live oral vaccine in 1962. Interestingly, Cuba was the first country to eliminate polio, due to a campaign of taking the vaccine to the people, going door-to-door to immunize every child in the country. That’s a lesson we could learn with COVID.
Changing the course of history in wars:
- · Revolutionary War: George Washington ordered smallpox inoculation (variolation) of the army, which affected the outcome of the war.
- · Haitian Revolution: yellow fever arrived from Africa aboard slave shops, along with its mosquito vector; slaves were more resistant to yellow fever but European slavers and Napoleon’s troops sickened and died.
- · War of 1812: a third of Napoleon’s army died of dysentery (Shigella) on the march to Moscow, and then most of the rest died of typhus (Rickettsia) on the march back to France.
