A Brief History of Plagues and Pandemics: From the Black Death to COVID-19
Daily life in the age of coronavirus has affected us in different ways. For science writers, it means that many of the physicians and scientists we would in normal times talk to are too busy saving lives. At the same time, the science and medical journals are spewing articles faster than we can keep up, peer review necessarily delayed.
For the first half of March, I wrote breaking news articles and quickly burnt out. No one was giving interviews as the publication cycle continually compressed, sometimes doubling back to correct errors as new information flooded in.
And then the webinars began, some for media, some for physicians. I’ve been doing as many as I can, from government agencies, patient advocacy groups, and the journals. This is my sixteenth piece on the novel coronavirus, thanks largely to these constant updates from the experts. My favorite webinar series is the Live Stream Q&A sessions from The Journal of the American Medical Association’s editor-in-chief Howard Bauchner, MD.
I especially liked the webcast on April 2 with Frank Snowden, PhD, professor emeritus of history of medicine at Yale and the author of Epidemics and Society: From the Black Death to the Present, published fortuitously this past fall. Listening to him reminded me of my favorite books about plagues and pandemics, which I’ll list at the end.
Dr. Anthony Fauci, who needs no introduction with his face plastered on tee shirts and donuts (I’ve joined his Facebook fan club), does the JAMA webinar regularly, most recently on April 8. So I’m going to pretend that both gentlemen are sitting here with me and my cats in my living room, briefing me on the past and future of COVID-19, and how it fits into the grand sweep of epidemiology.
“An Extraordinary Convergence of Events”
Dr. Snowden attributes the current pandemic to an “extraordinary convergence of events.”
“Number one, I am struck by the ease with which it has spread throughout the world, which is partly because of the kind of world we’ve built. Number two, I am struck by the lack of preparedness. The world was totally unprepared in ways that are difficult to comprehend, because since 1997, when we had avian influenza, a surge of epidemiologists and virologists were saying that another pandemic challenge is an inevitable part of our future.” He expanded on the issue.
In 2005 and 2006, in the wake of the SARS epidemic, the US Congress, the World Health Organization (WHO), and companies began working on preparedness plans. But they dropped the ball when the epidemic faded, “even after Anthony Fauci said to Congress that if you are living in the Caribbean, you’d expect a meteorologist to say a hurricane is inevitable, but couldn’t say when it would hit or how powerful it would be. Virologists could tell you another epidemic was coming. We didn’t know how powerful or when, but it was inevitable,” Dr. Snowden recalled.
By the time Ebola struck in West Africa in 2014, the world once again wasn’t ready. “In 2018, WHO appointed a commission to look at global preparedness and they produced a report in 2019, “A World at Risk,” Dr. Snowden said. He was amazed that the report predicted that millions could die in a pandemic, yet some countries (names unmentioned) cut their preparedness and public health budgets.
“Thirdly, the lack of taking science seriously is what disturbs me the most about the onset of the pandemic,” Dr. Snowden said, pointing out that skepticism about science persists in many nations. He brought up calling the new pathogen “the Chinese virus” long after the WHO had officially named it the more scientifically meaningful SARS-CoV-2. “In addition to being stigmatizing, that is saying to the scientists of the world. ‘we’re not taking your concerns seriously,’” he added.
Comparison to 1918 Influenza
Which past pandemic most resembled the current one? Dr. Snowden immediately answered “1918 influenza.”
“There is still debate about where and how it started: China or Kansas or at the British military base at Étaples in the north of France. It spread quickly from Étaples with forced movement of troops to the western front. From November 1918 into the new year, it caused 50 million to 100 million deaths, many times more than the number of deaths from the first world war.”
An important factor, ironically, was the peace that followed the war. Returning soldiers brought the disease to the U.S., where welcome-back parties fueled the fires of contagion. After a parade in Philadelphia, hundreds of thousands of people fell sick. “Other major cities took measures that look like what we’re doing today: masks, social distancing, canceling major events like church services where people congregate,” Dr. Snowden said. Did the mayor of New Orleans know about the Philadelphia parade when Mardi Gras 2020 happened?
Another striking feature is that the 1918 pandemic was largely forgotten. “How could a disease that caused 100 million deaths not sear a long-term memory into our institutions and economy? It was overshadowed by war, and then by peace, and it didn’t besiege communities like bubonic plague, but swept and left devastation and was gone in a few weeks,” Dr. Snowden said. He pointed out that Britain has many monuments to remember the first world war and the bravery of the soldiers, but just one monument to remember “the heroes of the 1918 influenza, the doctors and nurses who put their lives on the line to care for patients and their colleagues.”
The influenza virus circled the globe in three undulations. “The early waves were in the spring of 1918 and were rather benign, not a major cause of mortality. Probably the virus mutated between the spring and the autumn, when it became catastrophic and coincided with the end of the war. The curve of mortality was pronounced,” Dr. Snowden said.
Curiously, the influenza pandemic of 1918 spared the very young and the elderly, creating “a W-shaped curve and not a U, with that spike in the middle the young people, like the soldiers,” Dr. Snowden explained. The soldiers died of an overactive immune response that filled their lungs rapidly with fluid, the “cytokine storm” that today is ravaging lungs infected with SARS-CoV-2.
In 1918 the young were vulnerable because they were crowded in the hellish environment of war, on transport ships and in military camps. Their elders may have been protected from having survived previous flu epidemics and building up a strong antibody response to similar viruses.
Will COVID-19 follow a path similar to the 1918 flu? If so, it will do so over a landscape vastly different from the scattered towns and cities of the U.S. a century ago.
“There was extraordinary morbidity and mortality in 1918, and yet it didn’t affect the world in the way that this coronavirus seems to be doing. The new virus may be having a more lasting effect, we don’t yet know. Clearly there will be major long term effects on the economy, on the relationships between industrial countries and emerging markets, international supply links, and all sorts of things,” Dr. Snowden said.
The Legacy of Cholera
“Each epidemic, each pandemic, is unique. Pandemics are not interchangeable. Each is experienced by society a different way. It’s interesting to think about why some have left a huge footprint and others seem not to have,” Dr. Snowden said. He recalled the classic epidemiology tale of London’s Broad Street water pump handle, to which local physician Dr. John Snow and Reverend Henry Whitehead traced a fierce epidemic of cholera in September, 1854 that would have lasting effects on public health.
Patient zero was a baby girl who lived at 40 Broad Street and developed severe diarrhea on September 28. Her mother washed her nappies out a few feet from the pump, sending bacteria-laden stool into the neighborhood’s water supply. Ten percent of the street’s residents died within two weeks. Cholera kills in days.
The cholera outbreak “had a huge impact on the sanitary movement: making drinking water safer and instituting housing regulations paved the road towards the idea of the germ theory of disease. These accomplishments emerged out of this major cataclysm that was much smaller than the 1918 flu,” Dr. Snowden said.
The Black Death and Tuberculosis Breed Blame
Parallel to the spread of a pathogen may be the spread of discrimination.
Bubonic plague, caused by the bacterium Yersinia pestis, is perhaps the most long-lasting and pervasive example. Dr. Snowden spoke softly of the horrors.
“The Black Death was a time of extraordinary violence. In Strasbourg (on the border of France and Germany, in 1349) 12,000 Jews were rounded up and taken to a Jewish cemetery and given the option to convert or be killed on the spot. Half refused and were burned alive.” The Jews had been accused of poisoning wells with plague bacteria.
A novel published in 1827 and set in 1630 Milan, The Betrothed, by Alessandro Manzoni, illustrated another plague-driven travesty. “The Spaniards were innocent, but in the wrong place and time and were rounded up and tortured until they confessed. Their bodies were broken on the wheel and they were burned alive, accused of spreading a disease by poisoning the wells,” Dr. Snowden said.
Tuberculosis also seemed to bring out the worst in frightened people. “With TB it began, paradoxically, when people understood that it wasn’t hereditary but caused by a germ, which they associated with filth. Working classes were held responsible. Social tension and stigma arose on a class and ethnic basis in places like New York because immigrants were more likely to be dangerous,” Dr. Snowden said.
HIV/AIDS vs COVID-19
Closer to our own time, Dr. Snowden pointed out, is the horrific stigmatization of the “4H” groups that emerged as high risk in the early days of the HIV/AIDS pandemic: in the language of the time, homosexuals, Haitians, hemophiliacs, and heroin addicts.
Dr. Fauci was on the frontlines back then. He recalled:
“I got involved with HIV a week after the first report in the MMWR (CDC’s weekly newsletter) in June 1981. I completely turned my lab around to delve into a disease that had no name, no known etiology, and we didn’t know what we were doing. In the early years of HIV/AIDS, 30,000 to 35,000 people died a year. It was insidious then, seeming to involve a very circumscribed demographic.”
He compared HIV/AIDS’ stealth trajectory to the stunning speed of COVID-19:
“HIV/AIDS didn’t instill fear for awhile. It was only when we found out, through antibody testing, that ill patients were the tip of the iceberg did people realize it was turning into a global problem that would extend four decades and at the end of the day would kill infinitely more people than COVID-19. With COVID the timeline is truncated into weeks. It explodes and everyone is vulnerable all over the world, in real time, and all are afraid.”
My grandfather met my grandmother in the midst of the 1918 influenza pandemic – she was his nurse. He rarely got so much as a sniffle in his remaining years, dying at age 103. Those antibodies must have been powerful.
We don’t remember the 1918 influenza. Plague is now exceedingly rare, and cholera and TB no longer seen in many parts of the world.
But people my age remember the “childhood diseases” of measles, mumps, chickenpox, and rubella, the empty classrooms, the “parties” parents held to expose their little ones to get the diseases over with, for only rarely were they dangerous (see “Vaccine Memories”).
We can all recall recent outbreaks of influenza, and the vaccines that might not seem to have worked, partly because other types of viruses, like rhinovirus, adenovirus, syncytial virus, and other coronaviruses, cause respiratory infections too. The shared symptoms reflect the responses of our immune systems, not weapons that the pathogens directly deploy.
We’ve all heard of HIV/AIDS. And SARS.
So anyone who didn’t think a pandemic was possible just wasn’t paying close enough attention – to the clues from history and to the informed predictions of today’s scientists, medical researchers, clinicians, and others.
Will we let a pandemic sneak up on us again? Is the warning from COVID-19, enough?
Dr. Fauci thinks this crisis is a game changer. “I hope when we get out of this that we take a look at long term investment in public health. We have a habit of when we get over a challenge, we say ‘let’s move on.’ We should never be in a position to be hit like this again and have to scramble to respond. This is historic.”
Ricki’s Pandemic Reading List
The Great Influenza: The Story of the Deadliest Pandemic in History, by John Barry
The Ghost Map: The Story of London’s Most Terrifying Epidemic and How it Changed Science, Cities, and the Modern World, by Steven Johnson
The American Plague: The Untold Story of Yellow Fever, the Epidemic That Shaped Our History, by Molly Caldwell Crosby
The Hot Zone: The Terrifying True Story of the Origins of the Ebola Virus by Richard Preston
Fever: A Novel by Mary Beth Keane
and of course Spillover: Animal Infections and the Next Human Pandemic, by David Quammen
Hi am not a scientist person but ? If I walk around sick people of con 19 and I don’t get sick or I don’t test positive wat wrong wit me ?
You probably didn’t inhale enough viral particles, which can also enter through the eyes, to test positive. You could have a viral titer too low to be detected. For some patients the first diagnostic test is negative but subsequent ones are positive. By test positive, do you mean for the virus or for antibodies? The antibody response takes a few weeks.