While historians do not predict the future, when it comes to epidemics and pandemics, any historian would almost certainly agree that another one was coming. (Illustration by C R Sasikumar)
I am a historian. I don’t predict the future. And I generally don’t write about the present. I think about how the past created the world in which we now live. But these days, amidst the coronavirus pandemic, I find the past, present, and future colliding with one another. My knowledge of the past, especially past epidemics and pandemics, means I cannot help but draw eery parallels between the past and the present. For example, in 1851, when the French delegate to the International Sanitary Conference spoke about cholera’s spread around the planet, he could almost have been talking about our world in 2020: “Add now the communications between the peoples, today so numerous and more and more rapid; the navigation by steamship, the railways, and on top of that this happy tendency of the populations to visit each other, to mix, to merge, a tendency that seems to make of different peoples a sole and large family, and you will be forced to admit that for such a disease, so widespread and under these conditions, cordons and quarantines are not only powerless and useless, but they are, in the very great majority of cases, impossible.” Decades later, as pandemic flu made its way around the world, in 1918, reactions in many places bear a striking resemblance to contemporary responses to coronavirus. When influenza first appeared in Bloemfontein, South Africa, initial reactions were muted. The city considered itself so healthy that a local guidebook called it the “South African sanatorium”. So confident was the city in its ability to ward off ill health that in early October, while flu was killing people in West Africa, the local newspaper wondered how dangerous could “our friend the ordinary common or garden influenza, be?” They soon had an answer as bodies piled up and hospitals became overwhelmed. An elder of the Dutch Reformed Church said later in October that “It seemed to me that it was the end of mankind.” The shock thrust the city into action—cinemas and schools were finally closed, though for many it was far too late.
While historians do not predict the future, when it comes to epidemics and pandemics, any historian who has studied their history would almost certainly agree that another one was coming. I would have been willing to go even further: Not only would I have expected the arrival of another pandemic, I would have easily imagined, based on patterns from the past, a rise in nationalism in some places; xenophobia, especially in disease naming practices; governments denying or lying about the seriousness of the threat; and an overwhelming burden on the world’s crumbling public health infrastructure. All of these things happened in the past, over and over again, and they are happening now.
Because epidemics and pandemics have been part of human history for millennia there are many things that their histories can teach us. But in our current moment, a few will suffice. For one, epidemics and pandemics force us to reckon, again and again, with the obvious fact that the natural — or non-human — world has a powerful effect on the human world. At the same time, we must keep in mind that there is nothing natural about why infectious diseases strike when they do or why they affect one place or people and not another. As David Arnold wrote about cholera in mid-19th century India, “Like any other disease, it has in itself no meaning: It is only a micro-organism. It acquires meaning and significance from its human context, from the ways in which it infiltrates the lives of the people, from the reactions it provokes, and from the manner in which it gives expression to cultural and political values.” Just as our values give meaning to microorganisms, the conditions that gave rise to epidemic and pandemics only a occur within particular historical contexts and thus infectious diseases only emerge as epidemics when particular social and biological conditions are present.
Take cholera. While there is strong evidence that cholera had been epidemic in India in the18th century it was not until the 1820s that it travelled the globe. Key developments in world history made this possible: British colonialism in India increased travel and trade between the East and the West; faster and faster travel by ship, especially as steam replaced sails; railway lines continued to link huge swaths of previously unconnected space such as the Mediterranean and Red Seas; the opening of the Suez Canal accelerated the pace of travel between parts of the globe; increased urbanisation across Europe — the reasons go on.
While influenza’s lethal effects in 1918 were surely because of the strain’s peculiar virulence, it could not have spread as it did even 20 years before. For one, rail lines and shipping networks kept increasing in pace and volume. As a result, no part of the planet was left unscathed. The pandemic reached some of the most remote communities in the world. In the Pacific Islands, the flu was devastating—mortality rates were higher in these islands than anywhere else. Almost no island lost less than 5 per cent of its population. Western Samoa was the hardest hit: 22 per cent of its population of about 38,000 died in a matter of weeks. One historian has written of the pandemic’s travels through Africa: the “nature of the 1918-1919 disease agent was such that influenza seemed to rage through sub-Saharan Africa as though the colonial transportation network had been planned for the pandemic.”
The same was true for AIDS in the 1970s and early ’80s: It arrived when it did for reasons peculiar to the times, revolving mostly around migrations to and from central Africa to the Caribbean—indeed the transportation and trade networks that helped the flu spread across Africa in 1918 also facilitated the movement of HIV/AIDS across the continent later in the century.
The point might be obvious, but it’s one I want to stress: Epidemic diseases do not occur outside of a human context. This is why understanding their history is so obviously important.
Epidemics and pandemics always have a disproportionate effect on the poor and the marginalised. Paul Farmer, one of the co-founders of Partners in Health, has called epidemic diseases like tuberculosis “biological expressions of social inequality”. We have known this for centuries. Writing of the plague in Marseilles in 1720, a doctor wrote the following about a neighbourhood spared of the pestilence: “The streets are wide, the houses large, and inhabited chiefly by persons living in a state of opulence, and such are always the last attacked by a contagion, on account of the means they have to place themselves out of its reach.”
We will see this play out, tragically, as COVID-19 inevitably makes its way into the places least able to contain it. When cholera began to make its way out of India in the 1820s “It,” as the historian Mark Harrison wrote, “defined the contours of a new world economy, revealing its connections and also, more starkly, its divisions.” The same will be true of the coronavirus.
Since the laboratory revolution of the late 19th century, and especially since the invention of antibiotics and other “miracle drugs” in the years after World War II, we have over-relied on technology and biomedicine to keep us safe while at the same time we have steadily, but surely, dismantled any semblance of robust public health infrastructure. The result has been overconfidence and unrealistic promises about the demise of disease—seen most recently in US President Donald Trump’s unwarranted claim that chloroquine would cure coronavirus. In the past century, and in our current one, a dangerous side effect of medical progress has been an irresponsible optimism concerning the power of biomedicine to rid the world of epidemics. Overconfidence became especially prominent as a result of the laboratory revolution of the late 19th and early 20th centuries. For example, the 1918 pandemic arrived at a time when modern medicine was armed with newfound confidence regarding its ability to discover the causes of diseases and then offer cures. Yet, before the development of a vaccine in the 1930s, when it was identified as a virus, modern medicine was utterly defenceless against influenza. And because flu was unstoppable, despite the claims of modern medicine, the pandemic severely tested the confidence and promise of scientific medicine. Beginning in the 1890s influenza was thought to be a bacterial infection—called Pfeiffer’s bacillus after its discoverer. During the pandemic, a raft of vaccines appeared as did countless cures. None worked. Bacteriology was of no use. During the pandemic, nothing could prevent it nor cure it. Despite this, the NYC health commissioner remained convinced, well into fall 1918 and despite no evidence, that a vaccine was on the way.
In England, and its colonies, the confidence in modern medicine’s ability to combat the flu was misguided with tragic results: In many places ineffective “cures” were distributed but quarantine was not instituted. In Britain, the medical profession urged people to carry on with business as usual and based on their confidence in their own abilities to manage the epidemic downplayed the significance of the flu—going so far as to chastise the press for drumming up a secondary epidemic of fear so convinced was the medical profession that fear itself would bring on the flu. Indeed, downplaying the severity of the epidemic was common, but shutting down public gathering places, like cinemas, where flu could spread was largely ignored until it was too late.
In west and central Africa modern medicine was no more effective than the frequently criticised “native” medicine it was supposed to replace. But not actually having effective treatment did not stop doctors from offering a wide array of “cures”. The Native Commissioner in Belingwe, Southern Rhodesia, achieved “remarkable results” from a combination of mustard plaster, castor oil, brandy, and pneumonia mixture. Others used paraffin and sugar. Confident at first in these remedies, colonial administrators and doctors eventually admitted that Africans saw these “cures” for what they were — quackery. The Native Department reluctantly admitted that the progress doctors and clinics had made in convincing people to abandon indigenous medicine vanished during the flu pandemic as people “lost much of their confidence in the efficacy of European medicine.” And in Spain, at least one religious official also abandoned scientific medicine. A Bishop in Spain, believing that the pandemic was God’s wrath and prayer was the only response, refused to abide by the public health authorities’ prohibition on public gatherings and held a novena in honour of St Rocco, the Patron saint of plague and pestilence. In Sierra Leone, the colonial authorities’ handling of the pandemic prompted a September 1918 editorial in the Sierra Leone Weekly News to opine that because the British authorities handled the epidemic so ineffectively and their medical interventions were so useless: “The epidemic ought…to be made a distinct point of departure in the history of our country. It has been made ten times plainer…that our welfare lies in our standing up and doing things for ourselves.”
By the end of the fall of 1918 and into the winter of 1919, medical professionals began to reflect on their inability to control the epidemic. Some simply said they had no idea, in fact, what caused influenza. One official at the New York City Department of Health wrote that “The real cause, I am afraid, we must admit to be some vagary of plant life beyond our ken up to the present time.” So ineffective was modern medicine that Alfred Crosby, one of the first historians of the pandemic, called it the “greatest failure of medical science in the twentieth century or, if absolute numbers of dead are the measure, of all time.”
None of this diminished, nor should it necessarily have, the optimism associated with scientific medicine. With the discovery of antibiotics in the 1940s confidence in medicine only accelerated—and kept doing so in the 1950s, 60s and 70s in the “golden era” of medicine. People even began to talk about the eradication of infectious disease. In public pronouncements and in the mainstream press, in the 1950s and 1960s especially, there was a buzz in the air about disease eradication and wonder drugs. This was the climate in which infectious disease specialist T. Aidan Cockburn claimed in Science in 1961 that “we can look forward with confidence to a considerable degree of freedom from infectious diseases at a time not too distant in the future.” He went on to write a book about it: The Evolution and Eradication of Infectious Diseases. Walsh McDermott, a prominent TB and international health expert, claimed in the early 1960s that because of antibiotics the control of TB “is one of the few instances to date in which a major disease can be decisively altered without having to await improvement in the social infrastructure.” This is a remarkable and dangerous claim. William Stewart, the Surgeon General of the United States, is even said to have claimed in the late 1960s that “it is time to close the book on infectious diseases, and declare the war on pestilence won.” And in 1973, at the height of biomedical optimism Frank MacFarlane Burnett, a Nobel prizewinner in biology from Australia wrote in one of the most widely used textbooks in medical education, The Natural History of Infectious Disease that because infectious diseases had largely been done away“one of the immemorial hazards of human existence has gone.”
But, of course, this kind of optimism was wildly misguided. For one, even in 1973, lurking and ready to take off, was one of the most devastating infectious diseases in human history: HIV/AIDS. When it made its public debut less than a decade after Burnett’s claims any bluster about the death of infectious disease by the hand of biomedicine or hope of living in a world free of pestilence disappeared. HIV/AIDS was a new infectious disease thriving in a world once thought—by some, anyway—to be on the verge of being rid of such menaces.
None of this means that drugs or medical research are not essential for the control of epidemics. They are, of course. Anti-retroviral therapy, an extraordinary discovery by any measure, has been essential in the fight against HIV/AIDS. Yet, access has been uneven. Since its discovery in the 1960s, oral rehydration therapy for cholera has been lifesaving. But it does nothing to address the reasons why millions of people in the global south are drinking faeces infested water. TB can be cured with antibiotics, yet we have more TB now than at any other time in world history. The very simple point—made by many others—is that there is a relationship between disease and social conditions, conditions that do not exist everywhere and that will not be alleviated with biomedicine.
No historian could have predicted the current coronavirus pandemic. But most historians of epidemics and pandemics are likely unsurprised by some of its key features: the power that the natural world still holds over human life; the disproportionate effect of pandemics and epidemics on the poor and the marginalized; and the over-reliance on biomedicine to the exclusion of a robust public health infrastructure.
This article first appeared in the print edition of April 13, 2020, under the name ‘Connections and divisions’. The writer is associate dean for the social sciences and professor of history, University of Virginia