2020: Putting our pandemic in perspective

No event in human history has affected the entire world so quickly and comprehensively.

Map of the world.
Map of the world. Credit: Adobe Stock

Historians are masters of teasing momentous events from apparently insignificant details. The most obvious such effort is Ray Huang’s 1587, A Year of No Significance: The Ming Dynasty in Decline, which considered a number of little examined incidents and trends that took place in or began in 1587 and that, in hindsight, anticipated the collapse of the Ming Dynasty two or three generations later. In choosing what to expand upon in his study, Huang, writing in 1981, had the benefit of nearly four centuries of research, debate, and interpretation. We can be sure that his choices would have been wildly different had he been writing in 1587.

Predicting the future is a mug’s game, but even accounting for the distortion caused by capturing one’s own likeness in an historical selfie, it seems a safe bet that 2020 will never be regarded as a year of no significance. The coronavirus pandemic has affected the entire world more quickly and comprehensively than any other single event in human history. Given the universality of its impact, it is hardly surprising that reminders of the past are everywhere, especially with respect to the ways in which individuals, communities, and governments have framed their responses in terms of personal behavior, health science, and public policy. The media, medical, and economic environments of 2020 may look nothing like they did a century or five hundred years ago, but the range of human impulses that animate them are familiar.

The disease’s worldwide diffusion was sparked by international travel and public attention to the contagion was first drawn by the plight of cruise ships. Thus it seems fitting to consider our reactions to the coronavirus against a backdrop of maritime trade, which, until the start of the jet age sixty years ago, was the fastest and most direct line of transmission for pandemic viruses and therefore a primary focus of governmental concern and public interest. It is quickly evident, however, that policies intended to contain or alleviate the stress of disease very often reveal or further rend tears in the social fabric, between haves and have-nots; between knowledge, belief, and ignorance; between us and them.

Before the widespread acceptance of germ theory – the idea that many diseases are caused by microscopic pathogens – little was known about the pathology, cure, or containment of diseases. The first pathogen identified was Mycobacterium leprae, which gives rise to leprosy (Hansen’s disease), in 1873. While leprosy and plague now refer to specific diseases, historical sources tend to use these terms as catch-all descriptors for a variety of ailments with similar characteristics. People likewise treated infected people with a broad brush, and they divined early on that segregating the sick – particularly if their disease was notably disfiguring or fatal – from the healthy was one way to keep from spreading illness.

Ancient Indian texts regarded leprosy and similar skin ailments as contagious and advised against close contact with people so afflicted or their belongings. The Book of Numbers explicitly recommends keeping ‘out of the camp every leper, and every one having a discharge’ to prevent their infecting those not so afflicted. Less well known is a more comprehensive approach towards communicable disease described in the Chinese Han Shu (Book of Han): ‘In a.d. 2, after the drought and locust plague occurred, people were infected with the plague. The local government told them to leave their homes, go to a special institution, take medicine for medical treatment and receive isolation treatment.’

Leprosy was widespread across Eurasia in the medieval period, and there are abundant references to it in European writings. The earliest known leper house was established in the fourth century, and judging from contemporary estimates, there were hundreds if not thousands of leprosaria across Christendom in the thirteenth century. Not all lepers were confined to leprosaria and not all leprosaria housed only lepers. The most famous was the hospice of St. Lazarus, established outside the walls of Jerusalem at the start of the first crusade in the twelfth century. Lazarus was the patron saint of lepers and beggars described in the Book of Luke, and such institutions were commonly called lazarettes or lazar houses in his honor. Despite enormous advances in our understanding of epidemiology – and, indeed, of the nature and causes of poverty – the equation of physical ill health with financial ill health embodied in the person of St. Lazarus has long infected societal responses to communicable disease.

The most widely used term for isolating people for medical reasons is quarantine, a practice that has its roots in the maritime cities of southern Europe in the decades following the black death (1346–53), the first and most virulent episode of the second plague pandemic caused by the bacterium Pestis yersinia. (The first pandemic was Justinian’s plague, which ravaged the Mediterranean, c. 541–c. 750 ce.The second lasted until the nineteenth century, which is when the third pandemic started.) The black death has received the most notice in large part because western historians have long considered it a watershed crisis in European history, a portal from the medieval world to modernity, although the validity of this claim has come under scrutiny. Not all parts of Europe were affected in the same way and, while the black death had catastrophic effects across Eurasia and parts of Africa, other regions did not share Europe’s economic or technological trajectory.

It is said that the black death spurred advances in health policy, but various cities had begun implementing sanitary initiatives well before the plague hit, and tactics like quarantine were not implemented until decades afterwards and in response to briefer, less traumatic pandemic aftershocks. While quarantine today can apply to individuals, households, and larger aggregations of people, quarantine originally referred to the practice of detaining ships before allowing them to land their passengers, cargo, or crew. In 1377, the Great Council of Ragusa (Dubrovnik) held ships for thirty days if their port of origin was experiencing an outbreak of the plague. In 1383, the port of Marseilles started to keep ships for forty days (quarantina giorni). Although the duration of quarantine varied from port to port and depending on the disease, the term quarantine stuck, in part because a period of forty days has a rich Biblical pedigree, including the duration of the flood, Moses’ stay on Mt. Sinai, the temptation of Christ, and the season of Lent. Ships carrying infected people flew a quarantine flag. Today, this is the international signal flag for the letter L, four squares alternating yellow and black. Upon reaching a port, the captain was interviewed about the health of his passengers and crew, and the nature and condition of the cargo, which for many centuries was considered a potential vector of contagious disease.

By 1470, at least seven northern Italian cities had determined that lazarettes were essential to any programme for containing the plague. Inasmuch as quarantine is a form of segregation, it is only a short step to discrimination, which has taken many forms in the history of disease. The most common divisions are between rich and poor, and between residents and foreigners. The more affluent have always had an advantage in being able to flee hotbeds of disease for more salubrious and less crowded estates outside of cities, thus consigning the masses to bear the brunt of whatever illness is raging. And while riches do not necessarily confer immunity against disease, they can render one immune from rules designed to protect public health. In fifteenth-century Italy, officials frequently gave merchants, ambassadors, and the rich preferential treatment even if they arrived from places where the plague was known to be raging, but they were quick to ban the poor on the suspicion they might be unhealthy.

A more modern example of economic inequality affecting community response to epidemics took place on the eve of the American Revolution. In 1764, the city of Boston suffered one of its recurring bouts of smallpox, which had ravaged Massachusetts since before the Pilgrims landed in 1621. Nearly 5,000 people were inoculated against the disease, of whom only 46 died, or 1 in 109; of the 669 people who were infected by smallpox, the death rate was 1 in 5. Smallpox broke out again a decade later, and leaders in the neighboring port of Marblehead opposed mass inoculation on the grounds of cost, in favor of building a privately funded inoculation hospital. Voters approved the latter option in the belief it would serve the common good, only to discover that inoculations would cost the equivalent of several months’ pay for the average worker. When it turned out that the authorities and patients at ‘Castle Pox’ were not observing their own rules on isolation, protestors turned violent and ultimately put it to the torch. Chastened by their experience, when smallpox returned in 1777, the town voted to ‘goe into inoculation’ as Boston had done thirteen years before.

If the struggle over Castle Pox set a rich elite against a poor majority, the broader contours of the debate over quarantine for much of the following century pit commercial interests against public health, although the contest mirrored disagreements over epidemiology within the medical establishment. Most doctors of the time believed in miasma theory, which had a classical pedigree going back to the writings of Hippocrates and Galen. This holds that diseases arise from and are spread by bad air—literally mal’aria—emanating from rotting organic matter. (Malaria as we know it today was attributed to the fetid tropical air of West Africa, home of the Anopheles mosquito, which transmits the parasite responsible for the most virulent form of malaria.)

Among the most influential exponents of miasma theory in the United States was Benjamin Rush. The eminent doctor and signer of the Declaration of Independence maintained that the yellow fever outbreak that devastated Philadelphia in 1793 resulted from a load of coffee beans that had been left on a dock and ‘putrefied there to the great annoyance of the whole neighborhood.’ Thanks to miasma theory, coffee and animal hides – both of which are especially susceptible to decay – were among the items most likely to be quarantined at Philadelphia. A third was rags, used in paper making, though less because they might rot than because of their identification with rag pickers, an impoverished class of people wherever they were, and the possibility that the rags might have originated as slum dwellers’ clothes.

When it came to infectious diseases like yellow fever and cholera, doctors fell into one of two groups, contagionists, also called importationists or quarantinists, and anticontagionists, known as localists or sanitarians. Contagionists believed that diseases could be introduced to a community – from the West Indies in the case of yellow fever – and that one way to prevent this was by quarantine. Anticongationists considered epidemic diseases to be of local origin and thought they erupted spontaneously and that the only way to reduce the risk of epidemics was through improved sanitation. The economic implications of this view were significant, for if disease originated locally, quarantine and the interruption of trade were unnecessary. Not surprisingly, localism was favored by laissez-faire proponents of free trade opposed to what they perceived as government overreach. As Dr. Benjamin B. Strobel noted, ‘It is the object and interest of all commercial communities, to establish, if possible, the non-contagious character of all diseases; and for the very plain reason, that the restrictions necessary to prevent the extension of such diseases, are calculated to interrupt free intercourse between commercial cities.’

Since the turn of the nineteenth century, the Medical Society of South Carolina had argued that yellow fever was not contagious and that quarantine was unnecessary to prevent the disease from spreading. Nonetheless, an 1840 law stipulated that ships with sick passengers or crew had to remain at the quarantine anchorage for twenty days. Although the science was as yet unproven, Strobel believed that if a disease did arrive from somewhere else, there was a moral imperative to exercise all caution to keep it at bay. He went on to ask, in words eerily familiar in the age of Covid-19, ‘Dare we place the life-blood of our fellow men in one scale, and coldly calculate how many pounds, shillings, and pence in the other shall preponderate?’

As it happens, yellow fever is not contagious via casual person to person contact. It is spread via Aedes mosquitos passing a virus between an infected person and an uninfected one. People who recover from yellow fever have a lifetime immunity to it and are considered ‘acclimated.’ Quarantine measures were effective in keeping yellow fever away from susceptible populations because the anchorage was farther from shore than mosquitoes can fly, but anticontagionists secured the repeal of the 1840 quarantine law, anyway. This, combined with an influx of unacclimated Irish and German immigrants, meant the port suffered from repeated outbreaks of yellow fever that escalated in severity in the decades before the Civil War.

Discrimination against people susceptible to disease on the basis of social status was not always a given. Cholera, which spread through water and food, reached the United States in 1832. On overcrowded and unsanitary immigrant ships and steamboats, drinking water was put in communal barrels for the use of passengers and crew. People ladled out their share with their mug or cup, and thus shared the Vibrio cholerae bacteria with which they were infected, or picked them up from someone else. An acute disease, cholera can kill its victims within twelve hours of ingestion. Although it was widely associated with immigrants, the mass of whom were poor, its effects were not limited to them and it was widely feared. Yet despite anxiety about the disease, antebellum Americans were well-disposed towards immigration, and during an outbreak in St. Paul, Minnesota, in 1854, the town council buried reports of cholera for fear the news would keep away immigrants badly needed in the state’s rapidly expanding forestry and other industries.

Few people were willing to show such largesse later in the century, when disease, illness, and poverty became tools for suppressing immigration, and the threat of disease became an excuse to discriminate against the foreign-born. There was nothing new in this. During the second plague pandemic, Europe witnessed countless attacks on beggars, lepers, foreigners, and Jews. But by the mid-eighteenth century, Europeans (and subsequently Americans) had fixated on a nebulous East in an exercise historian Nükhet Varlık has described as ‘epidemiological orientalism.’ Writing for Diderot and d’Alembert’s Encyclopédie (1751–72), the physician and scholar Louis de Jaucourt, declared ‘Plague comes to us from Asia, and for two thousand years all the plagues that have appeared in Europe have been transmitted through the communication of the Saracens, Arabs, Moors or Turks with us, and none of our plagues had any other source.’ For Europeans concerned with bubonic plague (which was endemic in Europe), the East referred to Muslim lands of the Middle East and North Africa. But in the second half of the nineteenth century, Americans viewed China and the Chinese as a font of disease, especially in California.

This was a function of undisguised racism on the part of European-Americans, who went out of their way to limit Chinese immigrants’ access to government, work, and medical facilities. Even after germ theory was widely accepted, the Anti-Chinese Council of the Workingmen’s Party of California could write that ‘the physician who tries to trace the source of infection is mostly unable to do so, and we believe that the existing evils in Chinatown [in San Francisco] are the proper source.’ This applied to virtually all infectious diseases but especially plague, which in 1905 was declared ‘an Oriental disease, peculiar to rice eaters,’ because most of the 118 people who died from it were Chinese. Plague broke out again in the wake of the San Francisco earthquake the next year, when ‘very few Orientals were affected,’ according to an official report, ‘almost all of the 160 human cases, of which 77 died, being white persons, many of them in a good condition of life, subsisting on generous diet and dwelling in houses that would commonly be called sanitary.’

Highlighting such details from society’s past responses to outbreaks of contagious disease can strengthen the brave, ground the fearful, and give pause to the cocksure. For while we may never forget our collective suffering and worry this year, it’s worth noting that the author of 1587, A Year of No Significance all but ignored the deadly epidemics that afflicted the Chinese in the late 1580s. If the past is a foreign country, though, we must remember that people lived there as vividly as we do now. Those shadows and reflections of the past – they are us.


Lincoln Paine