by Simon Ballam & Dardis McNamee
As the coronavirus rages around us, it is hard to avoid the uncomfortable feeling that we may have brought this horror on ourselves. For an answer, we have only to turn to Yale professor of medical history Frank Snowden: Several times in the last century, he shows us, experts have proclaimed infectious diseases defeated, only to have them rise up once again. Now with COVID-19, we can safely say that the hubris of homo scientificus is indeed largely to blame.
To say that Snowden’s book is timely is likely the understatement of the year. His engaging narrative aces in relentless chronology the plagues of antiquity, the Black Death of the Middle Ages, the Spanish influenza in the early 20th century, and the devastating outbreaks of SARS and Ebola in recent years. Without sparing us the horror, he documents the imaginative tenacity of the men and women who found solutions, or at least, recurring hope.
It was the great trading port of Venice that perfected a systematic regime of quarantine. Although they misunderstood the nature of the virus and how it was transmitted, they got the basic procedures right: Ships were kept off shore for 40 (quaranta) days, fumigated, their cargo laid out in the sun and the crew and passengers offloaded onto islands in the lagoon. The choice of 40 days was a gesture to divine providence, 40 being a significant number in the Judeo-Christian Bible. It was actually overkill (the bubonic plague bacterium lived about 24 days) but erred on the safe side. May our leaders today heed the lesson.
The Habsburg Empire applied an equivalent land barrier, a cordon sanitaire up to 20 miles wide, stretching a thousand miles from the Adriatic to the Romanian mountains. Patrolled by local militia, a 28-day quarantine was mandatory in normal times, 48 days in emergencies. The rules were strict – anyone caught trying to slip through could be summarily executed – and maintained until the late 19th century, when powerful business interests found them too restrictive. Again, an uncomfortable parallel tothe current stand-off between the guardians of public health and of the national economy.
Trial and Error
Part of the brilliance of Snowden’s book is how he seamlessly connects the strands of politics, warfare, commerce and science with natural pandemics and plagues. Thee species homo sapiens in its own struggle for survival. Today, dozens of cartoons anthropomorphize the coronavirus into an almost cute little creature, which is not entirely wrong. The bug, too, is fighting for survival.
Amid the broad historical sweep, the book concerns itself with the step by step medical progress of more recent times. Earlier measures had relied on pragmatic observation: The Venetians’ 40-day quarantine worked, although they never understood why. Their “poisoned air” theory was not entirely wrong, but the idea of infinitely small living organisms needed microscopes to be uncovered.
The long-time scourge of smallpox prompted a fundamental insight: at prevention was better than cure. It was clearly contagious and distancing helped, but what had long been obvious from the scarred faces of survivors was that people never got it a second time. Thus came the idea of deliberately inducing a mild case to protect from a life-threatening attack later. Snowden’s detailed descriptions of early inoculation procedures are somewhat stomach-churning – borrowed from the gardener’s technique of grafting – but they were effective. After a month or two’s uncomfortable illness, a patient became immune for life.
By the 18th century, the practice was common in Asia and the Middle East, but it took energetic efforts by the influencers of their day to convince Europeans. In England and Russia, the royal courts became early advocates, in pre-revolutionary France the all-round talent Voltaire and in the USA, the pragmatic Benjamin Franklin. Snowden, a cosmopolitan but still essentially American observer, cannot resist remarking that George Washington’s decision to inoculate his army probably helped defeat the British.
Money for Lives
For all its success, inoculation was risky and expensive, and by using the real smallpox, there was always the danger of setting off a wider outbreak. It was an English rural doctor who made the next important observation: Edward Jenner noticed that milkmaids, who often contracted the milder cowpox from their animals, almost never caught smallpox. He was not the first to see it, but his resolute experimentation was convincing enough that his procedure became government policy in many counties by the end of the 19th century. He called it vaccination, derived from the Latin vaccinus, from cows.
For a variety of abstruse reasons, its mass implementation provoked a virulent an vaccination movement in Europe and the US. Snowden – ever the scientist but with sardonic humor – cannot resist documenting some of the protest’s more hysterical outbursts. Cartoons showed vaccine recipients sprouting cattle horns and a leading purveyor of fake news of the day predicted that “ladies … would wander the fields to receive the embraces of the bull.” Nothing new about science denial, then or now.
This book is full of historical anecdotes that resonate eerily with current corona issues. Nothing new either about American concerns with cost-benefit analysis. The US contributed $32 million to the WHO program to eradicate smallpox worldwide (the last case occurred in 1977 in Somalia). Senator Dale Bumpers reported to Congress in 1998 that this modest investment “had repaid itself many times over.” The US, he commented, had recouped its investment every 26 days since then.
There follows a riveting 30-page historical excursion into Haiti’s struggle for independence from France. In the year 1802, Napoleon dispatched a fatally over-confident force of 60,000 men into an alliance of determined former slaves and yellow fever mosquitoes. Just about 10,000 survived. As so often, an epidemic had contravened the best-laid plans of human leaders.
An Endless Battle
The second half of Epidemics and Society tracks with increasing detail man’s relentless scientific assault on his ancient biological enemies. Both enlightening and depressing, it is a classic tale of two steps forward, one step back. Tuberculosis: By the late 19th century, society had almost come to terms with “consumption,” the romantic and glamorous affliction of Puccini’s Mimi and Uncle Tom’s little Eva. But the reality of filth and poverty in the great cities recast the disease as the villain it was, a slayer of millions. In 1882, German microbiologist Robert Koch identified the pathogen, a momentous success. But his remedy – a concentrate of liquid cultures called “tuberculin” – was a disaster. It was another 50 years until the beast was tamed by the arrival of antibiotics. One step at a time.
The post WWII years saw a boundless faith in the advancements of science. At least in the West, proclaimed Australian virologist and Nobel laureate Frank Macfarlane Burnet in the 1970s, there was a “virtual absence of serious infectious disease today.” Improved hygiene and sanitation standards combined with better nutrition and a safer food supply had defeated cholera and typhoid; quarantine had worked against the plague, vaccination against smallpox and quinine against malaria. Then came penicillin, the first true wonder drug.
By mid-century, the advances seemed too rapid to keep track of. And with a belief in “microbial fixity,” writes Snowden, most in the profession assumed that “the diseases we have are the ones we will face.” Needless to say, they were tragically wrong. Already in 1945, he notes, Alexander Fleming, who discovered penicillin, warned in his Nobel-prize acceptance speech that the drug’s efficacy would be biologically limited, that viruses would mutate and develop resistance to every new drug developed. Scientists continue to confirm Fleming’s warning. In today’s language of the global ecological threat, they describe antibiotics as a “non-renewable resource.”
What Snowden dissects with brutal clarity is the fatal nexus between health care and politics. He draws his conclusions from the recent Ebola crisis, “a human experience… that is far from over.” He quotes the legendary former American CDC director William Foege, who argued that “public health is the protection of all” and a matter of social justice. Foege pleaded for a well-funded and ever-vigilant WHO as a bulwark against “ tragic and avoidable” global suffering. Sadly, it seems too few are listening, certainly not in the White House.
“In the ancient but permanent wisdom,” writes Professor Snowden in closing, “salus populi suprema lex esto (public health must be the highest law) and it must override the laws of the marketplace.”