With the spread of Covid 19, it may feel like our way of life is being broken apart. Politicians and media commentators have told us that the new conditions we face — social distancing, isolation, mass–quarantine — are “unprecedented.” But really, we have been here many times before. How did authorities try to “flatten the curve” in pandemics past? How did social distancing work out in the medieval countryside, or in the crowded cities of the earlier twentieth century? How long did lockdown take to work, and at what points did order begin to break down? And how have people coped, shut away in quarantine like many of us are now, throughout history?
The Black Death (1347–51)
The Black Death was the emperor of all pandemics. Striking with an 80–90% mortality rate, between c.1347–1351 this disease killed an estimated 50-60% of the European population. Infection was caused by the bacteria, Yersinia pestis, which was transmitted to humans by fleas living in the fur of black rats. Many at the time believed the plague came from China, although evidence now suggests it originated in the Steppe lands of Central Asia, traveling along the roads and sea routes that defined the global trade network of the late Middle Ages. According to the writer Michele da Piazza, it first came to Europe with the arrival of infected Genoese sailors at Messina in October 1347. “Its victims,” he said, “violently spat out blood.” Others grew enormous buboes in their groins and armpits, their extremities turning black with necrosis until they died, usually within three days.
Infection still seemed like a distant prospect in England in the spring of 1348. Most approached the disease as a problem that could be tackled at the individual level, perhaps through extra prayer or pilgrimage. People in the village of Walsham in Suffolk exchanged stories of how the plague was slowly working its way up through France from the Mediterranean. It was getting closer and closer, they said, and soon it would cause total havoc in rural England. But these still seemed like the tall stories of sailors. Many mocked the illness, while others simply took precautionary day trips to the shrine of Saint Edmund in Bury.
When the plague eventually did hit England, the response was panicked. Bishops sent out directives ordering Christians to confess their sins, sing the Psalms, say prayers, and make communal religious processions. This way, they could “prepare themselves… to come into the presence of the Lord.” Groups flagellated themselves in town squares, hoping that God might be moved to spare their community. Eventually citizens, like those in Walsham, took to barricading their city walls. But this was futile. Unknown to them, the flea-infested rats continued scurrying in with the disease.
Desperate quack remedies began to trend. “Expert” treatises advised that skipping baths, eating light meals, and abstaining from sex could keep everyone plague-free. Believing that the disease was transmitted through bad smells (a mistake repeated for centuries to come), the writer John of Burgundy told people to “inhale aromatics every morning” before going outside, and to burn juniper branches at bedtime. Safety would come through sniffing “ambergris, musk, and rosemary” for the rich, or “cloves, nutmeg, and mace” for the poor.
But as many quickly realized, the best defense was staying at home. The writer Giovanni Boccaccio described how Florentines shut themselves away from the sick, “consuming choice food and wine in moderation,” and “avoiding all excess.” With a regime of total self-isolation, they stopped speaking to anyone from outside the house, and even avoided “hearing any news of the dead or sick.” Instead they enjoyed cultural pursuits, telling stories and making music. Others chose the opposite path, flouting measures in social-distancing and dedicating themselves to getting as much enjoyment out of their last days as they could. For these doomed rebels, “heavy drinking, pleasure-seeking, and going round singing” was the only way of remaining sane.
Political experiments in Italy demonstrate sharp contrasts between a naïve and a seasoned response to the pandemic. Upon first encountering the disease in early May, 1348, the city government of Pistoia, Tuscany, imposed a set of draconian rules. No citizen should go to or come in from the infected cities of Lucca or Pisa, they said, threatening a penalty of 500 pence. Aware that dead bodies were dangerous carriers of the disease, they limited attendance at funerals to the immediate family only. Yet just a few weeks later these rules needed adjusting. There was now little point in focusing on the threat of Lucca and Pisa, as the sickness was paying no respect to borders. Instead, the government struggled harder to make the city clean, hoping the absence of filth might make the illness go away. By June there had been so many funerals in the city that they had run out of candle wax.
With the fourth wave of plague, precautions became more advanced. Faced with an outbreak in January 1374, the Duke of Milan imposed rules centered on the isolation of the sick. Any person who had swelling or a tumor, he said, should leave the city immediately and find refuge in the “open country” until they either recovered or died. He ordered a ten-day quarantine for all people who had recently met with someone who had died of the plague. In relief to the 500-pence fines of Pistoia, the duke enforced these laws with threats of violence. Priests were required to examine the sick in their parishes, with the warning that failure to notify authorities of any new cases of plague would result in them being “burnt alive.” He also announced that all the property of those known to have brought the epidemic from another place would immediately be seized.
In the initial response to the pandemic, there were fanatics who thought they could stop the illness through xenophobic genocide. In Tárrega in Catalonia, “several men of the village whipped up the populace to a fever pitch,” convincing them that Jewish people were to blame and that they should be killed in revenge. Many were killed, and many more were driven from their homes. But these reactions were widely condemned, and quickly stamped out. Ultimately, communities understood that the only real hope for action against the Black Death came through coordinated, cross-border efforts. When surgeons in England and Italy shared their analyses internationally, or when the medical faculty at Paris advised towns across the continent to tackle poor hygiene, they showed that the best way of beating the global disease network was with the global knowledge network.
The Great Influenza (1918–1921)
In terms of raw numbers, the Great Influenza (c.1918–1921) was the deadliest pandemic in human history. The disease was first publicized by the Spanish media, earning it the nickname “Spanish Influenza,” although historians have suggested that it really began in the United States. It was both violently contagious and highly deadly. Infecting as much as a quarter of the global population, it carried a mortality rate of 10–20%. Best estimates of the worldwide death toll stand at around 50 million, although this may be a gross underestimate. Unlike other forms of influenza, it disproportionately affected young people, pregnant women, and those with strong immune systems. Symptoms included fever, a severe headache, aching limbs, and delirium. Coughing was often so hard that it would rip the abdominal muscles, lasting until blood was pouring from the nose and even the ears. Death came after a few days, usually through pneumonia and suffocation.
When the pandemic first arrived in America in the Fall of 1918, many dismissed it as just another round of ordinary flu. “There is no occasion for panic,” said the Bridgeport Times on October 11th. “Influenza itself has a very low percentage of fatalities,” with only about “one death out of every 400 cases.” The newspaper even took the opportunity to exploit the crisis for some advertising funds. “Use Vick’s VapoRub,” it said, a remedy used “in over a million homes” that could be bought “in three sizes at all druggists.” Although deaths continued over the following month, the paper continued to spread the good news that VapoRub could help them at the first sign of influenza symptoms. It was only as deaths rose sharply in December that the paper finally gave an acknowledgement that “patent medicines should not be trusted” for treating the illness.
Federal authorities were a little more helpful in the initial stages of the crisis. Responding early, Rupert Blue, Surgeon General of the US Public Health Service, sent out advice to the media for people to “work, play and rest” to keep their bodies strong and keep illness at bay. Anybody continuing contact with an infected person, he said, should wear “a simple fold of gauze or mask” to protect from “dangerous disease germs”. These masks were soon seen everywhere, from New York and Memphis to London and Paris. The American medical community also made a decisive early effort to offer practical advice. An October 12th 1918 editorial in JAMA, the Journal of the American Medical Association, recommended that patients be “quarantined until all clinical manifestations of the attack” had subsided and temperature had “been normal for three successive days.” Those who threatened public health, they said, should be cordoned off in specialist hospital wards.
Yet, unsurprisingly, federal recommendations had little sway over state and civic authority. In practice, the American response consisted of a thousand different efforts, each one conducted locally, and each one a kind of “laboratory” for testing out how to fight the disease. Some cities, like Saint Louis, took a hardline approach, closing schools, bars, theatres, and stores, and banning public gatherings while cases were still in the low double figures. With this policy, as well as with the heroic initiatives of the local Red Cross, Saint Louis was able to limit its death toll to one of the lowest in the country. Yet this kind of action had obvious economic repercussions. As one observer in Iowa put it, “practically every owner of a movie show, restaurant, temp bar, dance hall, taxicab or other place of business … claims that the ‘flu’ has hit him hard.” Seeking to avoid the economic fallout, some cities were much looser, hoping that staggering the opening hours of businesses, while insisting on good hygiene, would be enough to hold back the tide. Boston waited thirteen days after the influenza death rate accelerated before imposing social distancing measures, and paid the price. Suffering one of the nation’s steepest mortality curves, the city lost an estimated 5,000 lives that quicker intervention could have saved.
Cincinnati’s erratic response dramatizes many of the social and economic dilemmas thrown up by the pandemic. Conscious of actions in other parts of the country, Mayor Galvin wanted to act immediately. He ordered a ban on all public and private meetings, whether indoors or outside, and insisted that all bars operate as takeaway only while there were still just fifteen officially reported cases. “There is no epidemic here,” he said. “We are doing what other cities should have done — We are preventing.” But, unfortunately for the mayor, fifteen turned out to have been an enormous underestimate. By November, the city had recorded 681 influenza deaths.
It was at this point that Cincinnati turned to a partial lockdown of the city. This was a policy with some recent precedent in American cities. During an outbreak of bubonic plague in San Francisco in the 1890s, civic authorities sought to isolate infected neighborhoods, restricting trade and preventing residents from leaving. Yet this quarantine seemed to be more influenced by racial association than any genuine medical concern. Popular opinion had associated the disease with Chinese residents, and paranoia centered on “cleaning up” Chinatown. Bands of workers were sent to the houses of all Chinese people, regardless of their health, to fumigate them. As the San Francisco Chronicle observed, there was a “careful discrimination in fixing the line of embargo,” to the extent that “not one Caucasian doing business” was affected, while their “Asiatic neighbors” were “imprisoned within the lines.”
In Cincinnati the death rate began to slow, and thoughts returned to saving the city’s economy. Every day the mayor was bombarded by appeals to reopen businesses, many of them from people living in desperate poverty. On November 11th (Armistice Day), he finally caved. “The people are tired of hearing of influenza and want to forget it,” he announced. “The psychological time for raising the restrictions has arrived.” This was a great mistake. Within a week of schools reopening the disease came back with a vengeance, affecting children in particular. Reacting on the fly, the mayor issued a new order banning the city’s under-16s from all forms of public life. Every time there was a set of encouraging figures arguments raged again to lift restrictions, but ultimately the mayor held firm. Measures were finally relaxed in the final days of December, with the worst of the crisis over. Health authorities estimated that almost a quarter of Cincinnati’s population became infected over the last four months of 1918, attributing nearly 1,700 deaths to the influenza.
Tuberculosis (TB) — an airborne disease, caused by bacteria attacking the lungs — has always been a threat to human life. Analyzing remains from over four millennia ago, paleopathologists even identified TB in the bodies of several Egyptian mummies. Symptoms of the disease in its advanced stage, as shown in a bronze statuette of a beggar from third-century BCE Alexandria, can include spinal collapse, as well as fever, night sweats, rapid weight loss, and the coughing up of blood. For those who become ill, the mortality rate is around 15%.
TB erupted as an epidemic health crisis at several points throughout the twentieth century. In Ireland in 1904, it accounted for nearly one in every six recorded deaths. Doctors called for facilities to allow patients to be isolated in hospitals, urging that private wards, combined with the construction of new sanitoria, could “flatten the curve” of the outbreak. Yet the British government’s response to the request was half-hearted. Although ministers issued the Tuberculosis Act in 1908, only a handful of local Irish authorities adopted it. This was because, while it called for the construction of new TB sanatoria, it deferred costs entirely onto the individual Irish counties. As these were ill-equipped to pay, the act effectively undermined itself, and the disease continued to kill Irish people in vast numbers throughout the following decades.
Governmental strategy only changed with the heroic effort, in the 1940s and 50s, of Noël Browne. Both of Browne’s parents had died from the disease, and he himself was treated for it at a specialist sanitorium in England. After he recovered, Browne trained in medicine and then became a member of the reformist political party, Clann na Poblachta. Upon his election to the Dáil, Browne was immediately appointed Minister for Health. He introduced free mass-screenings for TB, and worked on developing a range of dedicated sanitoria, funded through sweepstakes lotteries and the strategic sale of government assets. Outstripping the facilities that saved his own life in England, Browne’s sanitoria offered patients comfortable beds in private rooms, sun verandas (onto which they were wheeled to enjoy fresh air), nutritious food, and the treat of two pints of Guinness every day. Cases of TB finally began to fall away, and by the 1970s there were only a handful reported throughout the country.
Britain also experienced upticks of TB at points throughout the early-mid 1900s. Although cases had been declining slightly in the 20s and 30s, increases during the war led to so much anxiety that the House of Commons considered seizing control of German sanitoria in Switzerland for the use of British patients. Although notable casualties included George Orwell, the disease disproportionately affected the impoverished, malnourished, and homeless of cities like London and Birmingham. The new National Health Service provided over 22,000 specially staffed beds, yet this was still not enough to meet the surge of cases. By July 1948, there were around 9,200 infected patients stuck on hospital waiting lists. Although many made private quarters for themselves at home, the government’s refusal to offer financial support for these remote patients meant they were unable to pay for additional care.
One person lucky enough to find a bed was Mary, a thirty-two-year-old professional from Bristol. After she was diagnosed, in late March 1944, she was immediately separated from her husband, Bill, and from her fifteen-month-old baby, Mark. She kept a diary, recording the pains of life in isolation. “My idea,” she said, “is to let off steam when I am fed up”. Separation from her baby boy was especially painful. “Mark already ignores me,” she wrote. “I think it is because I am in bed and I am a ‘stationary’ object.” She was also heartbroken at the thought of being unable to have a second child. But she was determined to remain upbeat, reminding herself that getting well was essential to her family’s happiness. As a way of coping, as well as a way of structuring her life alone, she gave herself a set of rules to follow.
- Never give way to self-pity. List the disadvantages and then, having conquered them, forget them. […]
- Always appear cheerful. Partly for self-discipline and partly because people will soon get sick of me if I don’t.
- Interest myself as much as possible in outside things — both world-wide, through the newspapers, books and also personal […]
- Try and improve my mind by reading and thinking … in preparation for trying to make some constructive contribution to the good of the world.
- Do not talk about myself and my illness.
- Do not organize other people [from the bed] […]
- Reconcile myself to avoid movement myself.
- Later on, try writing articles […]
Mary was given the all-clear in October, and by late November she was back to cooking, shopping, and doing housework, although she still avoided “polishing, washing or ironing.” But one day the following January, while she was relaxing in the lounge after dinner, she began coughing up blood. The disease had returned. Her next spell in hospital lasted for seventeen months, followed by two years of regular trips back for monitoring and medication. In the Spring of 1949, doctors finally advised her that she was safe to get pregnant again, and she gave birth to her second baby on February 9, 1950. She went on to live, disease-free, to the age of 86.
Countries such as Ireland and the UK, which rolled out vaccines to all school leavers in 1952, were ultimately able to bring TB under control only with the concerted reform of their health systems. But the disease is still far from gone. In fact, it remains the deadliest infectious illness in the world today. In 2018 alone, TB claimed the lives of 1.5 million people, 95% of them in the developing world. The BCG vaccine, developed first in the 1920s, continues to offer the best chance for protection, while antibiotic regimens offer the chance of cure. Efforts by the WHO and the CDC to inoculate communities in the Global South have saved more than fifty million lives in the past two decades. Nevertheless, the struggle depends on extending expert medical support, and making healthcare accessible and affordable for vulnerable populations worldwide.
If we can learn anything from these moments of history, it is that individual resilience, communal spirit, and an informed cross-border leadership have always been the best hopes for overcoming a pandemic. Strong and decisive governmental measures have also been essential, particularly in the face of economic and business pressures. The isolation of cases has long been effective in limiting the spread of infection, although these have typically required the kind of spending that some administrations have balked at paying. Lockdowns have also been crucial, when adopted early, although these measures have often carried excessive exclusionary politics of their own. Ultimately, it is sobering to be reminded that pandemics have rarely been overcome simply. Wars with diseases are wars of attrition, requiring patience and commitment to get through. Seeing ourselves as true historical subjects, we might be able to put the inevitable losses and damages we face from Covid 19 into some perspective. Like others in the past we will suffer, but, like others in the past, we will rebuild to fight again.
picojoule / firstname.lastname@example.org