Epidemics in Western Society Since 1600

HIST 234 - Lecture 1 - Introduction to the Course

Chapter 1. The Historical Importance of Epidemics [00:00:00]

Professor Frank Snowden: The first thing I want to say is that there’s a thesis to the course, that you don’t have to share, but that I’d like to test for the next twelve or thirteen weeks. And that thesis is that infectious diseases are too important to leave solely to the doctors. Epidemics, in other words, have had an impact on history that I would regard as equal to that of revolutions, wars and economic crises. They are part of the big picture of historical change, and not some exotic special interest. Epidemic diseases have had an enormous impact on religion, on the arts, on the colonial expansion, on the establishment of New World slavery, on the rise of modern medicine, and on strategies of public health.

To examine this thesis, we won’t be looking at all diseases. We’ll be looking only at a subset of high impact infectious diseases that have affected Europe and North America. So this means certain exclusions. We won’t be looking at chronic diseases, such as cancer, heart disease, diabetes, asthma, obesity. We won’t be examining occupational diseases such as miner’s lung or asbestosis. We’ll eliminate also a whole range of tropical diseases that haven’t had a major impact on the industrial West, such as dengue, or sleeping sickness, or Chagas disease. All of these, and other diseases, I would agree entirely are important and worthy of study, but it would take far more than a semester to examine them all, and lumping all diseases together would lose all coherence.

Epidemic diseases — that is, high impact, infectious diseases — make sense intellectually as a separate category of analysis. That is to say they were, and still are, experienced differently from chronic disease, and give rise to distinctive fears and anxiety. As you can see in your own day, having heart disease can be a frightening and even a lethal experience. But it’s qualitatively distinct from being diagnosed with HIV/AIDS, or, up to the middle of our century, with syphilis, or being stricken with Asiatic cholera. Cardiovascular disease can have massive impact, but it doesn’t give rise to scapegoating, to mass hysteria, to outbursts of religiosity, to works of literature and art.

So, epidemic diseases are distinctive and have left a particular legacy in their wake. And since our interest is in history, we need to note that throughout human history, until the twentieth century, and still today in the twenty-first century in the developing world, infectious diseases have been the most important cause of suffering and death. Infectious diseases today are the leading cause worldwide of death, and one of the jobs of our course is to give an explanation of why that’s so. Furthermore, we’ve had a number of recent scares from new diseases like SARS, avian flu, swine flu.

We’re living in the midst of a global experience with the persistence of HIV/AIDS, tuberculosis, malaria — and these events remind us that epidemics are still major threats, even in the industrial world. Indeed, how we deal with them may be an important factor in whether and how we survive as a species. So, the course will raise the question of how prepared we are today. What are our major defenses against microbial disasters? How do they evolve? How robust are they? And what are the most important sources of vulnerability today?

Well, then, let’s think about the geography of our course. Our focus will be primarily on Europe and North America; and I wish to say entirely for reasons of manageability. And you’ll be grateful because if we attempted to include the whole of the world throughout the period, and all tropical diseases, you’d have a reading list that would be four or five times as long as the one you have. But I would also say that when we come to the twentieth and twenty-first century, and deal with such global pandemics as HIV/AIDS, malaria and tuberculosis, we will look quickly a little further afield. It would be perverse to discuss HIV/AIDS without paying attention to Africa, which is its place of origin, its epicenter, and the place where the disease is causing almost unimaginable burdens of suffering and loss.

We’re inescapably part of a global world in which microbes refuse to recognize political borders, and we have to take that into account. So, that’s the geography, focusing on Europe and North America, but branching out for the very modern part of the course. Chronology: when, what period do we cover? Well, really we look at the centuries from 1600 to the present. We’ll start with everyone’s idea of a worst case scenario in terms of epidemic disease; and by that I mean bubonic plague. And we’ll end with the current situation and the latest threats to have emerged, like SARS, avian flu and swine flu. As a student, I always felt disappointed when history classes on the modern period didn’t come right up to date. So I feel a motivation to bring us up to the newest papers today. In fact, one of the goals of the class is to help equip ourselves with the critical tools we need to confront today’s events, in a more informed and productive manner.

Since I’ve mentioned influenza, we’ll certainly ask in passing — and I hope some of you will answer the question — why it is that the most threatening pandemic afflictions of the twenty-first century seem to be respiratory diseases? Why is that? How did that come about? Then I want to talk with you for a couple of minutes about the diseases that we’ll be examining. I’ve told you so far the ones we mostly won’t be looking at. Well, first, what are the criteria by which I’ve chosen them? First, I’m going to be looking at epidemic diseases that had the greatest social, scientific and cultural effects. We’ll call them high-impact infectious diseases. That’s a first criterion, their impact.

Second, I’ll be looking at diseases that have had the most important role in the development of public health strategies to contain them. A major concern throughout the course is the variety of efforts that societies have made to prevent, contain, cure and eradicate infectious diseases. Our course is not only about disease, but also about public health, and so we’ll give that a privileged place; to that and to those diseases that stimulated various styles of organized and effective societal responses.

A next criterion is that we’re going to look at those diseases that were the most feared killers of each of the centuries that we study. We’ll also want a varied diet, in other words diversity, and to that end some of our diseases will be bacterial, some viral, some parasitic. Some will be transmitted sexually, some through the air, others through food and water, and some are carried by insects. And by these criteria, we’ll focus in particular on bubonic plague, on Asiatic cholera, smallpox, syphilis, tuberculosis, polio, HIV/AIDS and yellow fever, with influenza bringing us right up to date.

Chapter 2. Themes of the Course [00:09:28]

So, those are the diseases we’ll be concentrating on. Well how do we deal with them? What’s our strategy? What’s our way forward? And I want to stress that this is not a biology course but a history course. Epidemic diseases are biological events, and we’ll need to have some understanding of what they are, where they come from, how they were transmitted, how they affect the human body. It would be inconceivable to study the history of medicine without coming to terms with the medical and biological aspects of disease. Indeed, one of our goals will be to examine major changes in medical thinking and philosophy. But the biology will be throughout in the background, and the exams and the papers will not test you specifically on that aspect of the course.

Our concern will be with the impact of disease on society, religion and culture. But we want to do a lot more than examine a series of ghastly biological invaders; although we will do that. And so the course will stress a number of long-term themes. The first of those I’ve already told you about, and that’s public health strategies. We’ll look at vaccination as a strategy; quarantine and sanitary cordons; urban cleanups and sanitary movements; sanatoria, as for tuberculosis; magic bullets like quinine, penicillin, antibiotics. And we’ll also look at an unfortunate public health policy, by which I mean concealment, to hide the presence of disease, as China did during SARS, but following a long precedent in which other governments have a history of adopting similar policies; and we’ll be looking at that too.

Then we’ll be looking at intellectual history. Epidemic diseases, in other words, had a leading role in the development of the modern biomedical paradigm of disease, with the germ theory and such disciplines as tropical medicine and infectious diseases. And I’ll want to argue, or at least will be testing the idea, that perhaps medical ideas, one of their aspects is that they’re ideologies, held not only for scientific reasons, although that’s true, but also because of the kinds of societies they promote, or the power they convey to nations or strategically placed elites within them. That will be a question we’ll be examining.

Then we’ll be looking at ethical issues: What are the ethics of human experimentation? And we’ll be looking at some horrific failures in ethical standards, and in particular we’ll examine the Tuskegee Syphilis Study. We’ll also be looking and thinking about diseases as a tool for the historian: as a means of casting revealing light on how societies are constructed; on the relations of human beings to one another; on the moral priorities of statesmen and religious leaders; on the relationship of human beings with their environment, by which I mean both the natural environment and the built environment, the cities in particular in which they live.

Responses to epidemic diseases will be important to us. How did people respond? And we’ll be looking at stigmatization, witch-hunting and scapegoating; at flight and mass hysteria; at upsurges in religiosity; at changes in art and in philosophy. The course will also try to provide some understanding of a number of major concepts and terminology in public health. By the end of the class, you should be fluent in using words like etiology, case fatality rate,nosology; and you should know the difference between incidence and prevalence, between an epidemic and a pandemic, between inoculation and vaccination.

And then another theme will be an assessment, as I said, of where we stand today in the twenty-first century. What have we learned as a society from the experience of the past four centuries of recurring and dreadful epidemics? In 1969, the U.S. Surgeon General had a premature surge of optimism in the age of antibiotics and he declared, as he put it, “We’ve turned the page on infectious disease.” And medical schools and the public health community taught that it would be possible to eradicate one epidemic disease after another, like smallpox or polio as models. But our Surgeon General turned out to be spectacularly wrong. Today, in 2010, infectious diseases are the number one cause of death worldwide.

It’s also clear that it will be impossible to write the history of the twentieth and twenty-first century without giving a central place, at the very least, to HIV/AIDS, and to other pandemics as well. Furthermore, we know too that there’s a whole host of emerging diseases: Ebola, Lassa fever, West Nile virus, SARS, avian flu, AIDS and, of course, swine flu. And familiar diseases have re-emerged in resistant and threatening manners, such as drug resistant tuberculosis or malaria, and other diseases as well. So, the threat has been made clear in dress rehearsals we’ve had in our new century: SARS, avian flu and, as we speak, swine flu.

And indeed, the nature of modern society may make us more vulnerable, rather than less, to such threats. We’ll want to think about some of the factors that may make that true, such as a high and ever-growing world population density, as we rapidly reach a figure of seven-billion people, before very long; rapid movements of population by rail, road, cruise ship, but above all the airplane; rapid and chaotic urbanization, with the appearance of ever more mega cities, with populations in excess of ten-million people; places like Tokyo, Mexico City, Lagos, Delhi, Mumbai, New York, Jakarta, Buenos Aires and others. These, many of them, conjure up images of overcrowding, of poverty, substandard housing, inadequate access to healthcare, extensive illiteracy, open sewers.

Then there’s the perennial problem of warfare, and the terrible dislocations that wars leave in their wake: Displaced people; refugee camps; the collapse of health systems and sanitation; extensive poverty and widening social inequalities; climatic change and environmental devastation; and the failure to provide such basics as safe and adequate water supplies for untold millions of people in the developing world. Unfortunately, not one of those factors seems likely to abate in the near future, and some of them are gathering momentum as we speak. Well, it’s possible, and reasonable even, to ask whether it is true that the way we handle epidemic diseases will be crucial to our survival as a society. In addition, I would argue, that it’s important to examine these diseases, the ones that have been most prevalent, as they hold up a mirror to ourselves.

I would argue that every disease, and epidemic disease in particular — these are not random events — that every society has its own specific types of affliction, and to study them is to learn about its living conditions, its moral priorities and relationships. For all of these reasons we could argue that epidemic diseases are great bearers of meaning, and our job is to decipher the meaning embedded in them as contemporaries experienced them, and to understand them retrospectively. Well, then, that brings us to our first couple of weeks, and where we go next.

Chapter 3. Humoralism and Bubonic Plague [00:18:48]

On Wednesday we’ll roll up our sleeves and get down to work, looking at the meanings that Europeans gave to epidemic diseases when they first struck the continent and as they were seen through the lens of the reigning medical doctrine; that is, the humoralism philosophy developed by Hippocrates and Galen. At the time of plague in the seventeenth century, humoralism, which was the first embodiment of what we might call scientific medicine, was still the dominant medical paradigm for disease, as it had been for nearly two millennia. And so our first task will be to examine a topic in intellectual history of medicine; a topic that will help us to understand how the first epidemic disease that we’re going to study, bubonic plague, was understood, how it was experienced by physicians, statesmen and educated laymen. We’ll also be in a position then to understand that epidemic diseases fundamentally challenge humeral notions, and help to lead to a major intellectual paradigm shift that we’ll discuss later in the semester.

So, our course then will begin with the legacy of two of the most influential doctors who ever lived, both Greeks: Hippocrates from the fifth century B.C., and Galen from the second century of the Common Era. Looking at their philosophy of medicine will give us a framework to understand the ways in which the experience of a plague was a tremendous shock. Most obviously it was a shock in terms of death and suffering, but it was also a shock because it undermined the foundations of medical and intellectual understandings of disease. The passage of bubonic plague through European society was not only a biological and material event, but also a major intellectual, religious and psychological one.

Having done that, next week what we’ll do is turn to bubonic plague itself. Now, the plague is everyone’s candidate for the worst-case scenario. A plague is synonymous with terror. One reason was that it was an extraordinarily rapid and excruciating killer, with symptoms that were dehumanizing and agonizing, with no effective therapy, and a kill rate that ensured that the majority of its sufferers perished. It was also readily transmissible, so that it seemed poised at various times to destroy the whole population of Europe. And it did kill an enormous proportion of the population; up to half in major European cities. So, here was the origin of a terrifying cliché about plague: that it struck down so many that there weren’t enough people left to bury the dead.

So, what will we do next week? Well we’ll look at symptoms of plague, its horrifying effects on the individual human body. We’ll look at its devastating impact on society, and at the responses of whole populations to the time of plague: mass flight; scapegoating; social disorder; upsurges in religion; new cults of saints; new iconographies in the arts. But there’s more to it than that. The plague led also to the first successful strategies of public health to combat pestilence; strategies that were often draconian, in direct proportion to the magnitude of the threat. These strategies included, as we’ll see, boards of health, with almost unlimited powers during the emergency: quarantine; military lines and naval blockades to isolate cities, or even whole countries; and we’ll see pest houses to confine and isolate the sick and dying.

As a guide to our experience we have this book, which is Daniel Defoe’s Journal of the Plague Year; which is the first reading assignment. And I want to talk about it for a minute, because some of you may want to start reading it straight away. I’m not too good as a salesman, but I do think it’s appropriate to make a plug for great books. And in this case, of Defoe, I want to introduce one of the classics of a whole genre of what you’ll become familiar with as plague literature. Defoe’s masterpiece is a powerful description by a contemporary — in fact a survivor — of the most dreadful outbreak of bubonic plague in the history of the British Isles; the catastrophic visitation of 1665.

Plague had returned in successive waves in European history, ever since the first visitation of 1347. But one of the terrible features about it is that over the centuries it didn’t become milder, and some of its last visitations were the most violent and horrendous of all, including the epidemic that ravaged London in 1665. Now, a possible issue for some may be overcoming the barrier of language. So I want to throw out a challenge. The book, I will admit, can start out a bit slowly for some of you. So I want you to think not so much at the outset, as you open it up, as to whether you immediately enjoy it; although I’m hoping that you will. But I want you to think instead about why it’s so important.

I’d like you to think about what you can learn from being in the company of someone who had the experience of living through the worst of all public health calamities, and to ask yourselves why this book has been read avidly for four hundred years. It may interest you also to know that during the SARS outbreak in Toronto in 2003, thousands of people were quarantined in their homes, and at the top of their list of books that they read to pass the time and make sense of their experience, was this one: Defoe’s Journal of the Plague Year. Well, history, after all, is in part about sharing a common culture and common memories, and reading this book then is certainly part of that. And if you think of it in those ways, with those questions in mind, I think — and this is my secret agenda — you’ll really enjoy it.

I also think that you’ll find that it’s a wonderful account of how a society responded to one of the greatest of all challenges. Defoe recounts the flight of the king and other authorities from London, in fear for their lives. He tells us about religious enthusiasm; about how people understood the catastrophe they were experiencing, what it meant to them. He tells us about the hunt that was on for witches and scapegoats and culprits. He talks about plague-induced crime; the helplessness of physicians; about popular culture; and desperate attempts of people to save themselves; and then about the extreme measures of shutting people up in their homes by government authorities, or taking them away by force to pest houses. And since this is a comparative course, I’ll hope that you’ll begin to reflect on how far we’ve changed and progressed from the time that Defoe wrote. And I’ll draw your attention, for example, to the early years of the HIV/AIDS epidemic, and we’ll think together about some possibly very troubling similarities.

In fact, one of the constants in the centuries since the plague itself, in the West, has been a tendency in times of public health crises to resort to plague measures of self-defense. We’ll see that very dramatically in the nineteenth century, in the time of cholera, when the desperate attempt was made to stop Asiatic cholera with measures that had worked against plague, but turned out to be entirely counter-productive. And we’ll see it again in the early years of the AIDS pandemic, and in that case too with haunting consequences. So, now you know where we’ll begin: on Wednesday with medical science, in its first but long-lasting embodiment, and the way that Europeans experienced plague, through the lens of humoral theory. And then next week we’ll deal with the most devastating epidemic to strike the Western world, bubonic plague; and in Daniel Defoe you have a really good guide to accompany you on your journey. So, I’ll see you next time.

[end of transcript]