Epidemics and Society: From the Black Death to the Present, by Frank M Snowden. Yale University Press, 608 pp, $22, ISBN: 978-0300256390
Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky. There have been as many plagues as wars in our history; yet always plagues and wars take people equally by surprise.
Albert Camus, The Plague (1947)
The Covid pandemic has shocked and stunned a world that had chosen to ignore repeated warnings that microbial pandemics, or as Camus would call them, “plagues”, would inevitably “crash down on our heads”. Can a historical exegesis of past pandemics and plagues enlighten mankind and assist in preventing future global catastrophes? The republication of Epidemics and Society asserts that the behaviour of mankind to past pandemics can enlighten future preparedness. Snowden, professor of history and the history of medicine at Yale, has written two acclaimed books on global infections ‑ Naples in the Times of Cholera (1995) and The Conquest of Malaria: Italy, 1900-1962 (2006) – and is well-qualified to gather and assimilate the vast scientific and popular literature in one thesis. This weighty volume will be an invaluable resource for scholars and those with an academic interest in the subject but should also guide the politicians and governing bodies responsible for devising future preventive strategies. One of Snowden’s objectives is to demonstrate “that epidemics are not an esoteric subfield for the interested specialist but a major part of the ‘big picture’ of historical change and development”’. Regardless of the causative infection, the reaction by the general public and the desire for information in recurrent deadly epidemics over the past four centuries show common predictable trends that should guide contemporary policy.
The devastation caused by past pandemics can be attributed more to the incompetence of government and the misuse of available preventive and treatment measures than to the virulence of the infecting organism. Historical examination of pandemics such as plague, cholera, smallpox, tuberculosis, poliomyelitis, typhus, dysentery, yellow fever, HIV/AIDS and Ebola illustrate repeatedly that the behaviour of the most intelligent species on the earth when faced with annihilation is often downright stupid. With the Covid pandemic, international complacency, environmental and behavioural practices aiding the passage of animal microbes to man and the transportation of infected persons to susceptible populations in countries across the world have amounted to what might be best termed “hubris of mankind”.
In the course of examining past attitudes to infectious diseases, Snowden makes an interesting observation by showing how differently society has reacted to sporadic epidemic diseases compared to the ever-present chronic illnesses, such as heart disease and cancer. Although these everyday diseases are constantly with us, killing millions of people and placing an enormous burden on the finances of society, in contrast to epidemic diseases they “do not give rise to scapegoating, mass hysteria, and outbursts of religiosity, nor are they extensively treated in literature and art”. To dwell on this point for a moment, it is interesting to note that plagues and pestilence have not only intrigued historians and scientists, they have also fired the imagination of fictional writers so that we are the beneficiaries of a vast literature in both genres.
A study of the history of pandemics reveals that although the preventative and treatment strategies available to manage the Covid-19 pandemic in 2021 are very different from those available to treat bubonic plague in the seventeenth century, the societal responses are very similar. Take for example the observations of the great diarist Samuel Pepys, who made pithy observations on the Great Plague of London, which had decimated urban society in 1665. Is Pepys’s description of a “lockdown” much different from what might be written in 2021: “But, Lord! how sad a sight it is to see the streets empty of people, and very few upon the Change. Jealous of every door that one sees shut up, lest it should be the plague; and about us two shops in three, if not more, generally shut up.” Another similarity (for some) is Pepys’s perverse delight in welcoming the restrictions imposed on him by the societal efforts to overcome the plague: “I have never lived so merrily (besides that I never got [earned] so much) as I have done this plague time.” I have heard this sentiment expressed by an acclaimed novelist, who having been spared the necessity to travel and engage in meetings devoted to nonsensical discourse (that were a feature of his life in so-called “normal times”) has been able to concentrate on his writing during the lockdown imposed by Covid.
Each of the major past pandemics, be it cholera, poliomyelitis, smallpox or Ebola, has served to inspire fictional literature, depictions in painting and latterly cinematic film. However, none has done so more than the great bubonic plague that swept Europe on a number of occasions. Just to focus on a few examples: Shakespeare cast Romeo and Juliet in a society afflicted by the plague epidemic; Boccaccio featured the Florentine plague in The Decameron; the Milanese plague provided Alessandro Manzoni with the setting for The Column of Infamy and The Betrothed; Daniel Defoe wrote a semi-fictional novel with scientific tables to support his narrative portrayals in A Journey of the Plague Year, published in 1772; Albert Camus in The Plague, published in 1947, portrayed pestilence, quarantine, untreatable illness, sacrifice and societal reaction to an outbreak of bubonic plague in the French Algerian city of Oran; on a lighter note Kathleen Winsor in Forever Amber, written in 1994, takes readers on a frolic through Restoration England and offers vivid images of fashion, politics, affairs and public disasters of the time, including the plague and the great fire of London.
The recurring theme, which becomes the dominant message, in Epidemics and Society is the urgent imperative to establish a state of global preparedness capable of enacting an immediate international response to the first sign of a local epidemic threatening to become more widespread. Devastating though the Covid pandemic may be in terms of mortality, financial upheaval, personal hardship, societal readjustment and the withdrawal of the usual health care for the illnesses of longevity, the reality is that if Covid-19 is not perceived as a stark warning for the need to prepare for even worse pestilence in the future, the future of homo sapiens may be in serious jeopardy. Indeed, the more one looks at the increasing literature and the social media interchanges on Covid, the more it becomes apparent that our preoccupation to contain the pandemic, our belief that vaccination will allow us to return to some form of normality, and our efforts to contend with the financial and societal consequences are all distracting us from facing the horrifying reality that this particular battle against the corona viruses is merely the prelude, a viral dress rehearsal, for the many, possibly more horrible, microbes that lie in wait.
Regrettably, past experience has shown that instead of heeding warnings and putting international structures in place to deal with pandemics, society has chosen to ignore such predictions. Why was the former president of the US, Donald Trump, permitted to withdraw financial support from institutions that could have implemented global protection, such as the Center for Disease Control and the World Health Organisation? Trump, who showed arrogant disregard for scientific fact, must bear the brunt of blame for the deaths of more than 600,000 American people, a figure that is likely to double before the pandemic is contained. Why were recommendations from the United Nations to instigate international procedures to combat pandemics ignored? If there is an explanation, it is, as Snowden has shown, simply a matter of human hubris and, unfortunately, there is no reason to believe that this will be altered by our experience of this pandemic. Governments across the world are now preoccupied with containing the Covid pandemic, which by virtue of viral mutations is gaining the upper hand. Along with the imperative to prevent people dying and to cope with the long-term effects of the illness, society is also grappling with the enormous financial burden of the pandemic. There is, therefore, a preoccupation to restore so-called “normality” without fully appreciating that the normality of the past can never again be the normality of the future.
There have been numerous warnings about the forthcoming threat of viral pandemics. Broadcasts, interviews, correspondence, books, films and articles have tried repeatedly to alert a world that did not listen. Exhortations have come from former presidents GW Bush and Barack Obama, Larry Brilliant (author of Sometimes Brilliant, the story of smallpox eradication), Michael Bloomberg (former mayor of New York), Laurie Garrett (author of The Coming Plague), Dr Margaret Chan (director-general of the WHO), Steven Soderbergh (director of the film Contagion), David Quammen (author of Spillover: Animal Infections and the Next Human Pandemic), Bill Gates (his TED lecture entitled The next outbreak? We’re not ready has been repeatedly broadcast), Anthony Fauci (director of the US National Institute of Allergy and Infectious Diseases and the chief medical adviser to President Biden), Ed Young (author of The Next Plague is Coming: Is America ready?)
Bad though the past may be, our concern must now focus on the future. Epidemics and Society devotes its concluding chapters to the threat of emerging and re-emerging diseases and how best to prepare for the inevitability of future pandemics. Snowden concludes with a plea for science to be the prime guiding factor: “Epidemic diseases are not random events. As we have seen throughout this book, they spread along fault lines marked by environmental degradation, overpopulation, and poverty. If we wish to avoid catastrophic epidemics, it will therefore be imperative to make economic decisions that give due consideration to the public health vulnerabilities that result and to hold the people who make those decisions accountable for the foreseeable health consequences that follow. In the ancient but pertinent wisdom, salus populi suprema lex esto ‑ public health must be the highest law ‑ and it must override the laws of the marketplace.”
I am not an advocate of the “I told you so” school, but Epidemics and Society did awaken a sense of déjà vu, a feeling that I had been over this ground a long time ago. Back in 1996, Kofi Annan, the then secretary general of the United Nations chaired a symposium at which I was invited to make a presentation on “The diplomatic implications of emerging diseases” (the proceedings were published by Basic Books as Preventive Diplomacy: Stopping Wars Before They Start, edited by KM Cahill). I opened my presentation with the following observations: “Since the discovery of antibiotics in the forties, complacency in medicine has walked hand-in-hand with public credulity in the mistaken belief that all infection can be conquered by science. In 1967, the U.S. Surgeon General, William H. Stewart, was able to announce to a White House gathering that infectious illness was all but history and that health resources should now be diverted to ‘the new dimensions’ of health, the chronic degenerative and neoplastic diseases. That such optimism was not without foundation seemed surely vindicated with the announcement by the World Health Organization (WHO) a decade later that one of the vilest of infectious diseases, smallpox, had been eradicated from the world. This optimism might be said to have reached its zenith in 1978 when the Member States of the United Nations signed the Alma Alta ‘Health for All, 2000’ accord. In this scientifically naive and misleading (albeit well-intentioned) declaration, all humanity would be immunized against most contagious disease, and basic health care would be provided to every man, woman, and child regardless of class, race, religion, or place of birth. Why, half a century later, has the threat of a contagious plague, the very demon that science was to have banished from the globe, become an international issue of such magnitude as to merit inclusion under the title of ‘Preventive Diplomacy’? Why is it that medical science has had to warn the politicians of the world that mankind is faced with the greatest threat ever to its existence, and why is it that the politicians of the world have been so reluctant to heed these dire predictions?’ This, I repeat, was in 1996.
Idealistically, as time has proven, I went on to suggest what has been subsequently voiced by many commentators: “The issue is one that cannot be handled by doctors and scientists alone, nor by the political leaders of the world indulging in scientific isolation in expedient and ineffective measures. Rather there is an urgent need for medical science and the international body politic to join together in devising strategies that will permit man to come to terms with the microbe that now threatens his existence. Not alone must doctors and politicians work in harmony as never before, but there is also need for politicians to bring the nations of the globe together in a bond of international brotherhood the likes of which has hitherto been voiced only by idealists and philosophers.” I highlighted in detail how humanity was threatened by a multiplicity of viruses with potential for mutation and the ability to negate the efficacy of vaccines. I also emphasised how mankind had facilitated the emergence of pandemics by the creation of an ideal environment for microbial propagation in mega-cities and refugee camps, by the destruction of animal habitats, and by facilitating transmission with aeroplane travel. This UN symposium concluded that there was an urgent need to establish a global collaborative mechanism to deal effectively with future pandemics. Indeed, had the recommendations of this symposium been instigated, Covid-19 would not have occurred.
Epidemics and Society has shown that the threat of the pandemic that scientists have been predicting is real and that our defence strategies are utterly inadequate. In short, the terms in which we consider the human condition, at least insofar as international cooperation is concerned, need to be rethought. The affluent countries of the world must develop a more altruistic attitude to the public health requirements of their less well-to-do neighbours so that the provision of essential health services is seen as being in the interests of global survival, rather than being merely the granting of aid to be repaid at a later date.
If mankind’s global intellectual development has not reached a maturity sufficient to appreciate that survival depends on acting without delay, then Armageddon is nigh. Man and microbe are jostling for survival in a world that may not be able to sustain both, and as of now mankind is losing the battle.
Eoin O’Brien is a cardiologist who has written a number of books on medical history and literary biography. His latest book, co-edited with Professor Gerald Dawe, The poems of Ethna MacCarthy, was published by Lilliput Press in September 2019.