PANDEMANIA OR A SHORT HISTORY OF THE MEDICALISATION OF LIFE –THOUGHTS IN TIMES OF CORONAVIRUS – PART I

One of the many curious features of coronavirus, declared a pandemic by the World Health Organisation in March 2020, was the belief that the outbreak was unprecedented. The mainstream Western media not only assumed its global impact unique, they also anticipated its consequences in a rhetoric that mixed the mawkish with the morbid and the apocalyptic. In an atmosphere of media hysteria governments reinforced the sense of impending doom, embracing an epidemiological prediction of death rates of one per cent of the West’s population unless they locked down the economy, quarantined households and suspended all non-essential activity.

A rationalist preoccupation with a very short view of the past and a much longer view of the future informs this, otherwise perverse, neglect of past pandemic events and the manner in which Western governments and society have historically responded to them. Ironically, this nescience is one of the few things that are unprecedented about the current crisis. How, we might wonder, have societies reacted to pandemics in the past? Are there psychological, social, political and economic responses in the past that repeat themselves in the present or, alternatively, might past practice offer insight into our current predicament?

DISEASE IN HISTORY

To the extent that the media takes account of past pandemics it is to invoke a vicarious sense of horror. Newspapers and periodicals have recalled inter alia the epidemic, described by Thucydides in his History of the Peloponnesian Wars that did so much to undermine the Athenian war effort in the early years of its campaign against Sparta, the Black Death (1348–1350), the London plague of 1665, vividly described by Daniel Defoe in his Journal of the Plague Year (1720) and, more recently, the Spanish influenza outbreak (1918–1920), the little understood pandemic that in the last months of the First World War may have killed between 40 and 100 million people. Journalists recall these pandemics and their traumatic psychological effect upon popular consciousness to show the disruption and death they caused to societies with limited knowledge of microorganisms, their transmission or control.

Treating these epidemics as discrete infectious events nevertheless leads to some broad and perhaps questionable inferences. The Black Death, the most frequently cited pandemic event, was responsible for the death of between a third and a half of the European population over several years between 1348 and 1350. It affected, like all the epidemics we discuss, the poor and labouring classes disproportionally. The high death rate amongst the rural peasantry and urban poor led to the decline of the manorial system and a fall in agricultural rents particularly in England and France. Labour shortages, despite measures, like the Statute of Labourers (1352), to restrict their movement, eventually led to a general increase in wage rates. To infer that a similar effect might be generated from the current pandemic, given its relatively low case fatality rate (CFR) however, is highly debatable. Similarly, to the extent the media analyses the impact of the Spanish flu pandemic, it is to show that although the lockdown as well as the death rate, especially in the US, was initially severe, the economy and the labour market recovered rapidly as the twenties roared.

One of the few studies, by economists from the Bank of San Francisco and the University of California, to assess the comparative impact of pandemics over time found that between 1348 and 2009 pandemics with a death rate in excess of 100,000 had a depressing effect on real rates of return on interest and a “somewhat elevated” effect on real wages.1

All pandemics, it seems, have depressing effects on investment that take decades to work their way through the economy. Are there, we might wonder, similar comparative social, political and psychological effects that can be educed from pandemic events over the longer run?

THE HISTORIOGRAPHY OF DISEASE

Historians of medicine and disease have conducted broad and, in Roy Porter’s case, finely detailed studies of diseases and their scientific, social and political effects over time. As Porter observed in his encyclopaedic study of the history of medicine, “illness is not just biological but social. Concepts of the body and its sickness draw upon powerful dichotomies: nature and culture; the sacred and the profane.” Sick bodies possess “eloquent messages for society”.2

Conceptions of the body shaped that most enduring of political metaphors, the body politic, found in Plato’s Republic, Aristotle’s Politics, and John of Salisbury’s Policraticon. The 19th-century “father of modern pathology” and leader of the German Progressive Party after 1872, Rudolf Virchow pathologised this metaphor when he wrote: “medicine is a social science and politics nothing more than social science on a grand scale”.3

From this perspective, A. H. McNeill in Plagues and Peoples (1975) considered human history evincing “a precarious equilibrium between the micro-parasitism of disease organisms and the macro-parasitism of large bodied predators, chief of which have been other human beings”.4 In his best-selling Guns, Germs and Steel: The Fate of Human Societies (1997) over 13,000 years, Jared Diamond presents human development as a Darwinian struggle shaped by conquest, epidemics and genocide, in which the transmission of germs by conquering armies, notably the Conquistadores, during the unequal Columbian exchange between South America and Europe, played a determining and neglected role in understanding the rise and fall of civilisations.5 Eurasian germs killed far more native peoples than European guns and steel. Less sensationally, the French Annales school historian, Emmanuel Leroy Ladurie in his quantitative examination of mortality statistics in Europe demonstrated how infectious diseases, notably the great plague pandemics of Justinian (541 AD that swept through Merovingian Europe and the Middle East), the Black Death from 1330 when it first emerged in China to 1350, the impact of smallpox visited upon the Inca and Aztec Empires of South America by the Spanish after 1492, as well as successive cholera outbreaks in the 19th century have unified the globe through disease. “A large part of the human populations of the world, especially in Europe and America”, Ladurie writes, “perished between 1348 and 1600, in the flames of a microbial holocaust – causing loss of life on a scale serious in Europe, devastating in mainland America, and total, or near total, in the Caribbean.” Moreover, Ladurie concludes, “the spread of cholera in the nineteenth century is proof that the era of microbial unification is not yet over”.6

Not only has the macro-historical impact of infectious diseases been neglected in the post-historical aftermath of the Cold War, so, too, have the recurring themes that distinctive infectious diseases. These range from leprosy in the Old Testament, to plague in the 14th to the 17th century, and cholera and tuberculosis in the 19th.

The most predictable and enduring reaction to pandemic disease from Moses to Albert Camus’ Father Paneloux in The Plague is to consider it either a religious judgement on a wicked people or a test that the righteous must suffer and endure. According to Habakkuk the Lord travels with “pestilence” before him.7 In the Book of Exodus, the Lord informs Moses that He will pass over the congregation of Israel but smite their Egyptian hosts with plague.8 Elsewhere Psalm 91 reveals that “the Lord is my refuge and my fortress”, trusting in him will “deliver thee from the snare of the fowler, and from the noisome pestilence”. Consequently, “thou shalt not be afraid for the terror by night; nor for the arrow that flieth by day, nor for the pestilence that walketh at night, nor for the destruction that wasteth at noonday”.9 Finding his Bible open at this psalm, the narrator of Daniel Defoe’s Journal of the Plague Year decides to remain in London and keep a record of the great plague that devastated the city in the summer of 1665 leaving grass growing in the locked down streets around Bishopsgate and killing a fifth of the population.10

The historic response to epidemic disease was a heightened preoccupation with sin and salvation. Defoe observed this in London in 1665, Boccaccio and Machiavelli in the plagues of Florence in 1348 and 1527, and Camus in his fictional Oran in 1947. Not only did sinners flock to church and more especially to shrines dedicated to the plague saints Sebastian and Roch, but also to join new fanatical movements like the Brotherhood of the Cross, the flagellant sect that appeared in Germany in the summer of 1348. The sect engaged in ritual flagellation in town market places across Northern Europe and called upon the people to abandon their sinful lives and follow the cross. The movement’s chiliastic attachment to the more apocalyptic passages in the Book of Revelation that foresaw Christ coming down to rule for a thousand years over the saved made them an object of political concern. The Papacy declared the sect heretical in 1349. Religious enthusiasm also encouraged scapegoating, particularly of Jews widely accused of poisoning the population. Attacks on Jewish communities were, somewhat unsurprisingly, most common in Germany.11

The rapid and shocking mortality rate of infectious diseases also encouraged a preoccupation with Death, the pale rider of the Book of Revelation. An iconography of Death dominated the later middle ages, celebrated in murals depicting the Triumph of Death and Death’s Dance. The iconography endured and was vividly recalled in Bergman’s Cold War masterpiece The Seventh Seal (1956).

Fatalism could also engender psychological crisis, denying God and provoking a recourse to nihilistic self-indulgence. Boccaccio found some Florentines believed “that to carouse and make merry and go about singing and frolicking and satisfying the appetite in everything possible and to laugh and scoff at whatever befell was (one) very certain remedy for such an ill”.12

Describing the plague that devastated the city two hundred years later, Machiavelli observed that:

Florence, at the present, resembles a city that has been sacked by the infidels and afterwards abandoned. Some of the inhabitants […] have retired to country villas to escape the deadly plague; some are dead and others are approaching death; so that while present circumstances offend us, the future threatens us; so as one struggles with death, one fears for one’s life…The neat and beautiful streets, which used to be bursting with rich and noble citizens, are now stinking, ugly and swarming with the poor…The shops are locked, the businesses closed, the courts and the lawyers dragged away, prostrating the laws. Now one hears of this theft, now of that murder: the piazzas and markets, where the citizens used to be in the habit of gathering frequently, are now made into communal graves, and vile dens of thieves.13

150 years on from Machiavelli, Daniel Defoe found that whilst “the better sort first took alarm hurrying themselves” out of London, as “if all the city was running away” to self-isolate on their country estates, some who remained, like “the dreadful set of fellows” who frequented the Pye Tavern in Houndsditch, behaved “with all the revelling and roaring extravagances as is usual for such people”.

They sat generally in a room next the street; and, as they always kept late hours, so when the dead-cart came across the street end to go into Houndsditch, which was in view of the tavern windows, they would frequently open the windows, as soon as they heard the bell, and look out at them; and, as they might often hear sad lamentations of people in the streets, or at their windows, as the carts went along, they would make their impudent mocks and jeers at them, especially if they heard the poor people call upon God to have mercy upon them.14

Boccaccio concluded that “the sore affliction and misery” of epidemic disease undermined “the reverend authority of the laws both human and divine”.15 Those who survived the Black Death gave themselves up to a “more shameful and disordered life”.16 Boccaccio, like Machiavelli, Defoe and Camus after him tried to record lessons from the popular response to plague for posterity. In this they followed the example set by Thucydides who first attempted to inform future generations of what to expect when an epidemic overwhelms a city state like Athens (430 BC).

Thucydides described in detail “what sort of thing it was”, specifying its symptoms and analysing the process by which the contagion spread. Thucydides observed, as did Boccaccio, Machiavelli and Defoe, “the despair into which people fell, when they realised that they had caught the plague for they would immediately adopt an attitude of utter hopelessness”. The catastrophe “was so overwhelming that men not knowing what would happen next to them, became indifferent to every rule of religion or of law”. Funeral ceremonies whether in ancient Athens or medieval Florence and early modern London “became disorganised”.17

Whilst the Athenians resorted to throwing bodies onto funeral pyres the magistrates of medieval Florence and 17th-century London consigned the dead to plague pits like the one Defoe describes in Aldgate.

REASON, MEDICINE AND EPIDEMICS

However, it was Thucydides who “with greater precision than the medical profession would achieve for nearly two millennia thereafter”, identified for the first time “two processes of profound importance: person-to-person transmission and specific acquired immunity”.18 His realistic precision not only informed his politics and statecraft, it also reflected a distinctively Greek approach to knowledge of the healthy physical, as well as social, body, its humours and its balance. Hippocrates (c. 460–c. 377 BC), Thucydides’ contemporary, developed in his collection of cases a patient-centred, healing system founded upon natural philosophy and reason independent of magic, or supernatural speculation.19 The Corpus Hippocraticum included seven books devoted to Epidemics (Epi Demos). Hippocrates not only coined this term for those diseases that fall upon a people or circulate within a country, and that invariably, like the Athenian pestilence or later bubonic plagues, arrive from the East, he also described the environmental and temperamental factors that determined their outcome.20

Subsequently, Galen, the most prolific Roman clinician “perfected” Hippocrates, rendering the corpus more logical, scholastic and anatomical. He contributed a new emphasis on the pulse and blood-letting to restore the bodily humours to equilibrium. This corpus adapted to the Muslim world from the 8th century through the contributions of Averroes, al Razi (Rhazes) and Avicenna. Muslim medicine also added the use of drugs (a word of Arabic coinage). This Galenic worldview amplified by astrology, astronomy and Thomist scholasticism informed the medieval and early modern plague doctor’s diagnostic approach to bubonic plague as well as other endemic diseases like yaws and leprosy. One of the pilgrims accompanying Chaucer to Canterbury a few decades after the Black Death included a:

…Doctour of Phisyk / In al this world ne was ther noon him lyk/ to speke of phisik and of surgerye; / for he was grounded in astronomye … /He knew the case of everich maladye, / were it of hoot or cold, or moiste or drye, and where engendered, and of what humour, / he was a very parfit practisioner.21

“Parfit practisoners”, however, were not much use in controlling the spread of infectious diseases like the plague. Marginally more effective perhaps were the religious orders that had founded hospices and hospitals for the poor, the sick and the needy. Crusading orders like the Knights of St John established foundations catering for pilgrims en route to Jerusalem in the 12th century. By the late 13th century Paris had its Hôtel-Dieu and London its St Bartholomew’s and St Thomas’s hospitals.

During the plague era, that lasted in Europe until 1720, hospitals could be turned into lazaretti or pest houses, catering for those suffering from what came to be recognised as contagious diseases carried along trade routes to European port cities like Venice, Genoa, London, Amsterdam and Marseilles. It was the wealthy trading city states of Renaissance Italy that first developed public health commissions comprised of nobles and public officials to address “the culture of poverty, dirt, promiscuity” and over-population in which plague thrived, or what Ladurie described as that fatal medieval “ménage à trois” between, the black rat (Rattus rattus), the flea (Pulex irritans) and man.22

Venice and Florence established boards of health as early as 1348. By the early 15th century, Milan had developed a permanent magistracy monitoring and regulating civic health. These developments followed the growing recognition that disease came from the outside and along trade routes. The first isolation of shipping occurred in the Venetian Adriatic colony of Ragusa in 1377, and the quarantine of suspect maritime commerce developed from there.23 In 1374, Milan and Mantua also introduced controls on overland commerce, the beginning of more rigid border regulation and cordons sanitaires in the following centuries. In 1374, in Milan again, the contacts of those infected, as well as the sick themselves, were isolated, and between 1450 and 1470 many of the city states of northern Italy set up isolation hospitals, lazaretti, in further attempts to prevent contagion. By the 17th century, an administrative programme was in place in most large cities which could be adapted for use against an epidemic threat. Defoe comments favourably on the Lord Mayor’s efficiently organised lockdown of the City of London and isolation of the sick in July 1665. The Mayor quickly appointed24 examiners for every parish and appointed two watchmen to each “infected house”.

The administrative attack on contagion developed, then, from the late 15th century in Western Europe. It owed much to the association of plague with poverty and it may also have owed something to the observation of subsequent epidemics, like typhus, smallpox and, in the 19th century, tuberculosis and cholera. As Paul Slack observed, the public health model of government “came late, and as the result of a learning process”.25

THE STATE OF DISEASE AND EARLY MODERN STATECRAFT

It was during this learning process that medicine and science broke decisively with the Galenic and scholastic tradition, and began to apply the new empirical science and the resoluto-compositive method promoted by Bacon, Galileo and Gassendi to the understanding of the body. However, it was raison d’état and the new political science associated with Machiavelli, Bodin and Hobbes, rather than new medical knowledge, that drove administrative campaigns against epidemic diseases, as well as other forms of internal and external threat.

Sovereign states, with pretensions to absolute power, emerged from the disintegrating cocoon of Christendom in the era of religious enthusiasm and confessional strife that beset much of Europe from 1517 to 1648.26 By the mid-17th century, plague, typhus, syphilis and smallpox were endemic, the population in decline and trade in disarray. Historians have for several decades debated whether a little ice age devastated the economy, causing a global crisis, or whether Europe suffered from a distinctive “general crisis”.27 Whatever else, the century witnessed European warfare on a continental scale, famine, poverty and, of course, epidemic disease. Bubonic plague followed in the train of Wallenstein’s imperial troops. War disrupted trade and displaced people carried infection. Peter Wilson’s comprehensive overview of the human and material costs of the Thirty Years’ War concluded that “disease was the main killer”. The first major plague epidemic occurred in Bavaria in 1622–1623. Three others followed between 1625 and 1650. Typhus and typhoid fevers also appeared on the scene. Bubonic plague, however, was “responsible for most of the mortality”. Wilson writes, “the frequency and scale of outbreaks after 1618 suggests a pandemic where the infection ebbed but never completely disappeared”. By 1650, the population of Munich had fallen from 22,000 in 1618 to 14,000.28

Jan de Vries, evaluating the European economic collapse of the 17th century argues that rather than “a crisis provoked by endogenous processes, unique to the technologies, institutions and reproductive practices of particular societies, the 17th-century demographic crisis appears to have had a proximate cause that was exogenous – infectious-disease vectors possessing a history of their own, and before which societies stood powerless”.29 The process, he maintains, decentred and recentred the European and world economies. It saw the decline of the Mediterranean world and the rise of the maritime Atlantic trading states, the Dutch Republic and England, as well as absolute monarchies dominating continental Europe, from France to Czarist Russia.

The impact of changes in the capacity of the state, Enlightenment rationalism and the transformation of medical science upon infectious disease and its implications for the medicalisation of political life will be discussed in Part II in the next issue.

Notes:

1 Jordà, Òscar, Sanjay R. Singh, Alan M. Taylor, “Longer-Run Economic Consequences of Pandemics”. Federal Reserve Bank of San Francisco Working Paper 2020–09. San Francisco, 2020. https://doi.org/10.24148/wp2020-09.

2 Roy Porter, The Greatest Benefit of Mankind. A Medical History of Humanity from Antiquity to the Present. London, 1997.

3 Peter Baldwin, Contagion and the State in Europe 1830–1930. Cambridge University Press, 2004.

4 A. McNeill, Plagues and Peoples. New York, Anchor Books, 1998, p. 48.

5 The Europeans exchanged, amongst other things, smallpox for syphilis or “the pox”.

6 Emmanuel Leroy Ladurie, “A Concept: the Unification of the World by Disease”. In The Mind and Method of the Historian. London, The Harvester Press, 1981, p. 82.

7 Habakkuk 3.5. The Bible Authorized King James version with apocrypha. Oxford University Press, 2008, p. 1018.

8 Exodus 12:23. Ibid., p. 79.

9 Psalm 91:2–6. Ibid., p. 691.

10 Daniel Defoe, Journal of the Plague Year (1720). London, Longmans, 1896, p. 16.

11 See Philip Ziegler, The Black Death. London, Faber & Faber, 1997, especially Chapter 5.

12 Giovanni Boccaccio, The Decameron or Ten Days Entertainment. New York, The World Library, 1947, p. 28.

13 See Landon, William J., Lorenzo Di Filippo Strozzi and Niccolo Machiavelli: Patron, Client, and the Pistola Fatta per La Peste/An Epistle Written Concerning the Plague. University of Toronto Press, 2013. Accessed 8 May 2020. www.jstor.org/stable/10.3138/j.ctt5hjtpc.

14 Daniel Defoe, Journal of the Plague Year (1720), p. 62.

15 Boccaccio, op. cit., p. 28.

16 Ziegler, The Black Death, p. 137.

17 Thucydides, History of the Peloponnesian War. London, Allen and Lane, 1974, pp. 154–155.

18 Paul Rahe, “What the Great Historian Thucydides saw in Athens Plague and Our Own”. The Federalist, April 2020. https://thefederalist.com/2020/04/08/what-the-great-historian-thucydides-saw-in-athens-plague-and-our-own/.

19 Roy Porter, The Greatest Benefit of Mankind, p. 56.

20 It is not clear why Hippocrates chose the term, rather than the more conventional nosos (disease) to apply to his collection of medical cases. Thucydides had used polemos epidemios to describe a civil war circulating in a country. Epidemics 1 (circa 400 BC) gives a detailed description of an outbreak of deadly mumps in Thasos. See W. H. S. Jones (ed.), De Morbis Popularibus. Cambridge University Press, 1896, p. 3. http://www.perseus.tufts.edu/hopper/text?doc=Perseus%3Atext%3A1999.01.0251%3Atext%3DEpid.%3Abook%3D1%3Achapter%3D1%3Asection%3D1.

21 Porter, op. cit., pp. 115–116.

22 Ladurie, op. cit., p. 50.

23 The word derived from the Italian quarrantino or the forty day isolation that Venice imposed upon trading vessels. See Brian Pullan, “Plague and Perceptions of the Poor in Early Modern Italy”, in Terence Ranger & Paul Slack (eds.), Epidemics and Ideas. Essays on the Historical Perception of Pestilence. Cambridge University Press, 1992, pp. 101–125.

24 Defoe, op. cit., p. 40.

25 Paul Slack, “Introduction”, Epidemics and Ideas, p. 16.

26 Mark Greengrass, Christendom Destroyed Europe 1517–1648. London, 2015. As Greengrass notes, protestants increasingly used the term Europe rather than Christendom in the 16th century, p. 29.

27 See inter alia Hugh Trevor Roper, The Crisis of the Seventeenth Century. Indianapolis, 1967, especially Chapter 2; H. G. Koenigsberger, Politicians and Virtuosi. Essays in Early Modern History (London, 1986) and Geoffrey Parker, Global Crisis War Climate Change and Catastrophe in the Seventeenth Century (Yale, 2017).

28 Peter Wilson, Europe’s Tragedy. A New History of the Thirty Years’ War. London, 2010, pp. 791–792.

29 Jan de Vries, “The Economic Crisis of the Seventeenth Century after Fifty Years”. The Journal of Interdisciplinary History, Vol. 40, No. 2 (Autumn) 2009, pp. 151–194. See also Fernand Braudel, Civilization and Capitalism, 15th–18th Century. III. The Perspective on the World, New York, 1981.

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