Editor’s note: We open this issue with two articles pertaining to the current pandemic crisis: one by a virologist and the other by a historian of science & medicine. Despite their differing perspectives the two pieces have a surprising number of things in common. Both contain an allusion to the same medieval work literature, and both highlight the practical value of our discipline in the wider world, serving as a timely reminder that we imperil ourselves when we ignore history.
COVID-19: Lessons from History?
By Robin A. Weiss
“The low transmissibility of the virus, combined with infectiousness after the onset of clinical symptoms, made simple public health measures, such as isolating patients and quarantining their contacts, very effective in the control in the control of the SARS epidemic. We were lucky this time round but may not be so with the next epidemic outbreak of a novel aetiological agent.”
Diagram of COVID-19, courtesy of the U.S.
Centers for Disease Control and Prevention
The above statement appeared in a chapter by Roy Anderson and colleagues following the 2003 SARS outbreak published in SARS: A Case Study in Emerging Infections (Oxford University Press 2005) as the augmented proceedings of a meeting on the topic held at the Royal Society. In the concluding chapter, Angela McLean and I advised that we should “expect the unexpected” and alas, seventeen years later, we are not so lucky with the outbreak of COVID-19. It is caused by a virus formally named as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) because its genetic sequence is closely related to the SARS coronavirus, but it’s more commonly referred to in the media and by the World Health Organization (WHO) as “COVID virus” or “Coronavirus.”
The high rate of virus transmission before symptoms appear has allowed COVID virus to spread much faster in the community than SARS, although its virulence in most infected individuals appears to be lower. At the time of writing (March 8), the global mortality threat appears to be lower than the 1918/19 flu pandemic (the “Spanish” influenza pandemic that claimed ~50 million deaths) but might eventually overtake the 2009 flu pandemic (~280,000 deaths).
During the past 40 years, advances in the technology of virus identification and characterization have proceeded apace. Following the appearance of AIDS in 1981 as a novel affliction it took two years to identify the causative agent, HIV-1, and a further 18 months before its genome was fully cloned and sequenced. With the advent of SARS in 2003, it took only 2 months to characterize it as a member of the Coronavirus family whereas in January 2020, Chinese scientists obtained the full genetic sequence of the newly isolated COVID-19 virus within 3 days. Yet therein lies one of the unlearned lessons: because the genetic sequence turned out to be 70% similar to the SARS virus, investigators in Wuhan initially assumed that the transmission dynamics would also be similar, and they lost a crucial window of opportunity to nip the epidemic in the bud.
Complacency about the spread of COVID-19, together with the desire of local authorities to downplay the significance of the outbreak, has resulted in the international spread of this virus. However, once they realized the gravity of the situation, the Chinese seem to be managing to contain the epidemic at its original epicenter, Wuhan in Hubei province, in contrast to, say, Italy. Mathematical modeling for predicting the course of novel epidemics has also become much more sophisticated since the SARS outbreak and has informed contingency planning. But politicians are reluctant to allocate large budgets for pandemic preparedness against something that hasn’t happened yet; funding to the Centers for Disease Control and Prevention in the USA, and support for the WHO declined in real terms, until this month.
Despite the rapidity of developing genome-based diagnostic tests, it takes time to scale up and distribute them in countries with advanced economies let alone in poor and middle-income nations. An effective vaccine may well be devised based on the virus’s “S” protein since similar constructs have proved effective in pre-clinical tests with the SARS virus, but that will take years rather than months to roll out across the world. In a report on Research in Global Health Emergencies published on January 28, the Nuffield Council on Bioethics emphasizes the need for clinical trials to proceed ethically even in emergencies.
Antiviral drugs are being investigated that might help to ameliorate severe disease. I favor testing existing, licensed, inexpensive drugs that might be repurposed to fight COVID-19. For instance, we already know that this coronavirus docks onto the same cell surface molecule as the SARS virus, namely, angiotensin converting enzyme type 2 (ACE-2). Drugs such as Valsartan and Losartan are ACE-2 receptor antagonists, taken by millions of people (including myself) to lower blood pressure. But be careful, for while they might help protect against COVID-19, they may exacerbate the situation instead.
What else can we fall back on in the face of this emergency? Well, traditional historic methods: quarantine and personal hygiene. Boccaccio and his friends self-isolated outside Florence against the Black Death in 1348, as did the altruistic villagers of the Eyam in Derbyshire, England during the plague epidemic of 1665. And, as Ignac Semmelweis railed against his unheeding medical colleagues in the 1840s: “Now wash your hands.”
Robin Weiss is an Emeritus Professor of Viral Oncology, Division of Infection & Immunity at University College London.
What the Plague Can Teach Us About the Coronavirus
by Hannah Marcus
This article originally appeared in The New York Times op-ed pages on March 1, 2020.
The city that gave us the word quarantine nearly 600 years ago is once again facing an epidemic. On Feb. 23, officials in Venice canceled the final days of its Carnival festival, which brings hordes of tourists to the notoriously overcrowded lagoon city. The coronavirus COVID-19 had arrived.
Faced with a novel virus, it’s worth reconsidering Italy’s long experiences with epidemics and heeding the lessons. Though the etiologies of plague and the present coronavirus differ hugely, the social consequences of these outbreaks resonate in alarmingly similar ways.
As a historian of medicine, my research focuses on Italy in the early modern period, from 1400 to 1700. In this period, many of our current public health approaches, including tallying fatalities, emerged in response to outbreaks of plague. The word quarantine derives from the Venetian word for 40 days, the length of the isolation period imposed on ships during times of plague. City officials during the Renaissance, faced with recurring bouts of plague, developed our statistical approach to tracking outbreaks. From the 1450s in Milan and the 1530s in Venice, all deaths in these cities were systematically recorded to monitor outbreaks. In 17th-century England, these tallies were printed weekly as broadsheets, which counted plague deaths by parish under the gloomy headline “Lord have mercy upon us.”
The distant past is not our best source of advice for pathogen containment. But it does offer clear lessons about human responses to outbreaks of infectious disease.
In the Renaissance, Italy was made up of many small territorial states, and travel between them was regularly curtailed because of outbreaks of plague. Travelers moving between regions during these times had to carry health passes issued by local governments testifying that they were traveling from places free of plague.
Image of a collection of the Bills of Mortality for London in the plague outbreak of 1665, published the same year by E. Cores in London and attributed to a John Graunt. For further information see: https://www.christies.com, from where the image was obtained.
In the opening to The Decameron, the 14th-century poet and scholar Giovanni Boccaccio described reactions in his native Florence to an outbreak. He lamented that “the reverend authority of the laws, both human and divine, was all in a manner dissolved and fallen into decay.” We should take Boccaccio’s account as a warning. Despite Machiavelli’s call in 1513 for Italian unification in the final pages of The Prince, Italy only became a single nation in 1861; its deep regional divisions are still felt politically, linguistically, gastronomically and in the infrastructure of its transit systems.
In this time of coronavirus, Italy’s national identity—and that of Europe more broadly—is showing signs of strain. In addition to closing off certain towns with clusters of infections, regional governments are working to isolate themselves from the rest of the country. Most notably, the province of Basilicata has imposed a 14-day quarantine on all citizens entering from Piedmont, Lombardy, the Veneto, Emilia-Romagna and Liguria. These measures are about much more than health controls. They highlight regional identities and emphasize the tensions between local and national actions being taken to contain Italy’s outbreak.
Beyond the exacerbation of regionalism in Italian society, we should be on guard against the ways that outbreaks of disease have historically led to the persecutions of marginalized people. One of the best documented social outcomes of the plague in late-medieval Europe was the violence, often directed at Jews, who were accused of causing plague by poisoning wells.
Since the eruption of the coronavirus, we have witnessed widespread, global anti-Asian discrimination and numerous acts of violence against Asians. We should learn from the past, identify these violent attacks as the scapegoating they are, and condemn them swiftly and harshly.
In Italy, anti-migrant sentiment is also being conflated with anxieties about the new coronavirus. The Italian interior ministry announced that the 276 migrants who were rescued off the coast of Libya last week would be placed in mandatory quarantine in Pozzallo, Sicily, though they had no connection to people or locations affected by the coronavirus. Leaders of the far-right Lega Nord party are stoking the flames of fear and fury, protesting that even in the face of the coronavirus crisis, with cities and towns under lockdown, Italy has not closed its ports to migrants. This kind of slippage from disease to blaming a vulnerable social group, is an outcome that we have seen throughout history—as foreigners, prostitutes, Jews and the poor were blamed for outbreaks of plague.
The predictable turn to xenophobia, racism and persecution represents the breakdown of our society’s laws and morals in the face of fear and disease. It, too, is a symptom of disease, if not a biological one.
In the coming months the coronavirus may continue to spread. We will need to be on guard against contagion, but we will also need to be on guard against our own human instincts.
Hannah Marcus is an assistant professor in the Department of the History of Science at Harvard University.