COVID-19: Insights from history

By Sarah Whitebloom

Self-isolation, lock-downs, economic chaos and closed borders: responses to today’s COVID-19 pandemic have their roots in history. In the past, there has also been panic-buying, attempted flight, fake news, quack remedies, beleaguered health authorities and a race for vaccines – all in the face of millions of deaths.

From earliest history to the SARS epidemic, the world has endured plagues, viruses and infections that have inspired panic among populations, rulers and politicians alike – as well as countless untimely deaths.  From the Black Death of 1348 to the London plague of 1665, from the repeated impact of cholera in the 19^th and 20^th centuries, to the millions lost in the 1918 ‘Spanish’ flu, leaders have often struggled to know what to do while populations have reacted with fear and later, occasionally, fury. The reaction to COVID-19 can be seen very much in this tradition, as concern has turned into pressure for the strictest containment measures, alongside the determined – and unprecedentedly rapid - pursuit of a cure.

During cholera epidemics, propaganda was used to urge people to pursue physically and morally 'healthy' habits from staying calm and washing their hands – just as it has been today -  to praying for salvation and quitting alcohol. In the 1918 epidemic, face masks were in common use and, in earlier times, people were ordered to quarantine. In the distant past, though, civil disorder sometimes followed. Public compliance eventually turned into public dissatisfaction with measures, which included infected people literally being shut into their houses.

In the 1918 epidemic, face masks were in common use and, in earlier times, people were ordered to quarantine

As in the past, in the current crisis there will be ‘pinch points’, according to historians, for instance if the number of cases rises despite social distancing and the authorities will need to issue reassurance or adjust the measures being taken. While social distancing is an internationally agreed approach, as the situation changes, governments around the world will be under pressure to put in place policies for an eventual move to less draconian measures. At that point, Oxford Professor of the History of Medicine, Mark Harrison, maintains international leaders will need to look for an ‘exit strategy’ or an end in sight from the current lockdown approach.  Professor Harrison says: ‘Governments will need to ask, how do we de-escalate? What measures do we put in place and can we re-escalate at a later point?’

Although the threat to life from the plague was in a completely different order to that presented by COVID-19, the measures taken in London in 1665 were not dissimilar to current international social distancing.  From the beginning of the plague outbreak, there was strict quarantine of infected people, trades closed down and many fled the city. But, in chaotic Restoration-era London, crime  and disorder followed harsh restrictions. Samuel Pepys wrote in his diary: ‘This day, much against my will, I did in Drury Lane see two or three houses marked with a red cross upon the doors, and ‘Lord Have Mercy upon Us’ writ there – which was a sad sight to me, being the first of the kind… that I ever saw.’

Although the threat to life from the plague was in a completely different order to that presented by COVID-19, the measures taken in London in 1665 were not dissimilar to current international social distancing

Opposition was swift. In the documents of a case discussed at court at Whitehall in the presence of Charles II, 28 April 1665, it states: ‘Upon Information given unto this Board, that the house, the Signe of the ship in the New buildings in St.Giles in the fields, was shutt up as suspected to bee infected with the Plague, & a Cross and paper fixed, on the doore; And that the said Cross & paper were taken off, & the door opened, in a riotious manner, & the people of the house permitted, to goe abroad into the street promiscuously, with others.’

This was not an isolated incident. In a letter from a civil servant, 1665, also in the National Archive, it states: ‘Death is now become so familiar, and the People soe insensible of danger, that they look upon such as provide for the publick safety, as Tyrants and Oppressors.’

Government experts are already talking about scaling back the strict measures over time. The current lockdown is initially going to last three weeks. And over the next 12 months greater and lesser restrictions may be applied, depending on the course of the virus. 

Widespread use of testing offers a way of relaxing measures but GPS monitoring advocated in South Korea is proving controversial there.  Professor Harrison says: ‘Maybe they [the government] will have to communicate with people that they will have to accept some risk as a price for their freedom. Maybe they will have to make available more intensive care beds, in expectation of more cases....The prime minister said there was light at the end of the tunnel of 12 weeks. That is the target. But there could be dissatisfaction if de-escalation doesn’t happen...Resentment could build up.'

In one important respect parts of the COVID-19 response are very different from previous centuries - or even decades.  This includes the speed with which scientists have been able to identify, sequence, and share information about a completely novel pathogen, the development of promising diagnostics, vaccines, and treatments within just over three months of the virus being identified, and global real-time disease surveillance

Problems could arise, if, as happened in 1665, there are secondary waves of infection. The plague raged in the City for more than 12 months, but according to the Bills of Mortality, the peak was not reached until September 1665 – a full year after the first reports of illness. And there were still deaths after this peak, affecting some people who had returned to London, in the expectation it had ended.  Professor Harrison says: ‘It is still too early to say what is working and what isn’t [in terms of the fight against the virus]. There’s a reasonable high probability that there will be some immunity [for people who have had the virus] but we don’t know how long that would last.’

Careful studying of how countries such as China and South Korea, which rapidly implemented strict social distancing early on and then balance a de-escalation of measures, will provide valuable lessons for the rest of the world. 

Dr Claas Kirchhelle, lecturer in the history of medicine at University College Dublin and fellow of the research and policy unit, the Oxford Martin School, says: 'Restricting the movement of people and implementing other rudimentary forms of social distancing have been mainstays of disease responses for centuries - alongside rumours, stigmatisation, and often desperate attempts to find remedies ranging from charms to quack medicines'.

Responses often varied according to cultural precedents and the specific biological profile of the pathogens involved. But, he says, in one important respect parts of the COVID-19 response are very different from previous centuries - or even decades.  This includes the speed with which scientists have been able to identify, sequence, and share information about a completely novel pathogen, the development of promising diagnostics, vaccines, and treatments within just over three months of the virus being identified, and global real-time disease surveillance.

Dr Kirchhelle says the response to COVID-19 marks a dramatic acceleration of disease response strategies, which gradually emerged from the second half of the 19th century onwards. During this period, the discovery of germ-theory gradually revealed the biological causes and transmission modes of previously mysterious and untreatable diseases.

Resulting blessings were manifold: from increasingly reliable diagnostics and more targeted non-therapeutic interventions like chlorination or campaigns against flea-bearing rats to the development of effective vaccines and specific therapies like antibiotics. At the same time, nation states also became better at coordinating their response to international disease outbreaks.  Convened in response to the cholera pandemics sweeping the globe, a series of international sanitary conferences began to lay the legal groundwork for standardised quarantine periods, disinfection methods, and international information sharing on infectious disease.

At the time of the 1918 flu pandemic, many people expected that science and officials would be able to take action. But the tried-and-tested approaches of traditional bacteriology failed. The disease was not caused by a bacterium but by an unusually deadly influenza virus. Not knowing what this was meant ‘they didn’t know what they were facing’. Coming at the end of the Great War and with actual incidence rates often censored by wartime and post-war governments, the 'flu' was able to move quickly around the world and across a broken Europe. And, as now, many people thought it was ‘just flu’. Dr Kirchhelle says: ‘There seemed no way to stop it spreading; it was explosive and devastating.’ Many people actually died of bacterial superinfections, which spread easily in malnourished bodies and in mass wards and could today have been treated with antibiotics.

Concerted international action has been critical in terms of tackling COVID-19. Although the current advice is very much in line with traditional attempts to starve a disease of susceptible new bodies, the rapid scientific response to a rapidly spreading infection has been ground-breaking. According to Dr Kirchhelle: ‘There has been a radical sharing of information and a very rapid sequencing of the pathogen's genetic code.’

He concludes: ‘The WHO in particular has worked well, despite chronic underfunding, and the fact that it has few actual powers to enforce compliance. The COVID-19 pandemic shows that new pathogens can rapidly spread globally. Hopefully, our current experience of vulnerability will lead to a long-term strengthening of international cooperation when it comes to tackling infectious disease and improving health systems in all parts of the world.'