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Florence Nightingale

The pandemic effect through history

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While digital apps evolve to keep us all connected during the Covid-19 pandemic, we look at what technologies and trends have emerged from previous waves of disease through the ages.

During the Crimean War, it was said that you were safer on the battlefield than in hospital. At the sharp end of the armed conflict, you at least had some chance of survival. But in the converted military barracks at Scutari that served as a field hospital, you had virtually none. Back in the mid-19th century conflict on the Black Sea, medical facilities were so rudimentary and sanitary conditions so appalling that the mortality statistics make grim reading. Of the 21,827 British troops that fell in the war, 4,602 were either killed in action or died of wounds, while 17,225 died of infectious diseases such as typhus, typhoid, cholera, and dysentery. Four times as many men died of disease as from battle wounds.

The conflict between the Russian Empire and an alliance of Britain, France, the Ottoman Empire and Sardinia has been called one of “notoriously incompetent international butchery”, and more than a century-and-a-half later historians are still divided over its cause and outcome. But there is one clear positive aspect of the Crimean War that resonates with us today. It represented a major turning point in our understanding of how to prevent the spread of infectious diseases.

This was the conflict from which Florence Nightingale, ‘the lady with the lamp’, emerged as a heroine, not for her strategy on the battlefield but for her professional nursing strategy in the hospital at Scutari. Such has been her influence on saving lives that the seven field hospitals rapidly constructed around England to respond to the increased demands on the NHS resulting from the Covid-19 epidemic were named ‘Nightingale’ hospitals.

Nothing could be more British. Nightingale, on seeing first-hand the conditions at the barracks, sent a strongly worded letter to The Times saying that the government should do something about it, the result of which was that the legendary 19th-century engineer Isambard Kingdom Brunel stepped in to save the day. In the space of five months, Brunel managed to assemble a team to design, build and ship a prefabricated complex of wood and canvas buildings to the Dardanelles in 16 ships.

The resulting hospital at Renkioi was an overwhelming success, with a 90 per cent improvement on patient recovery compared with Scutari. The success wasn’t due to any scientific breakthroughs in drugs or surgery, but an improved understanding of hygiene practices in purpose-built facilities, such as ventilation, the reduction of overcrowding and, most important of all, handwashing.

Nightingale’s legacy today rests on the nigh-on universal agreement among national health authorities that handwashing is the single most effective way to prevent the spread of infections. The Global Handwashing Partnership says: “Proper hand hygiene has emerged as a powerful tool to combat the spread of Covid-19. Similar to other respiratory illnesses that are spread through person-to-person contact, handwashing with soap can help rid of infection-causing germs.”

Archaeologists think that we’ve known about soap for five millennia, with a written reference found on a Babylonian clay tablet dating back to 2200BC. One of the earliest technologies still in everyday use, domestic soap is, in its simplest form, a mixture of fats and oils with a base that works by making particles soluble and so allowing them to be separated from the surface they are attached to. The reason soap is so effective in hand­washing is that it also kills microorganisms by disrupting their lipid membrane bilayer and denaturing their proteins.

Of course, none of this was known in Babylon, but the fact that soap allows surface contaminants to be washed away with water has been known and adopted, if not understood, by early civilisations globally, from the Roman Empire to Ancient China, from the Islamic Middle East to Medieval Europe.

The Romans in particular were obsessed with personal hygiene (as evidenced by the name of the city ‘Bath’), and with their departure from Britain in the 5th century came a deterioration in the use of soap, removing one of the possible defences against the Black Death that swept through Europe, peaking in the mid-14th century.

The catastrophic loss of life caused by the Black Death (70-200 million) led to a fundamental change in the way humans think, and is seen as the catalyst of handover from the Late Middle Ages to the Renaissance and, by extension, modernity. Social historians think that the sheer scale of death and associated economic depression caused a shift towards greater emphasis on the realities of existence on Earth rather than spirituality or the afterlife. With this came a new concentration on humanism that showed itself in not just art, music and literature, but also science and technology.

The invention of the metal moveable-type printing system – the printing press – by Johannes Gutenberg meant that information could now be disseminated at a pace that could not have been dreamed of in the Middle Ages, during which scribes copied individual religious documents by hand. Gutenberg also developed oil-based inks, and by the end of the century there were more than a hundred printing presses in Europe.

In 1476, William Caxton imported the first printing press to England, established his business in Westminster Abbey Church and became the first retailer of printed books in Britain. His first known publication was Chaucer’s ‘The Canterbury Tales’. 

After the Black Death had abated Britain was by no means free from the threat of pandemic. The ever-present spectre of the deadliest of all diseases – smallpox – was rampant in Europe in the 18th century and was to account for half a billion lives in its last hundred years up until 1977.

The response to smallpox built on advances in Renaissance science that paved the way to the development of technical instruments such as the microscope. It was also the era of the emergence of the discipline of vaccinology that was to plant both the hypodermic syringe and the name Edward Jenner on the map.

Jenner was the English physician who popularised the practice of vaccination and was a pioneer in immunisation. His work in the field was considered so important that his application to the government for funds to pursue it was supported by King George III. Jenner received £10,000 in 1802, and five years later a further £20,000 after the Royal College of Physicians confirmed the widespread efficacy of vaccination.

It is largely thanks to Jenner’s efforts that smallpox remains the only infectious disease to have ever been eradicated, declared as such by the World Health Assembly (the decision-making arm of the WHO) in 1980.

The Black Death was in fact the second global pandemic after the less well-known Plague of Justinian that ravaged the Eastern Roman Empire during two centuries of recurrence and only truly ended in the mid-8th century.

The outbreak of Yersinia pestis (the same bacterium that caused the Black Death), came from grain supplies imported from Egypt to Constantinople. Not only were the supplies contaminated by infected rats, but the rats thrived on the grain that was stored in large government-maintained granaries. This had the multiple effects of spreading the disease, sustaining a growing rat population, reducing food supply for the city and creating an economic crisis. With as many as 10,000 deaths per day in Constantinople, the Emperor Justinian was running out of people to tax, and the loss of income took its toll on infrastructure projects. The basilica at Philippi in Greece is an example not of Roman ruins, but a construction project that was only partially completed due to the economic downturn created by the pandemic.

Emperor Justinian wasn’t alone in discovering that pandemics can wreak havoc with the economy. If you look at today’s stock market indexes, you can see that the current corrections, while not entirely caused by Covid-19 (the failure of Russia and Saudi Arabia to reach a compromise on oil prices towards the end of 2019 was arguably as significant a catalyst), neatly track daily fluctuations in our confidence primarily in tech companies such as Google and Apple to lead the way out of financial chaos.

And it’s always been the case. At the end of 1918, the Dow Jones Industrial Average (DJIA) reached a nadir of crash proportions in response to the outbreak of ‘Spanish flu’ that hadn’t in fact originated in Spain (see panel). Then followed a steadily rising ‘bull market’ leading into the 1920s as post-war domestic reindustrialisation of national economies took effect. The initial drawdown on the curve in 1918 is virtually identical in shape to current indexes following the outbreak of Covid-19.

As with the Crimean War, the First World War was to suffer more casualties as a result of human infectious disease than there were soldiers killed in battle. And again, its influence on medicine was to be procedural rather than technological, the main effects being the consolidation of Florence Nightingale’s principles of hygiene-based nursing and the increase of women entering the medical profession, both of which are today pillars in the fight against the Covid-19 pandemic.

Numbers

Pandemics through history by death toll

Smallpox 1877-1977: 500 million

Last known case recorded in 1977 with certification of global eradication from WHO in 1980. Evidence of cases dating back to 3rd century BC. Five hundred million deaths in the last hundred years of the disease, but major outbreaks in Europe in the 18th century accounted for up to 400,000 deaths annually.

Black Death (bubonic plague) 1347-51: 70-200 million

The Black Death outbreak wiped out an estimated 30-50 per cent of Europe’s population and it took two centuries for the continent’s population levels to recover. The plague originated in rats and spread to humans via infected fleas. The single most fatal pandemic, which had far-reaching economic, social and religious effects, changing the course of European history.

Spanish flu 1918-20: 17-50 million (possibly up to 100 million)

At the end of the First World War the Spanish flu pandemic infected more than 500 people (about one-third of the world’s population) and accounted for more deaths than the war itself (9-11 million military personnel). It was the first of two H1N1 influenza pandemics (the other was swine flu in 2009). Radically changed attitudes to women in nursing.

HIV/AIDS pandemic 1981-present: 32 million+

According to the Global Burden of Disease Study research programme, the incidence of infection peaked in 1997 at around 3.3 million cases, sharply fell by 2005 to 2.6 million and has remained stable since.

Plague of Justinian 541-2 AD: 25-100 million

Named after the Eastern Roman Emperor Justinian I, the eponymous plague is estimated to have killed half the population of Europe with devastating economic effects. There are still unfinished construction projects in Greece dating from this time. All recurrences ended by the year 750 and it was the last major pandemic until the Black Death.

Selected others

Asian flu (H2N2) 1957-58: 1-4 million

Great Plague of London 1665-6: 100,000

Covid-19 (confirmed by 4 May 2020): 247,000

Swine flu 2009-10: 151,700-575,400

US flu season 2017-18: 60,000-80,000+

Pandemic

Spanish flu: what’s in a name?

There’s more to naming human infectious diseases than meets the eye. So much so that the World Health Organization (WHO) has published guidelines on the subject.

We’ve had Spanish flu, Asian flu and swine flu. But names that carry inaccurate, emotive or negative connotations could become a thing of the past, if the WHO has anything to do with it. The recent spat between the US and China over the name of Covid-19 has highlighted the issue.

In March 2020, Geng Shuang, an official at China’s Ministry of Foreign Affairs, told reporters “certain American politicians” were stigmatising China by linking it to Covid-19. Geng was making a thinly disguised reference to US President Donald Trump describing the pandemic as the ‘Chinese virus’. “I have to call it where it came from. It did come from China,” said Trump. Beijing’s response was to demand that the US “immediately correct its mistake and stop making unwarranted accusations on China”.

The incident showed the President to be out of step with current WHO ‘best practices’. In a memo published in May 2015, the WHO states that disease names may not include geographic locations such as cities, countries, regions or continents, to “minimise negative impact”. It also advises against using personal names (Creutzfeldt-​Jakob disease), animal terms (swine flu), food associations (paralytic shellfish poisoning), industry/profession terms (miners, nurses etc) and words that could induce fear (unknown, death, fatal, etc).

WHO wants to keep disease names free from emotive connotations to prevent unintended consequences such as those associated with what was known for nearly a century as Spanish flu, but is now called the 1918 flu pandemic. Despite there being little evidence for Spain being the point of origin for the disease, the name implies origin in the same way as Trump’s comments about the “Chinese virus”. Current theories of the geographical origin of the 1918 flu outbreak include the UK troop staging and hospital camp in Étaples in France, while some authorities claim that the virus had been circulating in European armies for decades prior to the First World War.

Spain got the blame because of its neutrality in the war. Censorship restrictions in the UK, Germany, France and the US meant there was a near universal blackout on coverage of the disease. But, Spain at the time had no media censorship, so most of the news on the pandemic in Europe came from Spanish newspapers, creating the mistaken impression that the country had been hardest hit. When the Spanish king Alfonso XIII became gravely ill with the disease, the association stuck.

That’s why WHO favours disease names based on ‘general descriptive terms’ such as those for clinical symptoms, physiological processes, severity, seasonality, environment and causal pathogens.

 

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