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Gloucestershire doctor Edward Jenner giving Parisians immunity to smallpox by “vaccinating” with a small dose of cowpox. Photograph: Ann Ronan Pictures/Print Collector/Getty Images

Epidemics and Society: History shows they are here to stay

Book review: Snowden explains diseases are not random events triggered without warning

“Who would have thought?” mused US president Donald Trump of the rapid and destructive spread of Covid-19. All across the globe states and societies were taken by surprise and exposed. Yet the danger of a pandemic was long foreseen.

The CIA and other intelligence agencies ranked it one of the greatest threats to national and global security, while scientists have warned for decades that the question was not if, but when.

How could we have been so unprepared for something that verged on inevitable? The answer, writes Frank Snowden, is that we have forgotten our past.

Concerned by “the unexpected vulnerability of modern society to sudden outbreaks of infectious diseases”, Snowden created a new course at Yale University – where he is professor of the history of medicine – on epidemics. This wide-ranging book, based on his lectures, argues that they have been central to the development of our world, and continue to pose a significant threat to its survival. Such a grim reminder could hardly be more timely.

The indigenous peoples of the Americas were decimated by smallpox to which they possessed no immunity

The “inescapable reference point” for the history of epidemics remains the bubonic plague, then and now “the worst imaginable catastrophe”. The Byzantine historian Procopius described the sixth-century “Plague of Justinian” as “a pestilence by which the whole human race was near to being annihilated”, while between 1347 and 1353 the Black Death may have killed half the population of Europe.

“Citizen avoided citizen,” Giovanni Boccaccio wrote of the Black Death in Florence. “Kinsfolk held aloof, and never met”, and the “affliction entered so deep into the minds of men and women” that loved ones were left alone and “unvisited to their fate, as if they had been strangers”.

Four centuries later Daniel Defoe would write of a plague year in London that “this was a time when every one’s private safety lay so near them that they had no room to pity the distresses of others”.

Political authority

Although a lack of medical knowledge meant pre-modern authorities “acted in the dark” against a disease that defied comprehension, some attempts to control the plague did work, most notably quarantines, cordon sanitaires, lockdowns and public hygiene. Plague regulations “marked a vast extension of state power into spheres of human life that had never before been subject to political authority”.

Snowden shows how the decline of one epidemic is generally followed by the rise of another, and by the 18th century a new “speckled monster” was terrorising Europe: smallpox.


Unlike the cyclical plague, Thomas Macaulay wrote, “smallpox was always present”, making it “the most terrible of all the ministers of death”.

Across the Atlantic its effects were even more horrific, with the indigenous peoples of the Americas decimated by a disease to which they possessed no immunity, easing the path of brutal and exploitative European colonisation, and hastening the mass enslavement of Africans in “New World” plantations.

Gloucestershire doctor Edward Jenner discovered that a small dose of cowpox could confer immunity from smallpox, and “vaccination” (from the Latin for cow) would slowly but surely bring the disease under control.

The practice, however, spawned opposition, and “the antivaccination movement in both Europe and the United States became one of the largest popular movements of the nineteenth century”, a grim preview of the “antivax” campaigns causing the alarming return of now-preventable diseases like measles.

Epidemics could occasionally become a weapon of the weak rather than their tormentor, as in revolutionary Haiti’s fight for freedom against Napoleon, where Toussaint L’Ouverture allowed yellow fever to paralyse the French armies. The emperor was again thwarted by infections in his invasion of Russia, where Snowden argues provocatively that epidemics of dysentery and typhus contributed more to his defeat than any military strategy.

Final victories over disease are to be celebrated as exceptions rather than as the expected steps toward a germ-free Eden

The epidemic of the century that followed was cholera, a disease that thrived in the overcrowded ports and slums of the industrial and imperial age. The tensions of the time saw it deemed “irredeemably filthy, foreign, and lower-class”.

Despite ideology and prejudice, London doctor John Snow’s pioneering work on the water-borne transmission of cholera is “now widely considered the foundational text of epidemiology as a discipline”, while Snowden shows that the efforts of Louis Pasteur, Robert Koch and others in developing a “germ theory of disease” were a “decisive advance”.

It is disappointing that the book does not cover the 1918-19 influenza pandemic at the end of first World War.

Discussions of other 20th-century epidemics reinforce Snowden’s argument that there was never cause for our “lapse into forgetfulness” on the power of disease despite the success of international campaigns against polio, tuberculosis and others. Better sanitation, hygiene, diet and standards of living all gradually made us less vulnerable but not immune. The “triumphant climate” of the 1960s and 1970s proved to be “spectacularly misplaced”.

While Snowden’s history is centred on the western world, more recent decades do concentrate on Africa and Asia, and the international community’s waning commitment to controlling disease. Snowden’s analysis of the HIV/AIDS pandemic that emerged in the 1980s shows how only decades of painstaking efforts in treatment, education and prevention – against dangerous cultural conservatism – have been able to bring its annual death toll below a million.

Humanity

A much more ancient disease, malaria, continues to infect and kill even more. Efforts to control it have relied as much on collaboration as medicine: “malaria, like all epidemic diseases, is a crisis not of nations, but of humanity”.

The fact that only smallpox has ever been fully eradicated reminds us that “final victories over disease are to be celebrated as exceptions rather than as the expected steps toward a germ-free Eden”, as does the way Ebola and Sars “painfully exposed” a global lack of preparedness.

“Epidemic diseases”, Snowden writes, “are not random events that afflict societies capriciously and without warning”, but instead forces that shape and are shaped by the worlds they infect.

Environmental degradation, climate change, unplanned megacities, inadequate public services, widening inequalities and a toxic nexus of healthcare and profit have all created cracks for infectious diseases to exploit today. The history of epidemics “is far from over”.

Dr Christopher Kissane is an editorial fellow at History Workshop