S1E32 / Epidemics Change History / Josh Loomis & Frank Snowden

Hey everyone, nominations for the 2020 People's Choice Awards open on July 1st. To show your support, please go to podcastawards.com and nominate us in the health category. That's podcastawards.com. Thanks for your support. I'm Dr. Saleen Gounder, and this is Epidemic. Today is Tuesday, June 30th. This, of course, is Monty Python and the Holy Grail. Bring out your dead! The shot opens with the camera zoomed in on the face of a corpse. It pans back to reveal a squalid medieval town. People are filthy and coughing. Coughing. The cart is practically overflowing with dead bodies, victims of the plague, the Black Death. John Cleese's character is trying to get rid of an old man who's not quite ready to go. I'm not dead. What?

Nothing. Here's your ninepence.

I'm not dead. Here.

He says he's not dead.

Yes, he is.

I'm not.

He isn't.

Well, he will be soon.

He's very ill.

I'm getting better.

No, you're not. You'll be stone dead in a moment.

Eventually, Cleese convinces the cart driver to bump off the old man.

Isn't there something you can do?

I feel happy! I feel happy!

Ah, thanks very much.

Not at all. See you on Thursday.

So the Black Death was a bacterial infection caused by a bug called Yersinia pestis that began in 1347.

This is Josh Loomis. He's a microbiologist and the author of Epidemics: The Impact of Germs and Their Power Over Humanity.

They estimate it killed roughly between 1/4 to 1/3 of Europe's population. People really thought at the time that the world was ending.

Back in the 14th century, John Cleese's character would not have been so eager to get rid of anyone as spry as this old man. You see, the Black Death wasn't just a health crisis. It was also an economic crisis.

The economic system back in the 14th century relied on, you know, land ownership by feudal lords that would hire peasants to basically work the land, and then those lords would pay the king.

This feudal system ran Europe when the plague hit. And if all those people died, there were suddenly a lot fewer serfs to make money for the lords of medieval Europe.

It really gave rise to the first kind of middle class that we see. We see a rise in merchants at that time, so they were able to negotiate for higher wages simply because there weren't that many of them. And so we saw a gradual decline in, in that kind of feudal way of running the land, and, you know, an increase in, in private land ownership, and really an increase in the economic stability of the population. So we saw a rise in the middle class, which is really interesting that, you know, a disease can, can so drastically impact the economics of the day.

The Black Death had huge implications for economics, politics, medicine, and religion. And it wasn't the only disease to upend a civilization. Smallpox, cholera, malaria, and yellow fever, just to name a few, have all played important roles in human history. In this episode of Epidemic, we're going to look at a couple examples of how disease shaped the world we live in today, and what those events might might tell us about what to expect after the COVID pandemic ends. The Black Death was actually the second of three plagues that ravaged Europe. It was a gruesome disease.

It would have started with a high fever and progressed gradually to necrotic lesions that would develop in the lymph nodes, and so you'd see these kind of blackened areas, often on the neck, but sometimes in the groin the armpits where the major lymph nodes are located.

But that's not what actually killed people.

So as grotesque as that looked, that's usually not what killed people. The bacterium eventually would spread into the blood and would cause shock, and then beyond that, it would spread into the lungs and cause a fatal pneumonia. Rats probably were responsible for spreading it between cities, but very likely it was the, the pneumonic form of the disease is how it spread within a city from person to person. It was probably not all that different than how COVID-19 is spreading through respiratory secretions.

And like COVID, the bubonic plague could infect anyone, including priests and nuns who were caring for the sick. People started to see that even these holy men and women were dying.

And so what happened was the European Catholic Church at the time, which was the only Christian church that existed, saw a massive number of people leave the church and essentially lose faith. And what was interesting, it also had a major impact in fundraising. You think about, you know, dead people don't tithe their salary, so the church was in a really dire need of financial rescue.

Some enterprising priests came up with a plan to make money quickly: indulgences. Basically, let wealthy people pay money to have their sins absolved.

Fast forward a couple hundred years to Martin Luther, the indulgences were one of the major things that he had up problem with when he began the Reformation.

If the Black Death set the stage for a schism in the Catholic Church in the 1500s, another disease helped move Christianity into the mainstream during the Roman Empire: smallpox.

There are stories of husbands leaving their wives and parents abandoning their children who were sick. People were really scared of dying of this horrific disease. You could really trace it, a lot of that, to the smallpox epidemics and the fact the fact that the Christians were handling the epidemic a bit differently than the people around them. They weren't fleeing, they weren't afraid of death because they had this, you know, hope in an afterlife. And I think it drew people in.

Over the centuries, smallpox became a normal, if deadly, childhood illness. If you contracted it, there was a 30% chance the disease would kill you. But if you survived, you were immune. And this would have important consequences as the Middle Ages ended in Europe and the era of colonization began.

You could make a strong argument that the introduction of smallpox and measles and flu to the New World is one of the most significant events in human history, because it not only changed the history of the Americas, it gave certain countries like Spain and Portugal and Great Britain an enormous amount of wealth, which, you know, obviously changed the power dynamics in Europe.

The encounter between Columbus and the Arawak people in 1492 marked the beginning of biological warfare.

The contact of the indigenous population with the Europeans meant that smallpox and measles spread like a conflagration, like wildfire, through those populations.

This is Frank Snowden. Frank is a professor of history and the history of medicine at Yale University.

Columbus had in mind to enslave the Arawaks to mine gold in the New World and to till the fields, but they died off so that within 20 years or so, they numbered just a few thousand out of the couple of million that were there.

Smallpox decimated indigenous Americans from the Aztec Empire on to the Incan Empire in the south. And the indigenous peoples of North America. But with no indigenous peoples to enslave, Europe looked elsewhere. While the shortage of labor from plague deaths in Europe would help set the stage for a middle class, in the Americas it would create the brutal institution of chattel slavery.

African slaves were brought to the New World, and there they did not die of smallpox and measles in the way that the aboriginals did. And so it was a major factor in the coming of slavery to the Caribbean, South America, and North America.

Indigenous people were not the only potential victims of smallpox. So were American colonists.

Sure, yeah. The Founding Fathers, one of the biggest fears they, they had was smallpox breaking out amongst their ranks and basically wiping out their army.

Josh Loomis again.

George Washington and John Adams and Jefferson, they knew that if smallpox were to ever break out amongst the main army, they'd be done. The revolution would be over. So George Washington had a brilliant idea that was extremely risky in 1777, 1778, actually in Pennsylvania in Valley Forge during the winter. They would take dried scabs, basically material from people that had— kind of gross— but had pustules, and they would dry into a powder, and people would either inoculate it into their arm or they would snort it.

This was called variolation. It was a precursor to modern vaccination that was used throughout Asia and Africa before Europeans were introduced to it in the early 1700s.

Well, variolation was somewhat effective, but it was also incredibly dangerous. It had a fatality rate upwards of 1 to 2%, which was much better than the 30% fatality rate of actual smallpox. But if you're in an army of, you know, that had tens of thousands of soldiers, you would lose a significant amount, and it made everyone sick as well.

But it did work.

And within a couple winters, his whole army was protected. And so we saw really the impact of this because there was an army that was going up into Canada and Quebec that wasn't protected, and smallpox did break out amongst that army, and the British had absolutely no problem defeating them. It was almost kind of a control group in this experiment of a group that wasn't variolated and smallpox decimated them, whereas Washington, you can argue his decision possibly saved the revolution.

Disease wasn't always a weapon for the colonizer. Tropical illnesses like yellow fever and malaria played important roles in turning away European colonizers. Let's go back to the island where Columbus encountered the Arawaks. While George Washington was varilating his troops at Valley Forge, the island was the wealthiest colony in the world: Saint-Domingue. The sugar plantations there made France rich, but the system of slavery that produced that wealth led to constant violence and uprisings. And there was another problem: Europeans had no immunity to yellow fever. In 1791, Toussaint Louverture led a rebellion on the island and overthrew the French planters.

This was the greatest slave rebellion since Spartacus and one of the greatest slave rebellions in the history of the world.

But France's new leader, Napoleon, was not done with Saint-Domingue. He wanted to get back control of the island's sugar wealth and reinstitute slavery.

So he resolved to send and a huge armada, something like 60,000 troops, sailed from France to restore order, French control, and slavery to Saint-Domingue. What he hadn't accounted for was that his men would be present in the hot and wet spring and summer when the mosquitoes breed, and there's this upsurge every summer of yellow fever in the Caribbean. Soon, the commanding general in charge of the French forces wrote back to France that 80% of his men had died of this single cause, yellow fever. The other 20% were convalescing and therefore were useless for combat, and that he could no longer continue to wage war. And so the French departed in defeat. And Haiti becomes the world's first free black republic in 1804.

Yellow fever turned back Napoleon faster than any army could. The defeat would prompt Napoleon to abandon his ambitions in the Americas. Slave routes were disrupted. France sold the Louisiana Territory to the then new country, the United States.

We see that yellow fever led in this case to starting decolonization, part of the first major step in the end of chattel New World slavery. It has a geopolitical shift in the balance between France and Great Britain, and also the emergence of the United States. Yellow fever then was connected with a really transformative event in world history.

Yellow fever and malaria also defended large parts of Africa from colonization.

This was the case all the way up until about the 1880s. And then what changed was the discovery of a very powerful and effective drug called quinine.

Quinine comes from the bark of a tree from Latin America. It was mass-produced, and colonizers carried it with them into the interior of the African continent.

So once they had this, this quinine protection, that was pretty much it. There was a meeting in Berlin in the late 1880s where they literally got a map of Africa and European powers carved it up And within, you know, a decade, all of Africa was under the control of the Europeans. So yeah, malaria and yellow fever was, was the primary African weapon against the European diseases, but quinine kind of ended that.

I mean, it makes sense, right, that a lot of our infectious disease research is done out of the Army and, you know, facilities like that today even.

Yeah, yeah, absolutely. Yeah, you have to protect your soldiers. And kind of a funny side story of that, the The tonic that quinine was made in, it was a very bitter extract from a tree bark, and the sailors would refuse to drink it. And so they eventually allowed them to mix it with the alcohol that they had on board, which was gin. So they believe that kind of gave rise to the modern gin and tonic. And if you look at tonic water, it still actually has trace amounts of quinine in it. For flavor. So yeah, it's funny how some of these impacts were major and some of them were minor. A lot of little things we don't know about that, you know, affect our everyday lives.

Not every disease or epidemic results in its own signature cocktail, but Frank says even the mundane details of everyday life determine how an epidemic unfolds. When, where, and how a disease thrives and the vulnerabilities it exposes are unique to each society at that moment in time. Take the example of cholera in Europe during the Industrial Revolution.

So you had the rise of teeming slums of the kind described by Charles Dickens. Housing was overcrowded, was inadequate. It also meant that there were no sanitary facilities in terms of sewage, toilets, clean water supplies.

People were getting cholera because their drinking water was contaminated with feces that carried the bacteria. But cities around the world started taking action to address these conditions. Things like sewer systems, clean drinking water, paved streets, and garbage collection were all implemented in response to cholera epidemics.

So that we could say that in New York City now, or Rome where I am, it's pretty unthinkable that Asiatic cholera would cause a major outbreak or epidemic because we have those bulwarks of sanitation to protect us.

We can see some parallels between the public health efforts that came out of the fight against cholera today. It starts with an English lawyer back in the 1830s named Edwin Chadwick. Chadwick was a believer in something called the filth theory of disease.

That disease was a product of people who lived in poverty and filth, brought upon themselves both sickness and also immorality. Drunkenness were all the product of poverty and social dissolution.

Chadwick saw the terrible living conditions in cities like London that gave rise to epidemics of cholera and typhoid. He also saw the revolution happening in France and was terrified of it spreading to England. He became fixated on the idea that sanitation was the key to preventing disease and as a result avoiding social turmoil.

He was concerned exclusively, almost obsessively, with the single issue of filth and wanted to create better housing, clean water, sewage systems, using of soap bars. All of this was part of Chadwick's vision, and it was a vision of making Britain healthier, cleaner, and much more socially stable.

Chadwick's obsession with cleanliness as a means of social control ignored a lot of other reasons why people were unhappy: terrible working conditions, low pay, and poverty weren't on his radar. But the sanitary movement he spearheaded made big improvements in the lives of people in Britain and eventually around the world.

It was a partial solution to the problem of health, but a very powerful one.

That partial approach to pandemics is still at work today. At the time of this recording, the June jobs report hadn't yet been released. But we know that millions of Americans remain out of work because of the coronavirus. In April, the unemployment rate skyrocketed to almost 20%. When Congress passed the CARES Act in March, it included an extra $600 a week in unemployment benefits. Those benefits are set to expire by the end of July. Texas Senator John Cornyn was one lawmaker arguing against extending the payments as the pandemic continues.

At a certain point, these benefits are going to do more harm than good, and I would say they already are starting to do that. So in extending unemployment benefits through next year would deter people from trying to return to work, because why would they? Why would someone choose to do more work for less money?

Were you able to hear that?

I did hear that, I'm afraid, yes.

You did, yes.

What's disturbing is how they do sound so much like a repetition of 19th century Chadwickian ideas. And the problem with Chadwickian ideas is that they were powerful, they were important, but they were extraordinarily partial ideas with regard to the causes of illness and poverty.

Frank is talking about Chadwick's other legacy, the Poor Laws. Chadwick believed that the English social safety net was too expensive and too lenient with the poor. Remember, Chadwick is talking about help for the poor in 1830. Along with his crusade for cleanliness, Chadwick thought society would be better off if people had to work harder to access necessities like food, shelter, and healthcare.

So extending unemployment benefits through next year would deter people from trying to return to work because why would they?

I actually think this is a profoundly disturbing concept and one that would bring us much worse health, much more social tensions in our society, and would end up not being effective because if the poor don't have access to healthcare, for example, and part of our massive unpreparedness for COVID-19 is that so many people are outside the system. Public health depends in the modern world on accurate timely information and having people outside the system means that public health officials are blindfolded and have their hands behind their backs.

Just like cholera exposed the weaknesses in European society, COVID is doing the same for us. Working-class Americans and people of color are disproportionately affected by COVID. They often can't afford health insurance or aren't offered it through their jobs. They can't afford to stay home to reduce their exposure to the virus, and they can't socially isolate because they live in crowded housing. And these are some of the reasons why COVID is hitting the United States harder than any other developed nation in the world.

I'm postulating that microbes reach us through channels that we ourselves create. And I think that the truth of the matter becomes inescapable that we are going to have to realize that like it or not, in the long run, what happens to the most vulnerable amongst us is going to happen to all of us.

Despite these challenges, Frank says he's cautiously optimistic. The bubonic plague and cholera, for example, were devastating pandemics, but they also led to the creation of modern public health and sanitation. There's still a chance for COVID to have its own silver linings. Even if we can't see them right now. Remember what Josh said about the Black Death?

People really thought at the time that the world was ending.

Over the weekend, Secretary of Health and Human Services Alex Azar sounded the alarm. Here he was on NBC.

The window is closing. We have to act, and people as individuals have to act responsibly. We need to social distance. We need to wear our face face coverings if we're in settings where we can't social distance, particularly in these hot zones.

This is a very dangerous disease, and we're going to have to listen to that danger and to readjust the ways that we live and how we move and conduct our business and live in our cities as a result, and the kinds of health that we provide the poorest amongst us. I think we learn as a species very slowly, unfortunately, but I think that This is a lesson that we have no choice about learning.

Epidemic is brought to you by Just Human Productions. We're funded in part by listeners like you. We're powered and distributed by Simplecast. Today's episode was produced by Zack Dyer and me. Our music is by the Blue Dot Sessions. Our interns are Sonia Baradwa, Annabelle Chen, and Julie Levy. If you enjoy the show, please tell a friend about it today. And if you haven't already done so, leave us a review on Apple Podcasts. It helps more people find out about the show. You can learn more about this podcast, how to engage with us on social media, and how to support the podcast at epidemic.fm. That's epidemic.fm. Just Human Productions is a 501(c)(3) nonprofit. 501(c)(3) nonprofit organization, so your donations to support our podcasts are tax deductible. Go to epidemic.fm to make a donation. We release Epidemic twice a week on Tuesdays and Fridays, but producing a podcast costs money. We've got to pay Zach, so please make a donation to help us keep this going. And check out our sister podcast, American Diagnosis. You can find it wherever you listen to podcasts or at americandiagnosis.fm. On American Diagnosis, we cover some of the biggest public health challenges affecting the nation today. In Season 1, we covered youth and mental health. In Season 2, the opioid overdose crisis. And in Season 3, gun violence in America. I'm Dr. Celine Gounder. Thanks for listening to Epidemic.