• On Pandemics: Historical Considerations of Pandemics – Part II

    Editor’s note: Scope asked Steven A. Newman, MD, to put the COVID-19 pandemic into context. In this, the second part of a four-part series that looks at COVID within the context of other pandemics, we look at the history of pandemics.

    Pandemics can be categorized chronologically. Egyptian mummies have evidence of smallpox involvement and it is possible that trachoma caused a pandemic in prehistory. Excavations in China also suggest pandemics may date back to at least 1000 BC. The Bible (Old and New Testaments) mentions severe epidemics but without enough information to identify timing or cause.

    One of the earliest recorded pandemics (likely typhus) struck Athens during the Peloponnesian wars. Smallpox or possibly even bubonic plague may have been responsible for the Antoninie and Cytopian Roman involvement. Bubonic plague which likely originated in East Asia ravaged Europe in the early part of the second millennium.

    In 1609, Galileo Galilei applied his expertise in optics to also make use of the first practical microscope. The compound microscope was first developed in Holland by two Dutch spectacle-makers and father-and-son team, Hans and Zacharias Janssen first practical microscope in 1590. Scientist Anton van Leeuwenhoek used a microscope with one lens to observe insects and was first to observe bacteria. This permitted scientists and physicians to question the previous theories of etiology of disease. Leeuwenhoek detailed these achievements in almost 200 letters to the Royal Society in London where no less a person than Robert Hooke validated them. This work was based on a simple single lens, handheld microscope. The specimen was mounted on the top of the pointer, above which lay a convex lens attached to a metal holder. The specimen was then viewed through a hole on the other side of the microscope and was focused using a screw.

    Figure 1 - El Museo de las Momias, mummies of Guanajuato, buried in 1833 due to a cholera epidemic. 

    This challenged the more conventional view that God or before that, pagan Gods, were the antecedent cause of various pandemics. Earlier, the Greeks, based on the teachings of Hippocrates blamed an imbalance of humors in the body. Treatment thus included sweating, urinating, defecating, vomiting, and of course bleeding in an attempt to rebalance the humors. Later outside influences were felt to play a role. These theories were grouped together as “miasma.” Obviously, the leading example was malaria which was originally felt to be secondary to “bad air” hence its name.

    Leeuwenhoek, Louis Pasteur, Robert Koch, and others eventually persuaded scholars that bacteria were the responsible parties for infectious disease. Anthrax, tuberculosis, and cholera had agents that could be seen and perhaps controlled, if not yet by antibiotics, then at least by sanitation. Cholera became widespread in the 19th century, killing tens of millions of people. Between 1817 and 1824, the disease spread from the Indian subcontinent, particularly in Bengal, across India involving 10,000 British troops and thousands of Indians, extending as far as China and Indonesia. A recurrence of cholera occurred between 1826 and 1837 in Russia, Hungary, and Germany. In London, England and also the United States and Canada a severe outbreak of cholera occurred between 1819 and 1860.  It also claimed 200,000 lives in Mexico (figure 1).

    Between 1863 and 1875 there was spread involving Europe and Africa with particular emphasis on those attending the Haj to Mecca. An outbreak of cholera in 1856 killed some 50,000 Americans. Between 1883 and 1887 there were 250,000 deaths in Europe and at least 50,000 in the Americas. Later in Russia, a quarter of a million people died in 1892, 120,000 in Spain, 90,000 in Japan and 60,000 in Persia. The most recent cholera epidemic began in Indonesia, reached Bangladesh and India and the Soviet Union in 1966.

    Typhoid fever is caused by a gram-negative organism related to salmonella. Typhoid, like cholera, is spread by fecal contamination. The first identification of an individual spreading disease was Mary Mallon a cook from Ireland who infected several individuals in New York. She was effectively quarantined for over 23 years. Typhoid was one of the first bacterial organisms treated prophylactically; mandatory vaccination of troops by the British before the second Boer War (1899). Vaccination dramatically reduced the incidence of typhoid during World War I.

    In 1905, the U.S. Supreme Court considered and upheld mandatory vaccination for U.S. citizens. Mandatory vaccination for smallpox (a public health issue) for school attendance was upheld by the Supreme Court in 1922. With the last wild case of variola major (smallpox) in October 1975, the world was declared free of smallpox in May 1980.

    Vaccinating the poor of New York City against smallpox in 1872. In 1863, mass production of smallpox vaccine was developed, allowing for broad immunization of North American and European populations. 

    Typhus was the cause of another pandemic (caused by rickettsia), which was particularly prominent during times of warfare and was also known colloquially as “Camp Fever.” As mentioned before, typhus was the likely cause of many deaths in Athens during the Peloponnesian War. This disease would spread rapidly in cramped quarters such as ships. Typhus was first reported during the Crusades and had a major impact in Europe, in 1489 in Spain, and in Germany during the Thirty Years War between 1618 and 1648. Later, typhus would play a major role in Napoleon’s defeat in his invasion of Russia in 1812, where disease in combination with the cold killed many more Frenchman than did the Russians. It struck again during World War I when it killed more than 150,000 people in Serbia. In Russia, typhus killed approximately 3 million people 1822 -1918.

    Koch went on not only to discover the bacillus causing tuberculosis, but also on a trip to Egypt was able to isolate the cholera bacillus. This, coupled with information regarding the transmission near the Broad Street pump, established the cholera bacillus as the cause of cholera. Asiatic cholera was epidemic in India then became pandemic in Asia between 1816 and 1830s, spread to Russia, Northeast Germany, and by 1831 appeared in England. It was first recognized in Virginia, particularly in the Tidewater region, in 1832, presumably introduced through Quebec. Mycobacteria, including tuberculosis (TB) and leprosy, accounted for multiple episodes of pandemic, particularly in sub-Saharan Africa. It has been estimated that one quarter of the world’s population has been exposed or infected with TB.

    “So the final lesson of 1918, a simple one yet one most difficult to execute, is that those who occupy positions of authority must lessen the panic that can alienate all within a society. A society cannot function if it is every man for itself. Those in authority must retain the public’s trust,” said John M. Barry, author of “The Great Influenza.”

    After the discovery and colonization of the new world, the smallpox epidemic probably killed between 5 million and 8 million of the indigenous population that were not immune. This was first recognized in 1519. The smallpox epidemic that soon followed probably killed 56 million people in the Americas.

    The 20th century brought us the Spanish Flu of 1918 regarded as one of the worst (in terms of numbers of people who died) epidemics of all time. But that’s a story for the third part of our series.

    Read other parts of the series: