Lockdowns, closed borders, quarantine facilities, special laws enacted to control behaviour and spread of disease, health boards to manage the pandemic, infected citizens isolated in special facilities, people required to remain in their homes, health passes, protests, business interests lobbying to keep international trade moving, people fleeing cities to avoid disease and restrictions, punishment for those breaking the new laws – these are the hallmarks of the COVID-19 pandemic. Unique, extraordinary, controversial, never seen before? Actually, quite the contrary.
I’ve been doing a little ‘light reading’ over summer and have been struck by how cities and states responded to the plague in 14th, 15th, and 16th century Europe, and in 17th century Britain. Their strategies were remarkably similar – allowing for our vastly improved understanding of disease – to those being applied today.
Most of us will have heard of the Black Death, the bubonic plague that swept through Europe and the Mediterranean countries in the 14th century killing an estimated 20 million people within three years, and eventually wiping out close to a half of Europe’s population. The plague, believed to have originated on the steppes of Asia, ricocheted around Europe until the 18th century. Those familiar with English history will be aware of the Great Plague of 1665/66 that ravaged London and the surrounding countryside. Official records report close to100,000 deaths in London, the majority from the plague (68,596 deaths were recorded in the city, the true number was probably over 100,000) and an equal number of deaths in the countryside. The death rate peaked in September 1665 when 7,165 Londoners died in one week.
Records show that the Black Death first made its mark in continental Europe in the early 14th century. The horrific symptoms, rate of infection and consequent mortality imparted fear and prompted strong action.
Roy Porter’s compendium of medical history “The Greatest Benefit to Mankind”, published by Harper Collins in 1997, records that in Venice, “a committee of three nobles laid down burial regulations, banning the sick from entering the city and jailing intruders”, while in Milan “the council sealed in the occupants of infected houses and left them to die”. Porter notes that this draconian measure may have worked – Milan suffered only a 15% mortality rate – compared with much higher rates elsewhere. In Florence, “a committee of eight was given dictatorial powers” to manage the pestilence. Even so, by 1427 Florence’s population “had plummeted by 60 per cent from over 100,000 to 38,000”.
As Porter writes, certain routines became standard, “The committees appointed to co-ordinate public health began to remove the sick to former leper houses beyond the city limits…while also establishing a system of exclusion, banning persons or goods from entering or leaving. Such measures were adopted throughout Italy”.
Several cities introduced quarantine measures. In 1377, Ragusa (modern day Dubrovnik) instituted a thirty-day isolation period on a nearby island for anyone arriving from plague-affected regions. Marseille did the same in 1383 and Venice brought in quarantine restrictions in 1423. Pisa followed in 1464 and Genoa three years after.
Large social gatherings were often controlled, although that varied depending on attitudes towards secular versus religious matters. In 1469, despite the risks, civic authorities in Breschia allowed a religious procession to go ahead, hoping this might offer deliverance through divine intervention. Whereas the Venice Health Board “banned preaching, processions and feast-day assemblies” and, later, churches were locked.
Around 1410, Milan established a permanent magistracy ‘for the preservation of health’. The board’s role evolved and came to include a physician, surgeon, notary, barber and additionally two gravediggers. Doctors acted as advisors. Other Italian cities followed suit, “In 1486, Venice appointed a permanent Commission of Public Health”. Florence set up a similar body in 1527, Lucca in 1549. Milan introduced Bills of Mortality, listing names and causes of death. Porter writes that “Health Boards extended quarantines and the closing of borders, and health passes were introduced.”
In their 2004 book, The Great Plague –The Story of London’s Most Deadly Year, by historian A. Lloyd Moote and microbiologist Dorothy C. Moote, published by the Johns Hopkins University Press, the authors write that the “Italian city states of Venice, Genoa, Florence, and Milan set the standard of care for the rest of Europe”. Venice opened a hospital for poor plague victims in 1424 on an island. A half century later a “new hospital was added for ‘suspects’ who might carry the plague because of their contact with infected persons”. As the authors state, “The need was obvious: in principle, all infected houses were closed up and the entire household was sent to some other facility until the home could be fumigated and clothing and other suspect possessions burned”.
This practice was copied by most other northern Italian cities and new plague hospitals were under construction by the end of the 15th century. These city-states handled an extraordinary number of plague patients and mortalities. During the epidemic of 1575-77, Venice counted more than nineteen thousand deaths in hospital and some twenty-seven thousand deaths in homes or elsewhere. As the authors write, “This thriving Adriatic port may have lost 90,000 of an estimated population of 150,000 during its eighteen-month siege, an astounding 60 percent.”
England was slower off the mark in setting up national strategies, but it did establish Plague Orders for London and another set for the rest of the country. The country’s first line of defence against the plague was the quarantine of ships and passengers on vessels coming from infected foreign ports and then placing guards at a city’s gates. In the early 16th century, following Italy’s example, London officials began tracking plague deaths in weekly printed Bills of Mortality. This told officials and householders “where the infection had been spreading”.
A new wave of the plague flowed steadily north through Europe in the 17th century, and by the early 1660s, English officials were becoming nervous as the pestilence reached major ports along the Northern European and Baltic coasts, “vital sources of timber and cloth for England’s war fleet”.
Consequently, the authors of The Great Plague tell us, “by the end of 1663, the king’s council ordered all ships from Amsterdam to be detained at the mouth of the Thames for a thirty-day ‘triantine’”. Attempts by ships to foil the system by hiding their port of origin, travelling via a third port, were soon discovered and the king’s council strengthened the orders, including other ports and extending the period of detention to forty days, giving us the word quarantine, from the Italian quarantina.
By April 1665, the Bills of Mortality were recording ominous signs of the plague in several of London’s parishes. Action came swiftly. The chief justice of the Court of King’s Bench ordered all suspect houses to be inspected. If infected, “a residence was to be shut up, and everyone inside, whether well or sick, sealed off from the outside world. For forty days, counting from the time of the last plague death inside, a “watcher” would guard the house and a live-in nurse would care for the family’s needs, with medical supplies and food passed in through a window by a courier”.
The orders were not well received. Reaction was “swift and ugly”. A riot broke out, doors were ripped open and people from infected houses released into the streets. The king countered with orders that rioters should be apprehended and subjected to “the severest punishment”.
The following month, May, as fatalities became more publicly known, civic authorities (The Guildhall) were empowered to take action, and the mayor ordered “all householders and shopkeepers in the city… to clean the street in front of their places every day”. Londoners were, however, slow in complying and the mayor required each alderman to hand in “a weekly certificate of every person failing therein”. Those who failed to comply would face legal prosecution.
Dissenters took to the streets and handed out “subversive tracts”, in the words of physician Peter Barwick, “printed by noe body knows for whom nor by what”. As The Great Plague’s authors note, “The plague had kept alive the Puritan era’s millenarian hopes of a Second Coming of Jesus and the end of the world as it was known”. This led to fears by Restoration officials of the spectre of old revolutionaries turning the world upside down, and the response was a clamp-down on the protestors.
At times it felt as though the world was coming to an end, or at least that anarchy was breaking out. There was a mass exodus from London at the end of June 1665, as many as two hundred thousand fled the capital leaving the city largely occupied by the poor, city officials and those public health workers who chose to remain. There were increased health risks for women during childbirth, many died as a result, and for the poor. Far more poor people died than any other group. As the authors sombrely write: “There were more poor people than not, for one thing, but also their workplaces and homes were more likely to carry the infection, and, of course, they lacked the resources to gamble on flight that took many wealthier persons out of danger.”
In the country, “fear and suspicion of Londoners gripped townspeople”. Mounted guards watched over the four bridges of Oxford and “ports from Bristol to Newcastle turned ships away from the capital”.
Counting the financial and human costs loomed as the country moved into 1666 and the number of infections started to diminish. In January, the Mayor of London discharged the public physicians from further duty. Meanwhile compensation for surviving medical personnel and widows dragged on interminably and city fathers asked colleagues to determine if bills from several apothecaries were valid. The Great Plague recounts that Guildhall accounts for medical team and supplies, pesthouse and burial-ground construction and maintenance, and subsidies to needy parishes amounted to twelve thousand pounds. All up, the plague cost the city of London at least forty thousand pounds. As the authors summarise, “For a metropolitan area whose economy had come to a standstill and whose population was reduced by 20 percent by deaths plus perhaps 40 percent by flight, that financial outlay was impressive.”
All of which is a salutary reminder about the vital importance of what we can learn from history. Viewing and judging the world in the limited and limiting bubble of our personal experience is arrogant and self-defeating. To ignore the wisdom and experience of those who lived with lethal epidemics for centuries makes no sense. Looking back at how authorities and individuals responded to the Black Death, we can re-affirm and reassure ourselves that managing and, as far as possible, controlling the transmission of disease and the number of fatalities is critical and indeed the only humane path to follow; that some form of isolation is critical and inevitable; that having lay and medical officials work together to administer and implement established rules and regulations is fundamental; that the demand for health facilities will exceed availability and that calls to invest in more hospitals/clinics/isolation facilities should be heeded; that the poor and disadvantaged will be the worst affected and require the greatest efforts and that there will inevitably be dissenters, often loud and angry, albeit a minority; and finally, that successive waves of the pandemic are almost inevitable.