Protecting, Sustaining, and Empowering: A Historical Perspective on the Control of Epidemics

Protecting, Sustaining, and Empowering: A Historical Perspective on the Control of Epidemics

Christine E. Hallett


Does not the popular idea of “infection” involve that people should take greater care of themselves than of the patient? That, for instance, it is safer not to be too much with the patient, not to attend too much to his wants? Perhaps the best illustration of the utter absurdity of this view of duty in attending on “infectious” diseases is afforded by what was very recently the practice, if it is not so even now, in some of the European lazarets—in which the plague-patient used to be condemned to the horrors of filth, overcrowding, and want of ventilation, while the medical attendant was ordered to examine the patient’s tongue through an opera-glass and to toss him a lancet to open his abscess with! True nursing ignores infection, except to prevent it. Cleanliness and fresh air from open windows, with unremitting attention to the patient, are the only defense a true nurse either asks or needs. Wise and humane management of the patient is the best safeguard against infection (Nightingale, 1860/1980, pp. 23-24).

From its beginnings, the human race has shared its habitats with infective microparasites. Harmless—even beneficial—microbes inhabited our planet long before we emerged as a species. They began the long evolutionary process that would enable them to live alongside—often in parasitic or symbiotic relationships with—their neighbors before the antecedents of the human species had even emerged from the primeval ocean. Catalyzing vital processes, such as the decomposition of the planet’s toxic organic waste, microbes have long existed in a precarious, yet often positive, relationship with other organic life. Yet human beings notice their presence only when they fail to adapt quietly and harmlessly to the changing patterns of human life.

Of the many microparasites that inhabit our environment, it is the most inefficient—the least well adapted—that cause recognized infections. A “bug” that fails to live symbiotically with its host may expect to limit its own lifespan. If it kills its host, it will die. If it keeps the host alive yet in a weakened state, it can expect that its host will eventually find a way to eradicate it. The purpose of this chapter is to trace the means by which humans have attempted to eradicate certain of those “bugs” they consider harmful: the bacteria and viruses that cause epidemic and endemic infections. The chapter focuses on three case studies of specific diseases appearing at specific historical moments: bubonic plague, as it appeared in the early modern Italian city-states during the 16th and 17th centuries; “Spanish influenza” as it appeared in the cities of the United States in 1918 and 1919; and AIDS as it appeared in the United Kingdom during the 1980s.

The bubonic plague bacillus and the influenza virus caused epidemic diseases that affected such large sections of the world’s population that they came to be seen as “global epidemics” or, more correctly, as pandemics. HIV exists on the cusp between endemic and epidemic disease, affecting large numbers of people worldwide; it is often spoken of as an epidemic because of its capacity to spread rapidly in certain populations and geographical areas of the world at certain times.

Humans have taken a range of measures to protect themselves against or to destroy pathogenic microorganisms. Through its case studies, this chapter considers four different approaches to disease: state-sanctioned control measures, medical interventions, nursing care and support, and individual empowerment. It traces the means by which human societies, more or less effectively, learned to protect themselves against, overcome, and survive severe life-threatening infection on a large scale. It focuses, in particular, on how societies mobilized and used nurses as “front-line” agents in combating infection.

Protecting the People Against God’s Wrath: Bubonic Plague in Early Modern Italy

The Black Death—the second recorded pandemic of the disease known as “bubonic plague”—swept across Europe from Central
Asia between 1348 and 1353, causing millions of deaths and devastating entire villages (Alexander, 1980; Hirst, 1953; Preto, 1978; Slack, 1985; Zinsser, 1935). Caused by the bacterium later to be named Yersinia pestis, the disease was carried in the body of a particular species of flea known as Xenopsylla cheopis, which in turn inhabited a particular species of rat, Rattus rattus, also known as the black rat. It may seem extraordinary that a disease carried by one species of microbe in the bloodstream of one species of flea on the back of one species of rat could destroy so many communities, yet the lifestyle of the Middle Ages created an ideal ecological niche for these species. The black rat could live easily in the thatched roofs and grain stores of the largely agrarian communities of the 14th century, and the frequent overcrowding and lack of opportunities for good hygiene practices meant that flea and lice infestations were commonplace. Once the opening-up of trade routes to the East transported the plague to Western Europe, it rapidly gained a foothold there.

The first case study considers one small corner of the world two centuries after the plague caused its first great wave of devastation. The case-fatality rate of bubonic plague was probably around 30%, and its associated form, pneumonic plague, was even more lethal, with an 80% casefatality rate. Having burned itself out by killing a large proportion of its host population, the Black Death remained endemic in the European rodent population, literally hovering at the gates of the towns and cities of early modern Europe. At particular risk were the inhabitants of the Italian city-states such as Venice, Florence, Naples, and Rome that traded with the East, bringing within their borders goods likely to be infested with the black rat. Although they did not realize the disease was carried by rat fleas, the populations of these cities nevertheless recognized that it was somehow “imported” from outside. These states were the first to introduce systematic measures to protect their populations from plague (Christensen, 2003).

When confronted by plague, the magistrates of the city-states had three aims: to avoid allowing the disease to arise in or to enter the city; to prevent its spread; and to maintain social order while, as much as possible, caring for the sick. Health magistrates, known as “Provveditori alla Sanita,” appeared to have thought in terms of a complex relationship between plague and disorder. Plague was itself a form of physical disorder that could most easily arise in a disorderly environment that exuded disease-forming “miasmas” (or “pestilential” states of the air). Once plague had taken hold of a community, the relationship between the disease and social disorder was mutually reinforcing. The effect was perceived to be a spiral one in which the health—both physical and moral—of the community grew increasingly out of control. The work of the magistrates was to arrest this process. To properly coordinate their efforts during epidemics, the governments of Italian city-states appointed specialist Health Boards, known as “Sanita,” with wide-reaching powers, which became permanent in many Italian city-states during the course of the 1400s (Campbell, 1931; Carmichael, 1983, 1986; Palmer, 1978).

Arising from a disorder within nature, plague threatened to create chaos within the community. Italian sanitary legislation aimed to prevent such chaos. Many of the measures in force during the Renaissance were introduced by legislation of the early 13th century, which preceded even experience of the Black Death (Carmichael, 1986). There were numerous attempts to legislate for cleanliness within city-states. Unpleasant smells were believed to be particularly dangerous, because they were associated with noxious harmful vapors that composed the miasma. By the end of the
14th century, there was already legislation against the keeping of animals such as pigs and ducks in Florence and against the selling of manure inside the city (Carmichael, 1986). The health authorities came to regard it as their responsibility to control the release of offensive smells associated with industrial activities such as tanning, butchery, and the retting of hemp (Cipolla, 1992; Palmer, 1978).

In taking responsibility for the eradication of plague, the patriciates (nobilities) of early modern cities fulfilled their roles as guardians of order and protectors of the state. King (1986) has identified the main preoccupations of Venetian patricians as evident in their humanistic writings. Noblemen such as Gasparo Contarini, Daniele Barbaro, Paolo Paruta, and Nicolo Contarini promoted the myth of a Venetian republic that was ordered and harmonious and in which the nobility conformed to the principle of “unanimitas.” The Venetian patriciate presented itself as the personification of order within the state. Furthermore, its members also saw themselves as the state’s defense—as “moenia civitatis,” or the “walls of the city” (King, 1986; Pastore, 1988; Ulvioni, 1989). The Italian Health Boards were the most effective and efficient organizations for controlling plague in Western Europe, and their measures became models for the establishment of health controls in other states (Cipolla, 1979, 1992).

Calvi (1989) examined the efforts of magistrates to maintain stability in Florence during the epidemic of 1630-1631. Through a close examination of the criminal trial records of the Health Magistracy and a reading of Francesco Rondinelli’s contemporary account of the plague, she discovered that the regulations imposed during the “virtual dictatorship” of the public health officials reflected the desire for order and uniformity. Most of the 300 trials she examined dealt with violations against property, crimes committed by public health workers, and the unlawful hiding of the ill (Calvi, 1989).

It had been recognized since the Black Death that some diseases could be transmitted between individuals (Biraben, 1975; Campbell, 1931). An idea of contagion was part of the general stock of knowledge in early modern Europe. In Thomas More’s Utopia (1516), the hospitals were situated outside the town so that people with diseases “such as be wont by infection to creep from one to another” (p. 35) might be separated from the rest of the population (Ficino, 1989). However, a theory of contagion was not articulated effectively until the mid-16th century, when it formed the basis of a work by Girolamo Fracastoro (1930). His De Contagione et Contagiosis Morbis et Eorum Curatione, Libri III, first published in Venice in 1546, has interested historians because its theories bear some superficial resemblance to a germ theory of disease (Fracastoro, 1930; Nutton, 1990).

Fracastoro emphasized that where plague was concerned, the most frequent means of transmission was contagion between individuals. He distinguished between diseases that were merely common to communities and those that were also contagious (Fracastoro, 1930). The dominant theme in his work was the idea that plague was caused by invasion. It could be passed on from person to person rather than simply arising spontaneously from a disordered environment. It could also be carried in fomites—porous objects such as cloth and wood—and thus be transported between one community and the next. These ideas had immense influence in the Italian city-states, where plague came to be seen as an invading force against which siege measures must be adopted.

During the early modern period, as plague came to be identified more as an invasion from outside the state, measures taken by city-state
magistrates to preserve order were increasingly reinforced by a range of defensive strategies; many of these plans were already quite old, dating from the time of the Black Death, but all appear to have been imposed with increasing rigor and determination during the 16th and 17th centuries. In the late 1500s, Gasparo Contarini (1599) commented on the work of the Provveditore alla Sanita, the city’s health magistrate:

His chiefest office is to forsee that there come not into the citie an contagious infection, which if at any time it happen to creepe in (as sometimes it chanceth) then to take such diligent and carefull order that in as much as maybe the same come not to spread any further. (np)

Throughout the early modern period, when it became known to its neighbors that a state was affected by plague, it was usual for commerce with that state to be banned. This meant the cessation of all forms of communication, including trade, with the plague-infested region, against whose inhabitants the frontiers were closely guarded (Carmichael, 1983). Banning was controlled by means of a system of health passes that permitted only those who were well or who came from healthy areas to enter a territory. Passes were introduced by Milan during the 15th century and were then used by other states in the first half of the 16th century (Brozzi, 1982; Cipolla, 1973, 1979; Modena, 1988; Palmer, 1978; Petraccone, 1978). Centorio degli Hortensii (1631) described a series of measures introduced by the health deputies of Modena during the plague of 1575-1577: “Besides unpaid officials at the gates, paid officials will be posted at the pass of the Fossa Alta, at the pass of the Marzoia at the high bridge and the low bridge… at Buon Porto, on the bank of the River Secchia, at San Marino, on the border with Mirandola” (p. 17). They added that guards at these posts must be able to read and write and must be in possession of an official seal to stamp the passes of those allowed through (Hortensii, 1631). The defensive nature of these measures is striking: They illustrate the extent to which plague came to be associated with invasion.

All ships coming to the early modern state from any area suspected of plague were made to undergo quarantine. Crew members were not permitted to enter the city or unload goods during the quarantine period, which usually lasted 40 days. This measure was originally designed to provide an early warning system for diseases on ships but became one of the most enduring measures against contagion (Campbell, 1931; Carmichael, 1983; Palmer, 1978). It also became a measure for isolating entire communities of people: During a general quarantine, only doctors and members of the government were allowed to leave their homes (Petraccone, 1978; Ulvioni, 1989).

When plague was diagnosed in an Italian city-state, the victims were quickly segregated from the rest of the population. The sick were examined, and persons discovered to be suffering from the plague were taken to the “lazzaretto,” or “pest house.” The Lazzaretto Vecchio of Venice, founded by decree of the Senate on August 28, 1423, was the first permanent pest house in Europe (Campbell, 1931; Palmer, 1978). It was situated about two miles from the city on a small island off the Lido that had previously been the home of the Eremite Monastery of Santa Maria di Nazareth (Chambers & Pullan, 1992). A decree of the Venetian Senate on April 17, 1464, provided for “two suitable and competent citizens not of noble rank” (Chambers & Pullan, 1992, p. 114) to be appointed for each sestiere of the city to ensure that all infected persons were taken to the Lazzaretto Vecchio and all infected houses evacuated. The notary, Rocco Benedetti, described the horrors of the Venetian
Lazzaretto Vecchio, which seemed to him like “Hell itself” (Chambers & Pullan, 1992):

From every side their came foul odors, indeed a stench that none could endure; groans and sighs were heard without ceasing; and at all hours, clouds of smoke from the burning of corpses was seen to rise far into the air. Some who miraculously returned from that place alive reported, among other things, that at the height of that great influx of infected people there were three or four of them to a bed. Since a great number of servants had died and there was no one to take care of them, they had to get themselves up to take food and attend to other things. Nobody did anything but lift the dead from the beds and throw them into the pits… . And many, driven to frenzy by the disease, especially at night, leapt from their beds, and, shouting with fearful voices of damned souls, went here and there, colliding with one another, and suddenly falling to the ground dead. Some who rushed in frenzy out of the wards threw themselves into the water, or ran madly through the gardens, and were then found dead among the thornbushes, all covered with blood. (pp. 118-119)

A sufferer who died at the pest house was buried there or in a cemetery apart from the city. Survivors were usually sent to a convalescent hospital to undergo a 40-day quarantine before being returned home (Chambers & Pullan, 1992). The lazzaretti were also centers for the disinfection of fomites. In the Venetian lazzaretti, goods from infected homes and ships were aired for 40 days and, during that time, were constantly turned and moved to release any infection they might have absorbed (Brozzi, 1982; Castellacci, 1897; Pastore, 1988).

The monitoring and control of the poor were closely associated with the prevention of plague: It was a means of propitiating God, a measure for promoting order, and a defensive strategy. Indeed, the development of organized systems of poor relief was probably stimulated by the experience of plague, a disease associated with poverty at an early stage in its history (Preto, 1978; Pullan, 1971, 1992). Governments and physicians observed that the poor were affected in greater numbers than the rich. Theorists devised explanations for this pattern: The poor lived disorderly lives, their inadequate diets were a source of corruption that could spread through the community, and they did not dispose of waste properly and hence lived among filth that might create a poisonous miasma (Anselment, 1989; Biraben, 1975; Carmichael, 1986; Grell, 1990).

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