Can the history of epidemics help us to better understand the coronavirus pandemic? What have we done wrong in the past and which mistakes should we never make again? How has Covid-19 changed our relationship with death? To answer these and other questions, I spoke at length with Frank Snowden, an expert on the history of epidemics and medicine and a Professor Emeritus at Yale University, who is living in Italy for the time being.
Emergency circumstances like this pandemic have, in some cases, shifted the war on the virus to a war on democracy. Emergency circumstances are, in fact, in some instances, being exploited by some to allow an extension of state powers and a control over the economy and, in extreme cases, downright sweeping powers and the rise of authoritarian regimes like in Hungary for example. Has this happened in the past? Have epidemics “legitimized” authoritarianism?
Pandemics do have the possibility of strengthening authoritarianism, you’re absolutely right. What’s happening with Viktor Orbán in Hungary but also in Poland, are two very clear examples of the way in which the pandemic is a cover and a legitimation for far right authoritarian steps to destroy democracy and institute nationalist, pseudo populist governance. So that is a danger.
Sometimes we think that perhaps this is a law of authoritarianism, that it is always experienced as a military emergency and we have seen that’s part of the way these leaders are behaving: saying this is an emergency and we have no alternative to authoritarian measures. On the other hand, this is not an inevitable process. It is a contingency. If you look at the last great pandemic, Spanish influenza in 1918, we saw many measures put in place, like no assemblies, a sort of precursor of lockdown, no demonstrations or parades, and citizens had to be monitored by the state. And yet at that time, I don’t think anyone would have said that they were permanent and they were rescinded. And you wouldn’t say, for example, that the result of the Spanish influenza was a dictatorship. On the other hand, in Eastern Europe, cholera in the 1830s saw the imposition of almost medieval draconian measures that were clampdowns. And that was something that was lasting.
So I do believe that it is possible for authoritarians to exploit these possibilities created by pandemic diseases. But it is worth always remembering that this is not a law of the history of pandemics. The effect can also be the opposite. We can remember that the end of plantation slavery in a modern Haiti, for example, was promoted by the destruction of Napoleon’s Armada through yellow fever. And that was a major impact that was a liberating one: the first black Republic free, the first major slave rebellion in history, in part rooted in differential mortality and immunity between Europeans and African descendants: Napoleon’s troops and Europeans had no herd immunity to yellow fever, whereas the African slaves did.
So I would say liberty can also be promoted by pandemic disease. So what happens this time I think is a matter of choice. The future isn’t predetermined. How vigilant and how responsive citizens are, will make a huge, decisive difference.
So dealing with a pandemic doesn’t necessarily entail authoritarianism, correct?
Right. There are many people who raised the issue of whether dealing with pandemic disease necessitates authoritarianism and that democracies are no good in dealing with pandemics. I would say that democracies are better able to enlist popular support and institute rational public health policies because they allow free information to flow, and modern public health actually depends on free information.
I’m hopeful that measures such as those applied in South Korea actually represent a model of what a democratic governance — or mostly democratic governance, I’m not trying to boost South Korea, but I’m just saying it is an elected governance — can do even without emergency powers: practicing accurate diagnostic testing, social distancing, quarantine and contact tracing. Those are the essential components of what needs to be done at this moment. We have no other weapons; there is no vaccine, no treatment. I don’t think the idea that we need a dictator to deal with the crisis is actually true.
In an interview with The New Yorker, you said that, “epidemics are a category of disease that hold up the mirror to human beings as to who we really are.” This concept stayed with me. And then you also said that they reflect our relationships with the environment, both built and natural. Is this true for the coronavirus pandemic as well? Are epidemics a mirror of human vulnerability?
I believe that this is emphatically true of the coronavirus; this is the first great epidemic disease of globalization. And I believe that all societies create their own vulnerabilities.
Let me make a contrast with another disease that was the most feared of its century: cholera in the 19th century. That was a disease of a different era. It was a disease of industrialization and therefore rampant urbanization — that is the built environment, which was catastrophically built because there were teams of people streaming into major cities across the industrial world without any sanitary or housing preparation. In cities like Naples or Paris there were teaming slums with people — nine or 10 people to a small room — who lived with no sanitary arrangements in terms of sewage or safe water. And therefore a disease that was transmitted by the oral-fecal route adapted to that environment and took full advantage of it. Typhoid, and Asiatic cholera, I would argue, are tuned diseases of industrializing conditions and hold up a mirror in that way to globalization.
With coronavirus, there are at least three dimensions that are reflected in this disease that are critical to who we are as a civilization. The first is that we are now becoming nearly 8 billion people worldwide. We also have this myth in our minds that you can have infinite economic growth and development even though the resources of the planet are finite, which seems like an inherent contradiction. And yet we built our society on that myth thinking somehow they can be reconciled. So there’s a problem. In addition, this transforms our relationship with the environment and particularly with animal habitat. We have waged a war against our own environment. We are destroying animal habitat. This is the era of species eradication.
What happens is that human beings come into contact with animals, with a frequency and in ways that never happened in the past. And we can now point to what are the kinds of diseases that illustrate that: avian flu by definition, and so do MERS and SARS and ebola. And now we have coronavirus. I would say that this pattern is not accidental. It means that we are living in an age of a repeated spillover from animal reservoirs of disease. And particularly it seems we’re very vulnerable to those viruses for which bats are a natural reservoir.
Another feature of globalization is that we have now created a world of mega cities, and they’re all connected by rapid air transportation, meaning that a spillover that happens, let us pick a place, in Jakarta in the morning… that same microbe would be present in Los Angeles and London in the evening. So I would say that the coronavirus is exploiting channels of vulnerability that we as a world have created. And therefore, I would say it is the quintessential epidemic of a globalized society. Globalization means destruction of the environment, this myth of infinite economic growth, huge demographic growth, huge cities and rapid air transportation, linking them all together.
What about the pandemic in developing countries? What does the mirror show us?
This is a great worry of mine. The director general of the World Health Organization was asked, “What keeps you awake at night in this crisis?” And he said, “What keeps me awake is what might happen if this virus makes its way into the under-resourced nations of the world where I don’t know the unimaginable havoc it could create.”
And I’m worried now that as we’re speaking it is beginning to prosper in a number of countries in Africa, Latin America and in Asia. And I also fear it could cause unimaginable suffering in those areas. Social distancing and washing your hands are the basis of the response. Certainly here in Italy that is exactly what people are called upon to do. But what does that mean in, let us say, a favela in Rio de Janeiro or in a township in South Africa where you have 10 people living in a room? In a teaming apartment building social distancing is a mockery. What about those places with no sanitary facilities? Washing your hands means nothing.
And so I want to outline what I think is another vulnerability that our society of globalization reflects: global inequality. Even in a wealthy country like the United States this disease can afflict everyone, but preferentially and disproportionately it will affect the poor, the most vulnerable people in that country. We’re going to see the truth: this really is an era of globalization and what affects the weakest among us affects everyone everywhere. So I think that is one of the reflections that we’re about to see in this mirror. And it’s not a beautiful one.
It is clear that we’ve made mistakes. Will we keep making the same mistakes?
The worry now is that when this passes we will do nothing, except settle into amnesia. The hope is that, instead, we will realize that we are profoundly vulnerable, that it is inevitable that other microbial challenges at least as dire as this will recur.
Every environmentalist can tell you now that this is an inevitability because of the relationships we’ve created with nature: the spillover is going to recur and recur. Donald Trump raised the most poignant, disturbing question about this epidemic, and that was “Who could have known?” and I would say that everyone should have known. Since 1997, with the avian flu, epidemiologists have said that the great challenge the world faces is the challenge of pulmonary viruses. We are more vulnerable to them and we must prepare. We were caught totally unprepared for ebola.
Anthony Fauci testified to the American Congress in 2005. He said that if you talk to someone who lives in the Caribbean, you can tell that person that climate science predicts that hurricanes will inevitably strike the Caribbean and that it is central to be prepared for them. Science cannot tell when they will strike or how strong they will be, but they are coming and there is no escape from that. Similarly, he said we tell the world that a major viral pandemic, particularly a pulmonary pandemic, is coming. They can’t tell you when or how strong it will be, whether it will be worse than the Spanish influenza or weaker, but it’s inevitable that it will happen. And therefore we must prepare or we’ll have a pandemic.
Well, we didn’t prepare. And I don’t want to say that only the United States did not prepare, although it clearly did not. We can also talk about other countries. Italy is not free of this charge. The years before this pandemic are characterized by cuts to scientific research and to spending on the healthcare system. Mercifully, Italy has a public health and hospital system that is among the best in the world. Although here is the point: they lacked any search capacity and any supplies or protective equipment for healthcare workers.
However, the United States is going to suffer even more because it does not have what Italy has, which is a healthcare system available to all. One of the essential ways for the future to prepare is to ensure that everyone on the planet has access to free medical care, because if anyone falls ill to a pulmonary virus, it will affect everyone in the world. And so if anyone is to be safe, everyone has to be covered.
In your book Epidemics and Society (Yale University Press) you bring the example of the Sardinian success of eradication of malaria in the early 1900 to illustrate the importance of international assistance, which in that instance involved the United States. So to survive the challenge of an epidemic, must humanity adapt an internationalist perspective? I think there is a lesson here. What do you think?
Absolutely. I think that one of the things that is most worrying in this epidemic is the pseudo idea that the Trumpian wall might become the metaphor that lasts to describe the era that we’re living in, while we put our faith in walls and national boundaries and barriers to “protect” us. This directs resources away from the real measures that must be taken and one thing that we know is that microbes have zero respect for national borders and political boundaries and therefore those measures aren’t going to work. I do believe that there was some measure in the travel bands that were put in place on a temporary basis. The hope was that the countries that had a travel ban in place would gain a few weeks in which to prepare. Now, many countries squandered that time, they put the bans in place and then they did nothing. My own country, the United States, is a wonderful example of wasting all that time.
One of the really sad features of the European Union is that it was unable to develop and adopt preparedness plans that it could put in place as a unit, as a regional response to the disease. And therefore each country of the Union took measures without any coordination and the public was left confused not knowing which approach was better. And that is an environment in which mythologies and paranoia and conspiracies flourish. An epidemic of misinformation actually fueled the biological pandemic and helped it move forward.
During the third plague pandemic in China there was a tendency toward racism and the conviction that the epidemic would not go beyond Chinese borders, the conviction of “white immunity.” I can see this dynamic as recurring and present also at the beginning of the coronavirus epidemic in China, when the virus was limited to the Chinese territory. Do you think this is one of the elements that caused the West to underestimate the risk linked to this epidemic? A sort of psychological fallacy, the illusion that the coronavirus epidemic would not spread outside of China, that it wouldn’t affect the West?
I do absolutely think that’s true and you’ve said that in the way that I would have wanted to say — you mentioned the third plague pandemic and that idea was not confined in any way to China. It moved on with it as it spread. We saw this in India and also in a few places in the industrial world such as San Francisco where the third pandemic of plague in the early 20th century saw rampant xenophobia — it was the disease of Chinatown. So this idea of the third pandemic of plague as being characterized by an upsurge of xenophobia is absolutely true.
So where does that leave us? There is an unwillingness of so many political leaders to learn the lessons of the past. I was stunned that the Republican Party insisted on calling this virus the Chinese virus, turning to xenophobia as a way of dealing with this crisis. And I believe that’s done knowingly. I say all that because this is a perennial temptation, that has been part of many epidemics, that authorities have often concealed the presence of diseases because they can make governance difficult. They can make great difficulties in the economy and one can see there was a tendency at the start of this pandemic by president Trump to say, “Oh, this is nothing more than the common cold.” He took the wrong response. And public health depends on truth.
Which would have been the right response?
I don’t have a blueprint for preparedness, but I do have certain principles that I think are essential and underpin modern scientific public health. And that’s not me. That is the international scientific community. So public health as a scientific discipline depends on science, which is dependent on truth and the free exchange of information. That is to say no policy that is going to be effective and scientific can be taken where there isn’t proper information and where the public is not enlisted as part of that response. We know that lying to the public is destructive of public health policy. And I believe that medical science is an essential part of our protection against this disease.
I can’t tell you everything that Donald Trump should have done, but I can tell you that when he lied to the public he was taking a step that was profoundly at odds with the sound scientific defense of the country and the world against this pandemic. But I think no one would wish to study the history of pandemics — as I have been doing for 40 years — if the only thing that could be said at the end of that work is that it’s all about doom and destruction, that there is no hope. I think that I would be deranged by now. I think that epidemics, as I said, are a mirror of ourselves but they aren’t only the negative side of human nature, they’re also the positive side. And we can see that in the form of the emergence of public health, we can see that in the self-sacrifice of doctors and medical workers and frontline workers who are enabling us to survive this challenge. There is a lot to be grateful for. Public health has evolved since the bubonic plague, as you well know. The measures devised in Florence and Venice during the Renaissance were the start of public health. And we’re still doing some of the same things.
In certain cases, like for example with smallpox, if you get the disease and survive, your system becomes immune to that disease. Now, it seems that with Covid-19 there is no scientific certainty of immunity yet. If surviving the disease would not necessarily end up giving you a natural immunity to it, would this consequently mean that it is more complicated to develop a vaccine?
Yes, the argument that one is susceptible after recovering from the disease still needs to be demonstrated and investigated. If it is true, that does have profound implications. One of the features that made it easier to develop a vaccine against smallpox was that what needed to be done was to encourage the body to do something that nature already did, which was to create an immune response that we know already existed. Another feature of smallpox eradication was that there was no animal reservoir host. And so if you were to end the transmission of the disease, you could be certain it wasn’t coming back by spillover. Now, coronavirus is very different from that.
But also there’s another feature, and this takes us back to investigating the immune systems of bats. There’s a negative and a positive. The positive is that bats live very happily with lots and lots of coronaviruses that we haven’t even classified yet. They’re entirely unknown. And if one could uncover the secret to their immune system that makes that possible, that could potentially have profound implications for developing human immunity to the same virus. The negative, though, is that there are all of these coronaviruses and we’ve only encountered very few of them and no one has any idea of what is to come. And that is another feature that is worrying about a zoonotic spillover, which is what this began as.
Another consequence of this pandemic concerns the economy. Is there a way to protect the economy in situations like this pandemic? Or is it an automatic consequence that once these pandemics reach the crisis point, then economies will suffer greatly because of it?
What I can say is I don’t have a model for what a post coronavirus economy should look like, but I have a few premises that, it seems to me, such an economy should be based on. The first is recognition that this is a game-changer, that the world will not be the same after this event because it’s already clear that its economic consequences are much more profound than anyone anticipated. Many of the workspaces or jobs that existed are not going to come back and this means large-scale unemployment that will need to be addressed and it also means that the economy cannot just go back to business as usual. Einstein said that one of the marks of stupidity was the tendency to keep doing the same thing and hope for a better outcome. We need to put aside the myth of a constant, short-term profit, a frenetic permanent vision of growth that is not sustainable.
Diseases don’t afflict societies in chaotic ways, they’re ordered events — you say this in your book. So because they’re ordered events, can we use this to our advantage?
Diseases don’t affect societies randomly, but they do involve contingency. I don’t mean that they are totally structured, but they follow an inherent logic. The setting is very important. So if I’m right in saying that diseases exploit these established, visibly evident channels, or pathways, as they spread around the world — that does have a positive side. Because if we accept the fact that we ourselves are responsible, we look in the mirror and recognize that we ourselves created those pathways, those vulnerabilities, and we built them into our societies, this means that we ourselves can also change them and that we can alter the relationship we are in the midst of establishing with the animal kingdom. We can do something about it and that will protect the planet and it will also protect our health. Some colleagues argue that if we could fix our relationship with the animal kingdom, it would have a lasting, sustainable impact on our vulnerability to infectious disease. There’s a very important environmental component to the solution to our problem.
My next question is on a very different level. It was true with plague and unfortunately it remains true for Covid-19 that people end up dying alone, sometimes even without proper burial or the possibility of a funeral. How have epidemics shaped our relationship to mortality?
As you said, this is a question on a different level. This is a philosophical, moral, anthropological question and I have to say that it could be a research project on its own that I think is enormously interesting and important. And so I’ll say immediately that I wish I could answer your question, but I know that I’m just about to disappoint you. All I can do is to reinforce your question by saying that it is true that this is one of the features of bubonic plague and people worried enormously about their mortality. And in particular, it raised the question of sudden death. And that means facing the question, if you are religious, of what is your relationship with a God who would be omniscient, all-powerful and yet would allow the slaughter of his children. I think that did pose the question of faith and doubting faith. In the plague paintings, in the iconography, which is all about this, we see the skull and crossbones, the reality of our existence is actually death, or the hourglass with the sands running out, which represents the time of death. So yes, there’s every reason to say that that is a very profound and important question.
I think this question may also have a social dimension to it. This epidemic has brought the concept of death into our lives in a way that was not present before. When I say “our lives,” I’m obviously talking about the West. Our societies have had to do less and less with mortality and death, compared to the previous decades. And of course this is absolutely not true for many regions of the world that are plagued by war, conflict, famine and climate catastrophes. But in a way our “societies of comfort” have brought us further away from death. So I think part of the reason why I asked this question was because in Italy we are now talking about death a lot in a way we are not used to doing, at all.
Yes. I was very saddened by the death of the great historian of death, French historian Philippe Ariès, as he wrote about the very issues you’re talking about. How interesting it would have been had he been able to reflect on what we’re going through now in the light of the past. I remember an essay he wrote I think it was called, the Pornography of Death. His reflection was to make pornography a metaphor because when the Victorian morality crashed sexuality underground so that it could not find, shall we say, normal healthy channels, it wasn’t going to go away, but it exploded in pornographic ways that are unhealthy. He argued that if one takes that as a model, the same is true about mortality and death and that what we have done in the modern world is to suppress death so that we never face it — in the same way the Victorians never actually faced their sexuality. And the result of that is that we don’t know how to grieve. Death takes place in some institution and the institution tidies it up and takes care of it. It’s the death industry. Death is no longer personal. But if there’s a profession of death that tidies it, we don’t really confront the reality of it and what it means. I believe it profoundly, that Ariès is right. But I can’t replace Ariès. And I can tell you that this has convinced me that your question is vital. And I wish I had a better answer for you.
I know it is impossible to make an actual prediction of how long the pandemic will all go on for, but I’m wondering if history can help us, in this sense, to have an idea in terms of timing and what awaits us in the coming months.
I see the importance of your question, and at the same time I realize that I can’t make a prediction with any accuracy. That is a crucial point to make because this is a new disease that has been known to humans only since December. As a result, no one yet knows a great deal about it, and one of its mysteries is still the length of time it is likely to besiege a community.
Clearly, at one extreme it is not like the Spanish influence that passed through localities in just a matter of weeks; and at the other extreme it is unlikely to remain in a city for years as bubonic plague sometimes did. For that reason the future is very complex. It is not clear, for example, whether Covid-19 will become an endemic disease that is with us for a long time; whether it will rebound once communities emerge from the lockdown and go back to work and to a more normal life; and whether those who were infected will have immunity.
I guess that the danger of a rebound will prevent the authorities from allowing life to return to some version of “normal” for months. I suspect that the pace of change will be cautious, as it will be necessary to see whether such a progressive loosening of the rules is followed by a new wave of the disease. I believe that the return to “normal” will therefore be slow and gradual, and that some changes are likely to be long-lasting, at least until there is an effective vaccine, which would be a “game-changer.” This is not a prediction, but a guess.
My main point is that I think that everyone needs to be aware that this pandemic is a very serious matter and that the recovery from it will not occur suddenly, all at once, or very soon. It is also realistic to imagine that some of the changes in our lives will last for a longer period.
