The NEW ENGLA ND JOURNAL of MEDICINE

Perspective 

History in a Crisis — Lessons for Covid-19

David S. Jones, M.D., Ph.D.​​

W
History in a Crisis — Lessons for Covid-19
riting in the heady days of new antibiotics ond act, in which people demand
and immunizations, esteemed microbiolo- and offer explanations, both mech-
anistic and moral. Explanations,
gists Macfarlane Burnet and David White in turn, generate public respons-
predicted in 1972 that “the most likely forecast es. These can make the third act
as dramatic and disruptive as the
about the future of infectious dis- why something happened, you disease itself.
eases is that it will be very dull.”1 must attend to local circumstanc- Epidemics eventually resolve,
They acknowledged that there es. But there is something about whether succumbing to societal
was always a risk of “some wholly epidemics that has elicited an op- action or having exhausted the
unexpected emergence of a new posite reaction from historians: a supply of susceptible victims. As
and dangerous infectious disease, desire to identify universal truths Rosenberg put it, “Epidemics start
but nothing of the sort has marked about how societies respond to at a moment in time, proceed on
the last fifty years.” Epidemics, it contagious disease. a stage limited in space and dura-
seemed, were of interest only to Charles Rosenberg, for in- tion, follow a plot line of increas-
historians. stance, found inspiration in Albert ing revelatory tension, move to a
Times have changed. From her- Camus’s La Peste and crafted an crisis of individual and collective
pes and legionnaires’ disease in account of the archetypal struc- character, then drift toward clo-
the 1970s, to AIDS, Ebola, the se- ture of an outbreak.2 Epidemics sure.” This drama is now play-
vere acute respiratory syndrome unfold as social dramas in three ing out with Covid-19, first in
(SARS), and now Covid-19, conta- acts, according to Rosenberg. The China and then in many coun-
gious diseases continue to threat- earliest signs are subtle. Whether tries worldwide.
en and disrupt human popula- influenced by a desire for self- But historians have not limited
tions. Historians, who never lost reassurance or a need to protect themselves to description. Rosen-
interest in epidemics, have much economic interests, citizens ignore berg argued that epidemics put
to offer. clues that something is awry un- pressure on the societies they
When asked to explain past til the acceleration of illness and strike. This strain makes visible
events, historians are quick to deaths forces reluctant acknowl- latent structures that might not
assert the importance of context. edgment. otherwise be evident. As a result,
If you want to understand how or Recognition launches the sec- epidemics provide a sampling de-

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PERS PE C T IV E History in a Crisis — Lessons for Covid-19

therapy in 1996 dramatically re-

duced AIDS-related mortality, it
did not end it. Striking disparities
in AIDS outcomes persist, follow-
ing familiar lines of race, class,
and gender. As historian Allan
Brandt famously concluded, “the
promise of the magic bullet has
never been fulfilled.”3
Given what historians have
learned about past epidemics, it’s
hard not to be jaded now. This
particular coronavirus may be new,
but we have seen it all before. A
novel pathogen emerged in China?
That’s no surprise: China has
given rise to many past pandem-
ics. People were slow to recog-
nize the threat? That dynamic is
An Emergency Hospital in Brookline, Massachusetts, Where Patients Were Cared for what Camus described so well.
during the 1918 Influenza Epidemic Officials tried to suppress early
From the National Archives. warnings? Of course. Governments
have reacted with authoritarian
vice for social analysis. They re- to achieve success. In 1900, health interventions? They often do —
veal what really matters to a pop- officials in San Francisco strung though the scale of China’s inter-
ulation and whom they truly value. a rope around Chinatown in an ventions may be unprecedented.
One dramatic aspect of epi- attempt to contain an outbreak of A quarantine fails to contain the
demic response is the desire to bubonic plague; only white people pathogen? That has happened
assign responsibility. From Jews (and presumably rats) were al- more often than not, especially
in medieval Europe to meat mon- lowed to enter or leave the neigh- with pathogens like influenza vi-
gers in Chinese markets, someone borhood. This intervention did rus and SARS-CoV-2 that render
is always blamed. This discourse not have the desired effect. people contagious before they’re
of blame exploits existing social Syphilis, one of the great symptomatic. This does not mean
divisions of religion, race, ethnic- scourges of the early 20th century, that interventions are futile. When
ity, class, or gender identity. Gov- could have been ended, in theory, influenza struck the United States
ernments then respond by deploy- had everyone adhered to a strict in 1918, different cities respond-
ing their authority, with quarantine regimen of abstinence or monog- ed in different ways. Some were
or compulsory vaccination, for in- amy. But as one U.S. Army medi- able to learn from the mistakes
stance. This step generally involves cal officer complained in 1943, of those that had been hit first.
people with power and privilege “The sex act cannot be made un- Cities that implemented stringent
imposing interventions on people popular.”3 When penicillin became controls, including school closures,
without power or privilege, a dy- available, syphilis could have been bans on public gathering, and
namic that fuels social conflict. eradicated more easily, but some other forms of isolation or quar-
Another recurring theme in doctors cautioned against its use antine, slowed the course of the
historical analyses of epidemics for fear that it would remove the epidemic and reduced total mor-
is that medical and public health penalty from promiscuity. The tality.4 China’s aggressive response
interventions often fail to live up human immunodeficiency virus may have delayed the global spread
to their promise. The technology (HIV) could, in theory, have of the current outbreak.
needed to eradicate smallpox — been contained in the 1980s, but Two familiar aspects of the re-
vaccination — was described in it wasn’t — and though the ad- sponse to epidemics are especially
1798, but it took nearly 180 years vent of effective antiretroviral disheartening. First, stigmatiza-

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PE R S PE C T IV E History in a Crisis — Lessons for Covid-19

tion follows closely on the heels animal contact, urban crowding, the United States in 1976 in the
of every pathogen. Anti-Chinese global travel, and populations midst of a presidential campaign.
hostility has been a recurrent stressed by growing social in- Gerald Ford reacted aggressively
problem, whether with plague in equality? Given the historical rar- and endorsed mass immunization.
San Francisco in 1900, SARS in ity of catastrophic epidemics, such When people fell ill or died after
2003, or Covid-19 today. Second, a perfect storm must be unlikely. receiving the vaccine, and when
epidemics too often claim the But it is, regrettably, a possibility. the feared pandemic never mate-
lives of health care providers. Phy- History suggests that we are rialized, Ford’s plan backfired and
sicians died during plague out- actually at much greater risk of may have contributed to his defeat
breaks in medieval Europe, dur- exaggerated fears and misplaced that November. When AIDS struck
ing a yellow fever outbreak in priorities. There are many histori- in 1981, Ronald Reagan ignored
Philadelphia in 1793, during the cal examples of panic about epi- the epidemic throughout his en-
Ebola epidemic in 2014, and in demics that never materialized tire first term. Yet he won reelec-
China now. Though such mortality (e.g., H1N1 influenza in 1976, tion in a landslide. The current
reflects the willingness of health 2006, and 2009). There are count- administration, thankfully, has
professionals to put themselves at less other examples of societies not followed Reagan’s lead. Will
risk to care for others, it can also worrying about a small threat it succeed where Ford went awry?
indict governments that ask cli- (e.g., the risk of Ebola spreading Initial assessments of the U.S.
nicians to confront outbreaks in the United States in 2014) government’s response have been
without the “staff, stuff, space, while ignoring much larger ones mixed. The history of epidemics
and systems” they need to be suc- hidden in plain sight. SARS-CoV-2 offers considerable advice, but
cessful and safe.5 had killed roughly 5000 people by only if people know the history
Whereas historians excel at March 12. That is a fraction of and respond with wisdom.
documenting the drama of past influenza’s annual toll. While the Disclosure forms provided by the author
epidemics, they are less comfort- Covid-19 epidemic has unfolded, are available at NEJM.org.
able with prediction. How wor- China has probably lost 5000 peo-
From the Department of Global Health and
ried should we be about Covid-19? ple each day to ischemic heart Social Medicine, Harvard Medical School,
Some experts warn that half the disease. So why do so many Boston, and the Department of the History of
world’s population will be infect- Americans refuse influenza vac- Science, Harvard University, Cambridge, MA.

ed by year’s end, an incidence cines? Why did China shut down This article was published on March 12,
that could result in more than its economy to contain Covid-19 2020, at NEJM.org.
100 million deaths. History cer- while doing little to curb ciga-
1. Burnet M, White DO. Natural history of
tainly provides a litany of epidem- rette use? Societies and their citi- infectious disease. 4th ed. Cambridge, United
ics, of plague, smallpox, measles, zens misunderstand the relative Kingdom:​Cambridge University Press, 1972.
cholera, influenza, Marburg vi- importance of the health risks 2. Rosenberg CE. What is an epidemic?
AIDS in historical perspective. Daedalus
rus disease, and the Middle East they face. The future course of 1989;​188:​1-17.
respiratory syndrome. But cata- Covid-19 remains unclear (and I 3. Brandt AM. No magic bullet:​a social
strophic epidemics that kill mil- may rue these words by year’s history of venereal disease in the United
States since 1880. New York:​Oxford Univer-
lions have been exceedingly un- end). Nonetheless, citizens and sity Press, 1985.
usual, with just a few occurring their leaders need to think care- 4. Markel H, Lipman HB, Navarro JA, et al.
over the past millennium. Are we fully, weigh risks in context, and Nonpharmaceutical interventions implement-
ed by US cities during the 1918-1919 influ-
now in one of those rare moments, pursue policies commensurate enza pandemic. JAMA 2007;​298:​644-54.
facing a pathogen with just the with the magnitude of the threat. 5. Farmer PE. Diary: Ebola. Lond Rev Books
right (wrong?) mix of contagious- Which raises one last question 2014;​36:​38-9.
ness and virulence, with societies of history and political leader- DOI: 10.1056/NEJMp2004361
providing the requisite human– ship. A “swine flu” scare struck Copyright © 2020 Massachusetts Medical Society.
History in a Crisis — Lessons for Covid-19

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