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Plagues, Epidemics, & Quarantines

Venezia_c.1650.jpg
Wikimedia.org
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Hebrew University of Jerusalem and the Jewish National and University Library
Matthaus Merian (1593-1650) Copper engraving c 1650. During the bubonic plague, ships arriving in Venice were required to sit at anchor for 40 days. This practice, called quarantine, derived from the Italian 'quaranta giorni,' meaning 40 days.

What Does History Teach Us About Coronavirus?

Tamara Rubin is glad to be spending her days at home. Since early March, Rubin, her husband, and three of their four sons (the oldest is off at college) have been sheltering in place to avoid getting infected with coronavirus. A.J., age 17, Avi, age 15, and Charlie, age 11, have been spending their time doing art, playing cards, taking walks in the woods, and baking bread.

Rubin, who lives in SE Portland, is grateful for the statewide mandate to shelter in place.

“Two people in my family have chronic breathing issues, two of us are over 50,” Rubin explains. “One of my kids is on a medication that further compromises his already compromised immune system. This quarantine is necessary for my family and others like us, and we’re so appreciative of everyone who’s participating.”

Family in Woods
Tamara Rubin
A walk in nature with the Rubin boys.

Oregon has a population of a little over 4.1 million people. California’s population is ten times that number. As I write this, in both states most businesses and all schools are closed and people have been doing their best to stay away from each other. Every time I run out for groceries there’s a new distancing strategy in place. Last week it was plexiglass dividers between cashiers and customers. This week a manager was standing outside making people wait, allowing shoppers in one at a time to keep the number of humans in the same space together low.

The legally enforced social distancing to slow the spread of coronavirus that we are seeing implemented across the United States varies from state to state and sometimes even from county to county within states. This coronavirus is novel and this global panic is unlike anything most of us have seen in our lifetimes. But the public health strategy of separating people from each other that’s being used in America and many other countries actually dates back to the Middle Ages.

Europe’s Black Death

Bubonic plague, also known as the Black Death, swept through Europe in an epidemic that started in the mid-14th century. Bubonic plague was a grim and terrifying disease, transmitted to humans from black rats via flea bites, as well as from direct contact with other people. If you were bitten by an infected flea, the bacterium, Yersinia pestis, would migrate from the bite site into your lymph nodes, causing them to swell and form “buboes.” Buboes—which is where the name bubonic plague comes from—are enlarged pus-filled fist-sized bumps, usually in the groin area, thigh, neck, or armpits.

The public health strategy of separating people from each other that’s being used in America and many other countries actually dates back to the Middle Ages.

Highly contagious with a mortality rate as high as 80 percent, the devastation wrought by this novel bacterial infection was chronicled by Marchionne di Coppo Stafani, a Florentine statesman. In 1348 Marchionne wrote about the “great pestilence” of “fury and violence” that caused people to flee in terror.

Marchionne explained how Florence disposed of the dead:

“At every church [citizens] dug deep pits down to the water-table; and thus those who were poor who died during the night were bundled up quickly and thrown into the pit. In the morning when a large number of bodies were found in the pit, they took some earth and shovelled it down on top of them; and later others were placed on top of them and then another layer of earth, just as one makes lasagne with layers of pasta and cheese.”

People in Europe understood the Black Death was contagious. Since Biblical times, lepers—people suffering from leprosy—had been socially isolated. Leprosy is a disease that causes skin lesions, loss of nerve sensation, tissue degeneration, and disfigurement. Though the mechanism of transmission were not understood in the 1300s, leprosy was also known to be contagious. (Leprosy is also an infectious disease caused by bacteria, Mycobacterium leprae and Mycobacterium lepromatosis.) In medieval France more than 2,000 leper asylums were built to keep people with leprosy away from the rest of society. Though bacteria were not discovered until a Dutch cloth merchant named Anton van Leeuwenhoek pulled an infected tooth out of his own mouth and examined his pus under a microscope in the 1670s, the concepts of contagion and isolation have been part of the social consciousness since the Middle Ages.

Quaranta gioni

In fact, our word for “quarantine” dates back to when the practice began in the 14th century. Venice, situated on the Adriatic, was built on sea trade. Trading with the Byzantine Empire and the Muslim world, Venetians believed that the people on vessels coming into their port from other places were responsible for spreading the Black Death. In an attempt to protect coastal cities from the Plague, public health officials first tried a 30-day quarantine, requiring all incoming ships to anchor in the harbor.

It wasn’t entirely effective. The Black Death killed approximately 25 million people, nearly a third of Europe’s population. But this first Venetian experiment of isolating ships helped officials understand that from first exposure to bubonic plague until death was approximately 37 days. So officials started requiring ships arriving into Venice to wait 40 days—quaranta gioni in Italian—before allowing the people and goods on them to enter the city.

A “quarantino” in Italian is a set of forty. As the practice of isolating people suspected of being exposed to the plague spread from Venice through Europe, other cultures adopted both the idea and the word “quarantine” from the Venetians. At first forcing sailors, passengers, and their goods to sit at anchor offshore, Venetians started building quarantine housing on an unused island in the lagoon surrounding the city. They enforced quarantines throughout the 1300s, 1400s, and well into the 1600s as plagues recurred.

Social distancing in the United States

According to the International Leprosy Association, leprosy came to America between the sixteenth and eighteenth centuries. It’s a little-known fact that there were at least four leper colonies in the United States. A leprosarium was established in 1866 on a remote spit of land on Molokai in Hawaii. A quarantine center was established in 1885 on North Brother Island, a 13-acre piece of land between Riker’s Island and the Bronx in New York. Another opened in 1894 in Carville, Louisiana; and a fourth leprosarium was built on the 75-acre Penikese Island, off the coast of Massachusetts, opening in November of 1905.

Carville LA Leprosarium
Out-of-sight and out-of-mind, the first patients arrived at the Carville Leprosarium in 1894. Photo here depicts the ladies dormitories, circa 1940.

The founders of the leprosarium in Carville, Louisiana, lied about their cause: they told local residents they were establishing an ostrich farm. Afraid of social backlash, they brought patients infected with leprosy to the colony under cover of darkness. In 1999 the Carville colony was closed and the grounds were converted into a program for at-risk young people supervised by the Louisiana National Guard. Patients who were still living there at the time were given a choice of receiving a lifetime medical allowance, relocating to Baton Rouge, or staying on site.

Coronavirus concerns

We first started hearing concerns about a virus that caused fever, a dry cough, and lethargy—and that could lead to extreme respiratory distress, especially in older adults—in late January 2020. It was then that news agencies across the country reported that a 30-something Washington man had developed symptoms after returning from Wuhan, China. At the same time, the World Health Organization declared coronavirus, or COVID-19, a “public health emergency of international concern.” The next day, January 31, the State Department warned Americans not to travel to China and President Donald Trump closed the United States to foreigners who had been in China in the past 14 days.

Critics of sheltering-in-place point to the nationwide rise in domestic abuse, child abuse, suicide, and depression.

But America did not record a known death from coronavirus until a month later: on February 28, 2020. The number of cases at that time was believed to be about 87,000 worldwide, out of a world population of approximately 7.8 billion people. Then, in March, things started really heating up.

President Trump declared a national emergency and the CDC started issuing official recommendations to Americans to avoid large gatherings. The world watched as sports events, conferences, and even political debates were canceled. Public and private universities began contacting parents to tell them they were closing their campuses, and life in America came to a standstill.

Away on a 3-day trip and avoiding the news and the internet, my family and I were not aware of what was happening. Sure, Legoland during the second week of March was pretty empty. But we had purposefully planned our trip to California to coincide with the times it was always a “ghost town.” Carlsbad downpours notwithstanding, families at the amusement park all looked healthy and happy, as unmindful of the crisis brewing as we were.

We returned home to a world turned upside down: Our oldest was abruptly booked on a 38-hour journey back from South Africa, where she was just weeks into a public health study abroad program. Our second, a first-year student at Reed College, was told to pack her bags as the dorms and the campus were closing. We started getting urgent emails from college administrators exhorting parents to get their kids off campus. Then Spring Break “started early” for our youngest two children as Ashland public schools decided to close. My 16-year-old son lost his job at the bank. Just after we left, Legoland followed SeaWorld, Disney, and Universal Studios and closed its parks in Florida and California. All of a sudden, the country was in lockdown.

State by state

As the threat of coronavirus escalated into what has become an unprecedented personal, political, and economic crisis, I called James Mohr, Ph.D., a professor emeritus at the University of Oregon. Mohr is “well into” his seventies (he didn’t want to tell me his age) and taught history classes for 26 years, including classes on the social history of medicine in the United States. He explained why each state was issuing different instructions to its residents.

“Medical policy has always been determined at the state level,” Mohr told me. “In the Constitution all powers not given to the national government are reserved to the states. One of the reserved powers, under the Tenth Amendment, is health and medicine. Even today every state has its own licensing laws for physicians.”

As a child growing up in Irondequoit, New York, Mohr himself remembers when public pools were shut to stop the spread of polio and when public health officials would quarantine the beaches around Lake Ontario because the water was too rank with pollutants to swim in safely. These quarantine strategies were nothing new, Mohr points out. During outbreaks of yellow fever in small southern towns in the 1870s, armed vigilantes would stand on the piers and tell passing ships to move along. The yellow fever virus is related to West Nile virus and spread from human to human via infected mosquitoes.

“They didn’t understand how it was spread,” Mohr says, “but it was known to be an epidemic disease. They didn’t want people coming into town. So they would create vigilante teams, with guns, and turn people away.”

This phenomenon happened again in America during the 1918 flu pandemic, Mohr tells me, when armed citizen posses would block roads to keep people out.

1918 Flu Pandemic
Centers for Disease Control and Prevention
Red Cross Volunteers - Boston, MA. Governor McCall asked every able-bodied person across the state with medical training to offer their aid in fighting the epidemic. Here, Boston Red Cross volunteers assembled gauze influenza masks for use at hard-hit Camp Devens in Massachusetts.

Most states have responded to the threat of coronavirus by issuing orders to non-essential workers to stay home. As of this writing, 43 out of 50 states have stay-at-home orders. These include Washington, Oregon, California, and Idaho. In contrast, business is continuing mostly as usual in North Dakota, South Dakota, Nebraska, Iowa, Wyoming, and Arkansas. Washington, Utah, and Oklahoma have mandates in parts of the state only.

But Oregon’s lockdown is statewide, extending even to remote areas like Emigrant Lake (where teenagers who want to go hiking are being shooed away by the Jackson County sheriff). Oregon’s governor, Kate Brown, issued a definitive order on Monday, March 23, establishing restrictions on public activity. The governor’s orders stipulate that people must stay home except to travel to essential work, buy supplies or groceries. Oregonians who defy the state orders may be charged with endangering the public’s health, a misdemeanor that carries a $1250 fine or up to 30 days in jail. In addition to banning all recreational and non-essential travel, the governor’s orders have shut down playgrounds and camp grounds, as well as shuttering shopping malls, tattoo parlors, hairdressers, gyms, and any public space where people cannot easily keep apart. Hardware stores, liquor stores, cannabis dispensaries, and gas stations have all remained open.

Governments around the world (with the notable exceptions of Sweden, Belarus, Singapore, and South Korea) have halted nearly all public life while simultaneously urging—or even forcing—people to shelter in place regardless of their health status. The logic behind these orders is that if everyone stays home, not just those who are sick, asymptomatic carriers of coronavirus won’t be able to infect other people. With fewer infections, hospitals will not get overwhelmed, health care providers will stay safer, and we can “flatten the curve,” that is, slow the spread of the virus so people don’t all get severely ill all at once.

While many, like the Rubins, are grateful for these stay-at-home orders, others are not convinced that social distancing is the best approach. Critics of sheltering-in-place point to the nationwide rise in domestic abuse, child abuse, suicide, and depression. They also argue that humans thrive off social contact and that social isolation can be devastating to human health. Many have also expressed concerns about the economic consequences of shuttering businesses and laying off workers.

Paul Offit, M.D., a vaccine expert and professor of pediatrics in the Division of Infectious Diseases at Children’s Hospital of Philadelphia, is concerned that our fear of the virus may be doing more harm than the virus itself. “No one seems to be willing to consider the other side of this,” Offit wrote in a viral post on Facebook. “No one is working. Thousands are losing their jobs. Businesses are going under. As is true in previous financial disasters, there will be an increase in homelessness, addiction, crime, stress-related disorders, suicides, and domestic violence … That too is a public health disaster. I’m not trying to minimize this pandemic at all. I’m just arguing for a more surgical approach.”

Knut M. Wittkowski, Ph.D., a former senior research associate at the Rockefeller University where he worked on biostatistics and epidemiology, agrees. Wittkowski calls this indiscriminate social distancing “not well-thought-through.” Wittkowski says it’s important to keep the elderly and vulnerable separate. But he believes it is wrong of state officials to be closing schools. “Children do very well with these diseases,” Wittkowski explains in an interview that has since been posted on YouTube. “They are evolutionarily designed to be exposed to all sorts of viruses during their lifetime. And so they should keep going to school and infecting each other and that contributes to herd immunity.”

Among Wittkowski’s concerns is that social containment will actually prolong the epidemic. “With all respiratory diseases, the only thing that stops the disease is herd immunity,” he says. “About 80% of the people need to have had contact with the virus, and the majority of them won’t even have recognized that they were infected, or they had very, very mild symptoms, especially if they’re children. So, it’s very important to keep the schools open and kids mingling to spread the virus to get herd immunity as fast as possible.”

A wake-up call for America

Many people don’t realize that leprosy, now considered a mild and highly treatable disease, has not been entirely eradicated. In 2015, the most recent year for which we have statistics, there were 178 new cases reported in the United States, according to the National Hansen’s Disease (Leprosy) Program. Bubonic plague is not entirely gone either. According to the CDC, an average of seven human plague cases are reported each year. Most occur in Northern New Mexico, northern Arizona, southern Colorado, California, southern Oregon, and far western Nevada. But these illnesses no longer plague us. Your chances of getting one are minuscule. And we have ways to treat them, especially if they’re caught early.

Humans, like all multicellular animals, cohabitate with bacteria and viruses. Our bodies are actually teeming with bacteria, both beneficial and otherwise. They live in us and on us. One of the many roles our microscopic hitchhikers play in our bodies is defense against harmful infections. While we may never entirely “beat” or “conquer” infectious diseases like COVID-19, there is no question that we can all improve our health so that viral and bacterial infections don’t overwhelm us.

That we can make simple changes to live longer, healthier lives is a message Shanhong Lu, M.D., Ph.D., an environmental medicine physician based in Mount Shasta, California, would like more people to understand. Lu has been following the coronavirus outbreak closely. When I reach her by phone she has just ordered 50 blood spot tests to measure antibody levels. Though experts are not yet sure if humans can be infected more than once, when you have antibodies to COVID-19 it means you have been exposed and are presumed to be immune. Lu is eager to test herself and her husband as soon as possible.

For Lu, the current shelter-in-place orders are an opportunity for Americans to take better care of themselves. She points out that it’s not the virus itself that we should fear, but a severe reaction—like respiratory distress or death—to the virus. If you have a healthy immune system, Lu insists, you will be less likely to have a bad outcome. Lu believes it is because we eat unhealthy pro-inflammatory foods and because so many Americans have lifestyle-induced health problems, like heart disease, diabetes, and obesity, that we have been hit hard by the virus.

“Americans are prone to have higher incidents of bad reactions,” Lu says. “That’s a wake-up call. What we need to learn from this is that we need to get our bodies healthier, and less toxic.” For Lu being healthier means eating a diet of organic, whole, mostly plant-based foods and living a less toxic life. This includes avoiding alcohol and cigarettes and avoiding exposure to environmental toxins, especially glyphosate-based herbicides. Glyphosate is the main ingredient in the herbicide Roundup and other weed killers. “It’s a systemic disruptor of multiple symptoms of our body,” Lu says. “You can’t have optimal healing if you have a toxic inner environment.”

Getting outside is important too. Geoff Houghton, N.D., a naturopathic doctor based in Ashland, argues that limiting Americans access to nature is the wrong approach. “Closing down the more popular trails is counterproductive,” Houghton says. “The net effect is concentrating outdoorsy people in fewer places. We should have everything open so people can disburse, not limit people’s access to the outdoors.” My youngest is spending her days jumping on the trampoline, going mountain biking with her older siblings, and listening to audio books. Yesterday we went for a photography walk, wandering around the neighborhood taking pictures of the tiny white trillium flowers and the bright yellow Oregon Grape blooms. The pink and white magnolia trees are magnificent this time of year. My daughter is an extrovert and her heart aches from missing her friends. I worry about my children’s mental health. I worry about the economic impact of this shut down. But I’m an optimist by nature. We humans made it through the Black Death. We’ll get through this too.

Jennifer Margulis, Ph.D., is a regular contributor to the Jefferson Journal. Her recent feature for the magazine, “Shedding Light On Darkness,” tackled the difficult subject of the rise in suicide among young people. An award-winning journalist, Fulbright grantee, and speaker, Dr. Margulis lives with her husband and four children in Southern Oregon. Learn more at: www.JenniferMargulis.net.