Society after Coronavirus essay #10: a short history of plagues

This is the tenth in a series of essays exploring the economic, social and cultural effects upon the daily lives of persons living in the United States, western Europe and more broadly around the world, as we emerge from the global Covid-19 lockdown pandemic.

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By Matthew Parish

Coronavirus is not the first pandemic disease the globe has ever experienced, and by historical standards it is not remotely dangerous. Nevertheless the measures taken by government to fight this pandemic has been out of all proportion to any prior pandemic disease in respect of which a tolerable history exists. This gives rise to the question of why the reaction to Covid-19 has been so disproportionate. This turns out to be a bewilderingly difficult question to answer. The principal pandemic diseases from history that we might consider as rivals to the Covid affair can be enumerated shortly. They are these, with the more interesting pandemics being highlighted in bold.

From antiquity; the Plague of Athens of 430BC; the Antonine Plague of 165-180AD; the Plague of Cyprian of 250-271; the Plague of Justinian of 541-542.
From the Middle Ages and early modern era: the Black Death of 1346-1353; the Cocolitzli epidemic of 1545-1548; the American Plagues of 1519-1532; the Great Plague of London of 1665-1666.
From the eighteenth and nineteenth centuries: the Great Plague of Marseille of 1720-1723; the Russian Plague of 1770-1772; Philadelphia Yellow Fever of 1793; the Russian ‘Flu of 1889-1890.
From the twentieth century: American polio of 1916; the Spanish ‘flu of 1918-1920; the Asian ‘flu of 1957-1958; HIV / AIDS from 1980.
From the twenty-first century: Ebola from 2014-2016; Covid-19 from 2019-2020.

In terms of raw numbers of deaths, the Black Death is indisputably the winner with up to 200 million fatalities; behind it are the Plague of Justinian; the Spanish ‘flu and HIV, each of which may have killed up to 50 million people. Judged in comparison with these, Covid, that at the time of writing is estimated to have killed slightly more than 1 million people worldwide, in a world of far more people than any of its most predecessors, seems somewhat minor in comparison.

Indeed history teaches us that deadly pandemics are fairly common; there are far more than those listed above, but most kill, proportionately to the affected populations, far more than Covid-19. Add to this that Covid-19 tends to kill people who are close to death anyway. Therefore the number of life-years Covid-19 has deprived of people is far less than the greater majority of its principal predecessors.

By far the most dangerous pandemic infection is Bubonic Plague. This is a bacterial infection. Such infections can be treated by antibiotics, and hence since the invention of antibiotics in 1928 in London Bubonic Plague, along with many other bacterial infections, has died out as a killer pandemic. Now there are just a few hundred cases per year worldwide, with a death rate of perhaps 10%.

Nevertheless it took some 1,387 years for humankind to invent the cure for Bubonic Plague from its first recorded pandemic, the Plague of Justinian, and we might bear this in mind when hope for a quick vaccine for Covid. Without antibiotics, the mortality rate for Bubonic Plague was between 30% and 90% depending on the health of the individual infected. Like Covid, it was incredibly contagious but with a different method of transmission: the bite of an infected rat flea. The only way of mitigating against risk of the Bubonic Plague was to live wealthily and healthily in the countryside, where there was less likelihood of rat infestations.

With a mortality rate of up to 90%, social distancing measures might have been justified to prevent rat fleas jumping from one victim to another. During virtually every Plague outbreak, of which the Russian Plague was the last substantial one, infections spread rapidly amidst urban poverty and squalor in which people were living on top of one-another in unsanitary conditions, rat infestations and where people had poor immune systems.

With a global mortality rate of 2.7%, Covid seems for more marginal a case for such extreme restrictions upon liberty. Although during the various Bubonic Plague outbreaks in history relatively little was understood about how the infection spread or killed people compared to contemporary standards of medicine, it was understood that distancing people from one-another was an effective means of preventing the Plague from spreading. Even with people undertaking such social distancing measures as they could, the Bubonic Plague outbreaks lasted several years, in each case before dying out largely as a result of having thinned out the populations.

Bubonic Plague was generally associated with dramatic urban growth amidst unsanitary conditions: in other words, urban growth in respect of which public health policy could not keep up. By contrast Covid is a disease of urban regions not because of lack of sanitation, but because it is passed from one person to another principally via water droplets in the air.

Hence Covid infection rates are higher in places of higher population density. Public health measures cannot really assist in decreasing infection rates, because people tend to breathe in and out no matter what their underlying state of hygiene or or health may be. Mortality rates are correlated with underlying health of the victim, but it has not yet been shown that this entails more people are dying proportionately in poorer cities.

According to current data, wealth (and hence health) seem to have relatively little to do with it. However this point is controversial, with some claiming that presumptively poorer ethnic minorities in western societies have higher mortality rates. It is not yet established to a sufficient degree of certainty whether that correlation really exists; and the presumption that ethnic minorities are poorer in a relevant way is currently entirely unexplored.

Hence Covid-19 is importantly different from Plague, which was (until its effective eradication by modern medicine) a child in substantial part of poverty and degraded urban conditions. By contrast Covid-19 was first found in a high-density middle-income city (Wuhan, China) but it quickly spread throughout the world, initially affecting wealthier countries before poorer ones. That may be because wealthier countries have more personal mobility; the virus spread across Europe, where air traffic is (or, rather, was) the densest in the world.

Moreover because European cities include some of the most densely populated, we found that European cities suffered a particular brunt of the first wave of Coronavirus notwithstanding their relative urban wealth and want of urban degradation by global standards. For the transmission of Covid you don’t need any rats; you just need people close together.

Turn now to the influenza-based pandemics, which are similar in a number of ways to Covid in their means of transmission (air-based water molecules) but far more lethal. Ordinary influenza (the sort that ravages the populations of colder countries every winter) has a mortality rate of perhaps 0.1-0.3%, so less than one-tenth of the mortality rate of Covid. However like Covid, deaths are associated with older people and those with compromised immune systems or other serious underlying medical conditions.

The so-called Asian ‘flu of 1957-58 had a global mortality rate of approximately 0.67%. It has been estimated that at least 500 million people were infected by it, which makes Covid, so far with approximately 41 million cases, pale in comparison. However the total number of deaths caused was approximately 1.1 million, roughly the same as have died from Covid so far with a mere 8% of the infection rate. Hence we see the substantially greater mortality rates from Covid compared to the Asian ‘flu. The Asian ‘flu was a typical ‘flu in that it was disproportionately risky in terms of mortality (and other complications) to the elderly and those with underlying health conditions. If Asian ‘flu is a reliable guide as to the number of infections of a contagious airborne pandemic virus, then with a global mortality rate of 2.7% we are looking at a global mortality estimate of 13.5 million people. However the global population in 2020 is 7.8 billion compared with 2.9 billion in 1957.

Scaling up to that level, we might be looking at as many as 36 million deaths from 1.35 billion infections. This modelling, if correct, would suggest that we have only incurred 0.3% of the eventual total Covid infections so far. In other words, we are in for a long haul. However because so substantial a proportion of Covid infections pass without identifiable symptoms, it seems likely that the total number of global infections so far is much more than 41.3 million and the mortality rate is substantially lowed than 2.7%. The foregoing figures at least provide us with some indication of where we may be with this pandemic; but it may all be far less bad than indicated.

Something must be said about the Spanish ‘flu pandemic of 1918 to 1920, because comparisons between the Spanish ‘flu – by far the biggest viral killer of recent times – and Covid are frequent. The Spanish ‘flu was a particularly virulent form of influenza that was approximately as transmissible as Covid and as the other varieties of ‘flu we have been considering. Like the Asian ‘flu, it is thought that up to 500 million people were infected, in four waves; but in 1918 this represented almost one third of the world’s population that was approximately 1.8 billion. It is estimated to have caused between 17 million and 100 million deaths: so it may have had a mortality rate of as high as 20%. Hence it is by far the most deadly strain of influenza or similar viruses in recent history.

Were one to attempt to amplify the potential global mortality figures for Covid-19, one would start with the Spanish ‘flu infection rate; magnify it by references to the difference between the global population then and that population now; and reach a figure of 2.17 billion infected; then we would apply the Covid-19 established mortality rate of 2.7% to reach a global mortality figure of 58.5 million people (of which slightly more than 1 million have died so far). Again this would suggest we have a long way to go. Again this approach would be undermined by the fact (were it to prove so) that actual Covid infections are substantially more than the 41 million so far recorded, by reason of the fact that so substantial a proportion of persons infected have no symptoms.

Another way of looking at matters is that Covid-19 is nowhere near as bad as Spanish ‘flu; and nowhere near as bad as Asian ‘flu either. We are taking the strongest coercive measures ever recorded in history in response to a pandemic disease, where the disease is not nearly as bad as other viruses similar in at least some ways and that the globe was exposed to in living or near-living memory. If that is right, then it calls into question why we are reacting so excessively or extensively now, when we did not do so in prior emergencies.

Another way of understanding these figures is that we are getting better at combatting the spread of virulent viral infections transmitted by air-based water droplets. That is because on current projections global Covid-19 infections will not reach anywhere near 500 million people as happened in the Asian ‘Flu pandemic of 1957-58, even though population densities are higher as people have urbanised over time as well as the size of the world’s population having grown ever further. Perhaps the biggest single change since the twentieth century influenza pandemics is the dissemination of information and statistics about just how contagious Covid-19 is.

Hence people have an opportunity for themselves to take measures limiting the levels of the virus’s contagion. The reason more contemporary information may be being disseminated could be to do with the media, and the widespread role of the internet. At the current time, lockdown measures in some countries are changing on an almost daily basis. Without the internet, it would be impossible to change lockdown measures so frequently because people would not know the rules had changed. The quantity of information made available by the medical profession to government and hence to the population at large may also have increased.

However this may be a self-reinforcing trend in conjunction with the growth of internet news. Contemporary news requires constant updates; therefore the medical profession finds itself obliged to provide constant updates. In any event, the increased dissemination of information is surely a principal factor in society being able to fight higher transmission rates. Whether Covid-19’s relatively modest mortality rates, particularly counted in terms of life-years, justifies the enhanced government measures taken to mitigate against contagion, particularly in light of the economic consequences of those measures, remains to be seen. It is entirely possible that we subsequently conclude that by reason of excessive information flow, we over-reacted as societies to a more rational assessment of the menace of Covid.

Given that Spanish ‘flu killed far more people than it is estimated Covid will; and given that it removed exponentially larger number of life-years because the people most at risk of death were otherwise healthy people who died from an overreaction by their own immune systems, Covid seems trifling in comparison. It may be worth making the point another way: Covid seems so frightening to us, in comparison to prior pandemics, principally because of an over-exchange of information.

One consistent lesson of recent history is that viral infections are far more likely to die out of their own accord than by finding a vaccine. Vaccines for Spanish ‘Flu, Asian ‘Flu and HIV were never found. HIV continues to ravage communities who do not have access to the very effective treatment medication. Ebola kills itself off by being too lethal; but it is evolving to become less lethal so that it may infect more people. Covid’s contagiousness in this age of information technology and medical expertise in aIl likelihood derives likewise from the fact that it is not very lethal at all, and the vast majority of people who contract it just get better on their own and after a few days.

By the standards of history’s major pandemics, Covid is more of a social and economic crisis. Just as the Spanish ‘Flu exercised a disproportionate mortal toll over those of otherwise fine bodily health, Covid-19 seems to be destined to exact an economic and social price higher in wealthier countries that can and do over-react to it. Covid might, in geopolitical terms, become the economic leveller. Its long-lasting effects will in any event be economic and political far more than medical and in terms of public health policy.

Matthew Parish is an international lawyer and scholar of international relations based in Geneva, Switzerland. He is an Honorary Professor at the University of Leicester; was elected as a Young Global Leader of the World Economic Forum; and has been named as one of the three hundred most influential people in Switzerland. An expert in UN reform, he is the author of several books and over three hundred articles. www.matthew-parish.com

The views expressed in this article do not necessarily reflect those of TransConflict.

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