by Sean Martin
Contents
Introduction: Definitions, Origins
Chapter One: Prehistory
Chapter Two: Antiquity
Chapter Three: The Dark and Middle Ages
Chapter Four: The New World
Chapter Five: Early Modern to 1900
Chapter Six: The Twentieth Century
Chapter Seven: New Diseases
Notes
Glossary of Diseases
Bibliography
Index
Throughout history, disease has plagued human civilisations, claiming more lives than natural disasters and warfare combined. In the fourteenth century, the Black Death was responsible for taking the lives of one third of Europe’s population. In the modern day, physicians, scientists and historians continue to be challenged by new and resurgent diseases such as AIDS, malaria and Ebola, as they struggle to identify causes, antidotes and preventative measures to combat these epidemics.
A Short History of Disease chronicles the historical and geographical evolution of infectious and non-infectious diseases, from their prehistoric origins to the present day. It offers a comprehensive, accessible guide to ailments and the medical methods used to combat them. Analysing case studies including the Black Death, Spanish Flu, cholera, leprosy, syphilis, cancer and Ebola, Sean Martin maps the development of our understanding of disease into a thorough and enlightening timeline. The book offers a fascinating insight into an important area of social history, providing an easy-to-read introduction to all you need to know about disease and the ongoing quest to protect human health.
Sean Martin is a writer, poet and filmmaker. He has written books on The Knights Templar, Alchemy and Alchemists, The Gnostics, The Cathars, Andrei Tarkovsky and New Waves in Cinema. His films include Lanterna Magicka: Bill Douglas & the Secret History of Cinema (‘a fine documentary’ - Guardian), and Folie à Deux.
A SHORT HISTORY OF DISEASE
SEAN MARTIN
POCKET ESSENTIALS
To the memory of Waldemar Haffkine,
medical visionary and revolutionary
And for all those working in,
and fighting to save, the NHS
Acknowledgements
Thanks are due to the following: Stranger Than Fiction, the Edinburgh non-fiction writers’ group; Lois Martin; John Dodgson; David Cavalla; Norma and Ian Dorward; Glenda Martin; Maria McCann; Sarolta Tatár; Ion Mills; and Louise Milne.
Giles Perring and Christine McCourt, in whose house on Jura some of this book was written.
The staff at the National Library of Scotland in Edinburgh, and the staff at the British Library in London.
Thou shalt not be afraid for the terror by night; nor for the arrow that flieth by day;
Nor for the pestilence that walketh in darkness; nor for the destruction that wasteth at noonday.
Psalm 91
Introduction: Definitions, Origins
October is plague season in Madagascar. The humid rainy season begins then, and the warmer temperatures are a breeding ground for the fleas that transmit one of the world’s most feared and deadly diseases. Its second pandemic, known to history as the Black Death, hit Europe in 1347 and within two years had killed a third of the population; in some places half. In isolated spots, the mortality rate was one hundred per cent.
So Malagasy authorities were naturally concerned when, in the autumn of 2013, plague began claiming more victims than usual. A rodent disease that remains endemic in many parts of the world, plague finds a conducive home on Madagascar, with the island reporting more plague deaths each year than any other part of the world save the Democratic Republic of Congo. In 2012, Madagascar had 256 plague cases, 60 of them fatal, the highest number recorded anywhere that year.
The International Committee of the Red Cross and the Pasteur Institute were becoming concerned about plague in the island’s capital, Antananarivo, in particular the crowded and insanitary conditions of the city’s main prison, Antanimora. Its three thousand inmates share their quarters with a thriving population of rats. Hopping from an infected rat – or other rodent – fleas take up residence in bedding, clothing and food, finding human hosts in densely crowded conditions with ease. Staff could be infected just as easily as prisoners, and they had daily contact with the outside world. Unless conditions in Antanimora improved, the possibility of an epidemic remained.
As it turned out, the epidemic did not happen within the confines of a jail: in December, plague claimed 20 lives in the village of Mandritsara, in the island’s northwest. Four other districts reported outbreaks of plague. Of the sixty or so new cases, nineteen proved fatal. Alarmingly, some of these were the more infectious pneumonic form of the disease. Although vaccines against plague have existed since the 1890s, the problem faced by the Red Cross and others in Madagascar is the difficulty in getting the medication to the affected areas – often remote villages in rural areas – in time. 2013 saw the worst outbreaks in years, and the media was soon buzzing with stories about the possible return of the Black Death, or the evolution of forms of the disease resistant to antibiotics.
The Madagascar outbreak was not the only plague outbreak to make the news. A teenage boy had fallen ill that summer, in Ichke-Zhergez, a remote village in the mountainous northeast of Kyrgyzstan, close to Lake Issyk Kul and the Kazakh border. Doctors in the regional hospital at Karakol didn’t immediately realise what fifteen-year-old Temirbek Issakunov was suffering from. It was only after he died, on 22 August 2013, that they announced that Temirbek had contracted bubonic plague, probably from the bite of a flea, or eating infected meat.
No one had died from plague in Kyrgyzstan since 1981. Five days later, a young mother and her two children were hospitalised, also showing symptoms of the disease. A press conference was hurriedly called in Bishkek, where government health officials tried to quell fears that an epidemic was upon them. They pointed out that bubonic was not the most deadly form of the disease, and that these were isolated, unusual cases. But they took no chances: a state of emergency was declared, and the doctors who had treated Temirbek were quarantined, along with 105 people who had come into contact with the boy; two teams were dispatched to his home village to round up as many rodents as they could. The authorities in Kazakhstan tightened border controls, and the Chinese withdrew their athletes from the Issyk Kul Sport Games, due to start in early September.
Plague is arguably the most notorious disease in history. That it should still make the news reminds us how much of a threat diseases still represent. The 2014 Ebola outbreak in West Africa took international health authorities by surprise. The outbreak was the first time the disease – first noted in 1976 – had reached epidemic proportions. On 8 August 2014, the World Health Organization declared it a Public Health Emergency of International Concern, and took the unprecedented step of allowing untested vaccines to be used in the field.
Disease has always provoked fear, sometimes worse than the disease itself. In 627, the Chinese emperor T’ai-tsung asked Lu Tsu-shang, ‘an official of talent and reputation’, to become governor general of Giao province in northern Vietnam. ‘You have the ability to pacify this frontier; go and defend it for me, and do not refuse on account of its being far away.’ Tsu-shang thanked the emperor, but when the time came to take up the post, refused to go on the grounds that ‘In the south there is much malaria; if I go there I shall never return.’ Tsushang’s fear of malaria was greater than his fear of imperial wrath. The emperor was so enraged he had Tsu-shang beheaded.1
It is easy to understand the concept of disease in the sense of plague – an epidemic both rapidly fatal and so notorious that it makes its presence felt both in folklore and in metaphor (to ‘avoid like the plague’) – but w
hat actually is disease? Definitions have changed over time.
The Oxford English Dictionary defines ‘disease’ as:
A condition of the body, or of some part or organ of the body, in which its functions are disturbed or deranged.
The condition of being (more or less seriously) out of health; illness, sickness.
An individual case or instance of such a condition; an illness, ailment, malady, disorder.2
The OED also notes that disease can be used in the substantive sense of an ‘absence of ease’; figuratively, as ‘A deranged, depraved, or morbid condition (of mind or disposition, of the affairs of a community, etc.); an evil affection or tendency’; and can be combined to form ‘diseasegerm, -maker; -causing, -producing, -resisting, -spreading, etc.’ As a verb it can be to ‘bring into a morbid or unhealthy condition; to cause illness, sickness or disease in, to infect with disease.’
As Robert P Hudson notes in The Cambridge World History of Human Disease, ‘semantic and logical quagmires... await anyone audacious enough to safari through the changing concepts of disease, illness, and health.’3 Hudson points out that ‘Disease has always been what society chooses it to mean – neither more nor less.’ Furthermore:
(1) The definition of disease has varied with time and place in history;
(2) the names assigned to diseases are ultimately abstractions, although it is useful at times to act as though they are real; (3) what we mean by diagnostic terms, as with words in general, can be discerned more accurately by what we do with them than by what we say about them.4
There have been countless attempts to define illness, disease, and health. (Hudson cites a long list.) The history of disease, however we define it, is undeniably long, far longer than recorded history. This book, short as it is, will – of necessity – be somewhat cursory as a result. It will be largely a social history and, being mindful of semantic quagmires, scientific and medical terms will be kept to a minimum.
We will examine the prehistory of disease, noting its presence in the paleopathological record. Given the limitations of the discipline – as we’ll note in the next chapter, only certain diseases leave traces in bones – we will already be in one of Hudson’s quagmires. Ancient texts prove to be a veritable semantic minefield, with some ancient diseases remaining unknown. Likewise, ancient epidemics, such as the Plague of Athens, the Antonine Plague and the Plague of Cyprian, all pose epidemiological riddles that have yet to be fully solved. We only get onto scientifically firm ground in the nineteenth century, with the advent of germ theory and crusading figures like Louis Pasteur, Robert Koch, Rudolf Virchow and Joseph Lister. The twentieth century saw the advent of antibiotics and the development of public health.
It is in these great campaigns, beginning in the Victorian era, that we encounter disease in both the literal sense – people were dying of cholera, typhoid, and the like – and also the figurative: that people were dying was due to their communities being ‘deranged, depraved or morbid’ due to loose morals, lack of discipline, and poverty.
In the twentieth century, disease appeared in political discourse – Hitler’s references to the cancer of Judaism, McCarthy’s to communism – while at the same time medicine strode on, confident that all known diseases would be eradicated.
They haven’t been, of course. They’ve outsmarted us, evolving faster than medical research. For the ancients, disease was a punishment from the gods. Gods were replaced with miasmas, miasmas eventually with microbes. Every time human beings have changed their habits or their habitat, they have invited disease to join them.
It is in this sense that disease perhaps has its most useful definition, one we would do well to bear in mind, a definition that behoves us to keep on our toes, to remain ready for disease’s next evolution: disease is dis-ease, as the OED reminds us, a lack of ease.
1
Prehistory
There was once a time when there was no disease. Life spans were much longer than those we enjoy today, there was no suffering, and people possessed magical powers. They could fly, go to heaven at will, and understood the language of animals.
This is the myth of the golden age, found in cultures the world over. The oldest stories predate Eden: Sumerian cuneiform tablets speak of Dilmun, ‘a place where sickness, violence and aging are unknown.’5 When the sun-god Utu and Enki, lord of soil and earth, brought water, Dilmun flowered and became a beautiful garden. Another pre-Edenic tale is the ancient Persian story of Yima, the first human. During his time, ‘there was neither heat nor cold, neither old age nor death, nor disease’.6 Yima built a beautiful garden, the most widespread image for paradise. This is no coincidence, as Richard Heinberg noted: ‘The word paradise itself comes from the Avestan (Old Iranian) word Pairidaeza, meaning a walled or enclosed garden.’7
But then disaster struck. Myths of the fall are as widespread as those of the golden age. In Eden, the Serpent tempted Eve to eat the fruit from the Tree of the Knowledge of Good and Evil. In Persia – one of the few stories not to attribute the loss of paradise to the actions of a woman – the Fall was brought about when Yima refused to do the bidding of Ahura Mazda, the Zoroastrian god. Divine displeasure resulted in shorter life spans, pain, toil, conflict, and disease. We have been living in this world ever since.
If paradise in mythology was a garden, in reality, it was probably a beach. Bacteria found at the Strelley Pool Chert in Pilbara, Western Australia, is thought to be around 3.4 billion years old, making it the oldest known form of life yet discovered. At that stage, the Earth was dominated by ceaseless volcanic activity, the continents still in the process of forming, the skies a thick cloud.
We could think of it as an age without disease, but it was also an age without life, or at least life as we know it. We would have found it impossible to breathe, as there was at that stage of Earth’s evolution no oxygen: life at Strelley Pool was sulphur-based. The bacteria probably resembled the extremophile bacteria that can be found today in sulphurous caves, acid lakes and in rocks far underground. Rather than being the heavenly arbours of Dilmun, Persia or Eden, the Earth when Strelley Pool Chert was home to the first bacterial life probably more resembled an apocalypse from a painting by John Martin.
Bacteria are not only the original form of life on Earth, but also far and away the most successful and abundant. They had the planet all to themselves for at least a billion years. When the Earth had cooled sufficiently, a type of bacteria known as cyanobacteria began to photosynthesise. That is, they were able to use sunlight to convert carbon dioxide and water into carbohydrates. Oxygen is the byproduct of this process. As Earth’s atmosphere began to fill with oxygen, the bacteria slowly began to use it as another energy source.
Around two billion years ago some photosynthetic cyanobacteria invaded other primitive single-celled organisms to form the first plant cells, which were better able to generate energy because they possessed chloroplasts, filaments that were devoted to photosynthesis. Microbial organisms called alpha-proteobacteria amalgamated with other microbes to form mitochondria. These new organisms were eukaryotes, meaning essentially that they were a larger, more advanced form of microbial life. But it is from them that all other life evolved, being powered by chloroplasts and mitochondria.
There were other simple life forms. Single-celled protozoa belong to this category of early life forms. Among their number was thought to be the plasmodium that causes malaria. However, at this very early stage of Earth’s history, there were no life forms in which it could cause what we know as malaria; it was simply a microorganism going about its business. Then, as now, that meant finding somewhere to live, generating energy and reproducing. Left to their own devices, most bacteria can reproduce themselves every twenty or so minutes. In one day, a single bacterium can produce a colony of over four sextillion.8 That stupefyingly large number has twenty-one zeroes after it. Another way of expressing this would be to say that, in a single day, one humble bacterium can produce more of itself than there are vert
ebrate life forms on the planet.
Bacteria sustain life on Earth. They are in the soil, the air and the water. Each gram of soil contains between one and ten billion bacterial cells, each millilitre of seawater around a million. They are in nature’s engine room, constantly transforming matter into energy, constantly purifying, taking in and giving out. In the human body, bacteria outnumber cells by about ten to one (that’s roughly 100 quadrillion bacteria to 10 quadrillion cells). Most of them can be found in the gut, and aid the digestion of food, or our immune systems. Others live on our skin, in our mouths, and in places you can’t mention in polite conversation.
Another early, very simple and very small life form was the virus. Unlike a bacterium, a virus can’t live on its own (it’s what’s called an obligate parasite). It must of necessity invade a cell and use its host’s energy before it can come to life. Once it has done so, a virus will turn the cell it’s living in into a production line, spewing out thousands of copies of itself. The virus does not do this out of spite, it’s not trying to cause disease, it’s simply doing what it’s doing. But viral replication nearly always weakens and destroys the cell it’s living in, and once the cells start to die off, the organ or organs affected will start to weaken too.
No one knows exactly when viruses first appeared, and to ask why is perhaps to ask the wrong question. It’s possible some were the result of imperfect bacterial cell division (although such imperfect offspring usually result in mutated bacteria, rather than viruses). The eminent virologist Dorothy Crawford has dubbed viruses ‘rogue pieces of genetic material’9 which have broken free and found a way to reproduce inside cells. In their natural hosts, viruses can often be benign, only causing disease when they infect a new host. Bats, for example, can carry many viruses that are completely benign to them, but when the viruses make the species jump to humans, they can cause some of the worst diseases currently known, such as Marburg virus disease. We could think of viruses as the microbial equivalent of the Asteroid Belt or Oort Cloud, objects that were too small – or too far away – to become part of larger bodies like planets when the Solar System was forming, and have remained ‘free agents’ (albeit bound by gravity) ever since. Viruses have always acted to keep life forms in check when any given life form threatens to become overabundant, whether it’s human, animal or blooms of algae in the sea.