Aare Afe Babalola SAN Founder/President , ABUAD

PANDEMICS IN HISTORY : Was Nigeria Prepared for Covid-19? (2)

LAST WEEK, I commenced a discussion on the novel Corona Virus Disease (Covid-19) which has dealt a huge blow on the world’s socio-economic structure. I detailed the chronology of pandemics which have, in times past, shaped human existence, including but not limited to the Black Death of 1350 and the Spanish Flu of 1918. This week, I will examine the measures taken to prevent and treat pandemics from ancient time, through medieval and middle ages, to modern times.

The Medieval Response to Pandemics

Medical practice in ancient times is not the same as it is today. Earliest medical procedures were generally crude and certainly not as sophisticated as what obtains today. Consequently, the wave of the first known pandemic naturally met an unprepared people who had little or no knowledge of infectious diseases as well as curative and preventive measures. The overwhelmed physicians and health officials who fought a devastating outbreak of the bubonic plague in medieval Italy had no notion of viruses or bacteria.

At those times, there were widespread beliefs that plagues were an act of God – a supernatural response to the grievous sins that the people committed. According to Professor JN Hays, in his book titled Epidemics and Pandemics: Their Impact on Human History, people may have thought God had scourged regions and their atmospheres, and to counter this they tried to clear the air. To clear the air, for example in seventh century Syria, there was widespread breaking of pottery. Prayers and penance equally account for one of the earliest medieval responses to pandemics. The idea of sin and apocalypse, acts of God and alignments of the planets influenced the peoples’ reactions to outbreaks of pandemics with many people turning to prayers as a call to God for prevention of infection, cure or last prayer. An historian, Prof Adrian R. Bell, noted that Catholic priests formed something of a frontline in Europe. According to him, in the 14th century, there was a big demand for priests. Everyone who was dying had to be given the last rites, which meant the death toll among priests was huge and it was likely they had to fast-track replacements. Besides a call to repentance, there is also evidence that people tried to make sense of the devastation by resorting to xenophobic attacks to scapegoat outsiders. In England, there were violent attacks on Flemish merchants and weavers as the people tried to deal with the unexplainable pandemic. People attacked outsiders for no reason other than that they were different.

Despite the fact that health officials during the Black Death pandemic had no notion of viruses or bacteria, they understood enough about the outbreak to implement some of the world’s first anti-contagion measures. City officials put emergency public health measures in place that is precursory to today’s best practices of social distancing and disinfecting surfaces. According to Jane Stevens Crawshaw, the people knew that they had to be very careful with goods that were being traded, as they knew that the disease could be spread on objects and surfaces, and that they tried their best to limit person-to-person contact.

Quarantine: The First-known Preventive Measure for Pandemics

The first recorded history of quarantine as a way of curtailing the spread of contagious diseases was in Ragusa (modern day Dubrovnik) where a legislation was passed on July 27, 1377 by the city’s Major Council requiring the mandatory quarantine of all incoming ships and trade caravans in order to screen for infection. The law stipulates that those who come from plague-infested areas shall not enter Ragusa or its district unless they spend a month (thirty days) on the Islet of Mrkan or in the town of Cavtat, for the purpose of disinfection. This 30-day period was known in Italian as a trentino, but doctors and officials also had the authority to impose shorter or longer stays, depending on the circumstances of each case. The English word “quarantine” is a direct descendent of quarantino, the Italian word for a 40-day period.

The prescription of a 40-day quarantine period had great symbolic and religious significance to medieval Christians. When God flooded the Earth, it rained for 40 days and 40 nights, and Jesus fasted in the wilderness for 40 days. However, quarantine was not fully effective in the prevention of the plague as the city of Ragusa was a maritime city that survived on trade and it was therefore impossible to completely fence off the city without negatively impacting its economy. Nevertheless, Ragusa was also the first city to set up a temporary plague hospital on another island called Mljet. This new type of state-funded treatment facility would soon become known throughout Europe as a lazaretto. The facility served as both a medical centre and as a quarantine facility where plague-infected patients would receive fresh food, clean bedding and other health-promoting treatments, all paid for by the state.

During the Spanish Flu of 1918 – 1919 which, till date, is the worst influenza pandemic in history for killing an estimated 50 million people, quarantine was one of the immediate responses in curtailing its spread. Apart from quarantine, which had gained recognition and a measure of effectiveness during the Black Death plague, people used a variety of other measures to protect themselves from the flu. One of these was camphor extracted from camphor trees. People wore a bag of camphor around their necks to ward off the virus, while nurses and doctors might inject it into an infected patient’s arms and legs with a hypodermic needle. For others, the prevention of infection was best achieved through involved gargling saltwater, wearing facemasks, eating oranges and—at least for one set of parents—warning people not to kiss their baby.

The Modern Response

In the 21st century, advancement in technology and the broadened scope of medical practice is largely influential in the response to the outbreak of pandemics. The reduction of the spread of infectious diseases is, just as recognized during the days of Black Death, effectively achieved by social distancing between people. Other measures also include individual hygiene and personal protection, home-care of the ill and quarantine of contacts, ban on international travels and the use of pharmaceutical interventions to prevent infections and treat the infected.

The World Health Organization, in its 2018 publication titled: Managing Epidemics: Key Facts about Major Deadly Diseases, stated the modern-day, five-step sequence of events in response to pandemics. The steps are: anticipation, early detection, containment, control & mitigation, and eradication. In the first stage of response, i.e. Anticipation, involves the forecasting of the most likely diseases to emerge, and the quick identification of the drivers that will worsen the impact or facilitate the spread. It also involves preparedness plans to allow for a reactive response to the unexpected. Early detection: allows the rapid implementation of containment measures, which are the key to reducing the risk of amplification and potential international spread. Once a new disease is recognized by the health system, early laboratory confirmation is essential. Containment: involves effective and rapid control of emerging diseases. Rapid containment should start as soon as the first case is detected and it requires skilled professionals to safely implement the necessary countermeasures. Control and mitigation: Once the infectious disease threat reaches an epidemic or pandemic level, the goal of the response is to mitigate its impact and reduce its incidence, morbidity and mortality as well as disruptions to economic, political, and social systems. Eradication means that the disease is no longer considered as a major public health issue. However, intervention measures (surveillance and control) should continue to prevent its re-emergence. Three criteria need to be met in order to eradicate a disease: there must be an available intervention to interrupt its transmission; there must be available efficient diagnostic tools to detect cases that could lead to transmission; and humans must be the only reservoir.

   To be continued