Disease prevention – An historical Survey

B A. Ochia

In most developed parts of the world, life expectancy, defined as the number of years of life a person is expected to live from the time of his or her birth, has been increasing since the turn of the 20th century. These gains in life expectancy have been made possible, thanks to the advances in medical science for the control and cure of  diseases, use of antibiotics, increases in the quantity and quality of food supply, application of refrigeration in food preservation, provision of clean water and advances in environmental hygiene. These achievements were possible as a result of disease prevention and health policies adopted over the years. In this article the history of man’s attempt to fight and control infectious diseases and improve his nutritional state is summarised. For a more detailed discussion, the reader is referred to an excellent monograph by Sylvia Noble Tesh, entitled Hidden Arguments.

The death rate in Europe had been falling steadily since 1770. However, people were faced with such uncontrollable epidemics, as tuberculosis and other respiratory infections. Those diseases claimed up to two-thirds of the reported deaths; the remaining one-third was caused by a variety of other infections. Most of these diseases were accepted by the people with much forbearance, since the outbreaks were closely connected with the lifestyles of the people.  Among the poorest segment of the community with substandard accommodation, outbreaks of typhus, cholera, plague and yellow fever occurred so rapidly, and resulted in death so quickly, that they evoked mass hysteria and terror.

The disease typhus had a long history in Europe. It first occurred in Spain during the civil war of 1489.  During the next 400 years that disease accompanied every war and revolution that took place in Europe.  In the late 18th century typhus had also become a peacetime disease, appearing in tenements built around new factories of the Industrial Revolution and had commenced to attack and kill city dwellers in large numbers. In England and Wales, as claimed by some historians, the death rate from typhus in 1848 was 14 per 1000. With this frightening death rate typhus more than any other disease contributed to the reversal in the then downward trend in the overall death rate at that time.

Next to typhus as a mass killer came cholera, which was a little known disease in the 19th century.  Before 1817 this decease occurred regularly only in India. But from then on it suddenly took off from the Indian subcontinent and began to spread all over the world with pandemics lasting for 6 to 22 years. It was documented that between September 1830 and January 1831 there were 8431 cases of cholera in Moscow, of those 4588 were fatal. In Scotland there was an epidemic in 1832, and it claimed 10 000 lives.  In 1849 the disease killed 15 000 people in France. Neither did other countries escape that tragedy; in America, Asia, the Near East and Africa the disease decimated many populations.

The terror evoked by the epidemic of the Black Death and the plague was so overpowering that during the next 100 years following its departure people still felt jittery at the thought or mention of the decease.  In 1822, so the story goes, when the body of the poet Shelly was washed up ashore in Tuscany, Italy, the town authorities prevented Shelly’s friends from reaching it, as they strongly believed that the poet had died of the plague. According to Creighton in his History of Epidemics, there were rumours of the plague in London in 1799.

That overpowering dread of the bubonic plague was exacerbated by the knowledge that somewhere in Africa and the Americas many communities were affected by endemics of yellow fever. However, the people’s concern was not exactly justified, since only the southern regions of Spain and Portugal were affected by the yellow fever epidemics. The decease never affected Asia, but it wreaked untold havoc in the Americas. In the 18th and 19th centuries, the awesome devastating power of the disease is illustrated by the following statistics: in 1793, according to Charles-Edward Amory Winslow, the State of Philadelphia lost a tenth of its population to yellow fever; in 1798 the decease claimed 1 600 lives in New York. It was said that Americans dreaded yellow fever more than they did cholera.

Various theories were  bandied about as the bases for the treatment and prevention of those infectious diseases.  Sylvia Noble Tesh discusses those theories exhaustively. For the present, it suffices to summarise them briefly and discuss their social implications.

The first of them was the contagion theory. From the beginning of the 19th century it was popularly believed that from the time of the Black Death all illnesses were contagious and, therefore, every victim should be isolated from healthy people. The phrase ‘la quarantina’ was coined by the Venetians during the Black Death to prevent ships suspected of carrying the sick from docking. Traditionally, the normal period of a quarantine was 40 days during which the ships’ crews and cargoes waited offshore or on a nearby island. At times these quarantines were so drastic that whole ports were closed  down completely. Along the Black Sea some ports were even closed down for two years. The disruption in shipping resulted in economic hardship, since commodities could not be allowed in or out.

In other countries similar quarantine measures were instituted and enforced sometimes with military assistance. Around some infected towns and cities military cordons were set up. Sometimes healthy people were allowed to move in and out, but at times whole cities and their environs were completely sealed off to keep the sick in or the healthy out. In 1793, as the story goes, during the yellow fever epidemic of Philadelphia, residents of Baltimore denied entry into their city to anyone who had been in Philadelphia in the previous seven days. Similarly, in Moscow, shortly following the appearance of cholera in Russia, the authorities tried to protect their city simply by closing all the roads to it. As the epidemic spread, other Russian cities were so protected. The quarantine was extended to physical objects too. Suitcases and trunks belonging to travellers were taken from them, fumigated and returned to them, or kept at checkpoints for up to two weeks, even though the travellers were permitted to continue on their journeys.

In addition to isolating cities and towns from one another, authorities in some cities quarantined houses where any one fell ill and refused the entire household from going in or out until the patient recovered or died. In other areas the authorities actively searched out the sick and forced them out into isolation hospitals. During the cholera epidemic in Russia, the police who were charged with getting identified patients into hospitals became over-enthusiastic and actually took the law into their own hands, seizing anyone who looked suspicious, including the sick, the convalescing, the well-recovered, the drunks and down-and-outers and the handicapped. These unfortunate persons were “dumped unceremoniously into the dreaded cholera carts and hauled willy-nilly into the lazarettes, oblivious to the weeping and wailing of whole families often trailing the waggons.”

Those quarantine measures brought in their wake social and behavioural upheavals. Personal relationships suffered in all the areas under quarantine. Rowel graphically described in 1793, during the Philadelphia epidemic, how people quickly acquired the habits of living with fear: “Handshaking was abandoned, acquaintances snubbed, everyone walked in the middle of the street to avoid contaminated houses. Those wearing mourning bands were regarded as dangerous, as were doctors and church ministers. When along the streets, people manoeuvred in passing to get windward of anyone they met.” It was said that the fear of contagion so gripped the people that they even abandoned their family members who showed signs of illness. Clearly, those quarantine measures were becoming ridiculous. It was not unexpected then that some people began to voice their opposition to them. For instance, one John C. Gunn, the 19th century US Navy surgeon, denounced quarantine in the following words: “Humanity demands that the idea of contagion should be discontinued….since it calls forth the worst features of the human heart, in its ungovernable terror, and frequently causes even the mother to desert her dying child,  the sick and the friendless stranger to languish, uncared for and shunned.”

Throughout history the principle that every disease was contagious was enriched by whatever xenophobia and prejudice prevalent at the time. Take for example, during the Black Death thousands of Jews were executed for their ‘presumed role’ in causing and spreading the disease. Perhaps, as many as 6000 Jews lost their lives in Strasbourg alone in 1349, according to Philip Ziegler. In subsequent plague epidemics, it was said, grave diggers, lepers, suspected witches and Jews were unjustifiably subjected to ridicule, torture, ostracism or even death for the same reason.  In Brazil the 17th century yellow fever epidemic was used as an excuse to restrain women: all prostitutes were expelled from cities or, at worst, jailed; and upper-class ladies were forbidden from leaving their houses unless accompanied by their husbands, slaves or parents.

The next theory to be considered was known as the supernatural theory, the origin of which is lost in antiquity. In simple societies people had the simple notion that all diseases and sufferings were due to evil spirits or witchcraft. Early in the 19th century it was accepted, at least partly, by almost every religious sect that people were affected by disease because they went against God’s commandments. So strongly held was this belief that during the 1721 smallpox outbreak in Boston some puritans refused the newly discovered preventive technique of inoculation on the ground that it was against God’s laws. However, there were many who questioned the supernatural theory, and even among those who were deeply religious there were doubts as to whether disease could be prevented or treated simply by piety and prayer.
The third theory, known as personal behaviour theory, held that people by their unhealthy lifestyles caused their own disease. Thus, to prevent diseases attention was focused on the improvement in diet, personal hygiene and the lessening of emotional tension.

The fourth was the miasma theory, which was based on the idea that disease is associated with the environment. The concept of environmental implication was subjected to differing interpretations. In the 19th century many believed that the air was poisoned by such natural phenomena as earthquakes, volcanic eruptions, great storms, tidal waves, blazing comets and thunder and lightning. It is thus not hard to see why people were left helpless to fight or prevent disease, apart from merely fumigating the infected air.

The idea of air fumigation originated from the time of Hippocrates who was said to have ordered his followers to burn fragrant leaves, flowers and ointments during epidemics. Basically three methods were applied to fumigate the air: great bonfires were lit up in city streets; artilleries were shot or cannons fired into the air; and people took personal precautions to keep clean the air immediately surrounding them by using “sweet-smelling oils such as eau de cologne, onions or even dead toads. Some people shewed garlic or tobacco constantly, doused themselves with vinegar and carried camphor bags and smelling bottles”.

The most striking aspect of the atmospheric theory of disease control was that it identified some aspects of disease which were connected with human activities, a point which today’s friends of the earth would not disapprove. The pestilential air was a heterogeneous mixture of foul odours from decaying carcasses and corpses, decomposing garbage, slaughterhouse wastes and animal and human excrement. The air blowing over or emanating from decaying organic matter was rightly thought to be injurious to the body and dangerous to breath in. Note the similar present-day idea that the air polluted with radioactive fall-outs, asbestos dusts and factory chimney emissions is dangerous to breathe. To ensure that the air in cities was pure, the authorities prescribed that streets be cleared of garbage, the dead buried sufficiently deeply, overcrowded rooms adequately ventilated, and the air emanating from cesspools, sewers and privies controlled.

It was generally agreed that the Industrial Revolution brought in its wake changes in air odour. As people migrated into the towns and cities in search of jobs, there arose the pressing need for accommodation. Some unscrupulous businessmen erected makeshift dwellings around the emerging factories. Those dwellings had no sewage system. It was said that in some English cities as many as one hundred persons used a single privy. Since some of the houses were built back-to-back, passage of air through rooms was severely restricted. The unpaved streets in front were used as the most convenient avenue for discharging domestic refuse. Back-yards and side lanes wherever available were covered deep with filth. No wonder then that the surrounding air was thick with foul odour.

The poor conditions in which the workers and their families found themselves propelled some well-meaning people to advocate improvements in social conditions. Among the advocates was one Edward Chadwick who in 1842 produced a Report on the Sanitary Conditions of the Labouring Populations of Great Britain. That report recommended massive reforms, including the establishment of sewage systems able to carry household wastes and their odour away from towns and cities, provision of piped water supply to every home and the setting up of a centralised administration to be in charge of house drainage, street sewage, water supply, land drainage and road structure. The publication of the report was considered a significant milestone in the ten-year struggle for parliamentary support for the environmental approach to disease control. Although the report was opposed by a large number of influential people, physicians included, who favoured the contagion theory, water company directors, exponents of local, as opposed to centralised, government and the editors of The Times, it ushered in the passing by Parliament of the Public Health Act of 1848 which officially sanctioned the miasma theory and laid the foundations for the famous sanitary “revolution” of the 19th century. So, a new understanding of the importance of sanitation, hygiene and clean water re-enforced the demand for major developments in water supplies, building regulations, sewage disposal and public health education. Consequently, by the beginning of the 20th century, it was accepted that governmental action for public health should go hand in hand with provision of individual health care by doctors. All these resulted in the highly developed sanitary and medical services which we in the United Kingdom enjoy today.

At this juncture, the part played by medical sciences deserves some mention. Medical science provided a new understanding of the causes of disease. In 1880 the causes of typhoid bacillus, leprosy and malaria were discovered. The bacilli causing tuberculosis, cholera, diphtheria, Escherichia coli diarrhoea and pneumococcal pneumonia were discovered sequentially from 1882 to 1886.

Poor nutritional state of the working class exacerbated the effect of infectious diseases. In Great Britain a new public health crisis occurred in 1900 when the government, faced with the possibility of losing the Boer War, decided to embark on a recruitment campaign. It happened that so many young men, who reported at the recruitment centres, were considered too small and sick to enter the army. A special committee was scrambled, and soon it was established that malnutrition was the primary cause of the ill health and poor physical and mental performance of the young men. Studies were then conducted in Britain and many European countries to estimate the numbers of malnourished children. Results from the British studies evoked public concern, as they showed that 30 and 60% of children in Edinburgh and Manchester were, respectively, malnourished. A subsidised school meal service was started in 1926 to provide needy children with food to enable them make effective use of the education provided. School milk clubs and cheap milk were promoted, and cod liver oil was added to the milk to prevent rickets. School feeding schemes increased rapidly throughout the 1930’s, although by mid 1930’s the emphasis switched to use of milk instead of whole meal. This decision was unfortunate, as it exacerbated, rather than reduced, the deficit in energy intake.

Boyd Orr galvanised public opinion in the 1930’s by emphasising the link between poverty, poor diet and poor health. With the publication of his study on Food, Health and Income in 1936, there was united action by religious and women’s groups and by various voluntary organisations urging the government to provide free milk to the vulnerable groups in society, and those included infants, school children and pregnant and lactating mothers.

There are a few conclusions to be drawn from the above. Man’s attempt to contain disease has been a long, drawn-out struggle, involving the use of drastic and, at times, inhumane methods. One obvious result of the struggle is that today, at least in developed countries, most of the infectious diseases are things of the past, standards of living have risen tremendously, and people are generally better fed, and live longer and healthier. However, the struggle to contain diseases continues, albeit in a more refined and human-friendly way. Medical science played an important part in the past in establishing the basic causes of many diseases. Government and the people are aware of the link between adequate nutrition, housing, sanitation and provision of medical care, on the one hand, and the maintenance of good health, on the other. At the present time research on the aetiology of diseases like AIDS, CJD (the human form of mad cow disease), cardiovascular disorders, cancer and many of the psychosomatic disorders is being vigorously pursued, with the aim of fully understanding and eradicating the diseases. It is apparent that the war against human maladies will continue, as long as there is the wish and the will of societies to increase both the quantity and quality of life for the citizens.