People are People
Issue: September/October 2020
Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense
So how do you spend your COVID downtime? Some of us have been working extremely hard in extraordinarily difficult circumstances. Other emergency physicians who work in less affected areas have seen huge decreases in patient volumes or decreased hours and shifts. Even those who are not in hot spots when not working are similarly affected by the bunker mentality, which has been part of our new normal. What do you do instead of meeting family or friends or pursing your previously normal pre-COVID pursuits? I write this at the end of June, but the world may be very different even by the time it is published. We of course hope that this is a temporary issue, but as with all things COVID the truth is that most predictions which have been made during this time have simply been proven wrong. It is hard to be accurate when working from the dark hole, which is COVID.
People who know me realize that I like books and intermittently feel the need to read old books and talk about them. One of my personal COVID wellness programs has been to try and increase the time I spend reading in an effort to distract myself from what is going on in the world as the news is often simply too depressing. A positive side effect of this activity was to try and work through that stack of unread books in my office. I also like to read books with my adult children and discuss the books with them to keep in touch. My adult children were all fortunate in that they were able to stay employed, but they also have had more free time as their social lives took a more solitary turn. Everyone is looking for something to fill the hours, which used to be spent in more social situations, so we increased our reading. I saw on my shelf two plague related books and decided to read these. What better time to read about a plague than during a pandemic? This may sound strange, but I wanted to see how people from the past thought about an event like this before humans even knew that a bacteria or virus existed.
The first book we tried was the Decameron, which to be honest I did not like and abandoned about a half the way through. It is really a comedy and deals with a group of young people hiding out in the countryside outside Florence during a 14th century bubonic plague outbreak. It contains a series of humorous and irreverent stories, which the characters take turns telling. It was surprisingly risqué and anticlerical for the 14th century. It is fun but seemed redundant to me.
The other book, which we read was Daniel Defoe's A Journal of the Plague Year. This book is set in London during another bubonic plague outbreak, which occurred in 1665. It is a narrative by a man who stayed in London throughout the plague and tells an account of what he saw and read. I did enjoy this book and was amazed by the similarities between people hundreds of years apart in time regarding their thoughts, feelings, and reactions to a threat like a plague. It really surprised me the similarities between these events regarding how the average person dealt with the stress and dangers, which were presented to them whether it be from the bubonic plague or COVID.
One of the first things to strike me were the many "Bills of Mortality" which are present in the book. Defoe details the spread of the plague by parish across London during the year. The various parishes made a weekly report of the number of people who died and often compared the numbers to their normal death rates. It is easy to compare these to the daily charts of positive COVID tests and death by county, state, or country. They too watched the disease spread from one area to another. They also noted small areas with an increased rate of illness suddenly explode with cases. Another fascinating thing was that they quickly realized that many deaths were being misidentified as not being from the plague when they probably had simply not been properly diagnosed. This sounds much like all the talk about "excess deaths" related to COVID in our current world.
"The most controversial containment measure ordered by the Lord Mayor’s Office was the policy of shutting up houses. If illness was evident or suspected, the City had the power to sequester a property and shut it up, along with its inhabitants, for a period of one month, or until the virus had passed."
- Daniel Defoe, A Journal of the Plague Year
The government’s response to individuals also warrants some comparisons. The city of London decided to quarantine people at home and required the whole family to stay inside until the family either died or recovered by the end of a month of isolation. This entailed the government hiring a "watcher" who was stationed outside the house to make sure that the family did not try and escape. There was incredible fear related to been "shut up" in a house. Many people fled the city during this time and went to go live with their relatives in the countryside or in other towns. This helped spread the disease as has the return of students, tourists, and others home has led to a spread of COVID across the world in the past few months. Defoe states, "I am speaking now of People made desperate, by the Apprehensions of this being shut up, and their breaking out by Stratagem or Force." Individuals and families had to hire nurses to care for the sick in the home and have relatives bring them food to leave outside for the family to collect. The U.S. has not gone to these lengths but how many people have you told to "home quarantine" and have their family and friends bring them the necessary items of life? The intrusion of any government into the lives of these ill or potentially ill people and constricting their movement has a modern tone to it. We as Americans and all citizens of any nation are facing these same issues with COVID. Each country is restricting their citizens to a different extent and the debate will rage for years regarding how much government authority to regulate our lives is appropriate.
The effect of the plague on the economy of London sounds very familiar. Defoe states,”all trades being stopt, Employment ceased; the Labour, and by that, the bread of the Poor were cut off; and at first indeed, the Cries of the poor were most lamentable to hear; tho' by the Distribution of Charity, their Misery that way was greatly abated." He was complimentary to the public officials in London for the most part as they helped give out food to the needy. The city also hired the "watchers" to enforce the quarantine. This would seem to not be a great job but during the time there were thousands out of work who would jump at the chance to find even this type of work. Does this sound like the current hiring of thousands of contact tracers?
Although the medical profession in 1665 did not know about microbiology, they did understand what we would call a latent period and fully feared the associated danger to the population. Defoe wrote, "By the Well, I mean such as had received the Contagion, and had it really upon them, and in their blood, yet did not show the Consequences, nay even not sensible of it themselves, as many were not for several days: these breathed Death in every Place, and upon every Body who came near them; nay their Cloaths retain'd the Infection, their Hands would infect the Things they touch'd." He continued, "but that one Man, who may have really receiv'd the Infection, and knows it not, but goes Abroad, and about as a sound Person, may give the Plague to a thousand People, and they to a greater Number in Proportion, and neither the Person giving the Infection, or the Person receiving it, know anything of it, and perhaps not feel the Effects of it for several Days after.” This sounds familiar to me as a public health official briefing today explaining the importance of social distancing, compliance with mask wearing regulations, and home quarantining.
The response of the medical profession to the bubonic plague also is interesting. Medical knowledge at the time had little understanding of the disease and had no effective treatments. We certainly have had a vast increase in our understanding of disease, but the helplessness expressed at the time in terms of treatment seem familiar as we have tried numerous types of treatments for COVID with varied and often disappointing results. Defoe discussed numerous arguments among physicians at the time related to the value of one treatment or another which sounded like debates held today for and against various medicines and treatment regiments. One theme related to the medical profession resonated loudly to me. Defoe wrote “the Plague defied all Medicines, the very Physicians were seized with it….and they dropt down dead, destroyed by the very Enemy, they directed others to oppose.” Many of us sadly know of physicians, nurses, or other health care professionals who have succumbed to COVID or have been debilitated by the illness.
In late June of 2020 as I write this, there is a spike in COVID cases across sections of the country. This has been attributed by some pundits as an expression of rebellion against the frustration associated with the recent prolonged period of self-isolation. There is a fatigue with following rules and guidelines from the various sources of this type of information. The politicization of these recommendations has been a factor in using non-compliance with them as a means of self-expression and to some as an act of rebellion against what many consider an infringement of their rights by the government. Many people, especially young adults, seem to just want to get on with their lives and simply stop worrying about COVID. Certainly, in our current crisis only time will reveal the full consequences of this defiance.
In 1665, a similar situation occurred when the number of deaths from the plague started to decrease in London but certainly were not gone. Defoe noted an almost identical sense of restlessness in the population and related what could almost using modern prose be a press release related to COVID. He stated, "the Reason I take to be the Peoples running so rashly into Danger, giving up all their former Cautions, and Care, and all the Shyness which they used to practice; depending that the Sickness would not reach them or that if it did they should not die. The Physicians oppos'd this thoughtless Humour of the People with all their Might; and gave out printed Directions, Spreading them all over the City and Suburbs, advising the People to continue reserv'd, and to use still the utmost Caution in their ordinary Conduct; notwithstanding the decrease of the distemper, terrfying them with the Danger of bringing a Relapse upon the whole City, and telling them how much a Relapse might be more fatal and dangerous than the whole Visitation that had been already." It is fascinating to read the results in London when people took to the streets when the case count seemed to be waning (might we say “flattening the curve”) and the resultant spike in deaths. The stories of 1665 and 2020 seem to parallel each other almost exactly to me and really show me that people are just people and that we have not really changed much as individual humans in the past few hundred years. Our emotions, ambitions, tolerance levels, and the like have not really evolved to a higher level. Could we learn from our predecessor’s mistakes and use the lessons, which people 400 years ago learned to help us in our own modern pandemic?