In December 2019 the first cases of a severe respiratory illness affecting people in Wuhan, China emerged. The cause of the illness was unknown.
A Chinese ophthalmologist of the Wuhan Central Hospital, Li Wenliang was astute enough to make the link between the cases and the live animal market in Wuhan. Out of concern for his colleagues, Dr Li warned them via social media. His comments raised the attention of the local police who issued a warning, “According to the law, this letter serves as a warning and a reprimand over you illegally spreading untruthful information online,” the interpretation of the letter reads. “Your action has severely disrupted the order of society.” This style of response from the authorities is commonly seen in totalitarian regimes where fear of social disorder often outweighs fear of the real crisis. Under a repressive regime, the local officials delegated with the responsibility of controlling all aspects of residents’ daily living, are fearful that they will be held accountable for any potential loss of control or disorder. Thus, local officials react by keeping quiet and work at containing any problems locally.
Despite initial actions of concealment and containment, the Wuhan disease outbreak was a disaster that could not be concealed, either from Beijing or the rest of the world. The fear and hysteria of an unknown infectious agent, a modern plague, dispersed swiftly among Wuhan residents and beyond. In the end, the Chinese government took over the management of the evolving situation, contained the disease and shared information about this outbreak with the wider world, with more transparency than they have displayed in the past.
Dr Li was rehabilitated as a hero, only to die caring for the sick, a few weeks later. The local officials’ fear of repercussions became a reality, with Beijing dismissing most of the local senior officials in Wuhan.
We face this new infectious challenge in 2020, armed with the powerful understanding of modern science and medicine. Yet, the old fears of pandemic and plague can exert a powerful effect on the human psyche. The current coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread to infect too many people to disappear. Our efforts to quarantine have slowed its spread, but it is likely to circulate and infect many more people across the world. It will cause suffering and economic disruption. To defeat this challenge, humanity will employ public health measures to contain the disease. The ill will need to be supported by our medical services and with time, effective treatment or a vaccine will likely become available. As we progress, we must not forget those in the developing world where medical systems are not as advanced, and few individuals are able to afford treatment.
“The old fears of pandemic and plague can exert a powerful effect on the human psyche.”
Humanity is on a journey and how we respond to this challenge will be important. We should remember and learn from our past experiences. Calm and compassion should guide our responses and prioritized along with medical technology.
The current outbreak of the virus is very much in the news at the moment. As I write the numbers of cases in Australia are steadily rising. The news is full of medical jargon. An explanation of some of these terms may be helpful:
- An epidemic refers to an increase, in the number of cases of a disease above what is normally expected,this may be sudden and can occur in a known disease, such as influenza.
- An outbreak is essentially the same as an epidemic, but the term is often used if the disease occurs in a limited geographic area.
- A pandemic refers to an epidemic that has spread over several countries or continents, affecting a large number of people .
- The case fatality rate is calculated by dividing the number of deaths from a specified disease over a defined period of time by the number of individuals diagnosed with the disease during that time; the resulting ratio is then multiplied by 100 to give a percentage. The case fatality (CFR), reflects the severity of the disease . (For example; a population has 1,000 people; 60 people have the disease and 40 die. The mortality rate is 40 ÷ 1,000 = 0.04, or 4 percent; the case fatality rate, however, is 40 ÷ 60 = 0.67, or 67% percent.)
Disease epidemics give rise to a primeval fear. This is certainly a theme reflected in the Bible where people in ancient times were seemingly at the mercy of the natural world and they feared the consequences of these events – “There will be mighty and violent earthquakes, and in various places famines and pestilences.” Luke 21:11. Or they represented a direct punishment from God – “…this time I will send the full force of my plagues against you and against your officials and your people, so you may know that there is no one like me in all the earth.” Exodus 9:14.
These views would have been foremost in the minds of people living in Europe when the bubonic plague emerged from 1347 to 1351. This was not the first visitation of the plague to Europe, but it was the event that resulted in the most deaths with an estimated 25% of Europe’s population dying during this time. The very name, “Black death” or “La Moria Grandissma (the great mortality)”, has connotations of fear and finality. The disease, caused by the organism Yersinia pestis, was carried by fleas on the bodies of black rats to Europe from Central Asia.
Over the 5 years of the first wave of infections, 25 million people were thought to have died. Europe, having just emerged from the chaos of the Middle Ages, was undergoing rapid development of cities that were overcrowded with poor sanitation. Additionally, the population was afflicted by recent famine and wars. All these led to an extremely high susceptibility to the infectious disease. It was estimated that 60-80% of the population died. Over time, Yersisnia pestis acquired enhanced transmissibility, and pathogenicity. It spread through direct contact with the infected, but also by aerosol in the pneumonic form, that was especially deadly, with an 80% CFR. Society was overwhelmed. The scale of death was beyond the ability of any government to cope. Eyewitnesses such as Italian, Agnolo di Tura wrote; “… in many places in Siena great pits were dug and piled deep with the multitude of dead” and “I […] buried my five children with my own hands.” 
“Calm and compassion should guide our responses and prioritized along with medical technology.”
Chroniclers from the time hinted at the severe fear that gripped Europeans at the time: aerosol spread and a frighteningly rapid onset of symptoms, and then death. They reported a society gripped by fear and on the verge of collapse. Jean le Bel reports, “one did not dare help or visit the sick, nor could anyone find a priest who would agree to hear confession.”  According to the Scot John of Fordun, “because of fear of contagion, sons fled their parents on their death beds and visa versa.” 
Society, however, did not collapse and despite what must have been an overwhelming calamity, the initial surge of fear seemed to abate. A more humane and compassionate voice began to be expressed. Matteo Villani of Florence was disgusted by what he saw, “many were abandoned, and a vast number died that could have survived….mothers abandoned children and children their fathers and mothers….this cruelty was the habit of barbarians.” 
However, after his initial shock, not armed with modern medicine or even an understanding of the disease, Matteo reports a return of rationale thought, compassion and a desire to help others – “Florentines saw that some could recover, they began nursing the plaguestricken.” 
Later accounts of plague revisitations are not characterised by stories of abandonment. There is still fear and desperation, but perhaps a greater awareness that to survive, more was to be gained by assisting the suffering and maintaining society.
There were also stories of astounding courage and self sacrifice, none greater than that of the village of Eyam in England . In September 1665, a cloth merchant from London inadvertently brought the plague to the village, dying soon after. It was not long before the villagers started to be infected. As the plague swept through the village people prepared to flee. They were persuaded not to by their pastor, William Mompesson. He wanted to prevent the plague spreading to nearby towns and incredibly persuaded his parishioners to adopt a self-imposed quarantine. The local earl agreed to provide the villagers with food. For the next several months, the quarantine held. It was thought that 260 out of some 360 people in the village died. Whole families were wiped out. The pastor’s own wife also died. Yet for all that time no one broke the quarantine. This one village’s self-sacrifice almost certainly prevented the spread of the plague to nearby towns.
Another ugly side of previous pandemics have been the development of hysteria and fear, and the expression of these by attributing disasters to a scapegoat(s). Such an example is the massacre of the Jewish population of Strasbourg  that acted quickly as opposed to those that delayed measures . Reports were that peasants and merchants in the city were driven by fear and spread stories that the plague was the result of the Jews poisoning the water supply. Hundreds of the local Jewish population (men, women and children) were herded together on to an island in the middle of the river, locked in a warehouse and then the warehouse was set on fire with those inside perishing. While this event was reported to have occurred as the result of mob hysteria, evidence suggested that more sinister motives may have been at work. It seemed that the local bishop and surrounding landowners instigated the mob and, following, the massacre. They benefited from the remission of considerable debts owed by these so-called nobles to the Jews; with the Holy Roman Emperor confirming the remissions as well as distributing the property of those murdered to the same instigators, who attributed the blame to the townsfolks . The motives here are more likely to have been greed exploiting the fear engendered by the plague.
While these experiences have occurred in the distant past, many of our current public health practices evolved from these times. Quarantine comes from the Italian quaranta, meaning forty, representing the number of days people and animals had to be separated if they had come in contact with a contagion. Quarantine remains an important public health strategy to contain and prevent the spread of an infectious disease. Or at least, slow the transmission. As a measure, it has its limitations and is open to abuse by authorities, and the creation of xenophobia.
A more modern epidemic was that of the 1918-19 “Spanish Flu”. This was caused by a new strain of influenza virus infecting humans. Several countries, including Australia, placed a quarantine on ships from Europe. At the time, quarantine was unpopular, because it delayed the return of many soldiers from World War I. However, It did slow down the “second wave” of influenza reaching Australia, although did not prevent it . Closures of public events and schools in cities during the 1918-19 influenza pandemic was effective in delaying the spread of the virus and limiting mortality in those cities
In these instances, just as was the case during the 2009 influenza pandemic, quarantine did not prevent the spread of an infection that had successfully established itself in human hosts and in whom individuals could be asymptomatic.
Quarantine has been applied with varying success in the current COVID-19 pandemic. The efforts put in place by the Chinese authorities once the problem was appreciated, were both fast and effective. Most western commentators’ viewed President Xi Jinping’s rule as authoritarian if not brutal in its repression of dissent. However, it is hard to argue against the fact that this enhanced authority has enabled him to put in place draconian, disease containment measures that has led to the lockdown of entire cities of millions of people in Hubei province. These efforts have led to the containment of COVID19 in China and have bought us all extra time. It led Bruce Aylward, who co-led the WHO-China Joint Mission on COVID-19 to say that China’s efforts are “probably the most ambitious, and I would say, agile and aggressive disease containment effort in history” .
Quarantine can also lead to xenophobia, another primal fear of the unknown and the threat from others. This was the case with SARS in 2003 against people of Chinese descent, and even against Africans in 2014 with Ebola. In Australia there have been instances of individuals with Asian appearances being targeted. A Korean student was asked to leave a private school dormitory in Sydney for fear of infection, though she was not and had not been to China. Another student in Perth was evicted from her accommodation as she was of Asian appearance. Across Australia in January and February, there were reports of people avoiding businesses operated by Chinese.
Xenophobic views can easily be espoused on social media. Unfortunately, the reality is, the regular media can be just as guilty. On 26 January 2020, two of Australia’s highest circulating newspapers published provocative headlines. Melbourne’s Herald Sun’s headline read, “Chinese virus pandamonium”, a play on “pandemonium” alluding to China’s pandas; while Sydney’s Daily Telegraph’s headline read, “China kids stay home”.
These ill-conceived banners appeal to the lowest common denominator of society’s fears and are potentially very dangerous. Fortunately, and to the credit of Australians these headlines led to a petition with over 51,000 signatures demanding an apology from both papers.
The World Health Organisation declared the outbreak a Public Health Emergency of International Concern on 30 January 2020. The reality of the COVID-19 pandemic is sobering, but ignoring the threat will not solve the problem, and will only worsen people’s fears. The Chinese Centre for Disease Control has published the results of 72,314 cases . In 81%, the cases were mild. Another 14% were severe, requiring hospitalisation, and 5% critical. The overall case fatality rate was 2.3%, but in critical cases this was much higher at 49%. No deaths occurred in children under 10 years of age, but the CFR was higher in the elderly (70-79yo, 8%; 80+yo, 15%). The CFR was also higher in those with chronic diseases such as cardiac disease, diabetes, chronic lung disease and cancer.
Health care workers accounted for 3.8% of overall cases in China, but it was much higher in Wuhan. Of concern is that the disease appears to be more severe in health care workers, with 14.8% (247/1668) having severe or critical presentations.6 Despite such large numbers there is still confusion about how dangerous COVID-19 is. In Wuhan the CFR was 5.8%, but in the rest of China it was much lower at 0.7%, suggesting that during the early outbreak medical services were overwhelmed and this contributed to the higher mortality.
Similarly, on the outbreak on the Diamond Princess cruise ship, with a population skewed to the more elderly and so potentially at heightened risk, there were 707 people infected and 6 died; a CFR of 0.8%. At this stage the CFR of COVID-19 is unclear, but it is certain that COVID-19 is a serious concern compared to other pathogens that have caused pandemics (Table 1).
In a recent perspective written for the New England Journal of Medicine, Bill Gates, of Microsoft fame, but now a passionate advocate for several causes, including pandemic planning, calmly outlines his concerns for COVID-19 . He states it could be a once-in-a-century pathogen as the CFR is relatively high, and it can kill otherwise healthy adults. It is efficiently transmitted, with one person spreading it to 2-3 others and it can be transmitted by people with mild disease or who are asymptomatic, that will make it difficult to contain. Bill Gates positively reminds us that while governments need to work to contain the virus through public health measures and provide funding for research to better understand the virus, as well as to develop a vaccine or treatment. Efforts should also be made to assist our neighbours who may have greater need, especially those in the developing world; to work towards efforts to better prepare for future epidemics and by sharing data and resources. When solutions such as antivirals or vaccines become available, these cannot be sold to the highest bidder, or only be made available to those who can afford them .
“Efforts should also be made to assist our neighbours who may have greater need, especially those in the developing world.”
We do not yet know how seriously COVID-19 will impact upon the world. It has the potential to be the cause of much suffering and widespread disruptions. This can easily give rise to feelings of fear, and this fear can only too easily be exploited. We must approach this problem calmly and rationally. We have a greater understanding now of science and far greater resources than our forebears who suffered from previous epidemics. It is important to remember the remarkable bravery and compassion they displayed, in the face of limited knowledge and remedies.
Overcoming this fear and rising above it requires courage and faith. It is important to remember what is said in Matthew 25:35-40,
“For I was hungry and you gave me food, I was thirsty and you gave me drink, I was a stranger and you welcomed me, I was naked and you clothed me, I was sick and you visited me, I was in prison and you came to me. Then the righteous will answer him, saying, ‘Lord, when did we see you hungry and feed you, or thirsty and give you drink? And when did we see you a stranger and welcome you, or naked and clothe you? And when did we see you sick or in prison and visit you? And the King will answer them, ‘Truly, I say to you, as you did it to one of the least of these my brothers, you did it to me.”
Dr Peter Wark is a senior staff specialist in Respiratory and Sleep Medicine at John Hunter Hospital, Newcastle and conjoint Professor at the University of Newcastle. He is a senior investigator with the Priority Research Centre for Healthy Lungs at the Hunter Medical Research Institute
1. Prevention CfDCa. Principles of Epidemiology in Public Health Practice [Lesson 1; introduction to Epidemiology]. Available from: https://www.cdc.gov/csels/dsepd/ss1978/ lesson1/section11.html.
2. Zeegers MP, Bours LJ, Freeman M, D. Methods Used in Forensic Epidemiologic Analysis. Maastricht University: Academic Press; 2016.
3. Cohn Jr. S. Plague violence and abandonment from the Black Death to the early modern period. Annales de démographie historique. 2017;134(2):39-61.
4. Kelly J. The great mortality: Harper; 2006. 5. Tognotti E. Lessons from the history of quarantine, from plague to influenza A. Emerg Infect Dis. 2013;19(2):254-9.
6. Peckham R. COVID-19 and the anti-lessons of history. The Lancet. 2020.
7. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020.
8. Gates B. Responding to Covid-19 – A Once-in-a-Century Pandemic? N Engl J Med. 2020.