SARS-CoV-2 poses enormous challenges to scientific research and the management of public health. Are there lessons to be learned by looking back that can help us now and in the future? History, I would argue, suggests courses of action and a wider context in which to assess the way forward.
History is not just the distant past, there are lessons from recent experiences. Although the Ebola virus was first identified in 1976 and flared up on numerous occasions over ensuing years, the most serious episode took place from 2014-16, affecting Guinea before moving across borders to Sierra Leone and Liberia. With an average death rate of 50%, Ebola is a much more virulent virus than SARS-CoV-2, but successful efforts were made to contain it. Despite initial fears that the death toll might reach a million, the eventual loss of life was closer to 12,000.
What could we have learned from paying more attention to this outbreak and how it was managed? I put this question to Dr Mike Ryan (Executive Director, WHO Health Emergencies Programme), in a webinar that I organised for the Royal Irish Academy in October. One of his points really stood out for me. “In an African setting, communities are important. Very often my colleagues in industrialised countries think technologically first and then they think about it medically and then eventually they go and work it out and ask someone in the community, ‘How do we do this?’ My African colleagues start from the other end. The first thing that they think about, no matter how much they are an epidemiologist or clinician, is how is this impacting the community? How are communities going to participate and respond? It is their instinctive, first act.”
It is striking that the Covid caseload in Africa in general has not been catastrophic. Underreporting, a lack of testing and the much younger population may offer explanations. But there is also an embedded way of addressing outbreaks. Mike Ryan noted that in Nigeria, for example, there is a ‘muscle memory in the system’ when it comes to infectious disease, and they focused rigorously on breaking chains of transmission as the first course of action.
Experience with Ebola is one of the benefits of Joe Biden’s appointment of Ron Klain as his chief of staff. Klain served as White House Ebola Response Coordinator under President Obama. He advocated for the establishment of a permanent White House pandemic response office, which was implemented. President Trump got rid of it in July 2018. Klain has proposed the practical measure of revising the Stafford Act to include epidemics within the category of natural disasters that can be addressed without waiting for congressional approval.
Nearer to home, we could have acquired valuable perspectives from the outbreak of Foot and Mouth disease in 2001 in the UK, Ireland, and the Netherlands. This suggestion may come as a surprise since this epizootic event occurred among animals, not humans.But we have much to learn from veterinary medicine in the current crisis because the study and treatment of infectious disease is a major component of veterinary training and research. And COVID-19, when it comes down to it, affects an animal population. Ireland did well during that crisis, escaping with a single outbreak on a farm in Co. Louth. Effective and immediate government action made a huge difference.
Two days after the outbreak was identified in the UK (on 19 February 2001), the Irish Department of Agriculture banned imports of animals and animal products from the UK, including Northern Ireland. Significantly, Northern Ireland followed suit and also banned such imports from Britain. Ports and airports were placed on high alert. There was cross-border cooperation on tracing – exclusion zones were imposed in affected areas.
A report prepared not long after stated that senior civil servants and representatives of farming unions in both jurisdictions concluded that cross-border cooperation had played a major part in avoiding a catastrophe. People interviewed for the report ’emphasised the benefits of preparing an island plan’ to contend with future such emergencies.
This event offers an insight into the benefits of political cooperation. But there is a larger lesson to be learned by taking a ‘one-health’ perspective, integrating medicine and veterinary science. Here again, historical insight is instructive. Pioneers of this approach go back to the eighteenth century and include such eminent figures as the physician Sir William Osler (1849-1919). But we could have gleaned it from published assessments of SARS, when the outbreak of that coronavirus disease as recently as 2003 was traced to animal markets in Guangdong province, China.
The Flu outbreak of 1918-19 serves as an important point of comparison in terms of scale of and loss of life. Improvements in medical testing, medications, and technology constitute major differences between then and now. It is striking, nonetheless, how much we rely on the same non-pharmaceutical interventions: social distancing, quarantines, face covering, hand-washing. The toolbox has not changed very much. The other instruction from a century ago was to expect the illness to come in waves.
Right now, our attention may be fixed, understandably, on the emerging vaccines and protocols for mitigation, but it is worth recognising that the pandemic is as much a social and political phenomenon as it is medical. My advice, therefore, is to reach even further back to understand the social psychology of plague, the behaviour patterns that occur when illness strikes on this scale, and the difficulties of managing public health. No better guide exists than Daniel Defoe’s novel of 1722, A Journal of the Plague Year, set in the fateful moment of the Great Plague of London in 1665-66, which claimed 100,000 casualties.
Defoe drew on documentary sources to show how the disease played out. He excels in describing public susceptibility to magical cures, chafing at conditions of lockdown, the desire to flee, and attacks on public officials charged with enforcing isolation. History is a great teacher; much of what we have witnessed could have been foretold.
What might we learn as a country? First is the absolute necessity of meaningful cross-border cooperation. The Foot and Mouth crisis demonstrates the potential for coordinated action (admittedly under shared membership of the EU). Foot and Mouth also showed that restrictions on movement between Northern Ireland and the rest of the UK can be implemented. This is not political heresy; Wales banned travel by incomers from English hot spots and Scotland followed suit.
Second, Mike Ryan’s point about an African community-driven approach makes me wonder about the wisdom of investing heavily here in technological solutions. Tracing apps are a case in point. Much touted at the outset, their effectiveness is exaggerated and, paradoxically, they may diminish the acceptance of personal responsibility.
Defoe’s novel makes clear that public health must be managed at the local level, parish-by-parish in his case. National directives are crucial but they must be implemented on the ground, where buy-in begins. Defoe’s narrative also offers a range of cautionary tales. The rampant quackery that he describes has migrated in our time to the internet (and on occasion to the White House briefing room). A parallel problem will occur with anti-vaxxers. We have to step up countermeasures.
“The pandemic has also provoked a much wider reflection on where the world is going. ” Defoe’s other caution, highly applicable to the United States under Trump, is that communities became essentially self-governing during the plague. The court removed to Oxford, leaving aldermen, constables and others in charge in the City of London. Their dedication and fearlessness in the face of a terrifying disease still inspires admiration. If we diminish public service, all of us lose out.
And what about the university? An integrated research approach is essential, not just relying on the sciences for pathways but also on the social sciences and humanities. A centre for social value might be the way to draw together our priorities and speak to them in a wider national and international setting.
A final point. When we eventually overcome this coronavirus, the heroes of the piece may be the scientists who devise the vaccines and the health care workers who have got us through. But COVID-19 is only one virus – the lessons of history are crucial because they prepare us for a range of future challenges.