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Illness, Old and New

Epidemics, bubonic plague, and other nasty diseases have been a part of the history of medicine since before records were kept. Egyptian mummies from 500 BCE have been shown to have had tuberculosis, rickets, and congenital defects.

Concerning newer diseases, it’s not just COVID-19 (Sars-Cov-2) that’s new. Nature continues to shower us with new diseases. There is the continual evolutionary sowing of viral and non-viral pathogens. In the evolution of these organisms and viruses, a few of them have appeared since 1975, my start in medicine. (Ebola in 1976, Legionella in Legionnaire’s Disease ~1980, HIV-AIDS in 1981, toxic shock syndrome ~1982, and SARS 2002). There are no signs that nature is letting up with the frequency or the severity of these contagions. It seems that the opposite is true.

HIV-AIDShas infected 37.5 million people that live with it currently and 38 million have already died from it. HIV changed medical education in several ways. Pneumocystis Carinii was almost unheard of in 1978, now it is on everyone’s watch list because of HIV. It changed blood typing, infection control, and blood screenings, pre-op and other protocols. There were other pandemics in the last century that deserve comments.

There was a large poliomyelitis outbreak in 1916. The Spanish flu pandemic (1917-1919) killed 20-50 million worldwide and the third time it came around, in 1918, it was just as deadly. In some studies, it killed one-third of its victims, many times more deadly than COVID 19.

Other epidemics and plagues in history deserve mention not only for their length of infestation but also to look for patterns of an outbreak. For my purposes, epidemic and pandemic mean country and worldwide respectively. The word plague indicates Yersinia Pestis infection—also known as bubonic plague, Black Death, and “the blue sickness.” Bubonic plague included a rat and flea vector and was discovered in 1894 by Alexander Yersin in Hong Kong. Even people in the Middle Ages knew to be in a less populated country was safer than in the dirty cities full of people, human waste, and vermin.

Notice the frequency and especially the duration of the contagions that follow. Also of interest is that most of these severe outbreaks lasted for years, sometimes decades.

  • Antonine Plague in Italy 165-180. Thought to have been brought back by soldiers returning from campaigns. It may have been smallpox.
  • Plague of Cyprian 250-271
  • Plague of Justinian (also of Constantinople) 541-543.
  • Blue Death Plague of 1347-1355. An estimated 50 million people died over this time from the plague. (Estimates range upward to 200 million, 30-50% of Europe’s population.)
  • Plague of London 1615-1617. This may have been a viral hemorrhagic fever, but history records it as bubonic plague.
  • Plague of Italy 1629-1631.
  • Plague of Marseilles France 1720-1722
  • Plague of China 1850-1855. This plague spread to six continents before it fizzled out in the 1950s.

Plague has been around for thousands of years, but only when the mortality was of significant size did it achieve designated recognition. The notion that it came in and then was gone for one hundred or more years before it reoccurred would be an error. Then there were so-called “plagues,” which were other types of epidemics and just as deadly. Skin manifestations were part of the identification of plague, lacking any way to identify the bacteria. The “buboes” or pustule was common, thus the confusion between plague and measles and smallpox.

  • Plague of Athens 430-427 BCE. Noteworthy because it was likely typhus or smallpox.
  • Plague of Galen. 165-180. A 15 year-long “plague” this disease had pronounced in skin manifestations, probably smallpox or measles.

More recent epidemics and pandemics have included:

  • Philadelphia’s Yellow Fever (“Great Sickness” or bilious plague) in 1793, in which 5,000 died out of 50,000 in the city. Incidentally, Thomas Jefferson was vaccinated against smallpox in 1766 in Philadelphia.
  • Flu Epidemic 1889-1890 in the US.
  • Polio Epidemic 1916.
  • Spanish flu in 1917-1919 pandemic was especially rampant in eastern ports bringing back doughboys from WWI in Europe. Those soldiers inadvertently helped the virus spread.
  • Aztec and Inca epidemics of the 1600s in which upwards of 95% of indigenous populations were decimated by mostly Spanish explorers who brought smallpox, syphilis, measles, and hemorrhagic fever to America.
  • The Native American population was severely affected by infections, especially smallpox by expanding white settlers of the nineteenth century. No effort was made to create a record of the severity or penetrance of these contagions.

New Challenges

Several facts stand out to me reading more about these large outbreaks. I am not a population scientist or a viral research specialist, but the more I studied these large outbreaks the more concerned I became:

  • Although plague and severe bacterial and viral pandemics have “hit” the world populations every couple hundred years since antiquity, the frequency and severity of attack seem to be increasing in the last two hundred years (Polio of 1916, Spanish flu 1917-1919, HIV-AIDS 1981, COVID-19 are major examples.) These viruses combined have killed over 100 million people in four different epidemics in roughly just one century.
  • The evidence shows that the type of contagion varies widely and for the most part is outside our existing vaccine spectrum. Therefore, vaccines must be made after the infection is among us. That is not the same recurring bug that struck like the bubonic plague was during the last 20 centuries. Two organisms that caused tremendous devastation, smallpox, and polio, were eradicated with the use of vaccines. Occasionally diseases named as plague were something else, but predominantly Yersinia Pestis caused most of the large, recorded epi/pandemics of the first two millennia. It did not require a vaccine as public health improvements cleaned it up, plus the Yersinia infections that still occur are treated well with antibiotics.
  • Travel in a world economy creates the speed of spread, unlike anything we might have imagined just 50 years ago. What used to take months to barely pierce the US from, for example, Estonia or Poland, is here widespread in a week, and maybe less time. Remember the Ebola outbreak in Dallas in 2014? Deep in Africa to Dallas, Texas in three days.
  • Despite local Public Health Department authorities, CDC, and TDSHS, more people reject vaccines now than fifty years ago. Despite science-proven data and public testimonials, the citizenry is increasingly resistant to getting any type of vaccine. This includes parents (of school-age children) for MMP through COVID for adults, despite wide safety margins in human trials and in large clinical studies that have demonstrated good safety margins. Five hundred side effects to the vaccine with 345 million doses given put the chance of serious side effects at 0.000004%. That’s very close to zero. Among anti-vaxers, scientific facts are disbelieved as adequate proof. This boggles my science-trained mind but that is a fact. How do we convince someone of effect without using scientific evidence?
  • Until we genetically alter resistance to infections, vaccines have been proven for three centuries to be the best way to provide local- worldwide control and reduce deaths. The list of epidemic contagions controlled by vaccines is increasingly long: diphtheria, measles, smallpox, polio, hepatitis A and B, meningococcus, and yellow fever. But they have to be taken!

As we work ourselves into this century, we need to figure out how to increase community confidence in vaccinations and to anticipate more COVID and Spanish flu-like illnesses. A review of the last 1800 years shows a clear pattern of spreading pandemic deadly infections. Our mobile society lends itself to easily spread. In cases like COVID-19, it spreads as fast as airplanes could get from one place to another. This is not an extension of annual influenza. These infections are not one year and done infections. Vaccines have proved to be the best method of control (meaning fewer deaths, less morbidity, and limited exposure to the illness.)

The scientific data shows it to be true. That is not enough.

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References: Science Magazine, Scientific American Magazine, CDC.gov, Wikipedia, Britannica.com, NIH National Library of Medicine.

Photo by Steven Cornfield on Unsplash

Dan Stultz MD is a retired physician who was diagnosed with Parkinson’s disease 14 years ago at the age of 57. He practiced internal medicine in San Angelo, Texas, for 28 years and became the President/CEO of Shannon Health System. He served as President /CEO of the Texas Hospital Association from 2007-2014 working on medical and health policy. He served as guest faculty at the Texas A&M Medical School in Round Rock and retired in 2016. He and Alice live in Georgetown, Texas.